Why Everything You Guessed About Medicine Is Wrong

Ayelett Shani
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Ayelett Shani

You make a very provocative claim − that taking multivitamins could increase a person’s risk of cancer.

I’m not against vitamins, I just believe in data. Whenever we try to guess in medicine, we get it wrong. Twenty-five years ago, we told people, “Eat margarine, not butter,” and if you look at the data, we killed millions of people with heart disease. The data on vitamin consumption shows that there is no benefit to taking them, and it could even be harmful. This is a cross-analysis of 60 randomized studies. So if a man takes Vitamin E for three years, he’s increasing his chance of getting prostate cancer by 16 percent for three years after he stops taking the vitamins. You have to wonder why people keep taking them − and the answer is that they have the best branding in the world.

And a psychological effect.

Absolutely. We all want to be in control. There’s nothing easier than taking vitamins. You don’t need to adjust your diet or go to the gym, you just take a pill. We need to get away from this.

You also say that sitting in front of the computer is bad for your health.

Sitting more than five hours is as harmful as smoking a pack of cigarettes. We were meant to move.

If you could design workplaces, what would they look like?

The elevators should be coin-operated. When you take the elevator up, you’re costing the company you work for a lot of money because you’re at a high risk for disease. Put just a single coffee machine and printer in the office, far away. Give every employee a headset so he can turn around while he’s talking on the phone. When you schedule a meeting with someone, make it a walk. When I was treating Steve Jobs, that’s what we used to do − go for a walk.

In your TEDMED talks, you said, “Today we are completely different than who we were two decades ago.” What did you mean by that?

We’ve become a society of convenience. Let’s say I decide that I feel like eating some asparagus tonight. But this asparagus came from South America. It spent three days on a boat and then it sat on the shelf for four days. We need to get back to the basics. To think: What is fresh? That’s what we need to eat. We think we can take a pill or a powder and supplement what we’re lacking. No. We just need to eat real food. And to know what we’re eating. When you go shopping, find out: Was this fish bred in a fish pool? Was this beef grass-fed or corn-fed? We need to understand what we’re eating. This food is our future, our health.

You also believe we should stick to a regular schedule, day in and day out − eat at the same hour, go to bed at the same hour. Do you actually do this?

Yes. Again, the statistics speak for themselves. In people who eat whenever they want, we see 81 percent more cases of diabetes. Our body is designed to go out and hunt and return with the prey and eat it together with everyone, and we’ve developed accordingly. We need to get back to this too. To eat and sleep at regular hours.

In many ways, what you’re prescribing is “first world medicine” − the ability to plan and stick to a schedule, to carefully select good food. This is a privilege that not everyone has. Let’s say I’m a worker in a factory. I work shifts. I can’t arrange to have a regular daily schedule, let alone have that kind of control over my diet.

You’re right, we do see higher morbidity rates among shift workers. But control is still possible, to a certain degree. Even if you’re a shift worker, you can still eat at the same hours. If you know that you usually eat lunch at a certain hour, and today you can’t do that, you could eat some granola then instead, for example.

In a nutshell, your aim is to promote a transition from medicine that treats disease to medicine that focuses on preventing disease.

Definitely. Two or three times a week I’m sitting across from people and looking into their eyes and telling them, “There’s nothing more I can do to treat your cancer.” I don’t want to do that
anymore.

It must be an awful feeling.

It’s the hardest thing in the world. Truly. Yet it’s also a privilege. Because even if I can’t save them, I can still help them to live as long as is possible, to improve their quality of life as much as possible. But what about the feeling that many of these cases could have been prevented? It’s so frustrating that we aren’t doing this. There’s one pill that, if taken each day, reduces your chances of dying from cancer by 37 percent. Baby aspirin. And most of us don’t take this pill.

What’s wrong with the way we think of disease?

I’d like to change the way in which we think about disease. For me, disease is a verb. Someone can be “cancering” or “diabeting” − and I think we need to view it as a system.

The Chinese government turned some of the recommendations in your book [“The End of Illness"]  into law.

Yes, they liked it. They said − Hey, if we don’t enable people eat between meals, they won’t do it. If we make them take aspirin every day, we can improve their quality and length of life.

