Why We Won't See "The End of Illness"
Health is much more than just absence of disease.
Posted Mar 08, 2012
Sorry. We're not about to see "The End of Illness," the title of the popular new health book written by oncologist/entrepreneur Dr. David Agus.
Agus promises a lot. You will be able to "live robustly to a ripe old age of one hundred or more." Then you will die, but not from "any particular illness." Instead, "your body just goes kaput. You die peacefully in your sleep after your last dance that evening."
He can manage this feat because "I have developed a unique way of looking at the relationship of the human body to health and disease." In sum, he's discovered systems theory—that the human body is really complex.
Yet systems theory, information theory, and complexity theory have been used constantly for decades. And the really, entertaining, useful part of Agus' book is taken directly from the curricula of our nation's public health schools. The Cinderella stepchildren of American medical care, public health schools have been teaching and researching a far more comprehensive view of health than Agus even attempts—and doing so for a long time.
Because Dr. Agus, well known for his cancer research and for founding personalized genetics and protein testing companies, is still living with the standard physician view of health. It's a narrow view of medical care: one patient at a time. Health is tightly defined as the "absence of disease."
Believe me, as a doc with a patient right in front of you, absence of disease is a very, very big deal. Most physicians will very gladly settle for that. But the public, our economy and our society deserve far better. The World Health Organization definition of health is "complete physical, mental, and social well-being."
And a paradigm for that kind of health does exist—as I will try to show you. It looks at populations, not just individuals. It's really cost-effective. It accepts and exceeds Dr. Agus' excitement at using the coming informatics revolution. And it gives us a much more comprehensive view of the human body and how it works than any number of protein or genetics tests can achieve.
We also know that this health paradigm works. The irony is we can do much of what Agus promises—right now. America already has subpopulations living well into their nineties. They got there through a way of life that involves the most simple, ordinary parts of daily existence—how you eat, move, socialize and rest.,
We will have to emulate those populations - because we won't have a choice. The late Dr. John Knowles, head of Massachusetts General Hospital, thought American medical care would soon bankrupt the American economy. He wrote that in the journal Daedalus—in 1972.
At that time, health care was 5% of the nation's GDP. According to Agus, it is now 17.8%.
Over 50 million Americans have no health insurance.
Over 50 million are on Medicaid.
Many millions have only catastrophic insurance.
We better get this "new" health paradigm up and running quickly. We don't have the money to pay for our present health costs—let alone a future filled with aging baby boomers like me.
And that means we have to confront the big secret of health care.
Health Care's Dirty Little Secret
Human populations live a lot longer than they did in the past. At the beginning of the twentieth century, people in developed countries had a lifespan in the thirties. Within decades, it was into their seventies.
Most of the huge improvement in survival was not due to advances in medical care.
Another "tion," medication was a factor, but it comes farther down on the list.
Public health people know these facts. Yet doctors are, for the most part, not taught to think this way. Doctors think about the patient in front of them and what they can do—right now.
On page 24 of "The End of Illness" Agus puts up graphs demonstrating the decline in heart disease and stroke from 1950 to 2007. Seeing this sharp improvement, he states "This graph demonstrates the profound effect that therapeutics such as statins have had in heart disease and stroke."
It you look at the graph, most of the decrease in death has occurred before the late 1980's—when statins first appeared.
And what about the decline in smoking during that period? Changes in diet? Changes in behavior? Those were some of the many public health factors leading to the decline in deaths.
You can graph similar dramatic results for infectious diseases. Survival increased fantastically during this period - with most of the improvement before the advent of antibiotics.
Yes - virtually all of us will need medical care during our lives. But that's not why people are living so long.
Instead we should look at the landmark Eight Americas Study. In the United States right now, Asian American women in Suffolk County have an expected lifespan of 95.6 years. A much larger group in Bergen County - living inside a cancer hotspot - have an expected lifespan of 91.1 years.
These women, born in the US, are living five years longer than their mothers born overseas.
We can do it here. We've already done it in subpopulations—through public health measures and attention to how people live.
Agus does spends much of his book pointing out how food, activity, and sleep are critical to achieving individual health. Yet he emphasizes the power of medications and, most prominently, the relatively new area where his is a major entrepreneur—genetics and protein testing.
How do those factors stack up in improving health?
Agus really likes aspirin, statins, vaccines and bisphosphonates (drugs for osteoporosis.) He wants most every adult to use the first three.
I don't have much argument with vaccines, especially in our younger and older populations.
Yet drugs—and their supposed anti-inflammatory effects—are a far more complicated story.
In the most recent large scale, international study of over 100,000 people, reported in Archives of Internal Medicine, daily aspirin did not decrease cardiovascular deaths. Nor did it decrease cancer deaths.
Perhaps that study was too short term. We know aspirin can decrease long term colon cancer deaths, for example. But will that offset the deaths and disability it causes through increased hemorrhagic strokes?
You need a lot of experienced and cool heads to determine which populations—particularly those with cardiovascular risks—should be taking daily aspirin.
