Friday, May 28, 2010

Dear Dr. Val

Dear Dr. Val,

I enjoy reading your blog and the contributions from many of the leading medical bloggers that appear on it. Occasionally, the spirit moves me to post a comment, but for the second time in just a few months my comment has not made it to your blog. Why? I also tweeted you to ask if there are technical difficulties peculiar to my comments, but I did not get a reply. Why?

I know that some bloggers have a policy about what comments get rejected. I know that I will not accept abusive, profane or overtly marketing comments on my blog. I am sure you have the same standards. So, why not accept mine? I read Dr. Novella's post with great interest yesterday, and got passionate enough to write a pretty lengthy response. I am grateful to you and to Dr. Novella for allowing me to think through some of the issues that I commented on. But I was hoping for a dialogue... How will we ever arrive at mutual understanding or even better individual understanding without a cogent dialogue?

I do understand that the blog belongs to you, and you must have many reasons not to accept all comments, and that is your right. Perhaps you never even saw it, perhaps you no longer follow my tweets and thus did not get my queries. That is all fine. If I cannot get my comment on your blog next to the corresponding post, I will put it here and hope that you will come for a visit. If you do, I will welcome your comments. So, here it is:

What a great post! Dr. Novella makes the point that there is no evidence for the superiority of consuming organically produced foods over the conventionally produced ones in terms of health benefits. To arrive at this conclusion he relies heavily on a recent systematic review supported by the UK Food Standards Agency, which examined 12 studies, 8 of them in humans, 6 of which were RCTs and the remaining 2 observational studies. Because the article is available by subscription only, I could not access the whole paper. However, knowing what conducting clinical trials entails, I doubt that the 6 experimental studies followed the subjects for all that long. Perhaps not long enough to detect the benefit? Would love Dr. Novella to comment on this.
Additionally, divorcing the potential direct health effects due to consumption of organic products from the effects of the production on the environment is a false dichotomy. The pesticides do not just stay on the skin of the produce, but get into our water supply; the antibiotics given to the animals in CAFOs do not just get into their meat, but also get into the water and produce resistant pathogens -- there is plenty of work from the Netherlands to support the connection between agribusiness practices and human pathogen resistance emergence. Also, look at the staggering findings by the USGS about the contaminants found widely in our water supply and in what amounts.
The monoculture model of conventional agribusiness also requires enormous amounts of petroleum for fertilizers and pesticides as well, a resource that is dwindling. And, perhaps most importantly, the impact of monoculture farming on the land itself is devastating, decimating arable lands and creating essentially sterile deserts which need centuries to recover.
Having said all this, the mass-produced organic food business is not much more environmentally friendly than the conventional agribusiness, relying on monocultures and artificial fertilizing and pesticide management, as Dr. Novella aptly points out. Additionally, because it is concentrated in places remote from where it is consumed, its carbon footprint is still enormous. The really sustainable way to farm and eat, environmentally and human health-wise, is returning to small local farming, with a short distance from farm to table and a self-perpetuating cycle of earth's nutrient consumption and repletion by a diverse biome, just like nature intended.
My final sentiment is that, as people involved in healthcare of our nation, we must care about social and environmental justice. While these issues may fall more comfortably under the rubric of Public Health, doctors and nurses and other personnel at the bedside need to develop a greater appreciation for the context in which disease develops. This context includes healthy and sustainable food production and other social and environmental concerns.

Wednesday, May 26, 2010

When do tests improve mortality? A confusion worth clearing

This is a question well worth asking, particularly as we argue about the merits of mammography screening. The USPSTF has really stirred up the hornet's nest with this one, and the politicians cannot help but get on their populist pulpit, ignoring the facts completely. Oh well, what else is new?

But the question remains: do screening or diagnostic tests that are more sensitive save lives? A great talk on pulmonary embolism detection and outcomes by a recent graduate from the Dartmouth group at the American Thoracic Society last week prompted me to clarify this. We all hear that mortality from many diseases has decreased over the last few decades. But is this true? In order to answer this question, one has to ask what is meant by mortality. Even people well versed in epidemiology and biostatistics occasionally blur the lines between mortality and case fatality, and to our question the distinction is critical. Case fatality is defined as the proportion of patients with the disease that dies, while mortality is a population-based measure, a proportion of all of the population at risk for the disease that dies. The difference lies in our old friend the denominator, which will always keep us honest.

Let's go through a simple example to illustrate this concept. Let's pretend that the total number of cases of disease D diagnosed using stone-age test T 30 years ago was 100 in a population of 10,000 people. Of these cases, 90 died, giving us the case fatality of 90% and mortality of 9 per 1,000 population. Now, we have a new test for D, a super-Doppler-MRI-PET-cyberscan called über-T, a much more sensitive test than the old "gold standard" test T. And now we detect 1,000 cases of D in the population of 10,000 people. Of the 1,000 cases detected by über-T, 90 have died. The case fatality now has decreased dramatically from 90% to 9%, and we can pat ourselves on the back for a job well done, right? Not so fast, the population mortality from disease D has remained a steady 9 per 1,000 population!

