The Numbers Racket
One way to keep a population unhealthy is to endlessly worry them about getting sick.
For the last few decades, purveyors of cholesterol as the core of heart disease have created a medical industrial complex that is difficult to suppress. Now that complex is changing its spots again with new guidelines on statins from the American Heart Association and the American College of Cardiology.
What’s Changed with Statins?
If you’re at high risk of heart disease—you’re diabetic, had angina or a heart attack, you’ll still be told to take them. Others who by dint of age or factors like hypertension who’s score goes above a “risk threshold” will also be recommended to stay on the drug.
But looking with religious zeals at successive lipid levels will stop. The idea is to take the drug and stop looking at the numbers.
Why The Change?
The committee looked at the evidence and could find “nothing solid” about following up LDL and other cholesterol levels. As cardiologist Steve Nissen put it, these previous guidelines seemed to have been derived “out of thin air.”
Will This Change How Doctors Act?
Probably not. People like numbers. Doctors love numbers. Evidence based medicine is supposed to be what doctors do—this week anyway. And “evidence” generally means numbers —rather than listening to people or looking at how they live. An LDL cholesterol level of 70 “must be better” than 80 or 90—regardless of whether hard endpoints like heart attack and survival are affected.
Habit is hard to break, but it’s especially hard when one’s livelihood comes along attached. Urologists have not come to terms with the fact that for every person with a high PSA score where treatment “saved” them from death, 30 to 100 were therapized unnecessarily (please check Gilbert Welch's Overdiagnosed for more examples.) Instead of longer life many found impotence and urinary incompetence. Try using a bag for the rest of your life. In European trials, 50-100 people were treated for every “cure.”
Nonetheless, though the American Urological Association recommends most men over 70 never get a PSA, many such older men are still getting the tests, prostate biopsies – and the same “effective” treatments.
How Did This State of Affairs Come About?
There are many reasons. One was that the FDA was convinced that improving “endpoints” like “risk factors” was good enough to approve drugs. So instead of looking at life and death, hospitalization and morbidity rates or other "hard endpoints", they considered lowering cholesterol levels and decreased triglyceride numbers as sufficient.
The "end" end result was a field day for drug companies and laboratories, though not the public. Doctors and patients competed for having the lowest cholesterols. Companies created a panopoly of me-too statins. Labs tested and tested and tested, while patients worried and worried. And much of the useful effect of statins turned out to be not be about cholesterol lowering, but decreasing inflammation.
Yet drug companies bought into their own advertising. They spent billions creating and trying out drugs that increased HDL levels—the “good” cholesterol—until they found the drugs produced higher death rates.
Quantitate, Quantitate, Quantitate
In today’s world, policy is created by statistical models. In many companies, the “data” provide the answers—even if the most important, critical factors are never considered or quantitated.
Doctors have learned their lessons over the decades. A typical visit with a physician of today will include a few questions about symptoms, and then a detailed discussion of one’s “numbers.”
That doctors know little of statistics or the overall usefulness of epidemiologic modeling gets little reporting. And "numbers" look most impressive in a courtroom.
There are hundreds of known risk factors for heart disease. Few are looked at. Even less attention is paid to the characteristics that dramatically effect whether heart disease occurs and kills.
Health Versus Health Care
That our health care debates are ass backwards—about health care rather than health—also rarely gets much media attention. Statins are great for many heart patients. They also make tens of billions of dollars. Real prevention? Now that’s a different story.
That green space around your neighborhood knocks down disease rates by 30% receives little or no policy or public attention. Instead people have been taught that if they want to eat junk all day, all they need do is down a statin pill every night.
The American health model remains simple—more health care. If kids’ Tylenol is filled with high fructose corn syrup, and children have been thousands of sugared cereal ads before they can read or even speak, what’s the answer? Drugs for obesity; fat camps; and new pediatric dental suites to surgically remove crops of caries laden teeth.
We could do useful quantitation—like including research on what walking does for populations. What parks do for a city, it’s sense of place, and the survival and happiness of its inhabitants. Or study what worries about “high risk factors” do to the health of its sufferers.
We might then pay doctors to encourage people to walk and quit smoking rather than to push drugs and endless lab tests. We could get schools to create gardens, and have students tend some of the food they eat, learning about the environment and agriculture. We could get parents to push their kids out of the house and into the yard, away from video games and cell phones.
We could even work on real endpoints—survival and happiness, economic productivity and community satisfaction.
But how can that compare with seeing your cholesterol “score” get lower through taking drugs that can destroy kidneys, rot bones, and make people depressed?
Already the new statin guidelines are under attack. Many researchers say they will double the number of people taking the drugs—while improving their overall health not at all.
Instead health—not health care—should come first.