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Researching the Obvious
Often we do things because – that’s the way we've always done it. Yet when tested impartially, especially in medicine and public health, these “rules of thumb” frequently prove unsupported – or positively harmful. The standard joke about medical school education – “half of what we’re teaching is true, the other half false – we just don’t know which half” becomes uncomfortably true. How common is this problem? Here are three topics written about on the same day in one newspaper (The New York Times) describing three examples of such uncomfortable truths.
The really interesting questions is why?
Example 1 Childhood Diarrhea
Childhood diarrhea kills 700,000 kids a year. That’s the equivalent of at least one 9/11 incident every other day. For decades, the guidelines of treatment have assumed most of the infections are viral, that rehydration is the main answer, and that only the appearance of blood means bacteria are present – at which point you give antibiotics. But:
A. Dozens of pathogens cause child diarrhea.
B. The most common pathogens include numerous bacteria, and other non-viral parasites.
C. Most children afflicted appear to have several pathogens in their system, making it difficult to figure out which was the “cause.” This is a similar problem to what can happen with Lyme disease, where ticks can inject multiple bugs into you.
D. In a recent study, children hospitalized until “cured” - then sent home - died eight times faster than “healthy” children never hospitalized.
E. Lots of bacterial infections don’t show blood.
F. The appearance of blood is not a predictor of mortality.
So lots of kids die of bacterial infections causing the diarrhea. Millions grow up stunted.
Will the WHO change its guidelines? No. One fear – greater use of antibiotics will lead to further antibiotic resistance. Yet western tourists get antibiotics for these diarrheal infections – and millions of young children don’t.
Example 2 Vitamin D
Rarely do I see patients these days who are not taking supplements of vitamin D. Vitamin D is more than a vitamin – it’s also a hormone, affecting many physiologic arenas, including bone resorption. Finding “low D” among primarily older populations afflicted with multiple diseases, the answer has been “let’s fix it.”
Except the Institute of Medicine – using a panel of experts who generally did not do vitamin D research – thought supplementation a bad idea. They argued that the absence or low level of a substance in the blood of people who happen to have disease does not mean that adding it will make things better. They also worried that added vitamin D might increase cancer risk.
The result – people get vitamin D supplements all the time. I’ve even received “gifts” of vitamin D from friends to “aid my health.”
A new study looked at vitamin D supplementation for one year. It “worked.” People given more vitamin D showed higher levels of vitamin D in their blood – into the “normal” range. In the high dose group, calcium absorption increased.
Except bone mineral density and trabecular bone score – harbingers of osteoporosis – did not improve. Nor did fall rates. There was no clinical improvement.
The study time is rather short, the numbers relatively small. But without long term, prospective studies of vitamin D that look at many different potential results, how can the rush to use the drug be justified? We may be watching, in the case of “low D,” a replay of the story of “low T” – the present popularity of replacement testosterone. Does anybody recall the effect of “low estrogen” replacement on heart disease and breast cancer risk?
Example 3 – Getting the Right Shoe
For decades runners – and literally billions of walkers – have been told to “correct” their pronation through the "right" shoes. The foot pushes inward as we land on the ground. “Too much” or “too little” pronation would lead to pain and injury.
Except they don’t. Recent studies from the University of Calgary argue:
A. Overpronaters had less injuries than non-pronaters (that is, the “normal” folks had a lot more trouble.)
B. “Correcting” pronation in military recruits led to greater injury rates.
C. The best predictor of staying healthy – buying shoes that felt comfortable.
What fits the body? What fits your foot - comfortably.
The Conundrum of Complexity
What do these three examples demonstrate, beyond normal human fallibility? That:
1. We don’t like complexity. There’s too much of it in the world. It feels bad – just look at economics. Simple, "clear" answers – and guidelines – are thought to get more action – and more done.
2. Long term studies that look at overall results – because they are expensive and time consuming – get a lot less interest than new “cures” or successes.
3. Changing attitudes can take decades – and often fail even when “the data” are overwhelming. When enough bad events take place, we slowly become more willing to change – but generally not before.
4. Media understanding of statistics – and its underpinnings in mathematical theory – is dismal. Politicians and marketers know this, and use it to fool the population routinely.
So what is to be done? It’s time to fight back against guidelines and rigid rules.
Biology is information. Information is complex. The results of any action – like giving antibiotics to kids – have ramifications that ripple through families and communities, changing the entire biosphere – including the many millions of non-human species.
We need an information approach to how our bodies work, because that’s how biology works. Physiology doesn’t go from point A to point B to point C in a nice engineering textbook diagram. Biology is redundant. It does thousands of things at the same time. It uses continual work-arounds. It isn’t “logical.”
The end result of biological evolution is a wonderful series of ecosystems that includes us and our continuously updated, rearranged and rebuilt bodies. Change is how we live. Change is what we do and survive.
Except in medicine and public health. It’s time to look at how things connect and deeply affect each other.
And admit the truth that Paul Valery wrote about long ago – the simple is often false. Even if feels a whole lot better.