But that’s a little scary, isn’t it? Intrusive. What sort of society do you have in mind?

I don’t fantasize about a nanny-state; I think each of us is responsible for his own health. I’m not saying that everyone has to take aspirin. I’m saying that everyone should talk about it with his or her doctor. We check our investment portfolios every day, our bank accounts − I want to see us relate to our health in the same way.

You founded a company called Navigenics that provides medical advice on the basis of individual genetic mapping. Analysis of a saliva sample can predict one’s chances of getting certain diseases.

Yes, it’s a very powerful tool. Knowing what disease you could get can help you prevent that disease.

When doesn’t it work?

Look, these diseases are related to the environment as well as genetics. It’s not possible to prevent everything. But let’s say you receive a result that say you have a 40 percent chance of getting colon cancer, when the average is 20 percent. What it means is that you ought to start having regular colonoscopy tests, from a young age. It’s just one piece of the puzzle, but it’s a very valuable piece.

It also raises questions about the desire and the need to know.

Such as?

In my family, for instance, there’s a history of a lethal and incurable illness called Creutzfeldt-Jakob disease. I could get tested to find out my chances of
getting it. I chose not to.

That’s the determinist factor. But you’re right, one doesn’t always need to know. Take the case of Angelina Jolie, for example. She wanted to know. She had an 85 percent chance of getting cancer, and she decided to do something about it.

And what do you think? That it’s always better to know?

In Angelina Jolie’s case, yes, because there was something that could be done. In your case − there is no clear-cut answer. Some people would want to know and to become an activist to get research funding increased, to lobby the government, to support research centers working on the disease, and so on. Knowledge is empowering, but it certainly depends very much on the individual.

Again, isn’t this a kind of medicine that leaves the poor, not to mention the Third World, behind?

Undoubtedly. And let me make it clear that I feel terrible about that. The other side of the coin, though, is that technology benefits everyone. When we launched Navigenics, our basic service cost $2,500. Today it costs $99. You have to start somewhere. And the hope is that it will also help and heal people in the Third World, too. They can’t afford to do generic disease screening and prevention, but they will do more targeted things.

But won’t one thing necessarily come at the expense of the other? The focus on preventive medicine at the expense of medical treatment?

No. And we’re not that great at treatment in any case. The mortality rate from cancer didn’t change very much from the 1950s to 2007. So we need to improve prevention. A single baby aspirin a day costs $3 a year. This cost could be lowered to 70 cents a year. The Third World could afford that.

How is technology harmful to our health? I read in your book that the prefrontal cortex development in children has changed, due to technology.

When children sit in front of a computer all day instead of going outside to play, the brain develops differently, no question about it. We now know that down time is critical for us to be able to think, to create, to control our health. But we’re becoming a society that has no time for that. We’re constantly doing things. We need a little down time. We need to invest in our relationships. We’re turning into a society that doesn’t need such things. And I find that terrible.

What’s the most important thing we don’t know?

We don’t have a clear model for health management. The fact that I could take a little blood from you and obtain some sort of picture of the state of your health is not sufficient, because most of the things that you do will affect your health in another decade or two or three from now. If I recommend that you get a flu shot, you’ll say − Why should I bother? I’ve had the flu before, it’s not so bad. But 10 years from now you could develop heart disease or cancer, and it will be closely related to the inflammation caused by the flu.

What are the most dangerous diseases?

Cancer, heart disease, brain disease such as Alzheimer’s disease and depression.

Why is depression so dangerous?

Depression affects many different dynamics. When you’re depressed, it affects your children, your friends, your society − all your choices in life.

This is a holistic perspective − everything is connected to everything. Today’s flu is tomorrow’s cancer. My present depression is my children’s future problem. When you look at it this way, aren’t we actually completely helpless?

Not necessarily. People ask me what the most effective tool is for monitoring cancer patients and my answer is − my voice. I ask them how they’re feeling. Our body is continually holding a conversation with us, but we don’t listen to it. In the 1970s, for a pregnancy test they would take a drop of urine and inject it into a rabbit. A few days later they would kill the rabbit and examine its ovaries. A pregnancy test based on proteins only appeared in late 1977, and now we have the capability to map all the proteins in the body. It’s the start of a revolution. A drop of blood will enable us to see what's happening in the body at any moment. This technology will change our lives, will replace invasive and complicated tests and help in obtaining early diagnoses. Things are about to change.

