Anyone who follows this blog must get the impression that I am a nag and misanthropist. Nothing and nobody seems to please me. I alway find the sample sizes too small, the statistics too lazy, the data hand-picked, or the results too positive and the conclusions drawn from them too exaggerated. Also, I find the peer review system unreliable, not to mention support of mainstream research and giving to those who already have (‘Matthew effec’) by the funding agencies. I even dared to critsize the Nobel Prize an atavistic instrument celebrating the lonely, white male reseacher and genius. Artificial intelligence I find stupid, and the academic career system the core of all these evils. To name but just a few examples.
But that is far from the truth! I am a science enthusiast! I am convinced that science is the best that the 1500 grams of protein and fat encapsulated in our skull have ever produced. Yes, I am a science nut. So with this entry, at the beginning of the new decade, let’s start with a proper hymn to biomedical science.
The fact that we in the so-called developed, i.e. industrialised societies enjoy an average life expectancy of well over 80 years, and that we spend this time predominantly in good health, ows directly or indirectly to biomedical science. One immediately thinks of antibiotics and improved hygiene based on the findings of microbiology, including in the food sector. The eradication of childbed fever and the reduction of infant mortality. The list can be continued indefinitely and includes X-ray diagnostics, insulin, polio and TB-vaccination, organ transplantation, anti-epileptic drugs, anti-Parkinson drugs, anti-hypertensives, dialysis, immunosuppressants, and much much more. The last few decades have also brought many real ‘breakthroughs’, such as statins, proton pump blockers, HIV therapy, Herceptin and some other highly effective tumor therapies. The combined result of all these blessings: Not only has life expectancy continued to increase, but also the quality of life in old age. Notwithstanding the argument that we researchers like to use that exactly these successes will lead us into the demographic catastrophe in the future. Because we will – buzzword ageing – soon all be demented or nibble at beak cups in nursing homes. In reality, however, we are behaving so alarmistically only because most diseases become more frequent in old age, and we can therefore justify the demand for more funding for our research.
Fortunately, there is no reason to panic. After all, when adjusted for age, the morbidity and mortality of many common diseases decreases is decreasing. To name but two important ones: stroke and myocardial infarction. The mortality of cardiovascular diseases has fallen by more than 40% in the last 20 years. This too is an outstanding success of medicine: It is caused by the prevention of these diseases through comprehensive treatment of risk factors such as high blood pressure. In addition, there are novel effective therapies, such as the treatment of strokes and myocardial infarction by means of emergency reopening of the occluded vessels. A few other things were also important for these successes, for example, the realization that smoking is fatal, and the ban of cigarettes from public places not only dramatically reduced the lung cancer rate, but also the incidence of cardiovascular disease.
Indeed: Three cheers to biomedical research! But will this continue? The increase in life expectancy in the industrialized countries is slowing down, in the USA life expectancy is falling again. In contrast, however, more research is done than ever, and knowledge is still growing exponentially, at least measured as publication output. Both the specialist and lay press are giving us plenty of hope for imminent and spectacular breakthroughs in almost all areas of medicine. Gene therapy, personalised medicine, digitalisation, artificial intelligence and Big Data are supposed to lead us into a new age in which cancer, Alzheimer’s, et al. will be menaces of the past.
And there my skepticism is back. Not so much because these imminent ‘breakthroughs’ they will most likely be limited to treating a few patients with very rare diseases. And that therapy costs per patient will then easily exceed 1 million €. This is not an argument against research and clinical studies in these areas, but we should be realistic about the scalability of such ‘individualised’ therapies. Quite apart from the fact that it is still completely unclear how reliable evidence for the superiority of such personalised therapies compared to conventional therapies can be obtained. This is because randomised and controlled studies are not feasible with the small number of cases and the therapies for which studies cannot be randomised or blinded. The successes of conventional therapies cited above were all achieved in large populations, and large studies weighed the risks and benefits of these treatments. And since then, these therapies have helped large collectives of patients, not just a few individuals.
But I want to put aside my prophecies of doom and gloom about the promises of personalized and Big Data and AI driven therapies for now, and point to something completely different. I would like to juxtapose the hype regarding future miracle therapies with the results of the Global Burden of Disease (GBD) project. GBD ‘is dedicated to quantifying death, disease, disability and risk factors by region and population. This information can be used to weigh important information that can be used by policy makers to set priorities’ (Wikipedia). The results of GBD show us that we already have the medical knowledge in our hands to further reduce morbidity and mortality at home and globally based on hard evidence, and to further dramatically improve quality of life. On the one hand, the GBD, which has been running since 1992 – which in itself is a brilliant achievement of modern biomedical-epidemiological research – shows that the burden of disease can be reduced very effectively where we know the factors that cause the disease. We also already have very effective therapies in place should the diseases nevertheless occur. The identification of many of these factors, as well as preventive strategies and therapies based on these, are among the achievements of modern medicine and research. However, probably the most important risk factor, which underlies many, if not all others, lies outside the field of medicine. So-called ‘socio-demographic indicators’ correlate with almost all relevant risk factors, such as smoking, pollution by particulate matter, alcohol consumption and overweight. In plain English: How you make your living, and how much you are paid for, has major influence on whether you get a heart attack, diabetes or lung cancer. If you want to study the correlation of socio-demographic indicators with morbidity and mortality, you don’t have to do research south of the Sahara.
Already in my last post (about nutritional ‘sciences‘), I took the liberty of pointing out that in Germany the difference in life expectancy between the lowest and highest income groups is 13.3 years for women and 14.3 years for men. But what does all this have to do with the promises of medicine for the next decade? Imagine next week a researcher were to discover a drug that would allow a large proportion of Germans to live 10 years longer! A world sensation, fame and wealth guaranteed! But ‘therapies’ which could achieve this, are already known, we just don’t use them.
There would be many treasures to be discovered, and they are all well known: High blood pressure, high fasting blood sugar, overweight (high body mass index), high LDL cholesterol, alcohol consumption, smoking, particulate matter etc. are the leading risk factors according to GBD. In regions outside our comfort zone, there are also other factors such as unhygienic water supply, unprotected sex, etc. The great thing about these ‘risk factors’ is that they can be reduced or even completely prevented. There are even measures that address all of them at once, which are aimed at improving living standards and the consistent implementation of existing medical knowledge. But you cannot make profit with it! My point is that we already know what makes us sick and how we can prevent it. According to the conservative, official statistics from eurostat, one in three deaths in the EU could be avoided with today’s medical knowledge and technical possibilities.
This finding is actually trivial, but it’s nice that science has provided quantitative evidence for it. For example, in Europe, the fight against hypertension with long-known and inexpensive drugs, or (sorry smokers!) a further reduction in tobacco consumption, would be orders of magnitude more effective for society as a whole than any personalised tumour medicine or gene therapy could ever be in the future. And once big data from lifestyle trackers and electronic health records are evaluated using artificial intelligence, nothing surprising will come of it. We will find that alcohol, smoking and being a couch potato are bad, whereas a balanced diet and moderate exercise are healthy. We will also find that academics live healthier and longer than supermarket cashiers or hairdressers.
This is not a plea to reduce our research efforts in biomedine. Rather, it is a reminder that, when looking at the future blessings of personalised therapies and other popular medical visions of the future, we should not forget that the gold is literally already on the street. What can and needs to be done is not sexy, but it would be immediately applicable and, for all we know, extremely effective.
A German version of this post has been published as part of my monthly column in the Laborjournal: http://www.laborjournal-archiv.de/epaper/LJ_20_01/26/index.html