My 72- year-old mother cleans toilets at BYU. I cannot get her to retire to live with me. She wants to remain independent as long as she can and carry her own weight like many immigrants like her do. Yet, economic problems crushing them are likely to get significantly worse; I anticipate that this will finally motivate her to move in with me sometime next year.
As her paycheck shrinks she clings to hope that the future will be better for her. This is one of the reasons she voted for Senator Obama. The other reason is that she identifies with him, being half white (Basque) and half Chilean Mapuche. Understandably, she stayed up all night watching the news the night of the election, elated and basking in the glow of her idol’s ascendancy, just like millions did across the USA and the globe.
In the aftermath of the November election we all wonder if my mother’s hopes are well founded. Many in Utah disagree with her, to be sure. But, some pray that President-elect Obama is able to rescue our sinking economy for the sake of our whole country and our children’s future. And some of us may also share a degree of pride that our society finally concluded the Civil War and can get on with Reconstruction in earnest by electing a “mutt” to the Presidency[i] (Obama’s own words; besides, I am a mutt myself…)
As doctors we have a particular interest in Mr. Obama’s future administration: what will it do about our broken health care system?[ii] Will health care issues sink to the bottom of a very crowded “to do list?” Will “socialized medicine” come about to ruin/save our health care system?
The answer to these and many other questions will be evident soon enough. In the meantime I choose to focus on one single point about the economics of health care: will President-elect Obama fulfill his promise to save millions of dollars through prevention? In my opinion, that is the most important issue in health care. (If you feel it is the uninsured, consider that prevention would save millions that could be used to insure them or lower health insurance premiums enough to make it affordable for most people.)
“Putting prevention first [will] require political courage and a long term perspective. Unleashing the full preventive potential for public health is essential to build a healthier world.” [iii]
The Economics of Health
Our dependency on high-tech, pharmaceutical medicine has no doubt helped bring relief to millions of people. But, our single-minded focus on this type of practice has crowded out simpler and more humble modalities that are cheaper not only on the short term but in the long term. We spend great sums of money to treat the symptoms; yet, the roots of disease are seldom addressed.
The antecedents of disease (nutrition, lifestyles, addictions, poor relationships, toxins in the environment and emotional/spiritual/mental stress and economic stresses) often get only passing attention in academic/intellectual exercises that are seldom put into practice. Sometimes these factors leading to disease, despite having voluminous scientific evidence in our medical journals are considered “alternative medicine.”
“Clinical research involving pharmaceutical agents needs to focus more on the differential responses within diverse patient populations. This philosophy should be extended to the public to encourage healthy lifestyles rather than depending on the quick fix of drugs as panacea.” [iv]
Another way of stating these issues is that starting in medical school we focus on acute instead of chronic health care:
“Medical education should prepare students for the clinical problems they will face in their future practice. However, that is not happening for the most prevalent problem in health care today: chronic disease [which comprises] 78% of health expenditures… Chronic disease has dramatically transformed the role of the patient… [he/she] becomes experienced, is often more knowledgeable than the physician about the effects of the disease and its treatment, and has an integral role in the treatment process…. knowledgeable patients achieves better outcome. A collaborative physician improves both understanding by patients and health outcomes… Unfortunately, few if any medical schools are preparing their students adequately.” [v]
“As more and more Americans are afflicted with chronic diseases in which nutrition plays a key role, the need for improved nutrition training of physicians has never been more evident… Even though medical technology continues to make advances in the pharmacologic and surgical management of these chronic diseases, the cumulative evidence is that much of the morbidity and mortality associated with these conditions may be preventable through dietary and lifestyle modifications.” [vi]
Any discussion on health care reform is likely to focus on the high-tech approach mentioned above while ignoring Harvard’s Dr. Willet’s experience showing that 80% of health problems could be solved by simply helping our patients change their diets.[vii] My own pedestrian clinical experience confirms Willet’s research; by advising my patients to stay away from processed sugars and trans-fats I routinely see them stop 80% of their prescribed medications.
For example, I see 10-70% drops in serum cholesterol and 10-60 point drops in blood pressure. Most patients are able to stop oral hypoglycemic agents, antidepressants, anti inflammatory, acid-suppressant, migraine and many other drugs, thereby saving insurance companies significant amounts of money. Yet, I sometimes hear that such practice “is not the standard of care…”
The simple American Heart Association recommendations that patients be offered Essential Fatty Acids supplementation and that cholesterol-lowering agents not be used unless a diet trial has been seriously tried for 6 months is seldom implemented by physicians; no doubt they correctly guess that patients will not be receptive to diet and lifestyle modifications. But, could it be that our calling as doctors to be teachers and leaders to our patients takes a back seat to expediency and quick high tech fixes that are over-emphasized at dinner meetings sponsored by pharmaceutical companies under the guise of medical education? Could it be that our skills to help our patients with the “most powerful therapeutic force,” our relationship with them is being atrophied by reaching for the prescription pad?
