The Healthcare Delusion

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Stedman's
Medical Dictionary
defines delusion as "a false belief
or judgment held with conviction despite incontrovertible evidence
to the contrary." With all the current discussion about healthcare
reform it's time for some straight talk on health and disease and
the "healthcare system."

First of all,
we don't have a healthcare system. We have an illness care system
which, if it must be labeled, I would call the medical care system.
The task of the medical care system is mostly to ameliorate and
help people cope with the diseases that beset them. Some diseases
can be cured but hardly any can be prevented. Prevention has only
been documented for certain infectious diseases and this has been
accomplished mainly through public health measures such as provision
of clean water, chemical eradication of disease-carrying insects,
etc.

The idea that
"life style" habits such as diet and exercise can affect
the incidence of disease is especially pernicious as it provides
a rationale for totalitarian regulation of individual choice by
the government and the hordes of busybodies who yearn to control
the behavior of others. This should be clear to all libertarians.
It distresses me to see some of my fellow libertarians buy into
the phony arguments for "lifestyle" causation of disease
which is based on pseudoscientific gibberish that they would never
accept on another subject such as, say, global warming.

Much of the
confusion may be due to a lack of appreciation for the difference
between health and disease. Health is our natural condition. Disease
is a physical or biochemical alteration that causes one or more
of the body's organs or organ systems to malfunction. Once the infectious
diseases are excluded, there is virtually nothing known for certain
about the causation of disease. This is especially true for the
ubiquitous degenerative diseases that afflict all of us as we age
— predominantly cancer and atherosclerosis with the latter being
the underlying cause of heart attacks and strokes.

Most people
confuse health with the way they feel. Although almost all diseases
will eventually affect the way one feels, it is possible to feel
well for quite some time despite the presence of disease in the
early stages. Conversely, people may feel poorly for a variety of
reasons even though they enjoy good health (i.e. the absence of
disease). How one feels is subjective while the presence of absence
of disease is quite objective.

For example,
exercising and maintaining physical fitness certainly provide a
sense of well-being for most people. There is no question that physical
fitness provides one with a feeling of more energy and the ability
to get around with less fatigue, sluggishness, etc. But there is
not a scintilla of scientific evidence that exercise or fitness
prevents disease or prolongs life despite the never-ending exhortations
to the contrary.

Diet is an
even greater source of misunderstanding and misinformation. The
attempt to link diet to health and disease has a long and rich history.
The only thing lacking is any scientifically credible evidence that
the two are related. Most of the so-called "evidence"
that is cited comes out of a pseudoscience known as epidemiology.*

Epidemiology
was once somewhat useful in pinpointing the causes of infectious
diseases. But it has been counterproductive in elucidating the causes
of chronic and degenerative diseases. It has steered research down
a blind alley seeking "risk factors" and "lifestyle
choices" as causes of disease. This is done through that manipulation
of statistics using data that are highly suspect to begin with.
Much of what passes for medical research these days is nothing more
than "numbers crunching" to show correlations between
risk factors and disease. These "studies" give us our
health scare of the week where the media announces with great solemnity
that "investigators at X university have discovered that people
who drink y cups of coffee per day exhibit a higher incidence of
(name the disease)." These bulletins are popular with the media
because they provide an endless source of stories. They are favored
by researchers because they can crank out dozens of papers without
ever leaving their easy chairs.

An example
with which I am intimately familiar because it is in my specialty
field (cardiology) is the purported link between cholesterol and
coronary heart disease. I have written a book on this subject titled
The Cholesterol Delusion which I am hoping will be published
in the near future. The book attacks the cholesterol theory root
and branch and shows how the theory was built up on a few studies
which used correlations between unreliable statistics and conflated
tiny differences into significance through statistical legerdemain
and outright fraud.

The biggest
lie is that connecting diet to heart disease. There has never been
any scientifically credible evidence for this association. The best-designed
and conducted studies uniformly show that diet has no significant
effect on heart disease or cancer. Even if cholesterol was a factor
in the causation of atherosclerosis and heart disease, diet would
not be the answer. There are literally hundreds of studies dating
back many years showing that diet has a negligible effect on one's
cholesterol levels. The reason for this is that cholesterol levels,
like many other biological phenomena, are under the control of a
feedback mechanism. Most people are not aware of the fact that we
humans manufacture 80–90% of our cholesterol. This occurs mostly
in the liver, but many other cells within the body can participate
in this process as well. The reason for this is that cholesterol
is a vitally important biochemical and life would be extremely fragile
if we had to depend upon an external supply.

 



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Each individual
has a range of blood cholesterol levels that are set by the genes.
This range may vary quite a bit from person to person. If all the
cholesterol is removed from the diet, the body will simply step
up the rate of manufacture in order to restore the level to the
preset range. Conversely, huge amounts of cholesterol may be added
to the diet, but the body will only absorb so much and will reduce
the rate of manufacture so as to bring the level back into the normal
range. Biology is replete with these sorts of feedback control mechanisms
which operate as self-correcting means to maintain biochemical and
hormonal levels within the ranges compatible with life. Libertarians
can probably appreciate the similarity with market self-correcting
mechanisms.

Another source
of health misinformation is the currently hot topic of obesity which
was discussed in the recent
excellent article by Karen DeCoster
. There seems to be a lot
of hysteria about an "obesity epidemic" which is ruining
our national health (whatever that is). But the critics have yet
to confront the fact that life expectancy continues to rise despite
this horrible affliction. Actuarial statistics show that moderate
obesity (as currently defined) has no significant effect on life
expectancy. It is true that the morbidly obese have significant
health problems but these are most often due to mechanical factors
such as extreme obesity that limits the ability to breathe normally.

