Obstacles   to   Treatment     
  They don’t make it easy for you!  
    Introduction

In this section, we’ll focus on the issues you’ll face should you decide to take a proactive role in looking for an effective cure, and why it’s likely to be a “hard row to hoe”:

    A Time to Live – A Time to Die

Different people have very different intentions when it comes to looking for a cure:

*You may wish to keep looking for a cure right up to your very last breath. For you, nothing may be more important than the preservation of life.

*You may feel that looking for a cure, even just hoping for a cure, plays a key role in distracting you from the process of dying: either, there is a form of magical thinking that if you don’t dwell upon it, then it won’t happen; or there is a form of pragmatic thinking that if you don’t dwell upon it, then the mental anguish associated with dying will be curtailed.

*You may wish to continue looking for the present, but something tells you that, if unsuccessful, then there will come a time to “call it a day”. Beyond that point, to keep on searching for a cure would divert you from the process of dying; and you have an inchoate, nebulous feeling that it is important, in some way to acknowledge, to engage with the process: there is not just an external finalizing of affairs to be undertaken, but also an internal one, a mental “clearing of the decks” – it is important in some sense to “live out your death”.

*You may never even have considered looking for a cure. In your mind there is a season for all things, “a time to live and a time to die”, and, irrespective of whether or not a cure may be available, you know in your heart of hearts that the last leaves are on the tree and now is the time to say your farewells.

So, it’s worth reflecting on who you are, and what’s the best approach for you, as the way you go about your search may depend on what it is you are really looking for.

    Warning – On Looking Behind the “White Coat”

Ignorance is bliss? If this is your philosophy of life, then you are advised not to read these articles on “Finding a Cure”!

Why? Once you know enough to start asking your health-care practitioner the right questions, then it is highly likely that you will be disappointed by the answers, or the lack of them, that are forthcoming.

When it comes to searching for a cure you find yourself in a proverbial Catch-22 situation:

*Having a competent health-care practitioner plays a very important role in the successful treatment of any disease, but without doggedly asking the right questions you’re very unlikely to find a competent health-care practitioner and to get the best treatment available.

*However, minimizing anxiety and distress are also important, and discovering that your health-care practitioner isn’t offering you the best treatment, or doesn’t even know about the full range of treatments that are available can be dispiriting, to say the least. As, what we might call, the “Religion of Science” has become the basis for what many people now believe, health-care practitioners often serve as cut-down, surrogate, latter-day replacements for priests – the taking of the patient history and the periodic reviews of treatment outcomes lend a certain “confessional” element to the health-care practitioner-patient relationship. So, losing confidence in your health-care practitioner might have a much more significant impact on your well-being than just losing confidence in the efficacy of the treatment that he is prescribing.

You need a certain “intestinal fortitude” if you are to get second opinions, to do a lot of reading about your condition, and to take a much more proactive role in managing your treatment than is usually the case. If this is not you, then, perhaps, it’s best to imbue your existing health-care practitioner with a semi-divine status (as was once the norm), cross your fingers, and hope for the best.

So, think through this issue very carefully. Once you’ve stopped believing in Santa Claus and the Tooth Fairy, once the “Wizard of Oz” ceases to be quite so “wonderful”, once you’ve peaked behind that “white coat”, there’s no going back!”

    Who Cares about Your Health?

Of course, finding a cure for a disease or medical condition will not always be possible. But, in an ideal world, finding the best available treatment would not be difficult. Unfortunately, as you may well have noticed, this is not an ideal world:

*As far as health care is concerned, this world is ruled by a cabal of organizations far more powerful than any government, a cabal that strongly influences the health-care systems within most countries by way of their elected representatives, medical regulatory agencies, medical schools, doctors’ organizations, medical charities, journalists, and the editorial boards of research journals, a cabal that – while it doesn’t want you to die – doesn’t want you to live a healthy life, a cabal whose principal objective is to ensure that once struck down by a chronic illness you will spend the rest of your days suffering from that chronic illness. Now the symptoms of said chronic illness can, conveniently, be ameliorated to some extent by popping pills on a daily basis, pills that members of this cabal will readily supply, provided you, your insurer, or your government will recompense them for their “public-spirited benevolence”. This cabal has a name: big-pharma.

