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Some Thoughts on Herd Medicine
Farmer Bernie has 1,000 cows on his dairy farm. He learns that if he adds a certain new antibiotic to their feed, he is likely to experience a 10% higher yield of milk. Unfortunately this antibiotic causes a potentially fatal allergic reaction in about 0.005% of cows. There is a test he could do to identify the allergic cows ahead of time, but the testing is expensive. Also, separating out the allergic cows each day at feeding time would be impractical. What will Farmer Bernie do?
We all know what he will do. He and his Progressive friends are doing it right now, in their administration of our increasingly centralized healthcare system. And in doing so, they have firmly established a set of ethical precepts that perhaps we had better stop and think about.
I am not really a student of philosophy so maybe I am mistaken about this, but I trace the lineage of our current generation of medical ethicists back to Jeremy Bentham. Bentham formalized modern utilitarian ethics and attempted to make it scientific. First, he said, deciding on the ethical path is a simple matter of determining which decision will lead to the greatest good for the greatest number. And second, he insisted that the technique that should be used in making this determination is based on straightforward mathematics. (He called it “felicific calculus,” that is, performing the calculations that will reveal which choice will maximize felicity for society.)
It should go without saying that in the traditional practice of medicine, utilitarian ethics is anathema. Through history, medical doctors have taken oaths to always do what is best for the individual patient in front of them. The doctor’s relationship to the patient is supposed to be the same as the lawyer’s to the client — strictly defending the patient’s individual interests. Without their personal expert acting in a fiduciary role, a patient (like an accused felon) has little chance against the awesome competing interests of society. So according to classical medical ethics, above all else, doctors are obligated to advocate for the interests of their individual patients.
But in an era where healthcare expenditures are collectivized, that is, where society is footing the bill, classic medical ethics no longer make sense. Making the decisions that would optimize medical outcomes for each individual patient obviously would be prohibitively expensive for society. Equally as obviously, such decisions can no longer be permitted.
So, for at least three decades doctors have been trained to make decisions based on utilitarian ethics. I’m not sure the average American doctor would recognize this fact, because their Progressive leaders insist it’s not true, and the utilitarian decisions doctors are coerced into making are disguised sufficiently that, by employing generous portions of cognitive dissonance, many doctors can convince themselves it’s not the case.
As Bentham carefully described, much of the process has been reduced to math. We no longer call it felicific calculus (though I wish we did). We call it the randomized clinical trial.
Your average doctor will tell you that we rely on RCTs because they are the only way we can achieve scientific truth in clinical medicine. And while a well-designed RCT can indeed tell us things we would be hard-pressed to learn by any other method, RCTs do not actually distinguish truth from falsity. More accurately, RCTs allow researchers to do a study that more effectively incorporates the particular bias they wish to incorporate.
Most of the time, what medical researchers (at least the ones working at the behest of the central authority) are interested in is purely utilitarian — determining how to get the most benefit for society for the least money. So this is the bias they build into their research.
Let us do a thought experiment. Assume that you are the chief administrator of Medicare-For-All. Through the actions of evil automaker lobbyists, Congress determines that seat belts are an aspect of preventive healthcare, and therefore, if seat belts are to be required, automakers would have to be reimbursed for them by MFA.
This could be a massive hit to your budget, and suddenly you view seat belts in a whole new light. Fortunately, it is up to you to determine if seat belts are reimbursable. So you set up a study to see if they actually do any good.
You mandate that, of the next million cars sold in the US, seat belts will be randomly removed in half of them at the dealership — after the sales contract is signed, but before they leave the lot. (As the chief administrator for everyone’s healthcare, you are endowed, like Lincoln, with awesome power.) You then wait five years and count the dead people.
The results of this study are reasonably predictable. Auto accidents will account for a pretty small proportion of all the deaths that occur among the people who own those million cars, seat belts or not, and seat belts will likely not significantly reduce the overall mortality of this population. Seat belts will be declared “ineffective” according to the authority of your randomized trial, and you are off the hook.