“Advances of the past 70 years have clearly demonstrated the unity of the science of medicine with the art of medicine on behalf of the patient.” [viii]
I cannot profess to be exemplary in our calling as physicians, but I can say that I try to be more than just a technician or a hamster on a treadmill.[ix]
“The role of doctor is diminished to one of a competent technician who is interchangeable with any other with similar training… the same is applied to patients… they become interchangeable units of health need… These trends serve the politically powerful, because a system in which agents are interchangeable is much easier to control and organize… Mending through healing: dialogue between doctor and patient to discover coherent explanation of illness that makes sense to the affected person. This in turn, helps to reduce fear, uncertainty, and confusion, and by making room for optimism, boosts the body’s innate capacity for mending… “The irony is that the current destruction of the therapeutic capacity of doctors is occurring just as science is beginning to explain the mechanisms … of psych-neuro-immune-endocrine.” [x]
“The profession of medicine, in every aspect, clinical education, and research, has been inundated with profound influence from the pharmaceutical and medical device industries. This has occurred because physicians have allowed it to happen, and it is time to stop.” [xi]
I believe it is our calling to empower patients to manage their chronic health problems themselves by focusing on the antecedents of disease listed above.[xii] This is not easy, but it is cheaper and more economic, besides being the right thing to do.
Patients will always need emergent and acute care. Needless to say but necessary to state at this point, physicians who labor in stressful specialties dedicated to rescuing patients from serious complications of acute illness and from the clutches of death are providing incalculable and rewarding services to our society. Even as I write in the comfort of my home some of you are sacrificing entire weekends to man the trenches in Emergency and Operating Rooms. You make it possible for physicians like me to focus on chronic issues under less stressful circumstances; for that I am extremely thankful.
Again, by focusing on the need to shift our economics of health to chronic care I do not mean to discount the value of acute care. I merely wish to “balance our health account.” And now is the time to also thank those of you who focus on other issues in health care: the cost of lawsuits, the uninsured, mounting health care costs, any-willing provider, health insurance fraud, etc. You make it possible for me to focus on my own corner of health care. Again, I thank you.
Two more points on health care economics that don’t get much playing time:
One, the emerging understanding that our diets affect genetic expression.[xiii] By focusing on how food and environmental toxins affect the translation of our genes we may save significant amounts of money that otherwise are committed to more expensive high-tech genetic manipulation research:
I. “The recognition that nutrients have the ability to interact and modulate molecular mechanisms underlying an organism’s physiological functions has prompted a revolution in the field of nutrition… Nutrigenomics (diet influences gene function) and nutrigenetics (genes determine how food affects us) provide the necessary stepping stones to achieve the ambitious goal of optimizing an individual’s health via nutritional intervention.”
II. “Nutrigenomics and nutrigenetics optimize health through the personalization of diet, provide powerful approaches to unravel the complex relationship between nutritional molecules, genetic polymorphisms, and the biological system as a whole… It is the integration of these technologies that provides the optimal means to unravel the effects of a biological challenge on an organism; thus, the concepts of systems biology, or integrated metabolism.”
III. “Whereas pharmaceuticals have a targeted approach aimed at restoring health, diet is a multi-parametric approach to preserve and/or optimize health. Indeed, the diet is compromised of a multitude of nutritional and chemical molecules each capable of regulating disparate biological processes, and thus cannot use an approach similar to the pharmaceutical industry, i.e., the “one drug one target” paradigm. Hence, nutrition is a true integrative science that is well positioned to benefit from the exploitation of novel technologies capable of assessing biological networks rather than single endpoints.”
IV. “Unlike the pharmaceutical industry, which aims to target a specific dysfunctional gene to improve health, the nutritional industry must manage health through a complex mixture of nutritional molecules. Thus, in comparison with a medical compound, consuming a diet drastically increases the number of molecular endpoints that are capable of influencing phenotype, and thereby places the field of nutrition in a prime position to benefit from the technological innovations brought forth by the post-genomic era.”
