Biology, Health, recent, Science / Tech

A Contrarian View of Digital Health

“The pursuit of health is a symptom of unhealth.”
—Petr Skrabanek

Picture Jim from Kentucky. A farmer, tall, Peterbilt hat. Just retired. He takes basic meds for high blood pressure and diabetes. Arthritis slows him but he has no cardiac symptoms. He plays cards, goes fishing and hangs out with his grandkids.

Jim’s family bought him a smart watch, so he could improve his health. The watch kept telling him that his heart rate was low. Jim called his family doctor, who arranged an urgent cardiology visit.

Jim’s electrocardiogram showed occasional premature ventricular contractions (PVCs). His cardiologist worried because PVCs can indicate trouble. Jim tried to reassure his doctor, saying, “I feel well.”

The cardiologist insisted on further testing. One of the scans—known for its propensity for false-positives—showed an abnormality. So Jim, the asymptomatic happy man who met the cardiologist because of a smart watch, had a near-normal coronary angiogram—a test that requires placing a catheter in the heart.

Soon after the procedure, Jim stopped talking, his face drooped and he could not move the left side of his body. The catheter had disrupted a plaque that caused a stroke.

The stroke neurologist tries to help him. Months later, Jim makes slow progress in a nursing facility.

While social media amplifies anecdotes of “saves” from personal health devices, real-world clinicians understand two truths from Jim’s case: it is hard to make a person without complaints better and interacting with healthcare comes with risks.

In the 1970s, Ivan Illich, a philosopher, wrote a book called Medical Nemesis (1974). Illich’s thesis was that medicine had become a major threat to health. His bombastic prose and eccentric personality made his ideas easy to dismiss at that time. Yet now, with the expansion of the medical-industrial complex, including “personal” health devices, Illich’s ideas deserve another look. Could he have been prescient?

Illich described three ways the medical establishment has brought harm, or iatrogenesis, to society. Jim’s case illustrates the first type of iatrogenesis: direct clinical harm. But Illich taught that direct clinical iatrogenesis is not the worst form of harm. The expansion of digital health will endanger society in more pernicious but devastating ways.

One is a social iatrogenesis in which medical practice causes illness by encouraging people to become consumers of preventive therapies. H. Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, calls this “anticipatory medicine.” Welch observes that when we treat people with symptoms, we do so because patients are asking for our help. In anticipatory medicine, patients are being told they need our help.

Much of the digital health movement centers on anticipatory medicine. Smart watches capable of recording the heart’s rhythm are, essentially, massive disease-screening programs—akin to the blue and pink cancer campaigns.

An empirical look at the evidence supporting anticipatory medicine is sobering.

In 2015, three Stanford researchers systematically studied all the published trials of screening for deadly diseases and found “reductions in all-cause mortality with screening tests were very rare or non-existent.”1

Genomics, another form of digital health, looks equally dubious. Professor Christopher Semsarian from Sydney Australia recently wrote that “sequencing the genomes of people who are well and asymptomatic has great potential to do more harm than good.”2

Semsarian explains that sequencing a human genome in a healthy person can identify up to 12 potentially harmful DNA variants. That knowledge would surely induce further testing and unnecessary worry. Thus, every person who has their genome sequenced becomes a patient.

Use of genomic data looks no better for therapeutics. When Francis Collins boldly predicted at the turn of the century that we will see a complete transformation in therapeutic medicine in the next 15 to 20 years, he was wrong. This is not surprising given that the lifestyle diseases of today—obesity, diabetes, and cardiovascular disease—are linked to hundreds of gene variants, which taken together explain tiny fractions of the variance.3

And despite the many promises of precision oncology, two formal studies, including a randomized control trial, have failed to show tumor sequencing approaches (searching for  genomic alterations in cancerous cells and then targeting them with specific chemicals) have any advantages over conventional therapy.4, 5

Longevity data confirm the failure of anticipatory medicine: The CDC website includes graphs on average lifespans. No matter the category, the age at death has not budged over the past 15 years. In fact, for some categories, lifespan has actually decreased in the past two years.6 But worse is this stat: while deaths from cancer and heart disease have plateaued since 2000, deaths from dementia and Parkinson’s disease have risen greatly.7

Finally, Illich believed medicine’s greatest sin was a cultural iatrogenesis—an indirect sickening power or a health-denying effect. He thought that true health required adaptation. Healthy people adapt to ageing, to healing when damaged, to suffering and then to the peaceful expectation of death. But medicine’s metastasis into culture has dire consequences:

By transforming pain, illness, and death from a personal challenge into a technical problem, medical practice steals the potential of people to deal with their human condition in an autonomous way and becomes the source of a new kind of un-health.8

The tragic paradox of today is that gains from technology allow people to live with more illnesses, but this “progress” also prevents the normal adaptations of aging. Clinicians rarely say an elderly person suffers from old-age; rather she has diseases X, Y and Z.