The same is true for statins. They are, and can be very effective drugs. Agus wants most every adult on a statin—he's taking Crestor. He believes their ability to decrease inflammation may be at least as important as their ability to decrease cholesterol and lipids. He points to the 2008 Jupiter Study as showing that statins can decrease overall deaths—like those from cancer.
Yet other studies have not shown statins decreasing cancer death rates.
And statins have a lot of side effects—including new FDA warnings on cognitive impairment and diabetes that came out February 29th, 2012. Statins can and do make many miserable. On rare occasions they can kill.
Statistics, and interpreting them, is very complicated, difficult work. So far, only certain populations should be taking statins at this point—based on presently available information.
And when we read that bisphophonates have "people living five years longer" we need to be a bit skeptical. Drill down and the Australian study subgroup used for that calculation is only 121 people out of over 2000, followed for all of three years.
Agus is good in describing the pitfalls of statistics, particularly in his discussion of the vitamin D controversy. You really need long term, double blind studies to know if a lot of things work.
So let's apply those lessons to the matter of testing.
Genetics and Proteins Tests
Agus has co-founded testing companies Navigenics and Applied Proteomics. In his book and on the Net he vividly describes how "spitting into a tube" can provide you lots of information about your genes that you can then use to "guide" your personalized health care.
Be careful what you wish for.
It really pays to read Dr. H. Gilbert Welch and co-authors Schwartz and Woloshin's book "Overdiagnosed" before looking at the promises of testing. As the subtitle of the book explains, not understanding the implications of testing can result in "Making People Sick in the Pursuit of Health."
Consider the PSA—the prostatic serum antigen test. There are millions of people who have had PSAs—and been followed for many years. Welch estimates that for every person "saved" by PSA screening, thirty to 100 people will be treated unnecessarily.
With many of them becoming impotent, incontinent of urine - and sometimes worse. Dr. Robert Ablin writes "the test can't distinguish between the two types of prostate cancer—the one that will kill you and the one that won't." He describes the test as a "profit driven public health disaster."
Ablin should know—he developed the PSA.
Agus argues forcefully that cancer testing is the future—that's how you will prevent the disease.
So let's look at Genomics and Proteomics.
Genomics and Proteomics
Navigenics, like 23 and Me, provides genetics tests for individuals so they can personalize their care. Do we have data, like double blind trials of those who take the tests and those who did not, as to what they do to future treatment and health?
No. But consider the case of reporter John Lauerman, writing in the February 20, 2012 edition of Bloomberg Business Week.
Lauerman went to Harvard to have his genome sequenced. The type of complete genome test he got, which will soon cost about $1000, is more comprehensive than what is presently sold by companies like Navigenics—though that won't be true for long.
In "Do You Really Want to Know?" Lauerman finds out—according to test esimates—that he's not at much risk of Alzheimer's. That's a relief. But he does have a variant of the JAK2 gene. He talks with Harvard Professor George Church, the well-regarded researcher who started the Personal Genome Project, and Joseph Thakuria, its medical director.
They tell him that a study performed in Copenhagen that followed up some people 18 years demonstrated that 14 out of 18 with his variant developed cancer. Most of them lived into their seventies or eighties.
But there's nothing he can do about his JAK2 variant. As another director of an academic genetic center tells him, it just "invites anxiety into your life."
Will that cause Lauerman to ask his physicians to more actively test for cancer? What will be the side effects of those tests—and where will they lead in future treatments? How much will they cost—fiscally, psychologically, and socially?
And lots of people might want to know your genetic information—like Lauerman's employer and future employers. Such "pre-existing conditions" may preclude you from a job, or health insurance, or disability insurance.
And though Agus pooh-poohs privacy concerns, genetic and proteomic tests could be used— like other health information already is— to discrimate against many people. Dorothy Nelkin and Laurence Tancredi showed how that process works in their book "Dangerous Diagnostics" - published in 1994. Most clinicians can tell you how medical records are used against people - especially in the workplace.
And in the Internet's cloud, with our mandatory future of electronic health records, everything will be available—to parties scrupulous, and to those without any scruples at all.
Large amounts of medical data will soon be mined to extract useful treatment and research information. This may prove critical in future research. But the privacy issues have not been settled.
The New Health Paradigm
We do need a new health paradigm. Such a paradigm should improve the public health and individual health—and do so cheaply and effectively. It may also point the way towards more effective research.
Here are three parts of that paradigm: 1. Recognize that humans are organisms, not machines. We rapidly regenerate in order to stay healthy. 2. Just as in biology and physics (see James Gleick's book "The Information") we should see the body as an information processing unit. Our bodies take in information—of innumerable types—process and use it. All that knowledge then informs our basic, constantly changing regenerative processes that keep us alive 3. Give the body the right information—which includes how we eat, move, socialize, and rest - and we can collectively survive into a long, vigorous life—as presently occurs with Asian American women.
Regeneration is how the body works. Agus eloquently describes how proteins perform much of the information processing of the body.
Yet most proteins only last minutes to days. They are constantly made, used, repaired, destroyed and recycled.