V. “Nutrition in the 21st century is poised to be an exciting and highly relevant field of research, as each new day is accompanied by advances in our understanding of how the interactions between lifestyle and genotype contribute to health and disease, taking us one step closer to achieving the highly desirable goal of personalized nutrition.”
VI. “Nutrigenomics describes the use of functional genomics tools to probe a biological system following a nutritional stimulus that will permit an increased understanding of how nutritional molecules affect metabolic pathways and homeostatic control. Nutrigenetics aims to understand how the genetic makeup of an individual coordinates their response to diet, and thus considers underlying genetics polymorphisms… Complex cell and molecular biology coupled with biochemistry and genetics are required if the ambitious goals of nutrigenomics are to be realized.”
VII. “Add these two terms to the list of Genomics (analysis of genes,) Transcriptonomics (how genes are copied for function,) and Metabolomics (how energy is produced.)”[xiv]
Which leads to point number two: metabolomics, or the Universal principles of Thermodynamics applied to cellular use of Solar Energy and Information (E&I) harnessed by plants through photosynthesis. Just as Virchow, the cellular biologist in the 1800s and the physicist David Deutsch predicted,[xv] doctors are beginning to understand that everything about our health and disease is a matter of how cells use E&I to carry out their assigned tasks as encoded in their respective DNAs.
The disruption of cellular membrane communication[xvi] due to Toxicity,[xvii] Oxidation,[xviii] Inflammation[xix] and Less optimal Mitochondrial function[xx] or Mind-Body issues that boil down to Love deprivation[xxi] inhibits the free flow of E&I that we get from food and our relationships with people and our environment.
In other words, food = energy and information, E&I. That food has Energy is evident enough. But the new science of xenohormesis adds that food is also Information.[xxii]
Just like Deutsch predicted, everything about our bodies is E&I The Universal principles of thermodynamics applied to our body are known as Metabolism. This is why list of diseases comprising the Metabolic Syndrome will likely continue to grow.
The economics of our society and the economics of our 50-100 trillion somatic cells obey the same principles of E&I. For that matter so do all spiritual constructs such as relationships with our loved ones, the planet and our deities.[xxiii]
When our terrain or cells composing tissues and organs and our DNA are not well nourished and suffer from environmental and emotional/spiritual toxicity, our cell membranes and DNA T.O.I.L. (Toxicity, Oxidation, Inflammation and Less optimal mitochondrial function.) This leads to cell membrane and DNA dysfunction, which inhibits the flow of messengers of E&I from cell to cell: think of insulin resistance, the modern scourge of our society. Of course, when this happens we see resistance to just about every other messenger of cell communication; for example thyroid resistance.[xxiv]
Perhaps the best example that E&I concepts can save our society millions of dollars is cancer:
“In spite of substantial progress in the development of anticancer therapies, the incidence of cancer is still increasing worldwide. Recently, chemoprevention by the use of naturally occurring dietary substances is considered as a practical approach to reduce the ever-increasing incidence of cancer… By making modifications in the diet, more than 2/3 of human cancers could be prevented…. Dietary chemopreventive compounds offer great potential in the fight against cancer by inhibiting the carcinogenesis process through the regulation of cell defensive and cell death machineries…The two major pathways that initiate apoptosis are extrinsic (death receptor-mediated,) and intrinsic (mitochondrial mediated.) Mitogenic and stress responsive pathways are involved in the regulation of apoptotic signaling. Noteworthy is the crosstalk between some of these pathways.” [xxv]
In my opinion, the ideas in the article “Nutrigenomics and Metabolism Will Change Clinical Nutrition and Public Health Practice.”[xxvi]
The Health of the Economy
Money is but a symbol of the E&I we amass through our work.
Some economists feel that our current crisis, as complex as it is, also obeys not only the principles of Thermodynamics but Occam’s razor, the Physics principle that states that out of all explanations and solutions behind any complex problem the simplest one is the correct one: these economists feel that we are crashing because we got into DEBT, which may be defined as robbing our children’s future E&I to pay for our AFFLUENZA.[xxvii] John Adams, John Maynard Keynes and Paul Krugman, the 2008 Economics Nobel Prize winner agree.[xxviii]
The explanations and smoke and mirrors used by those who would rather continue feeding the bubble that has sustained our credit-deficient economy is bound to confuse most of us. But, a close inspection of the terms we hear to explain the economic crisis reveal that they are nothing but “expert talk” to define E&I principles. For example, the practice of “pump and dump” to inflate the true value of stocks coupled with CDOs and derivatives like SVTs are sophisticated inventions that bundle investments representing illegitimate debt like subprime mortgages with more legitimate debts. In reality, we have an entire “subprime economy.”