*Big-pharma – despite its giant stature – is not the only actor “strutting” its stuff back and forth upon the health-care stage. Look carefully, and you will also espy a collection of disparate organizations: the nutrition and herbal supplements industries, groups espousing traditional systems of medicine drawn from many different cultures, groups advocating off-label usages of existing drugs, together with a variety of techno-fringe and quasi-cult-like groups. These organizations yield little by way of power and influence; for the most part they genuinely want you to be healthy; and they believe passionately in the health-care products and procedures that they advocate. But, unfortunately, while these products and procedures are sometimes gold, they are sometimes dross. This ragbag of organizations also has a name: alternative medicine.

And then there is you! You who are supposed to navigate your way through this quagmire of misinformation and self-interest.

    Big-Pharma – The Profit Principle

Your chances of easily finding the best available treatment for some disease or medical condition are very slim because the profit principle readily triumphs over treatment efficacy: doctors all too frequently recommend treatments that vary from the manifestly minacious, to the downright ineffectual, to the “oh-but-you-could-do-so-much-better”– and they do so because, wittingly or unwittingly, they only recommend treatments that make “eye-watering” profits for big-pharma.

Big-Pharma Treatments Less Effective than Alternative Medicine: Big-pharma likes to give the impression that its products are more effective than those offered by alternative medicine. In the case of chronic diseases, this assertion turns out, more often than not, to be false:

*Not Invented Here: For example, a treatment that uses gene regulation to enhance protein synthesis and to extend telomere length has been shown in randomized, placebo-controlled, double-blind trials to increase lifespan by about 16 years (specifically, for groups of individuals with an average age of 80, after 6 years about 82% of individuals in the control group had died, compared to only 20% in the treatment group – when these mortality rates are converted to extensions in lifespan, those in the treatment group would have lived on average 16.2 years longer than the controls). But, you’re very unlikely to come across this treatment without a great deal of reading, since – as it wasn’t developed by, or licensed to, a big-pharma company operating in one of the main Western economies – it has never been strongly marketed.

*Herbal Treatments: For example, in developed countries about one in three people will die from cardiovascular disease (such as heart disease and stroke), due to endothelial dysfunction and the subsequent build-up of arterial plaque. But the standard treatment prescribed by many doctors is some 15 times less effective than another treatment (specifically, for the progression of non-stenosing, arterial plaques from class IV to class V).

For example, around 50% of the world’s population has either prediabetes or diabetes (type II), and the numbers are steadily rising (in the US, about 38% of the population has prediabetes and about 14% has diabetes [1]). And many people with prediabetes will go on to develop full-blown diabetes within 10 years. People with prediabetes or diabetes suffer from an increased risk of heart attack, stroke, blindness, kidney failure, circulatory impairments, brain shrinkage, and cancer (for example, people with prediabetes or diabetes have a 49% greater risk of dying from cancer [2]). Let’s take glibenclamide (glyburide), one of the most popular sulfonylureas drugs used to treat diabetes. Despite being widely used, it compares very unfavourable to another treatment: when it comes to reducing levels of fasting glucose, the other treatment is 3.8 times better than the big-pharma drug; when it comes to reducing total cholesterol and LDL-cholesterol, the big-pharma drug has no significant effect, whereas the other treatment leads to significant reductions of 12% and 23% respectively; and when it comes to increased levels of beneficial HDL, the other treatment outperforms the big-pharma drug by a factor of 6.0.

However, you’re very unlikely to come across either of these more effective treatments as they’re non-patentable, herbal treatments, unknown to almost all mainstream doctors.

*Vitamin and Mineral Supplements: Supplements containing vitamins, minerals, and various biochemicals produced by the body have long been popular with practitioners of alternative medicine. For example, a supplement combination that has been in use for over 30 years can reduce the risk of dying from cardiovascular disease by a factor of two (specifically, a double-blind, placebo-controlled study that enrolled patients with an average age of 78 – the patients took either mainstream medical treatments or mainstream medical treatments plus the supplement combination for four years – found that after five years those patients who were not taking the supplement combination were 2.1 times more likely to have died from cardiovascular disease – and the reduction in mortality rate was almost unchanged some six years after supplementation ended, when the average age of the patients was 88).

For example, in developed countries about one in four people will die from cancer. Low blood levels of a certain dietary mineral greatly increase cancer risk (by a factor of about eight in the case of thyroid cancer); but research has shown that supplementation with the mineral decreases the risk of dying from any type of cancer by about 50% (specifically, a multicentre, double-blind, randomized, placebo-controlled cancer prevention trial showed a statistically significant reduction in total cancer mortality, with 29 deaths in the treatment group versus 57 among the controls).