James Marcus, a former editor of Harper’s magazine, recently wrote of his dad’s end-of-life spiral in the New Yorker. At age 89, his father, a retired physician scientist, had become a “bundle of maladies.” Frailty led to falls and subdurals, then craniotomies, nursing home stays, delirium, pneumonias, and then death. Hospitals and nursing homes overflow with scenarios exactly like this.

Digital health offers no relief from Illich’s cultural iatrogenesis—it may even make it worse. That reality raises existential questions. Irish gastroenterologist Seamus O’Mahony writes in his latest book, Can Medicine be Cured?: The Corruption of a Profession (2019), that “medicine no longer knows what it is for.” O’Mahony asks good questions: Is the aim of medicine, or digital health, to keep the entire adult population under permanent surveillance? Does longevity trump all other considerations? What if we won the war on Cancer? And, what about the relief of suffering?

Sending millions more people to clinicians, creating a society even more fearful of lurking diseases, and systematically robbing people of the normal arc of life and death–this, I am afraid, is where the digital health expansion is heading.

As a doctor on the frontlines of healthcare, the beginnings of digital health look ominous.

Dr. John Mandrola practices cardiac electrophysiology in Louisville, Kentucky and is the chief cardiology correspondent for Medscape.


1 Saquib N et al. Does screening for disease save lives in asymptomatic adults? Systematic review of meta-analyses and randomized trials. International journal of epidemiology 2015; 44(1): 264–77. doi:10.1093/ije/dyu140.
2 Semsarian C. Genome sequencing for sale on the NHS. BMJ 2019; 364: l789. doi:10.1136/bmj.l789.
3 Joyner MJ, Paneth N. Promises, promises, and precision medicine. J Clin Invest 2019; 129(3): 946–948. doi:10.1172/JCI126119.
4 Tourneau CL et al. Molecularly targeted therapy based on tumour molecular profiling versus conventional therapy for advanced cancer (SHIVA): a multicentre, open-label, proof-of-concept, randomised, controlled phase 2 trial. The Lancet Oncology 2015; 16(13): 1324–1334. doi:10.1016/S1470-2045(15)00188-6.
5 Eckhardt SG, Lieu C. Is Precision Medicine an Oxymoron? JAMA Oncol 2019; 5(2): 142–143. doi:10.1001/jamaoncol.2018.5099.
6 National Vital Statistics Reports Volume 67, Number 5 July 26, 2018, Deaths: Final Data for 2016. : 76.
7 Divo MJ et al. Ageing and the epidemiology of multimorbidity. Eur Respir J 2014; 44(4): 1055–1068. doi:10.1183/09031936.00059814.
8 Illich I. MEDICAL NEMESIS. The Lancet 1974; 303(7863): 918–921. doi:10.1016/S0140-6736(74)90361-4.


  1. Speaking as a healthcare professional with no particular opinion on smart watches for health – do not blame them for bad medical practice. Asymptomatic bradycardia (a slow heart rate that does not produce symptoms) in a person with a basically normal ecg requires reassurance, not referral to a cardiologist. PVCs are not an indication for further testing and there are very few indications for cardiac catheterization in a patient without symptoms. This is a case of many layers of very bad medical practice that has nothing to do with the smart watch.

    • David of Kirkland says

      Nothing to do with the smart watch other than the smart watch triggered the entire scenario unfolding as it did….

      • Ray says

        Precisely David. In essence a “smart-watch” induces information overload on an already complex system – i.e., state of our complex human bodies in an even more complex environment. It can happily pump out “garbage” along with “factual” data. But it not only fails miserably at interpreting that data (factual or not), it can actually IMPEDE effective interpretation. So the technology does actually share a lot of blame.

    • What is being lost is the art of medicine. The smart watch, along with lab tests, is a poor replacement for the well-trained physician who balances those test results with knowledge of the patient and the experience of having examined many other patients. Sadly, today’s doctors seem to be trained to treat lab results, not patients.

