The Philosophy of this Blog, With A Parable

One (dis)advantage of the Internet is that it offers a forum for rants: passionate expressions of opinion.

Of course, one man’s passionate opinion can, from another perspective, appear to be nutty-as-a-fruitcake insanity.

My Nutty Post on the Corruption of Medicine

An incisive comment from Christopher M points out that my recent rant on the corruption of medicine is silly:

I think you go too far in your criticism of creeping disease-ification. You seem to have embraced the idea that we should ignore damage and decay to the human body if it is somehow “natural” — i.e., major muscle loss in the aging and elderly. But this is silly. Human suffering, decreased quality of life, and death are problems whenever they occur. Now, maybe the “disease” model isn’t always the best way to think about these questions. But I can’t imagine why we would want to carve out certain forms of decay and suffering as parts of the human experience to tolerate rather than try to avoid — with whatever imperfect means we can.

Now this is obviously correct. Human suffering and decay should be remedied wherever possible.

Christopher could have added to his critique. Doctors, scientists, drug companies, politicians and bureaucrats – all are well-intentioned, eager to heal the sick. How can it be fair to say that their industry is, in some ways, corrupt? Their intentions are good and they work tirelessly in the hope of turning their good intentions into good deeds.

And if they make a lot of money, what of it?  The laborer deserves his wage.

The Black-Box Perspective of Medicine

Conventional medicine is largely based around drug treatment, and drug treatment is based on a reductionist model of human health.

In this model, the human body is a sort of “black box” of which we know little. Drugs are interventions that affect the black box. Health is an output of the black box, characterizable by observable markers (such as, is the black box warm and moving, or cold, stiff, and still?). Medical research is conducted empirically. We do an intervention – provide a drug to the black box – and the black box tells us if it feels better or worse (or we look to see if its box-heart still beats). Millions of drugs are sorted through to find a few thousand that make the black box perform its box-functions a bit better, at least in the short term.

Obviously, this black-box model made a lot of sense before we knew about the human genome, before we could do molecular and cellular biology. It is how our Paleolithic ancestors discovered medicinal herbs. Many early drugs were refined from traditional herbal medicines.

In the modern genomic era, this black-box model of medicine has persisted with a reductionist approach to molecular medicine. Now that we’ve sequenced the human genome and can design drugs to target individual proteins, biologists can at will eradicate the function of any human gene or protein we choose. Much pharmacological research in recent decades has been devoted to “targeting” individual proteins or genes, and seeing if these interventions produce beneficial results in some disease or other.

So, from this perspective, it makes sense to say:  Let’s make a drug that targets a human enzyme – say, HMG-CoA reductase – and see if it can provide any benefits in some disease. Since HMG-CoA reductase is needed to make cholesterol, and cholesterol is correlated with high rates of heart disease (and low rates of infectious disease and cancer), perhaps targeting HMG-CoA reductase will have benefits in heart disease patients. So let’s do a trial, see if HMG-CoA reductase inhibitors make heart attacks less frequent. If so, let’s stuff heart disease patients with these inhibitors at a cost of $25 billion a year.

And this makes great sense – if all you know about human beings is that they resemble black boxes.

An Alternative Perspective

Now step back from that conventional perspective on health, and consider an alternative point of view that extrapolates from a few facts:

  • The human body is the result of a long evolutionary history. Our ancestral genome reached its current size, about 20,000 genes, prior to the Cambrian explosion. For over 500 million years, the thrust of evolution has been to make the gene-protein network as sophisticated as possible, as densely networked with subtle interactions between as many molecules as possible. Every gene has an important role to play in that network, and directly influences perhaps a hundred partners. Thus, targeting a single gene will not only deprive the body of that gene’s function; it will also deprive that gene’s hundred partners of the benefits of its interactions, and thus impair their function, which will have ramifications upon their partners, until the whole genome has been affected. Thus, all interventions in the human body have systemic effects. It is not possible to confine effects to a single “target.”
  • Hundreds of millions of years of selective evolution have optimized the human body to work very well if it obtains appropriate inputs: a good diet that is nutritious and free of toxins.
  • However: the human body is not alone. It is saturated with microbes – trillions of them –which have evolved independently to be effective parasites upon humans. These microbes sabotage the immune system, steal nutrients, obstruct the functioning of human proteins. Their goal is their own reproduction, and human health is only incidental to that goal. Some of them benefit from a healthy host, and these microbes are called “probiotic.” Some benefit from harming their host, and these are called “pathogens.”