You could have biased your study differently if you wanted a different result, of course. You could have compared results only in people who had auto accidents (instead of the whole population), in which case you would be far more likely to show a benefit from seat belts. But why would you want to do that? The greatest good for society, obviously, is saving money by not spending it on useless crap.
The game is established. First, mandate that, in order to remain a physician in good standing, doctors have to follow formal guidelines in treating their patients. Second, mandate that, in order for a therapy to be included in the guidelines, one or more RCT has to conclude that it is safe and effective. Third, gain control over designing the RCTs. The first two steps are largely in place. Medicare For All will finally complete step three.
Practicing medicine for the good of the individual, instead of for the good of the herd, would look very different. If seat belts were an option in cars, many would choose to buy them for the sake of their family, regardless of negative results of an RCT. Women with advanced breast cancer might choose to buy a new chemotherapy that has a cure rate of 5%, even though it might not significantly reduce the mortality of the whole population.
But as long as we insist on collectivizing our healthcare expenditures, those kinds of options will become less and less available. The distribution of medical care necessarily will be made on a purely utilitarian basis — to do what’s best for society as a whole — no matter how our overseers attempt to dress it up.
Published in Healthcare
I haven’t seen a single call anywhere, left or right, for a blanket prohibition against the use of antibiotics. Well, I take that back, sort of. Some people would want to eliminate their use as a feed additive for cattle, and I wouldn’t be against such a ban. But that’s not a blanket prohibition.
I haven’t seen a blanket prohibition either. I overstated that. I’m sorry.
But what I’ve seen is a real hesitance in doctors to prescribe antibiotics for the sake of the public health. I respect their caution, but I think it has been overdone, to the point that people and doctors are waiting too long to treat infections. The more entrenched the infection becomes, the harder it is to get rid of. And that’s the other thing. They are basing the time it takes to clear up an infection on the old data that from when doctors prescribed antibiotics more assertively than they do today.
Let’s say it is an anti-antibiotic mood that has been created.
Most of those 173 kids who died this year when they had the flu were more sick from the secondary infection than from the flu. We need to not hesitate. That’s what I’m trying to say. Let’s find another answer to the superbug problem than withholding antibiotics.
You are, likely in Heinlein’s sense, fortunate to have had good doctors who use antibiotics appropriately. But when wrote about papers going back decades inveighing against doctors giving antibiotics for colds, I was not exaggerating and such papers still appear because doctors still do it.
You’re right. Unfortunately intentions are irrelevant, and correct diagnosis is irrelevant for the development and transmission of antibiotic resistance. Bacteria exchange resistance genes to other species and to other microbiomes by multiple mechanisms, possibly including airborne carriage and, at least in vitro, even from dead bacteria.
The widespread use of antibiotics is what promotes resistance, and the less promiscuous we are with antibiotics the longer we’re going to be able to use them.
This is an ecosystem issue, and we, and the animals we grow for meat, milk, and eggs are part of our ecosystem.
Just in your own ecosystem, check this out:
• Patients given probiotics during antibiotic use are somewhat less likely to develop GI symptoms.
• Patients given probiotics starting right after antibiotic use are less likely to develop antibiotic resistance in their microbiome.
Then there are the antibiotics I saw behind the counter in a Chinatown herb shop, (maybe they were fake, of course but I doubt it. Also the powdered cinnabar I saw, but that is another story.) Or those available over the counter just across the border in Mexico and whose purchasers no doubt never ever use them for, say a cold. Of course, they also probably stop soon after they feel better, too, which may be a good thing, because the advice “finish the full course of antibiotics to prevent resistance” is not supported by any sound evidence and increasingly looks to be dead wrong.
Stubborn stubborn bugs like TB are an exception, but there the full course isn’t as simple as a ZPak.
Some of the papers on the NRDC’s bibliography here look pretty good. I know. NRDC.
Yes, acne involves an infection but what kids eat can affect their sebum consistency. By the way, zinc need goes up substantially in adolescents as it is important for sexual maturation; guys need more because it’s necessary for spermatogenesis. Zinc content per ejaculation can be as high as 1 mg or even more; 1 mg is about 10% of the RDA.