How far away are we?

Three to five years. Big things are going to happen.

Tell me about your routine. What do you do for your health?

I get up at 4:30 A.M. and go to sleep at 9:30 P.M. I exercise every day. I don’t take any vitamins or supplements. I take aspirin every day. And statins. I eat at set times − a Mediterranean diet, lots of good fats.

What do you think of veganism? It’s a huge trend in Israel. Is it really the best diet?

A vegan diet is wonderful. But we don’t have any data showing that a vegan diet is preferable to a Mediterranean diet. In fact, the latest study indicates that a Mediterranean diet contributes to greater longevity.

How do you envision the field of medicine 10 years from now?

My dream is that whenever you go to the doctor, he’ll take a drop of blood from you, map your body’s proteins and take an in-depth look at what your body is saying. He’ll go into the universal database and will be able to deduce your health risks from that. You will be contributing to the database of the human condition every time you go to the doctor, and the database will contribute to you.

You don’t believe in medical information being classified.

No. I think we all want and need to be part of the solution. Medicine is not going to change from the top down, it’s going to happen from the bottom up, in a process in which doctors and patients change medicine together. I think this is what we’re beginning to do now. People go to the doctor and say, “But I heard about such-and-such a study.” The doctor will read this study. The two of them will learn together.

That’s sounds quite utopian. When I go to the doctor, he’s dozing off at his desk. I don’t think he’s open to hearing my suggestions about reading material.

If that’s the case, you’re not going to the right doctor. If you go to the doctor and he just checks your blood pressure and gives you medicine, it’s not the right doctor. You want a doctor who will say to you, “Let’s collect some data over a couple of weeks, and then come back.”

The patient sitting opposite you today isn’t the same patient that was sitting there 10 years ago. The Internet has turned us all into amateur physicians.

Totally. Sometimes it’s not the patient himself. It’s his children, or a relative, or a good friend. Whatever the case, somebody shows up with a file folder. I think this is something that doctors should really like. It’s another way to improve the situation, to find the solution.

Has it ever happened to you, in your career, that a patient has been the one to solve the problem?

Yes. If you have a disease, you’re on the Internet all day long and finding things. The patient can suddenly find something that I haven’t thought about, that didn’t appear in any study. I think this is how it ought to be.

Can you give me a specific example?

When I began treating Steve (Jobs), I received hundreds of emails about research studies from people all over America. Some of them really helped.

Would you say that your desire to change things compensates for the built-in helplessness that comes with being an oncologist?

Absolutely. I require everyone who works in my labs to sit with me once a month and meet with patients. When you look into the eyes of someone who is going to die from cancer, you don’t just go home from work that night. You keep on working. And at the same time, the patient looks into the eyes of the researcher, and his hope takes real shape. It’s sitting right there. And I want these two things to mix. It’s an honor and a privilege to treat people. I can see the disease, I can smell it, examine it. Most of the people who work in research don’t treat people. It amazes me that these are two separate worlds.

In “Blink,” Malcolm Gladwell writes about how a group of art experts in a room were shown 10 paintings − nine authentic works and one fake. They all could tell which was one was the fake. They couldn’t explain why it was fake, but they could identify it. I have kind of a similar feeling about cancer. I can tell if the cancer will be good or bad, but I can’t say exactly why or how. Right now, medicine is more like an art, and my hope is that technology will help us turn it into science.

How do you cope with the helplessness, with the loss of patient after patient? Some, like Jobs, become your close friends.

It’s terrible. By definition, I nearly always fail. The patients die of cancer. But it’s a privilege to help them live longer. There are people who die the day their disease is diagnosed, and there are people who live every moment until the day they die. Steve lived until the day he died. And it was truly a great privilege to be a part of that. You learn a lot about yourself and about humanity.

What did you learn?

That every day is a precious gift. When I come home, I hug my children. When I get tired, I think about my patients, and it gives me tremendous motivation to
continue.

A representation of a brain.
Dr. David Agus.Credit: Gali Eytan

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