However, you’re unlikely to be offered either of these treatments by a mainstream doctor – prescribing vitamin and mineral supplements doesn’t generate revenues for big-pharma.

*Off-Patent Drugs: For example, the standard cancer chemotherapy treatment prescribed by many doctors is some 2.7 times less effective than another treatment (specifically, for the 10-year survival rate for colon cancer with higher CSLEX staining, post-operation, when treated with chemotherapy versus chemotherapy augmented with an off-label drug – the survival rates being 35% and 96% respectively). But, you’re very unlikely to come across this more effective treatment as the patent for the off-label drug has long since expired, and so it’s no longer a source of bountiful revenue for the big-pharma company that originally filed the patent (typically, what a big-pharma company will do in these circumstances of “patent-ending-impoverishment” is to try to develop yet another patentable drug, one that will increase survival rates ever so slightly – from, say, 35% to 40% – only to repeat the process when in due course the newly granted patent also expires).

These are just a small sample of those cases where alternative medicine has far more to offer than big-pharma – it would be possible to list dozens of others. So, why do mainstream doctors almost universally prescribe big-pharma treatments, treatments that are often so much less effective than those offered by alternative medicine? The most common views from the emails I receive seem to be divided between, on the one hand, “financial greed, coupled with a gross indifference to the welfare of patients”, and, on the other, “incompetence, deriving from inadequate training and an unwillingness to read the medical research literature” – though your views are usually framed in ... how shall I put it ... somewhat stronger, more “full-bodied” language!

In defence of the medical profession, I think that “financial greed”, while not unknown, cannot reasonably be considered the norm. And “an unwillingness to read the medical research literature”, while certainly true, stems from a lack of time rather than from an incurious taedium vitae – there are just too many patients still sitting patiently, or not, in that waiting room, and even when the surgery closes its doors at the end of a busy day, there are still many routine tasks to be performed before a “doctor’s day is done”. In addition, there are often practical constraints: a doctor in public-service medicine can only prescribe what the funding authority is willing to pay for. And, there is the not unimportant matter of protecting one’s livelihood: a scenario in which a doctor prescribes a big-pharma drug and people die is likely to elicit no more than a “regulatory yawn”; but if the same doctor were to prescribe an alternative treatment and just one person were to die, then he might well lose his licence to practice (to an outsider it might seem that it is not the number of patient deaths, per se, but rather the manner in which they have been “dispatched” that is of primary concern to health regulators). Yes, the “playing field” on which big-pharma and alternative medicine do battle can be called many things, but “level” is not one of them.

Most Treatments Ineffective: Big-pharma and the medical devices industry claim that they deal in “evidence-based” medicine – medicine the efficacy of which has been demonstrated by means of solid research. However, in almost all cases this claim is false:

*In times past, simple folk were easily duped into buying worthless “snake oil” medications: with their bright colours and pungent smells a gullible public could easily be persuaded as to their efficacy. Today, many will shake their heads in disbelief that people could once have been so foolish. Today, we know better. When that hospital consultant, surrounded by millions of dollars of high-tech equipment, expounds the benefits of the treatment he is recommending we know that all will be well. We know that we can have confidence in the recommended treatment.

*Well, think again! The singer may be different, but “the song remains the same”. Unfortunately, all too often, we are being scammed by “white-coated” con artists into taking treatments that are either harmful or no better than a placebo. And where’s the “evidence” that so-called “evidence-based” medicine isn’t “evidence-based”: well, for example, an analysis in BMJ Clinical Evidence (doctors reviewing the prescribing practices of other doctors) found that out of 3,000 clinical treatments used in mainstream medicine only 11% could be categorized as beneficial [3]. Has a doctor or hospital consultant ever said to you after making a treatment recommendation, “Oh, by the way, there’s no evidence that this treatment will benefit you, but I’m going to recommend you take it anyway” – I thought not!

Ineffective Treatments Still in Routine Use: Despite evidence that certain treatments are harmful, they are still being carried out on a routine basis; for example:

*Patients with advanced cardiovascular disease are still undergoing surgery to fit stents when there is good evidence that standard medical management leads to better outcomes, with a reduction in the numbers of strokes and incidences of major haemorrhage (specifically, for high-risk patients with intracranial artery stenosis treated with aggressive medical management or aggressive medical management plus stenting with the Wingspan stent – the likelihood of major haemorrhage was found to be 3.3 times greater in the stenting group) [4].

