Monday, February 20, 2012

Tinkering with health is not a laboratory job

Do you love Brussels sprouts? I do. And broccoli, chard and kale, too. Why do I ask?

Well, last week my friend Kent Bottles did a blog post on what the future of medicine may look like according to two of our prominent medical futurists, David Agus and Eric Topol. It left me scratching my head, so I went to find Agus on the interwebz, and came upon his 2011 TEDMED talk, which can be found here. The Brussels sprouts were just the beginning of nearly 20 minutes of bewilderment. I will get to the meat (ahem) of it momentarily, but I just could not get past his assertion at around 3:48, where he states that people in their 90s do not take up healthcare resources -- no mechanical ventilation, no weeks in the ICU -- and that they "die with dignity from whatever process ails them at that point." Really? In what country?

Here is the reality -- you can consult the Dartmouth Atlas for a lot of this info, but many other sources exist as well. There are approximately 2.5 million deaths in the US annually. Fully 1/3 of them occurs in the hospital, more that 1/2 of which involve ICU care. And incidentally, not to get all cost-conscious or anything, but 80% of all of the associated costs were due to ICU care. But wait, you say, this is not necessarily people in their 90s, right? OK, let's take it down a layer.

Among the 1/3 of all the annual deaths that occur in the hospital, nearly 3/4 are among the Medicare population, or those who are 65 years old or older. Furthermore, according to none other than the Dartmouth Atlas, up to 1/4 of all Medicare enrollees spend 1 week in the ICU in the last 6 months of life. OK, then. So, where are the data that old age is associated with low medical costs? Not here, that's for sure.

After this dubious beginning, Dr. Agus states the undeniable: humans are complex systems, and we need to think of them as such. Additionally, he advocates skepticism because much of what is done in medicine is not based on "true" data. OK, I can certainly go along with that. Then he goes astray. Here is how.

At around 10:30 he gets into technological solutions. You may be surprised that I do not fundamentally disagree with technology as the answer to disease. No, I disagree that technology is the answer to health -- this is where Brussels sprouts come in. At about 11:00 he starts to talk about aspirin and all the fantastic health benefits that are associated with it -- here is a screen shot of his slide:
And he suggests that aspirin should be mandatory, and that society should not have to pay for these diseases that develop due to what? Aspirin deficiency? Now, as veteran readers of my blog, do you see something funny about this slide? Is there something missing? Yes, you are right, where are the references for these statements? No, I did not cut off the bottom -- there are no studies referenced. One other critical piece of information is missing: whenever data on benefit are presented, data on risks must also be presented. Where are they? So, yes, be very skeptical. One more picky point: he brings up Michael Dell at 11:30 or so, telling the story of how his employees who smoked had to pay higher insurance premiums. By extension, Dr. Agus contends that we should charge higher premiums to employees who do not comply with aspirin. Unfortunately to get into the full controversy about the role of aspirin in these conditions is way beyond the scope of this post. But do let me give you a taste of what a balanced discussion of aspirin as a prevention for heart disease looks like -- here the Mayo Clinic web site is exemplary in providing a well-informed approach. Around 12:00 Agus builds the same argument for statins. And then he knocks down vitamins and supplements and suggests that people who take them should be penalized with higher premiums. OK, in my humble opinion this branch of inquiry has always been a fool's errand in a society that is fairly well fed, but higher premiums? Come on. I will not belabor this. And finally he sprinkles his comments with a few words on the microbiome. 

So what does Dr. Agus seem to say overall? My impression is that he thinks that we should tinker with maintaining our health by looking to manufactured drugs, such as aspirin and statins, as well as whatever we learn from the microbiome (more drugs?). What is missing here is the discussion of the risks vs. the benefits of such tinkering in healthy people. What is also missing is data to back up some of his fundamental assertions (see above). 

So, final words? Technology is not the enemy. If used correctly it can help us understand and cure disease. Tinkering with the healthy human is the job of evolution, not the laboratory. The potential "unintended consequences" of such tinkering are too colossal to ignore.  



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