From this perspective, what is likely to cause disease? Three factors are most obvious:

  • A malnourishing diet may deprive the body of needed nutrients.
  • Toxins, especially food toxins, may poison the body.
  • Pathogens may sabotage the body in pursuit of their own advantage.

If disease results from these causes, then we are forced to look to diet and nutrition as the first step toward health. And then to infections, which may be treatable with antibiotics, as the second.

If the human body is a highly-optimized densely-networked system, then we must be skeptical toward the “black-box” school of medicine – especially in its new, reductionist, human-gene-targeting form. If evolution has optimized the human gene network to maximize human health, then targeting human genes and proteins is sure to sabotage health, probably in unexpected and insidious ways.

A Parable

I often use economic analogies, because there are a lot of parallels between the cooperative functioning of people in a complex modern economy and the cooperative functioning of cells and molecules in the human body. Let me offer an economic parable.

Imagine a world in which every person manages a complex factory. This factory has tens of thousands of workers, and complicated machinery of thousands of varieties, which all has to work together cooperatively if the output of the factory is to be high.

Suppose that from time to time a factory suffers a loss in output. The workers don’t seem to be as effective; they occasionally fall down and die in the middle of the workday. Machinery breaks down for no apparent reason.

Suppose that, in fact, this is due to an invasion of the factory by malicious monkeys, who steal machinery parts, and ravenous wolves, who kill the workers. Suppose that food poisoning in the factory cafeteria has left the factory security guards and workers weakened and unable to defend themselves and their machines. Suppose further that the malicious monkeys and ravenous wolves are invisible.

One day your factory experiences such a slowdown, and you hire a “factory doctor” to help you fix the problem.  He explains that the reason for the decline in factory output is that your workers and security guards have gone bad. The factory has an “autoimmune” syndrome in which rogue security guards kill workers. Workers have been damaging machine parts. The solution?  Hire a sniper team and kill some workers. Remove the damaged machine parts and don’t replace them. Lock the security guards in the break room. The cost? A mere $20,000 a year, charged to your insurance company.

Now suppose another consultant comes to you.  His explanation: your factory has been invaded by monkeys and wolves. Food poisoning has prevented the security guards from driving them out. His solution?  Give better food to the security guards. Put a fence around the factory to prevent more monkeys and wolves coming in. Find an “infectious monkey and wolf doctor” who can “diagnose” the infection, making the monkeys and wolves visible. Then use his “antibiotic” team of monkey and wolf assassins to kill the invading animals. DO NOT KILL ANY OF YOUR WORKERS OR LOCK UP YOUR SECURITY GUARDS. The cost of this analysis? $25 – free if you can assemble the diagnosis from information scattered across hundreds of blog posts.

The Problem of Underemployed Sniper Teams

Now suppose that factory owners are not hiring enough sniper teams at $20,000 per year. So the factory doctors start going to factories with high output and saying to the owners, “Your factory has pre-disease. Although nearly all your workers and security guards are functioning well, a few have gone rogue. If you hire our sniper team and let us assassinate some security guards and workers, your factory will perform even better. Won’t you hire a few snipers?”

The $25 consultant responds with a nutty rant.

Conclusion

This parable is a work of fantasy. It bears no resemblance to any medical industry or blogger you may have encountered. Any resemblance to any actual medical industry or blogger is purely coincidental.

Leave a comment ?

12 Comments.

  1. We need lots more nutty ranters.

  2. Your previous post was a bit over the top, sure. But I think it was also contained a fair criticism.

    Given the abysmal health situation here in the USA, it’s clear that we are doing something wrong, and need to change to a better paradigm to fix it. I think a lot of this is going to happen organically, as books like Gary Taubes’ and your blog get more and more attention.

    We also, however, have to recognize that doctors have a pretty tough job. Trying to make people better on horribly imperfect information is no easy task.

    I just read “Western Diseases, Their Emergence and Prevention”, and while there’s much to be criticized in that book, it’s the result of a sincere effort and a lot of hard work to make people well.

    We’re lucky to have doctors like that.

  3. Hi Tuck,

    Yes, doctors have an incredibly difficult job and do it surprisingly well, given all the challenges they face.

    I have great respect for the doctors I know. And I didn’t even mean to include clinicians as targets in either of these rants. Rather, the industry-affiliated scientist-doctors who work in the government review panels and official standards bodies were, along with pharmaceutical companies and peer-review cliques and government bureaucracies, the target of the first post.