    • Jean Levant says

      I agree, all the more so as the author is a physician. As for the medical trend, Ivan Illich was right, perhaps a little too early.

  2. E. Olson says

    Great article. A problem with modern medicine is that it has created the expectation that we can be kept alive indefinitely, which to some extent is true if we are prepared to indefinitely hook the dying up to respirators and other mechanical and chemical-based life support technologies.

    Add in a culture that rejects personal responsibility or poverty as excuses to withhold even the most expensive or experimental treatments that might save the patient, which is manifested by public policies where someone else is paying for medical bills such as single payer/government provided health care systems, mandatory private health insurance, and mandates that hospitals provide care to all comers, has led to a further increase in both anticipatory medicine and “heroic” health care.

    In the litigious US, anticipatory and heroic medicine that exhaust all known possibilities to extend life also becomes standard operating procedure as part of defensive medicine to prevent lawsuits from patients and their families who are terminal or dead because some test wasn’t done or some treatment wasn’t prescribed.

    Finally, throw in a decline of religious beliefs in heaven/life after death/reincarnation and the possible joy of “meeting your maker” or joining deceased loved ones, and the desire to avoid death at all costs becomes much stronger among larger portions of society.

    And all these factors together are a big reason why medical systems are bankrupting government budgets around the world. Until medical research and practice is directed to find cheaper solutions, probably by requiring more “out-of-pocket” payment for medical care so that patients become more price sensitive, the problems are only going to get worse until the systems collapse.

    • DiamondLil says

      Incessant youth worship is also part of the problem. Unlike previous generations, I see boomers (like myself) approach aging as a personal failure. It is not enough to be happy and healthy, a woman must must continue to look and act as if she is in her thirties for decades beyond or she has failed in her duties somehow. I can only suppose that men are getting a similar message.

      • E. Olson says

        DiamondLil – you raise a very interesting point, but perhaps not in the way you intended. Medical interventions to “stay young” are some of the areas that are becoming more popular not only because our culture values youth over experience, but also because they are more affordable. Since cosmetic surgery and other “fountain of youth” interventions are most often paid out-of-pocket by the patient, their costs have not risen nearly as much as most other medical care because care-givers have to be sensitive about what they charge to maintain or increase their business. Such cost pressures mean that former “exotic” technology such as lasers are now much better and cheaper to use, but also speed up recovery and lower the cost of post-operative care.

        The fact that more people can afford such treatments does not necessarily mean they are good for the mental health of patients, however, if the lead to unrealistic goals about never looking old.

      • Lightning Rose says

        Nailed it, DiamondLil! I have friends who are very angry with me that I don’t “seek care” for self-limited “hip bursitis.” They insist that I need a total hip replacement so I can be ageless and “perfect.” Why? To trade a wear-and tear annoyance at 60 for the possibility of drug reactions, addiction, C-diff, MRSA, or Candida Aureus? No thanks, darling, I’ll keep the minor limp you Elites find so unsightly; I really have no ambition now to run a marathon, climb Mt. Kilimanjaro one-handed, or join Crossfit any time soon. My former life of athletic excess is what bought me this shot over the bow that I’m aging! But I still run my farm just fine.

        Quite acquainted with the books of Illich, Welch, and fellow-traveler Dr. Nortin Hadler, whose “Worried Sick” is a MUST READ. Vast diagnostic and treatment excesses are lavished on the wealthy “worried well,” who can afford the new ideal of ageless perfection unto the lip of the grave at advanced age, while the underserved are the POOR population who truly have the worst outcomes. Hadler states that “80% of the mortal risk is encompassed within the equation of socioeconomic status.” Much of the remaining 20% can be chalked up to genetics, while “lifestyle” issues short of heroin addiction barely move the needle.

        If you want to do ONE thing to keep you out of the clutches of iatrogenesis, eliminate all sugars and refined carbs from your diet. It’s beyond doubt at this point where all the “Western diseases” have come from, but the Powers that Be have been singing “I don’t heeeaaarrr youuuu for the last 60 years. Just Do it, and you likely won’t need lifetime pharmaceutical maintenance caused by the Feedlot Diet.