Misinformation: Big-pharma likes to give the impression that it has the public interest at heart, but the track record of big-pharma tells a very different story; for example:

*Big-pharma company Merck launched the anti-inflammatory drug Vioxx (Rofecoxib) in 1999. It was withdrawn in 2004, after it was discovered that the company had concealed treatment risks from doctors and patients. The FDA estimated that Vioxx caused up to 139,000 heart attacks, of which 30 to 40 per cent were probably fatal, during the five years the drug was available. The US case against Merck was concluded in 2010 with a settlement worth 4.85 billion USD [5]. In addition, big-pharma has a long track record of making personal payments to independent researchers, with the result that at least 36% of randomized controlled trials into big-pharma drugs that find in favour of big-pharma have been shown to be biased.

While fines in the billion dollar range may seem substantial to us “mere mortals”, the likelihood of a big-pharma company getting caught in the act of “being economical with the truth” is small, and with big-pharma having global annual revenues in excess of 1,000 billion USD [6], settlements like that agreed by Merck are just part of the cost of doing business.

Big-pharma tries to deflect the frequent criticism that comes its way through jocular references to “conspiracy theories”. And there is actually an element of truth behind its dismissal: it’s not as though the CEOs of the big-pharma companies conspire together in some smoke-filled room to agree upon a common strategy – if it were that simple, then breaking up the cabal would not be so difficult. Big-pharma, by and large, pursues the same anti-competitive practices, but the individual companies do so independently of one another. They are well aware that competing on price and chasing after market share would lead to a “race to the bottom”, one in which all the companies would lose out. So, the problem with big-pharma is in many ways a structural problem within the industry as a whole: the high level of vertical integration allows the true costs of drug development to remain hidden. Until the activities of treatment proposal (whether a novel drug or an existing alternative treatment), treatment investigation and validation (the assessment of efficacy and side effects), and treatment manufacture and distribution are allocated to different companies, with government bearing a portion of the risk as appropriate, then this structural problem will remain unresolved – the free market can work very well when it comes to delivering new treatments, but it can only do so given a structural framework that is fit for purpose. In particular, this separation of powers would allow the relative efficacies of novel drugs and alternative treatments to be assessed based on their disease-treating capabilities, and not on their revenue-generating potential for narrow, sectional interests.

    Alternative Medicine – The Distorting Power of Marketing

While alternative medicine likes to portray itself as a knight in shining armour, fighting valiantly against the evil that is big-pharma, the efficacy of its own much vaunted treatments is all too readily subverted by the power of marketing.

For example, let’s take the case of probiotics, dietary supplements that contain bacteria and which are typically used to treat lower gastrointestinal complaints. Big-pharma doctors tend to ignore the importance of the gut microbiome, as prescribing health-giving bacteria for their patients does not generate any revenues for their paymasters. However, the types of bacteria found in the gut can have a profound effect on health (changes in the gut microbiome have been correlated with various disorders, from inflammatory bowel disease to diabetes to obesity). An interesting perspective on the impact of a changing gut microbiome can be seen from a research study [7] which demonstrated that:

*When wild monkeys are brought into captivity (considerably restricting the variety of plant foods found in their diets), then the range of bacteria found in their guts also diminishes, and begins to resemble the bacteria found in the human gut.

*The reason behind this growing bacterial homogeneity seems to be that in the wild monkeys eat a wide range of different plants, containing a diverse range of fibres – with different fibres being digested by different types of bacteria. But, once the range of dietary fibre is restricted, or, even worse, the diet contains little at all by way of fibre (a “fast-food” style diet), then many species of bacteria disappear from the gut microbiome.

*What’s somewhat disconcerting is that the monkeys in this study began to develop gastrointestinal diseases, the very diseases that humans also suffer from (even more disconcerting is the fact that four of the captive monkeys in the study died from their digestive problems).

Perhaps you might care to bear this vignette in mind the next time you rush past the fruit-n-veg counter, and start stuffing your shopping basket with produce from the fast food aisle!

Now, probiotics have become very popular in recent decades and can now be found on the shelves of many supermarkets. A good development, you might think, but it’s not. Let me explain. When I go to my local supermarket, I can readily see two different probiotic brands prominently displayed, brands that are also heavily marketed via television and magazine advertisements. If I were an average consumer, I would be inclined to believe that these brands might well be effective. But, a review of the research literature shows that there is almost no chance that either of these two popular brands would bring any benefits:

*For a start, the research shows that only a tiny fraction of the bacteria they contain survives the harsh conditions of the stomach and reaches the intestines. And, on reaching the intestines, the growth rate of the bacteria is so slow that they would be excreted long before they had had any chance to produce a significant population and impact the overall balance of the gut flora.