That includes the heart pumping proteins that allow you to read this sentence. They're gone in 60-90 minutes. According to autophagy researcher Ana Maria Cuervo, who studies cellular recycling, most of your heart is remade in about three days.
You're new - even if you don't know it. Most of you has been remade within a few weeks.
And we are never remade the same way—otherwise aging and development would not exist. We constantly "update" our body information system, constantly learning new things.
If we don't constantly recycle, replace, remake, restore, renew, re-create, and make ourselves new all the time—we're toast. There's enough bacteria on a single human hand to wipe out a humanity that lacks a functioning immune system.
We learn or we die - constantly taking in new information.
The second part of our new health paradigm is that information rules the world. Physicists talk of quantum information theory—not quantum mechanics.
Remember that physics has recently recognized 96% of our universe is "dark energy" and "dark matter"—about which we know practically nothing.
Biology is not much different. In most sciences, ignorance is greater than knowledge. But for practical purposes, it's just amazing what you can do with a little knowledge. People built the pyramids thousands of years before Isaac Newton. The master cathedral builders knew nothing of mass and acceleration.
Let's look at food—what we eat to stay alive. Food is also information.
Food contains the proteins, vitamins, fats and calories about which Agus writes well. It further contains hundreds to thousands of other substances - most of which are uncharacterized.
It also contains MicroRNAs—small snippets of RNA. MicroRNAS directly change gene expression. Only in the last few months was it discovered that MicroRNAs can emerge unscathed following digestion. One simple MicroRNA changes cholesterol synthesis—immediately.
Yet these hundreds of thousands of different molecules are just the beginning of food as information. Timing changes the effects of food. We metabolize what we digest far more effectively in the morning than the evening. Eat a meal at night and lipid levels go considerably higher.
Color changes food—as in the color of the dining room. Give people exactly the same meal—in red rooms they eat one third more than in blue rooms.
Food is also cuisine, culture, celebration. You eat more when you're with friends. Fiber is information, too - eat a lot of fibrous vegetables at the beginning of the meal and the bulk somehow convinces the brain that it doesn't need as much food to feel full.
Food is also how we celebrate our loves and friendship. Food is used in many spiritual and religious ceremonies. It's an integral part of commemorations of many groups to mark their survival and persistence throughout history.
So information is much more complex than genomics and proteomics—as public health schools have long taught. We are not just bodies that contain large individual ecosystems—like the 100 trillion bacteria in our gut. We are people—part of cultures and societies. The seven billion of us may be individually "very unique," but we live and survive together. And what others do with us, by us, and for us, massively affects our health.
As does our environment. A healthy population requires a healthy environment . Live in a toilet and people get sick.
The informatics revolution Dr. Agus wishes for should come. Hopefully it will come. It may improve health care greatly.
But there are many kinds of information that affect health.
We're social animals. A large part of our overall health—and spiritual health—results from that fact. As Berkman and Syme just began to show in the 1970's, social support is a big factor in decreasing death rates.
It deserves a place in the information model just as much as changing protein levels.
The third part of the new paradigm is that health—mental, physical, social, and spiritual health—is an outcome. It results from the information our bodies and mind process and use.
Get the right information and you can last a long time—as do so many Asian American women.
Pieces of that useful information does appear in "The End of Illness." The new health paradigm looks at how you eat; how you move; how you rest; how you socialize; and that keeping body clocks regular can help synchronize the body so your physiology works smoothly.
But other factors matter greatly, too. Like having safe and accessible places to walk; socially cohesive communities; spiritual life and practices.
Health is much more than the sum of your medical tests—or the anxious waiting for them once your blood gets drawn.
In the end, the history of health has been the story of the success of public health. Elements like sanitation, nutrition, and education have been critical factors in prolonging and improving human survival. Today health comes from the simple, ordinary stuff that keeps us well—from using the body the way it's built.
Such knowledge is power. Americans should demand from our national leaders real health—not bandaids on our amazingly expensive, inefficient health care system. Rather than spending trillions on health care that gives us the health indices of Cuba, we should spend our bucks on promoting healthy regeneration in ourselves and our society.
Because health is shaped by communities—physical, mental, and social communities. Kids living in gated suburbs don't get as much chance to play with their fellows. They need cars—and car drivers—to get them to school and friends.
And something as simple as increased green space in a community - more parks and grass fields - decreased by half the survival difference between upper and lower class Britons.
Even the images of "total information health" that Dr. Agus sees as a final goal—with giant data bases and electronic records allowing you to supposedly mine lucrative veins of health information—is presently far more doable outside the US. Places like Britain, Switzerland and Scandinavia have national health systems - and systems of data. They've recognized for a long time something truly important—that a healthy economy requires a healthy population.
And cheap, simple public health measures get you better health - which means much less spending on health care.
Health should be our goal - mental, physical, social and spiritual health. It should rarely be the smaller goal of "disease avoidance" that busy doctors live by. Instead it should become the positive goal of people feeling whole, well, mentally sharp, physically safe and socially connected.
Health involves much more than disease absence. People want to feel productive—and that they're part of something larger and more significant than just themselves.
We can do it here. And we should start right now. We have the knowledge to do it.