    Sometimes also, good people can reach a bad equilibrium, with no individual being directly at fault. Missed opportunities and inertia are not necessarily blameworthy, but they can lead us to an unfortunate position.

    It’s easy to overstate one’s case, especially when writing quickly, and I hope readers will overlook and forgive me when I do so. I need such forgiveness because I undoubtedly mis-state my case frequently!

  4. Great post, Paul. I was talking to a very bright compounding pharmacist about this recently, and he said “if it doesn’t have side effects, it’s not a drug.” How true.

    In fact, the term “side effects” is a misnomer. Drugs have effects. Some of them are intended and welcome, and some of them are not. But if we understand the mechanism of how drugs work, it’s clear that the notion of a drug without “unintended” effects is absurd.

    By definition, drugs correct a specific imbalance by causing at least one other and often several other imbalances. When a drug is introduced into the body to address a malfunction in one biochemical pathway, that drug inevitably interacts with many other pathways.

    I wrote about this in an article called The Fatal Flaw of Prescription Drugs. There’s a great diagram in it showing the complexity of interactions among a small set of cellular proteins in a fruit fly. It graphically shows that it’s impossible to affect one protein or gene without producing a subsequent (and unpredictable) effect on several other proteins and genes.

    That’s not to say there isn’t a place for prescription drugs – as I know you agree. But there’s a vast difference to using them only when absolutely necessary, with full understanding that they will inevitably have unintended and undesirable effects, and handing them out like candy.

  5. Hi Chris,

    Yes, I think the pharmaceutical industry is actually going to be in big trouble at some point this century because drugs will lose their central place in medical/healing practice.

    Some drugs work wonders – especially antibiotics, and drugs that replace missing human compounds, like insulin for Type I diabetics. But many drugs, especially those that were designed to target specific genes, have negative effects that balance or exceed any symptomatic relief they may bring. Vioxx was not an isolated case.

    I think your brand of medicine is going to be proven to be the way to go in 90% of medical issues.

    It’s frustrating that all the money, research-wise and insurance/treatment-wise, goes into ineffective strategies. That was the point of my parable. I’m not blaming any individual person, but we have gotten into a bad equilibrium and we need to re-shape the practice of medicine and the way medical research is funded and organized.

  6. Who said weblogs are dead? Web-logs like yours are the reason why people still look for web-logs.

  7. Perfect Health Diet » Drugs: Often Unsafe at any Dose - pingback on September 18, 2010 at 11:21 am
  8. I have started to read the book ‘PHD’, and I have a question about how to understand what amount of starches in grams I should eat if I like to have say 200-300 calories from carbohydrates ‘to make it a little easier for my liver’. I’d like to know the amount of potatoes and rice in grams per day. In the book I read that PHD is a low carb diet, but somewhere else it looks like 300 calories could be 450 g of ex potatoes. That is a lot! Is this really a low carb diet then?

  9. Hi Lilli,

    Yes, you’re right, 450 g potatoes supplies about 75 g/300 calories digestible carbs.

    Cooked white rice is 2-3 times as calorie-dense as potatoes, and wheat noodles or bread are 2 times more calorie-dense than white rice.

    So you can eat a low-carb diet, and still eat a plant-food-rich diet!

    In my view, whether a diet is “low” or “high” in carbs is best decided by its number of carb calories in relation to the body’s glucose needs of ~500-600 calories per day. Below that is low and above is high. Most Americans eat over 1300 carb calories per day. So our diet is definitely low-carb and the average American’s diet is definitely high-carb.

    Best, Paul

  10. I have been eating a more low carb that your suggestion fore some years, but found that my blood sugar was very low, often during the days around 3,5. As I felt brain tired in a not nice way I have started to eat more starches, and it has changed to the better. Why my body is not able to produce glucose enough I do not know. Any ideas?

  11. Hi Lilli,

    Well, you need ~600 glucose calories a day, so if you only eat 100 you have to make the rest from protein, or substitute ketones. If you don’t eat a high protein diet, and most people don’t, you’ll invoke the starvation response and be short of glucose.

    There’s also factors that increase glucose utilization, like exercise and yeast infections, or that decrease the ability to manufacture glucose, such as adrenal fatigue or pancreatic damage or malnutrition.

    I wouldn’t worry about it, not everyone can run on an extreme diet. Just get enough carb+protein to run your body, preferably with as much carb as protein.

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