All extremely interesting. I took some out only so that I could reply. :-) It was all interesting.
However, I can’t help questioning the new research that it’s not important to complete the entire round of antibiotics. I question the objectivity of the research in the anti-antibiotic climate the research was conducted within, as well as the within healthcare rationing mood we are now in, as explained so well by Dr. Rich in the OP.
But more importantly, if they have found fault with the common shibboleth that patients should finish their prescribed antibiotics, how and why should I believe them on other things they say? Goodness, new research seems to contradict older research every day of the week. :-) In other words, every time I turn around there is new research that contradicts yesterday’s. If I don’t like the weather, just wait a minute. :-)
My daughter is coming for the weekend. I will ask her about the bovine mastitis research she did. I’ll come back Monday with a better reply. :-) She is a veterinarian now. :-)
We do it, because we are berated by patients if we don’t. I can’t tell you how many times I’ve had patients yell at me when I try to explain to them that they have a viral infection and antibiotics won’t help. ” I paid a 150$ for you to tell me you can’t do anything for me?”
After the yelling comes the complaining to either management or to try and get us in trouble with the state medical board, and now the delight of being slandered on the internet on Yelp or some other wonderful site.
Thanks to the delights of things like Press Ganey scores, which affect your ability get and keep a job and your reimbursement, patient satisfaction scores are a big driver here for lots of bad medicine.
If only there was a way to secretly prescribe placebos.
And then there’s this:
I would be interested in information on this. I once developed an apparent resistance to an antiobiotic when I didn’t take it on the prescribed schedule, and then had to pay for a much more expensive antibiotic to do the job right. I was careful to take that one on schedule. Of course, not taking it on the prescribed schedule is not exactly the same as not finishing the full course, so maybe I’m talking about a different thing.
What seems to be emerging for garden variety infections is something like “take it until you feel better and then a bit longer.”
It may also be a post hoc ergo propter hoc fallacy. My mother, may she live and be well, had an infection requiring antibiotics; this is a bit dicey since she’s had a lot of UTIs, both the typical and oddball bugs she gets are frequently resistant, and she has allergies and other reactions (rapid onset of tendon pain from Cipro, for example) that preclude other oral antibiotics. Anyway.
In the most recent go round, she had an equivocal response to the first drug, got worse, and then a slow response to the second.
Whether “not taking it on the prescribed schedule” would have caused what happened, I don’t know. Partly depends on exactly what that means, the pharmacokinetics of the drug in you, whatever might affect reaching therapeutic levels – if the bugs were suitably sensitive. I know some of the boxes, so I can ask the questions but I don’t do drugs for a living. Use drugs for a living. Hm. That’s not coming out right. You know what I mean.
Regarding the first paragraph of your essay: However, in order for a farmer to consider using an additive that will increase the cow’s milk significantly, the farmer is forced to rely on “science” regarding the risks.
Unfortunately for us in the USA, the EPA and FDA allow for the company that produces the wonder additive to do their own testing. The manufacturing concern can then trumpet how little risk and how much wonderful increase in milk the farmer can expect. All this is based on one or two studies. And they are done, I again must emphasize, by the same company that wants to sell the product.
Here in Calif, in the mid 1990’s, we saw the emergence of a “wonderful alliance between Big Energy and The Environmentally Aware.” This alliance resulted in a mandate to have the “air cleaning” product MTBE added by mandate to our gas. MTBE was to be 9% of the formula of Calif’s gasoline. Close to 1,000 studies showed the public that MTBE was safe. One spokesman for a producer of MTBE went so far as to say that he would allow his children to brush their teeth with it.
Reports in the field were not indicating that the product was safe. A company that employed 20 delivery drivers of the product found out that nine of the drivers fell ill with leukemia within 18 months of MTBE being delivered by their firm. People whose trailer park had its water supply co0ntaminated with MTBE had skin rashes, head aches, inability to take in nourishment (wasting condition) and those problems came about within hours, days and weeks of their exposure.