There have
been many attempts to link obesity with diabetes but this association
is tenuous at best. There are literally millions of people who are
obese but show no evidence of diabetes. Conversely, there are lots
of thin and physically fit individuals who are severe diabetics.
It is true that some people may show a diabetic-like pattern of
glucose intolerance when they gain weight and revert to normal when
they shed some pounds. These individuals may have a marginal genetic
tendency towards diabetes where the anti-insulin effects of excess
body fat may reveal a pattern of glucose intolerance. But they rarely
suffer the severity or the secondary problems seen in the truly
diabetic.

The idea that
one can eat his way to diabetes is sheer nonsense. Some of the confusion
arises because of fundamental misunderstanding about the disease
process in diabetes. Because diabetics have either a relative or
absolute lack of insulin, their blood sugar (glucose) level may
rise quite high if they ingest a glucose load. In order to avoid
the secondary metabolic effects of a high blood sugar (or, more
accurately, a relative deficiency of intracellular sugar), diabetics
need to pay close attention to the amount of carbohydrate in their
diet. But the glucose level in the blood is really only a marker
for the disease. The sugar itself does no harm other than dehydrating
the individual due to the osmotic effect. There are many other effects
which produce the typical diabetic syndrome (accelerated atherosclerosis,
kidney failure, blindness, etc.). It has been shown that even near
perfect control of the blood glucose level does little to prevent
these complications in the truly diabetic. The underlying cause
seems to be genetic and affects the insulin production and perhaps
other factors as well. But one can eat all the sugar one wishes
and never develop diabetes if the underlying genetic cause is not
present.

So what is
one to do in order to maintain health and well-being? It would be
nice if we could do so by following a "healthy" lifestyle
or diet. But, unfortunately, that is not consistent with biological
reality. Most likely good health is a combination of genetics and
pure dumb luck. This is not intended to be a statement of medical
nihilism, but rather to provide a realistic frame of reference for
rational individuals who are constantly bombarded by nonsensical
notions about health and disease.

It is certainly
normal human nature to want to believe that we can promote our own
health through clean living and healthy lifestyles. If only wishing
could make it so. No one wants to feel like they are subject to
the winds of chance when it comes to their health but a realistic
perspective should aid one in his or her own decision making when
it comes to matters of health and disease.

I see many
articles on this website and others touting this or that diet and/or
regimen of supplements that will prevent cancer and other diseases,
prolong life, etc. These programs are often listed under the title
of "alternative medicine." As a radical individualist
myself, I can relate to the impulse to question the accepted wisdom
and go against the grain. But to believe in such promises betrays
a form of magical thinking and unscientific irrationality that is
unbecoming to libertarians. Most of these are harmless and I certainly
wouldn't advocate their suppression. However, I find these attempts
to tinker with our biology analogous to Hayek's description of constructivism
as applied to society. Like a free market economy, the human body
has marvelous mechanisms for self-correction and will function best
under a regimen of benign neglect. This doesn't mean one shouldn't
consult a physician when something is wrong. Just don't waste time,
money, and resources on useless "health maintenance" measures
which have no biologic plausibility or scientific evidence behind
them.

What does
all this mean for 1) the "healthcare system," and 2) the
individual?

1) There is
nothing wrong with the system that couldn't be fixed with a healthy
dose of free market principles.

A) A good
start would be a free market in drugs. Any adult should be able
to buy any drug they wish without a prescription. They may choose
to consult a physician or not.

B) Obviously,
all government intervention into the medical field should be ended.
Medicare and Medicaid should be abolished. All licensing laws
should be repealed. Any person should be able to select or consult
with whatever type practitioner he chooses.

C) End all
regulation that hampers a free market in medical insurance. The
unpredictable nature of disease outlined above makes this area
ideal for insurance coverage just like that which is available
for disasters or other unforeseen calamities.

2) For the
individual:

A) Eat what
you enjoy. If you are moderately obese, don't worry about it.
Food doesn't cause disease. You may feel a little more sluggish,
but that is your choice. You can only make intelligent choices
when you know the true costs and benefits of any course of action.

B) Exercise
as much or as little as you like. It will only affect the way
you feel. It has nothing to do with health or disease.

C) If you
feel well, avoid contact with the medical system. If something
is wrong, consult a doctor to obtain a diagnosis and proper treatment.
Get second opinions — no one is infallible

D) Avoid
medications as much as possible — all are two-edged swords.

E) Carry
high-deductible "disaster" medical insurance. This will
be relatively cheap and protect you against the "big hit."
I have done this for years and my premiums have not increased
significantly over the past several years even though my wife
and I have had three surgeries during this time.

The best advice
I have ever read is to live a life of moderate hedonism and enjoy
the limited time one has on earth.

*For further
discussion of epidemiology see The
Epidemiologists: Have They Got Scares for You
by John Brignell.
There was also a very informative article several years ago in Science
magazine titled "The Limits of Epidemiology." I haven't
been able to locate my copy to give the precise reference but perhaps
it can be found on the internet.

August
12, 2009

Ernest N.
Curtis [send him mail]
a semi-retired cardiologist with 30 years experience in private
practice in Long Beach CA. His beloved 25-lb Maine Coon cat is named
Murray after guess who.

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