Ebola, Public Health, and Sloppy Thinking Part 1

Until the discoveries of Louis Pasteur, which were given clinical interpretation by Joseph Lister, physicians killed practically everyone they touched. If they didn’t get them with dirty hands or fleas, blood-letting did it. Some palliative medications, still used today, are based on poisons such as arsenic or belladona. But in the old days, the distinction between palliation and cure was poorly made, because the germ theory, or any etiologies at all, were far in the future. The occasional survival, or spontaneous remission, was interpreted as causation, a mistake highly in vogue today.

In spite of lack of historical evidence of the efficacy of the medical profession, people still chose to believe in their doctors. The patient-physician relationship is remarkably analogous to that between the adherent to Shi’ite Islam and his chosen Imam. The next time you get together with friends, tell them you’ve given up on the medical profession, and are doctoring yourself. It is likely you will be told you need a doctor, but who you chose is up to you.

You might tell your friends that (NIH) 90% of medical studies are later proven wrong. The Atlantic article about Dr. John Ioannidis, titled “Lies, damned lies, and Medical Science”, paraphrases Mark Twain to good effect. So you think you’re going to be your own doctor? Not so fast. If Ioannidis is correct, the foundation of medicine is quicksand, but yours is none at all.

Since people have had faith in their doctors since the dawn of history, and since the track record does not justify it, the grounds for the continuing faith lie, by exclusion, in the realm of the non rational. You can replace faith in your doctor by faith in yourself, but it is unlikely you will do better. But if you stick with your doctor, it is likely that, at some point, reflecting the results of one of Dr. Ioannidis’s refuted studies, you will be the recipient of treatment which is ineffectual or harmful, yet completely in compliance with the officially defined “standard of care” in effect at the time. In other words, they can kill you, but you can’t sue.

At least the above fate is unintentional. If you decide instead to doctor yourself, it is likely that you will fall victim to intentional harm, or harm of a more ambiguous sort, motivated by the desire to take your money without doing you any harm or good. The etymology of the word quack is medical. But if we put the difference between  quackery and legitimate medicine on the same line, it has an unpleasant tinge: quackery has no chance of doing you some good, while legitimate medicine has some.

None versus some isn’t what we want to read, but, shielded like bright bumper chrome by the antibiotic miracle,  emergency medicine, and cures for  acute diseases, lie the wreckage of medicine’s attempt to find out what we should eat, how much we should weigh, how much we should exercise, and every other question of health and prevention. But, since quackery in some cases rises to equivalence with manslaughter, governments exercise a degree of paternalism that would not be accepted in any other realm. For example, the genetic testing firm 23 and Me was ordered by the FDA in November 2013 to stop selling direct to the consumer. 23 and Me offers only tests, not treatments.

I’m not taking a position on this. I would want to study it thoroughly, and that’s not the purpose of the reference, which is to exhibit some very special relationships:

  • The desire of the individual to trust, or “believe in” a physician, which is probably motivated by the desire to remove uncertainty from a hazardous situation, and assign it to someone else.
  • The concept of “standard of care”, the official definition of what is the right thing to do at the present time. It changes in response to U-turns and huge gyrations in the “knowledge base.” Smoothed a bit by bureaucratic inertia, it presents a very curious state of affairs, with the past, and what medicine did in it, ruled off as if by yellow caution tape with the lettering, “Don’t look back.”  And so we continue to trust.
  • The  bureaucracy of health and medicine, which, while providing the individual with paternal protection from naivete and quackery, has a knowledge base that, Dr. Ioannidis has shown, has severe methodological flaws.
  • Mirroring the relationship with the physician, the  individual demands certainty from the bureaucracy. Nobody wants to go to sleep at night wondering if Ebola is a personal threat. The individual demands an answer, and the bureaucracy is under extreme pressure to provide one, even if it does not legitimately exist.

In “Ebola, Rats, Lice, and History, and Hans Zinsser Part 2”, I wrote, “Policies have recursive origins. A fix must dig into that recursion, or the new policy will be a simple reaction to the failure of the old. Things being what they are, good luck can fall off the table in any direction.”

The decision processes of the CDC and NIH are reliant on the same decision processes that create the studies torn apart by Ioannidis.  It’s the same culture. The brightest minds in CDC and NIH must know this in an academic way. But if all the real estate, stretching to the horizon, is quicksand, what does a builder do? You build anyway, institutionalizing defective thinking.

Thus the system has become acclimatized to sloppy thinking. The drift has been exacerbated by the demand for answers that do not exist, enforced by politicos wildly swinging axes to decapitate agencies we need to function now.

But all is not lost. Do not panic. I repeat, do not, under any circumstances, panic. “In the quite likely event of an emergency, put your head between your knees and…”