        There are many of us out here who refuse completely to participate in the blandishments of “anticipatory medicine,” a form of paternalism which could quickly turn totalitarian with the advent of mass surveillance devices as cited. Engage with the medical profession only in the presence of a Primary Complaint that they have a credibly useful treatment for; and accept the other stuff (low back pain, seasonal allergies, heartburn, leg cramps) as the Human Condition and treat it yourself. Fact-checking is your friend!

        Tag on a tea bag says it all: “You’re only young once, and if you work it right, once is ENOUGH!”

    • Farris says

      “A problem with modern medicine is that it has created the expectation that we can be kept alive indefinitely, ….”

      People now view life as an obstacle course. Thinking if they can avoid all the right obstacles, they can live forever. Jim Fixx died of a heart attack at age 52. He was correct in his desire to stay fit but there are no guarantees. Stay active, enjoy life, get regular checkups and when the time comes it comes. What if every minute one spent worrying about death, took a minute off that person’s life?

    • Daniel V says

      @E Olson – I’m Canadian and was raised with the idea that you only go to the doctor if you really need to and there is cause for grave concern. Partly because the cost is being shared by everyone and it’s not something to be abused or used frivolously. Just like welfare is always a last resort.

      Of course not everyone is like this and I know plenty of people that go running to the ER for anything and everything. These same people also seem to be constantly sick and seeking out alternative medicine since they complain out healthcare system can’t find the root cause of their issue. Paid naturopaths on the other hand are glad to diagnose a variety of sensativities and conditions that they are happy to treat with a variety of expensive remedies.

      I now happen to work in insurance and can say more out of pocket costs would likely reign things in quite a bit. The amount people spend and get reimbursed for paramedical costs is staggering, as is their sense of entitlement to the money as if the intent is a bonus with extra steps. When they don’t have to pay any portion of the cost they tend to maximize their payments year after year then complain when their premiums rise in response. As if money comes from nothing.

      • Farris says

        @Daniel V.

        Patients became customers and of course the customer is always right.

      • E. Olson says

        Daniel V – thank you for sharing your very relevant personal experiences. One other aspect that is also driving costs up are medical advertisements. After living in Europe (where they are mostly prohibited) and the US (where ever other ad on TV is for some wonder drug), I don’t know how any American with a TV wouldn’t come to believe they have some serious ailment that requires them to run to their doctor for a prescription for the wonder drug that cures or “manages it” (may cause brain tumors and lung cancer in some patients, use only as directed). If the patient was required to pay the price for the drug themselves, I suspect many would decide they aren’t that sick after all.

        • Rev. Wazoo! says

          @E Olson & Daniel V
          Yes, I live in Europe and in my country (it varies considerably) we pay 20% of doctor and medicine costs. Not enough to discourage the sick but enough to discourage not really sick. (catastrophic costs are all covered}.

          Doctor’s only get 45/visit but live well; the only time they went on “strike” (reduced hours on a rota) was when the health fund mistakenly tried to make over-the-counter medicine non reimbursable. They won so they can still “prescribe” cheap asprin/paracetamol and sniffle meds etc. Keeping patients who don’t need it away from powerful drugs is cheaper and healthier.

    • Blue Lobster says


      The idea that a decline in religious belief has contributed to iatrogenesis via increasing fear of death piqued my interest. As a non-religious, non-believer I must admit that I quite fear death and can, thus, imagine how religion might be evolutionarily advantageous. Are you of the opinion that the tendency of humans toward religiosity is cultural or biological in origin?

      P.S. I was raised in a household where medical treatment was reserved for when it was called for and I continue to live similarly. I accept the fact of my impending nonexistence, I just don’t like it.

      • MMS says

        @Lobster – You and me both but remember that non-existence also means non-existence of any pain or loss as well.. At least, after all is said and done, we will not be around to contemplate our non-existence anyway….

      • E. Olson says

        BL – Every culture in history has had religious beliefs of some sort, and one of the key questions that religion always addresses is the meaning of death, which is an important question to everyone since we all will go through it. You can believe that God has delivered the “meaning of death” to his disciples on earth, or you can believe they evolve from observing over time how people best deal with death and dying and also what doesn’t work (cultural), or you can believe that God or random selection has programmed some sort of genetic based instinct into our brains/souls regarding death and dying (biological). It seems some animals also have death rituals, so arguments can be made for a biological element, but since it is also part of all cultures, and likely also has some cultural element.