Health insurance companies, the food industry and pharmaceuticals have followed the same business practices that have haunted Wall Street, resulting in an over-reliance on pharmaceutical and high tech tools in health care. These practices result in “subprime heath care,” which does not address the economics/metabolomics of our cells. Instead these practices rob E&I from our own future, postponing and sometimes keeping our cells from the lifestyle changes they need to fix their metabolism or use of E&I.
Our health insurance companies do not help doctors spend enough time with our patients; this results in hurried and dissatisfying encounters where we prescribe the drugs they see in TV ads, and thus continue to feed the “bubble of chronic disease.”
As my mother and all of us head into an uncertain economic and political future we all hope that President-elect Obama wisely navigates the divisive waters of party dogma and rhetoric for the good of our country and our children’s future as he has stated he will.[xxix] Will he strike a balance between income inequality issues and excessive regulation that may stifle free enterprise?[xxx] Will he help people understand that we cannot continue to live on E&I stolen from our children’s future? In the words of the “Great Debaters,”[xxxi] “we better pray that he does.”
[i] CBS News, November 7th 2008
[ii] “Crossing the Quality Chasm,” Institute of Medicine; National Academy Press, 2001
[iii] J. Lancet 2002;360:1343
[iv] “The Conflict Between Complex Systems and Reductionism” JAMA 2008;300:1580
[v] “Chronic Disease: the need for a new clinical education,” JAMA 2004;292:1057
[vi] “An Evidence-Based Approach to Medical Nutrition Education,”
American Journal of Clinical Nutrition 2006;83(supp):929s
[vii] Book “Eat, Drink and Be Healthy” and several JAMA publications
[viii] “The Most Powerful Therapeutic Force,” JAMA 2002;287:1909
[ix] “How Should Hamsters Run? Some Observations About Sufficient Patient Time in Primary Care,” British Medical Journal 2001;323:266
[x] “Objectification of Physicians and Loss of Therapeutic Power,” J. Lancet 2007;369:886
[xi] “Industry Manipulation of Medical Science,” JAMA 2008;299:1800, 1813, 1833
[xii] “A Systems Approach to Patient-Centered Care,” JAMA 2006;296:2848
[xiii] “Epigenetics, a Window on Gene Dysregulation, Disease,” JAMA 2008;299:1249 &
“Epigenetics at the Epicenter of Modern Medicine,” JAMA 2008;299:1345
[xiv] “Nutrigenomics and Nutrigenetics: the emerging faces of nutrition,” J. FASEB 2005;19:1602
[xv] Book “The Fabric of Reality;” Penguin Books, 1997
[xvi]“Building Signaling Connections,” J. Science 2003;300:1461-1604
[xvii] “Hormesis: why it is important to toxicology and toxicologists,”
J. Environmental Toxicology Chemistry 2008;27:1451
[xviii] “Is Oxidative Stress the Pathogenic Mechanism Underlying IR, Diabetes and Cardiovascular Disease? The common soil hypothesis revisited” J. Atherosclerosis, Thrombosis Vascular Biology 2004;24:823
[xix] “The Energy Request of Inflammation” J. Endocrinology 2006;147:4550
[xx] Book “Mitochondrial Medicine,” J. Circulation 2008;117:2431, 2492
[xxi] Books “The Biology of Belief,” Bruce Lipton; Elite Books, 2005,
“Why Zebras Don’t Get Ulcers,” Robert Zapolsky; W.H. Freeman and Company, 1994 &
“Love and Survival,” Dean Ornish; Harper Collins, 1998
[xxii] “Nutritional Hormesis,” European J. Clinical Nutrition 2007;61:147
[xxiii] See Doctrine and Covenants Section 88 or any other religion’s holy writ, like Kabbala, Hinduism, Buddhism, etc.
[xxiv] J. Annals of Internal Medicine 1995;123:572
[xxv] “Apoptosis by dietary factors,” J. Carcinogenesis 2007;28:233
[xxvi] American Journal of Clinical Nutrition 2007;86:542
[xxvii] Nouriel Roubini; New York Times Magazine, August 17 2008
[xxviii] Book “The Great Unravelling;” W.W. Norton & Company, 2003
[xxix] Book “Team of Rivals,” Doris K. Goodwin; Simon & Schuster, 2005
[xxx]Book “The Forgotten Man,” Amity Shlaes; Harper Perennial, 2007
[xxxi] Film with Densell Washington, 2007