It took several years to get the Governor of California to insist on a real, and independent study of the toxin. That study, headed by John Froines, showed that there was no benefit and extreme risk to using MTBE in the 9% manner by which it was mandated. Governor Davis immediately banned such a high stipulated amount in our gasoline formulas. He believed the organic chemists who had testified before the state legislature that the toxin actually caused the polymers used in sealing up gas tanks to be eaten away, ending up in ground and water pollution. Some chemists believed that we would lose as much as 50% of all our aquifers to MTBE by 2015 were its usage continued. After all, even a 4 parts to a billion solution meant the water tasted exactly like kerosene.
For his time and effort on this project, Davis had a scandal that was drummed up against him by the Big Energy powers who operate the politicians in this state like the flippers on a pinball machine. He was voted out of office. Diane Feinstein saw to it that Arnold Schwarzenegger won the governorship, for two terms.
So unless this additive that increases cow’s milk has been actually tested by some independent researchers, I will say that it is still suspect in my book.
I love your pointing out the importance of probiotics for our health. Whenever someone in this household is sick, we do things like a slight fast, with apple cider vinegar mixed with water as a drink. Then this alkalizes the body and neither viruses or bacteria thrive. We do probiotics daily.
I thought drinking vinegar would actually make the body more acidic. But the first web article I read talked about lemon juice (citric acid) helps make the body more alkaline. However, the same article later states that an alkalized body is good for kidney problems, but not a panacea for other ailments.
Confusing, isn’t it?
Not really. Our stomach and upper small intestine is supposed to be acid. To accomplish that, we need trace minerals, including zinc. The acidity also helps us absorb minerals such as calcium, magnesium, zinc, iron, selenium, and so on. In part this is by promoting protein digestion, and many minerals are better absorbed when complexed with amino acids from protein. Acid from the stomach is an important signal for digestive processes farther down the tube. (Proton pump inhibitors have a nasty tendency to impair mineral absorption with long term use.)
Imagine our remote ancestors munching on a nice juicy cricket, or a small rodent, or if they really got lucky, gnawing on the bone of a large mammal. The protein and calcium tended to be packaged together. Depending on the mineral and the plant food, sometimes a food mineral is readily abosorbable, sometimes not. They did not gnaw on limestone or oyster shells (calcium carbonate) if they could help it; these require a lot of acid to absorb.
The linked article mentioned the importance of minerals in buffering the acidity of metabolic processes such as living. Intake of a lot of minerals in the form of leafy greens is more important than “being alkaline” though it becomes more important as we eat more protein, which does affect our pH in metabolizing it.
We have a number of systems both chemical and physiological designed to keep the various parts of our bodies running at the right pH. Buffer systems are part of this; minerals are one component, the interplay between CO2 and bicarbonate ion is another.
Basically: Veggies are good, particularly cooked and fermented, and raw in season. I’m not going to talk about the important concept of spore forming probiotic bacteria, but see raw and fermented foods. But veggies are not important for the reasons the “you must be alkaline” people say.
If you hang out with TCM practitioners, you get told “don’t drink cold water, drink boiled water or tea.” And “don’t eat raw vegetables, they are cold and damp which promotes diarrhea.” Chinese cooking often involves running veggies briefly through very hot oil.
Chinese agriculture has involved night soil for centuries. I think I’d boil my water and cook my veggies, but maybe “cold and damp” isn’t the whole explanation of a good observation.
Vinegar and citrus products are acidic. But the way the body metabolizes them ends up creating an alkaline system. Why, I don’t know, and maybe someone here knows and can explain it.
Do you remember what ailments flourish if the body is too alkaline? And BTW, the problem is possibly one that only afflicts someone who goes off the deep end and lives on vinegar. The American diet, with its High Fructose Sugars, the fluoride in so much of the liquids we consume, MSG and far too much sweetness and salt counteracts most of the effects of having vinegar once in a while.