        All I know is that the people I have observed who have lived with the least worries about death, and died without anger, worry, or regret (beyond concern for the well-being of those they leave behind) have almost always believed in a good after-life (e.g. heaven) and expressed trust in a merciful God.

        • Blue Lobster says

          Thanks, E.,

          My observations are similar to yours regarding the ability of people to meet their end with grace. I’ll just have to figure out the best approach for me to do so sans belief in an afterlife as that concept has always failed to take root in my mind as anything other than wishful thinking despite my religious upbringing.


          Well said. It’s just damned difficult to be at peace with non-existence when one has grown so thoroughly accustomed to existing.

          • E. Olson says

            BL – I wish you the best of luck in finding something that brings you peace and comfort, and hope you have lots of quality time to figure it out, but I might suggest you consider whether wishful thinking might not be a bad thing. After all, what is the downside?

  3. Joana George says

    I think I might be about to overshare, but there is another horrible side effect to this phenomenon that I can’t properly express without sharing this story.

    My grandparents were very happily married for over 60 years. When she reached her mid-eighties my grandma’s mind started to slowly fade. Around three years later, there was nothing left. Towards the end, she didn’t even seem capable of experiencing any joy anymore. She died soon after. Officially, she died for some medical reason or other (I think a bleed in her brain) after being in a coma for almost a week.

    That week is what I want to talk about. Everybody in my family was stating platitudes about “hoping for a miracle”. Theoretically, they were doing this for the sake of my grandfather, but when I got annoyed and mentioned that she was already gone and her surviving the coma wouldn’t be a miracle, it would be a disaster, my grandpa was obviously relieved. I talked to him about it some time later and he mentioned feeling guilt and worrying about being judged for thinking that it would be better if she died. I think that’s horrible!

    There is enormous pressure to put longevity above everything else and it is placed on people when they are already grieving and in a lot of pain. My grandfather took excellent care of my grandmother over those three years even though it definitely took a toll on him (he was in his late eighties as well). He did it with a lot of love and no resentment. Despite this, when she died, he was made to feel like he has failed her.

    I can’t help but feel that a lot of people have gone through similar things so I wanted to put this out there. My apologies if the story was too personal for this platform.

    • OleK says

      Not at all. You have some very salient points. Thank you for sharing your story (in the sincere way).

    • E. Olson says

      Joana – your personal story highlights the growing problem of people living longer, but not necessarily enjoying quality of life for many of the extended years of life because of dementia, severe physical injury/deterioration, severe pain from illness/disease, or even just plain loneliness from outliving family and friends, or lack of purpose. It seems that medical research is more often aimed at adding weeks or months to our lives, but we seldom seem to question how worthwhile such increases are in many cases.

      As I note in my comment above, the declining importance of religious belief also is having an impact on how we view the end of life. Through much of history when life for most has been extremely difficult and painful, religious doctrine offered hope of paradise after death, but to prevent mass suicide made killing ourselves a sin that could keep us out of heaven. Now when so many no longer believe, a mechanism for dealing with death and loss is gone because if there is no God or life after death why should we pray for a merciful death, or hope for a desirable outcome that may include death for those nearing the end? Perhaps that is why it seems the most vehement atheists are usually relatively young and healthy.

      • Jeremiah says

        If I make it to 80 and my wife is gone i’m just going to do every drug I can get my hands on. Might as well party when you’re that old. What do you have to lose.

        • GrumpyBear says

          One of my dad’s favorite expressions: “Everyone should get a motorcycle for their 75th birthday.”

          I’m glad he didn’t; he’ll turn 90 in a few months and is doing great.

          • E. Olson says

            GrumpyBear – Happy Birthday greetings to your Dad, and his outlook reminds me of my great Uncle who built and flew his own planes until he felt he was too old to safely continue when he was in his 70s, so he promptly bought a motorcycle as a replacement which he happily road well into his 80s.

  4. Caligula says

    A smartwatch at least does not present any direct risk to the user, yet the same can’t be said of other medical diagnostic technologies.

    An obvious example is a CT scan. A physician won’t order a CT scan for no reason, yet the urge to “just find out” in response to a patient’s vague complaint must be strong. The question (as always) is whether the benefit is worth the risk.

    CT scans deliver a significant dose of ionizing radiation, thus presenting a carcinogenic risk. Yet there will never be a way to prove that a particular CT scan caused any particular cancer, and in any case the risk lies decades in the future.