So, what does this mean? Does it mean that über-T, which costs 2 orders of magnitude more than its predecessor, is worthless? Well, decide for yourselves. What it means to me is that the additional cases detected by über-T, though finding earlier stage disease, thus increasing the denominator for the case-fatality calculation, has had no impact on the numerator and therefore has not in fact improved the only mortality that matters: population mortality related to the disease.

So, next time a politician tells you how well we are doing with technological innovation in disease management, ask this simple question: Has all the money and innovation really altered the important outcomes, or is this all smoke in mirrors, a mirage created by our irrational belief that technology is our salvation? This may be an uncomfortable epiphany for some. But think about the 900 excess cases of the pseudo-disease diagnosed in our example above -- how many people could have been saved becoming a chronically ill person, how many complications of follow-up procedures could have been avoided, and yes, how much money could have been spent on something other than healthcare? And asking these questions may help us to identify technological advances that actually improve our lives, as opposed to those that merely create attractive business opportunities and stimulate the economy.          

Tuesday, May 25, 2010

Is synthetic happiness authentic?

Dan Gilbert asks, Why are we happy?

TED talk from 2004

I am preparing a talk on REMS (Risk Evaluation and Mitigation Strategies) that I will be giving in Philadelphia next week. Instead of my initial thought to present definitions and case studies, I decided to talk about risk perception, evolutionary reasons for it, and the ethics of risk mitigation. In chasing some of the sources for facts and factoids, I came upon this fascinating talk. Enjoy! 

Oh, and check out minute 9...

Nancy Etcoff's TED 2004 talk on happiness vs. absence of misery -- also awesome! She makes a great argument for synthesizing happiness.

Monday, May 3, 2010

Health, art and libraries: more in common than meets the eye

Our grandparents used to tell us, "if it ain't broke, don't fix it". Management gurus, in their race to the Finish line (and what a Finish line it will be!) have turned this sentiment on its head by telling us that, if it ain't broke now, it will be soon, and if you do not fix it before it breaks, you will be behind the competition. This sentiment drives the annual corporate reorganization at every corporation that I or any of my friends has worked at, and puts millions of dollars into these gurus' bank accounts. 

Politicians have adopted this philosophy as well, to much detriment to the citizens. I live in the rural and much neglected Western part of the state of Massachusetts. We like being neglected by the State House in Boston; we are used to it and we like it. What we do NOT like is paying disproportionate taxes for fewer services than our friends East of I-495 get. One pearl of our Western MA civic life is our libraries: they are so much more than a place to get a book. They are community centers, places for people to meet and discuss current events, for local poets and artists to show their wares, for children to learn the responsibility of civic engagement through volunteering. In the economic downturn, where else can an unemployed person find employment and training resources for free? Where else can someone without access to the internet come and use a computer without spending $4 on a cup of coffee? Libraries are what makes our communities what they are. So, how ironic is it that the MA Library system, the very system that is working remarkably well on a shoe-string budget, is under the damocles sword in the budget planning process? The very system that ain't broke is about to get quite a fix. And we, the citizens along with it.

So, you ask, what does this have to do with healthcare or health? A lot! Personally, I am sick of ever-increasing taxes buying ever-decreasing services. Yes, there is inflation, and what a convenient excuse! This all falls for me in the same bucket as the travesty of our educational system, our healthcare system, and, in general, the quackery of the trickle-down economic theory. 

Let's take education. The first things to be cut perennially are arts and gym. What does this do? A lot! Do we really think that the obesity epidemic is somehow not related to devaluing physical activity in the schools? Of course it is, and I do not need a randomized controlled trial, or even a cohort study, to recognize this. Do we really think that art is not an essential component of educational foundation? Just because it will not lend you a corporate job in the future does not mean that it is unimportant. And schools are but a sample of the society at large. Look where we are as a nation: addicted to consumption of trash, creation of trash, assimilation of trash. We are more miserable and demoralized than we have ever been before, we work harder than ever before for less money than ever before, and we pray to the god of the free market more ardently than our ancestors prayed to the god of rain ever before. We have created more disease than we had ever thought possible, and along with it a $2-trillion godzilla of a healthcare "system", only too happy to treat anything and everything under the sun. Like an out-of-control cartoon bulldozer, we are razing our earth, our children's future and our own sanity. 

Of course, I am not saying that all of these ills can be fixed by reintroducing art and phys ed back to our schools, but it sure would be a start. But, indeed, we have been manipulated, duped, sold a bill of goods, taken for a ride! Our market-focused utilitarianism as the single raison d'etre has brought us here, and it has to go; we need to find our way out of this spiritual isolationism and regain our sense of community. It is absolutely an issue of health! Nurses, physicians and other healthcare providers, I call on you to start addressing the civic health of our communities. Get involved in your local politics, and not just because you are interested in maximizing your Medicare reimbursements. The time to act is now. You can start at your local library: have a discussion about how to maintain and improve your community's health, physical, mental and spiritual. It may not be fiscally expedient. But most important stuff in life never is.