*Furthermore, if I search the research literature for human trials that show any significant effect of probiotics on ameliorating disease, then I find none that mentions either of these two popular products.

But, the same research literature shows that there are two other probiotic brands whose bacteria survive the transit through the stomach in large numbers, whose bacteria grow rapidly in the lower intestinal tract, and for which trials demonstrate a significant impact on various gastrointestinal diseases.

However, these two effective probiotic brands are little known, won’t be found in the supermarket, or even in many health food stores. And, if you were to ask a health-care practitioner to recommend a probiotic, then you’re just as likely to be recommended an ineffective brand as an effective one. The problem here is that – surprise, surprise – the ineffective brands are cheaper than the effective ones, and wily marketers have long ago discovered that the average consumer will focus on product price, and not on product efficacy.

    Taking Charge of Your Health

The emphasis in this set of articles will not be on providing treatment recommendations for specific diseases. While providing recommendations is a good thing in principle, the problem is one of trust. The internet is bulging at the seams with health-care recommendations, but which ones should you trust. What if, say, I were to recommend for diabetes the drug metformin, pointing you in the direction of big-pharma, or, perhaps instead, the TCM herb gynostemma pentaphyllum, pointing you in the direction of alternative medicine. Would you take such a recommendation at face value? Perhaps, despite the polemic in the previous sections, this website is receiving funding from the pharmaceutical industry, or, perhaps, from some herbal supplement manufacturer!

My view, and it’s just my view, is that there is no one source that will provide you with information that is unbiased, complete, and attested. Apart from those sources that misrepresent what treatments are available by way of lies of commission, there are many more that do so by way of lies of omission – whether wittingly or not.

The only realistic approach to getting the best treatment for a particular disease or medical condition is to do some extensive reading online, review the relevant research papers, consult different medical opinions, ask the right questions, and, finally, carefully weigh up the answers. Yes, it’s possible. But, no, it’s not easy. It requires a considerable amount of time, more than average analytical skills, and a certain “cussedness” of character that will allow you to call the doctors, hospital consultants, and health-care practitioners you come into contact with to account. If this is not you, then don’t give up: perhaps a friend or family member can step in and do battle on your behalf.

So, the purpose of this set of articles is rather a modest one: to help you take charge of your own health, to help you to:

*Evaluate the stage of a disease and monitor its progression;

*Evaluate whether a treatment you’ve read about or one recommended by a doctor or health-care practitioner is worthwhile;

*Search for treatments – weighing up the relative merits of big-pharma medicine and alternative medicine;

*Determine whether a treatment you’re taking is working or not;

*Determine if your doctor or health-care practitioner is competent;

*Reduce the cost of drugs.

The objective is to provide you with some guidance on how to work systematically through all these issues, so that everything that is relevant will be considered. By doing so, I hope to play some small part in helping you to find the best available treatment.

Even if you discover that the disease you’re suffering from is terminal, by taking charge of your own health you will have the comfort of knowing that the treatment you’re following is the best available, that everything that could be done has been done, and this knowledge, in and of itself, can make the process of dying that much easier.

Good luck!

    References

[1] Menke A., Casagrande S., Geiss L., et al., “Prevalence of and trends in diabetes among adults in the United States, 1988-2012”, JAMA, 2015, 314(10), 1021-1029.

[2] Hirakawa Y., Ninomiya T., Mukai N., et al., “Association Between Glucose Tolerance Level and Cancer Death in a General Japanese Population – The Hisayama Study”, American Journal of Epidemiology, 2012, 176(10), 856-864.

[3] BMJ Clinical Evidence, “What conclusions has Clinical Evidence drawn about what works, what doesn’t based on randomised controlled trial evidence?”.

[4] Derdeyn C.P., Chimowitz M.I., Lynn M.J., et al., “Aggressive medical treatment with or without stenting in high-risk patients with intracranial artery stenosis (SAMMPRIS): the final results of a randomised trial”, The Lancet, 2014, 383:9914, 333–341.

[5] Wikipedia, “Rofecoxib”.

[6] The Statistics Portal, “Statistics and facts about the pharmaceutical industry worldwide”.

[7] Yong E., “Captivity Makes Monkey Microbiomes More Human-Like”, The Atlantic, August 29, 2016.