    And given a choice between a possible benefit now vs. a risk that lies decades in the future (along with the impossibility of showing causation for any particular cancer), it’s difficult to believe that all or even most physicians will not be biased toward even a small or unlikely present benefit.

    To be fair, the problem is addressed in medical literature, but, what’s relevant is the extent to which it’s expressed in everyday medical practice.

    In any case, if your physician proposes a diagnostic procedure, you really should ask (1) what are the risks, (2) how ambiguous are the test results likely to be, and (3) what difference would a positive result make in any treatments I might be offered? At a minimum, if the answer to (3) is “probably no difference” there would seem to be little if any reason to perform the procedure.

    • Lightning Rose says

      Ah, but they LOVE to order those CT scans at $5K a pop to keep that machine humming, and the hospital they’re affiliated with frequently insists on it. All this when you twist your knee playing tennis, where the old, sensible advice used to be Rest, Ice, Compress, Elevate and wait and see.
      Which, you’ll notice, is free and sans ionizing radiation . . . we used to call it “Suck it Up!” 😉

  5. molinas says

    My observation is that too much regulation and lawyers destroyed the health care profession. I guess I am living in a fantasy land where I expect the doctors to know things, give their professional advice based on research, years of experience, education and some dose of intuition.
    However what I am experiencing is doctors hiding behind tests, it seems nowadays most doctors order all sorts of tests to cover their asses.
    I went to a dentist once and he told me I have 5 cavities and I need a root canal and a crown, however my insurance money could either cover the 5 cavities or the root canal + crown. So I asked what does he recommend me to do, should I take care of the 5 cavities first so they don’t end up needing a root canal, or should I do the one bad tooth so it doesn’t cause me excruciating pain in a couple of months. Well it’s my decision.

    • Jeremiah says

      The Atlantic just recently ran a story about a lot of dentists just straight up scamming patients by performing a bunch of unnecessary procedures. Now if you’re in serious pain then the root canal is obviously what you should do since you know that’s a real issue.

  6. Daniel V says

    It’s worth noting Plato opined that a doctor who’s purpose is to make money ceases being a doctor and becomes instead a merchant as the only purpose of a doctor is to heal the sick. While I can appreciate the free market approach can result in better care it also results in waste and frivolous services. For example my wife was watching Jersey Shore and they hired a nurse to come out to give them IV feeds to recover from their hangovers. Something about that just seems wrong.

    • E. Olson says

      Daniel V. – you are certainly correct that something is wrong – why the heck is your wife watching Jersey Shore?

  7. My training is in pharmacogenomics and I can say that this author (correspondent for Medscape!!) seems to be misleading everyone regarding a particular reference. The author failed to mention that the article they cited “Tourneau CL et al” found that “use of molecularly targeted agents outside their indications does not improve progression-free survival compared with treatment at physician’s choice in heavily pre-treated patients with cancer.”

    Well of course it did. Targeted agents are indicated for a particular molecular target, hence their name. Using these drugs outside of their indication is not going to work. To be clear, the evidence for pharmacogenomics in cancer leans towards being positive. Getting tested and then starting targeted treatment is often considered first line therapy for many cancer types (NCCN guidelines). There are exceptions of course, and this is an ongoing field of study. But in this case, the author used an inappropriate study that did not prove his point at all.

  8. Riley says

    My grandmother refused to seek medical treatment for anything for the entire time I knew her. I have no idea how she delivered her seven children. I do remember her being ill and injured and yet successfully refusing every attempt by her children to get her to a doctor. In her 90th year, she tripped on a step and broke her hip. They took her, against her will, to get medical attention. I don’t know how she was treated. I do know that she lived to be a 104 and never saw a doctor again. I visited with her just after she turned 100. She was lively, with a great memory, was a great storyteller, and she was as cantankerous and bossy as ever. She did, however, take a few naps that day. She also accepted help getting up from the table. Unforgettable woman.

  9. luysii says

    Hopefully we’re smarter about what we do and advise than when this was written, but based on the comments and article — we aren’t

    The risks of risk reduction

    If a little is good more is better. Right? Not so. Two recent medical articles imply exactly the opposite. The first one should be taken with large grains of salt based on past experience. It says that women taking multivitamins were 2.4% more likely to die during the 19 years of the study. The study was large (about 39,000) and since the age at entry was 62 there were plenty of deaths (about 16,000) over the years of the study, so a bizarre effect involving small numbers is very unlikely. So the effect is real. Why should you take this with salt? Because the study is a naturalistic one. They just asked if the women were taking vitamins and watched what happened (e.g. I’m assuming that this was an observational study — N. B. I haven’t been able to get my hands on the paper yet, so I may have to eat my words). We have the horrible example of similar studies leading up to the Heart and Estrogen/Progestin Replacement Study (HERS).

    [ Science vol. 297 pp. 325 – 326 ’02 ] During the planning study for the Women’s Health Initiative, some argued that it was unethical to deny some women the benefit of hormones and give them a placebo. The reason the HERS study was funded was that Wyeth couldn’t get the FDA to approve hormone replacement therapy as a treatment to prevent cardiovascular disease. So Wyeth funded HERS to prove their case.

    [ J. Am. Med. Assoc. vol. 280 pp. 605 – 613, 650 – 652 ’98 ] The HERS study is in. There was no benefit of estrogen + progestin in 2763 women with coronary disease younger than 80 in a 4.1 year followup. However, only 75% of those assigned to hormone treatment were taking it at the end of 3 years. The patients weren’t worse, however, the number of venous thrombotic events was significantly higher in the estrogen/progestin group 34 vs. 12.

    Of interest is that 3 different meta-analyses concluded that estrogen replacement therapy decreases the risk of coronary heart disease by 35 – 50% — these were all meta-analyses of observational studies and not prospective and randomized.

    Actually patients on hormone replacement therapy did WORSE in the first 2 years and had an INCREASED risk of heart disease.

    More work from the Women’s Health Initiative trial in 16,608 women showed increased risk of stroke, dementia, global cognitive decline. In addition there was no benefit against mild cognitive impairment. This was published in the 28 May ’03 JAMA. The present work extends the initial early findings to followup to 5.6 years. The rate of stroke was 31% higher. 80% were ischemic. The increased risk was seen in all categories of baseline stroke risk. 40/61 women diagnosed with dementia were in the hormone (prempro) group. This is in a subgroup of 4,532/16,608 women in the study. The references are all JAMA vol. 289 pp. 2663 – 2672, 2651 – 2662, 2673 – 2684, 2717 – 2719 ’03.

    So what was the problem. Why were the results so different from what was expected? The women taking hormones in the 50 observational studies were (1) thinner (2) better educated (3) concerned enough about their health and vigor to take hormones — it is well known that compliers with mediation — even placebo medication — have a better outcome than noncompliers — believe it or not (4) smoked less.

    The second study is much better. It was prospective, involved large numbers (35,000 men) and was randomized, so that subjects either received extra vitamin E or extra selenium (or both or nothing) in the hopes of preventing prostate cancer. 620 of the men in the extra vitamin E group alone developed prostate cancer as opposed to 529 in those receiving a placebo. So the extra vitamin E was actually bad. The numbers are large and unlikely to be a statistical fluke.
    Oxidants are widely held (or worried about) to cause cancer. Vitamin E (with its tons of conjugated double bonds) is a free radical scrounger (had to put something in for the chemists), hence an antioxidant. Here’s a study showing it increased the risk of lung cancer. It’s old but good. The last paragraph shows how horribly illogical the practice of medicine and the ‘scientists’ working in clinical medicine were back then. Note that this stuff was published in Science (in the unrefereed Letters section).
    [ New England J. Med. vol. 330 pp. 1029 – 1035 ’94 ] The Alpha-Tocopherol, Beta-Carotene Trial (ATBC trial) randomized double blind placebo controlled of daily supplementation with alpha-tocopherol (a form of vitamin E), beta carotene or both to see if it reduced the incidence of lung cancer was done in 29000 Finnish male smokers ages 50 – 69 (when most of the damage had been done). They received either alpha tocopherol 50 mg/day, beta carotene 20 mg/day or both. There was a high incidence of lung cancer (876/29000) during the 5 – 8 year period of followup. Alpha tocopherol didn’t decrease the incidence of lung cancer, and there was a higher incidence among the men receiving beta carotene (by 18%). Alpha tocopherol had no benefit on mortality (although there were more deaths from hemorrhagic stroke among the men receiving the supplement). Total mortality was 8% higher among the participants on beta carotene (more deaths from lung cancer and ischemic heart disease). It is unlikely that the dose was too low, since it was much higher than the estimated intake thought to be protective in the uncontrolled dietaryt studies. The trial organizers were so baffled by the results that they even wondered whether the beta-carotene pills used in the study had become contaminated with some known carcinogen during the manufacturing process. However, tests have ruled out that possibility.

    Needless to say investigators in other beta carotene clinical trials (the Women’s Health Study, the Carotene and Retinoid Efficacy Trial) are upset. [ Science vol. 264 pp. 501 – 502 ’94 ] “In our heart of hearts, we don’t believe [ beta carotene is ] toxic” says one researcher. Touching isn’t it. Such faith in a secular age, particularly where other people’s lives are at stake. I love it when ecology, natural vitamins and pseudoscience take it in the ear.

    Caveat Reador

  10. TheSnark says

    I have read that doctors tend to refuse a lot of end-of-life care, the kind that they regularly recommend to their patients. it seems that they know it is very expensive and usually does little more than prolong life by a couple of (often painful) months.

    • luysii says

      It’s exactly why my brother and I (both docs) arranged it so our parents could die at home. We did have the luxury of one or the other of us being with them most of the time.

      As a neurologist, I saw lots of life-ending illnesses — strokes, meningitis, trauma, cancer etc. etc. The worst futile (and very costly) prolongations occurred when a relative (usually a child) who had been rather distant, barged in consumed with guilt and wanted ‘everything possible’ done — to show how much they cared.

  11. Lightning Rose says

    Heard today that the God-complex medicos are now overriding the DNR directives even of those who go so far as to TATTOO “DNR” on their chests; “Well, we can bring people back from so many things nowadays . . . ” is the justification. Who legally owns your body and life, already? You? Or the State, or the commercial medical industrial complex, who want you to keep providing them cash even when your viable, livable, endurable time is past? Why are they empowered (and by whom?) to override your own personal decision?

    When I say “for your own good, dear” medical paternalism is the backdoor to totalitarian control, this is EXACTLY what I’m talking about!

  12. Let’s face it, the American health ‘care’ INDUSTRY exists ONLY to make money out of people. I mean, it’s America in microcosm. The more they can squeeze out of you, before you stagger off and die…the better. Period. 🙂

  13. Carolyn F. says

    When I’ve said that “The best way to stay healthy is to not get sick,” most people look at me as if I were a fool. When I explain what underlies my tautology is that the sixth leading cause of death is from medical mistakes and other bad outcomes from medical interventions, those same people are often shocked. Good health is first and foremost a personal responsibility. It is, after all, the body that does the healing, not the doctor. For many habitual consumers of healthcare, this isn’t a welcome news. For them, a preventive CAT scan or lab test is so much easier than taking responsibility for losing that extra 50 pounds and exercising.
    Great article!

    • E. Olson says

      Shhh Carolyn – if word got out that healthy diet, regular exercise, and a positive outlook on life leads to better health and less need for medical “care”, 10 to 20% of the Western economy would collapse. We already have a lot of empty shopping malls, what would we do with a bunch of empty hospitals and clinics?

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  15. D. Moelling says

    As a small business employer and slightly older man with a family with some long term medical issues, I play close attention to the medical industry. But I’m also a technical guy with good experience in statistics, imaging and scientific practice. My recommendation to all is to relax. Medicine for 5000 years or more has been mostly about trying things that don’t work. Many did reassure patients which is a good thing, and over time people spotted the things that worked and also gained insights for the next steps. In my lifetime from the mid 1950’s to today, the advances are astounding. Also medicine is currently in a labor intensive mode. Part of this is make work or regulatory growth but a lot is just due to the level of technology. This too will improve with time. We just need to avoid restricting human freedom and flexibility in the false idol of state directed economy.

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  17. SB says

    This article is so true. If you want to live a long and healthy life, stay away from doctors.
    Doctors are just sales people for drug and imaging companies.

  18. “Yes, we suffer pain, we become ill, we die. But we also hope, laugh, celebrate; we know the joy of caring for one another; often we are healed and we recover by many means. We do not have to pursue the flattening-out of human experience. I invite all to shift their gaze, their thoughts, from worrying about health care to cultivating the art of living. And, today with equal importance, the art of suffering, the art of dying.”
    Ivan Illich

  19. We’re creating a nation of hypochondriacs. Too many people count the number of steps they take, keep track of their heart rate, and have every medical test they or their doctor can think of. Companies that require employees to have annual physicals and “encourage” reaching certain supposedly healthy goals add to the problem.

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