First published on on Sept. 17, 2014
In response to the question: What current health fad do you wish people would ignore?

It’s quite simple. ALL health fads should be ignored. The proof is simple.

If any fad were as startlingly effective as most fads claim to be, it would be easy for the medical profession to study and validate this effectiveness – at which point the fad ceases being a fad and becomes a bona fide medical therapy. QED.

So please don’t judge your physician harshly if she appears to roll her eyes when you talk about the latest internet sensation. She remembers shark cartilage, anti-neoplastins, laetrile, and dozens of other fads that were effective only at bilking the sick and credulous.

Yet, such fads inflame me far less than most physicians, because I have surrendered hope they can be eradicated. They are as inveterate in human society as cockroaches, and have been the hair shirt of physicians for millennia.

The great physician-essayist, Oliver Wendell Holmes Sr., illustrates this. In 1883 he irritably observed that “Ignorance is a solemn and sacred fact, and, like infancy, which it resembles, should be respected.”

But Holmes also understood the desperation of the sickbed, and captured what is surely a fundamental truth of human existence: “There is nothing men [and women] will not do, there is nothing they have not done, to recover their health and save their lives. They have submitted to be half-drowned in water and half-choked with gases, to be buried up to their chins in earth, to be seared with hot irons like galley-slaves, to be crimped with knives like codfish, to have needles thrust into their flesh, and bonfires kindled on their skin, to swallow all sorts of abominations, and to pay for all of this as if to be singed and scalded was a costly privilege, as if blisters were a blessing and leeches a luxury.”

Holmes omits that each of these therapies was once medical orthodoxy. The medical profession has fads, too.

First published on on Sept. 16, 2014
In response to the question: What health issue deserves more attention from investors than it’s getting?

The U.S. government is the world’s largest investor in healthcare. Consider, therefore, the following thought experiment: What might happen if the mission of the National Security Agency were expanded to include medicine?

As we have come to learn, the NSA has a voracious appetite and capacity to gather information about people. It listens and looks (or could listen and look) to everything you say on the phone, type on a computer, write in a letter, or say at home. By tracking your cell phone it can know where you go, how fast you drive, and potentially how fast you walk. It can know everything you purchase. And by tracking your internet use it can even know what you’re thinking.

Compare this to the academic physician who is trying to understand how environmental factors contribute to the cause and cure of a cancer. To do this, he or she may spend an entire professional career painstakingly designing and conducting a series of studies, each one able to collect only a few dozen data points about only a few hundred or a few thousand of people, each study only marginally better than the previous one.

What if the cancer researcher had access to NSA-quality data? First, he or she would weep with happiness. Second, he or she would be able to conduct experiments with unprecedented speed. Want to know if spinach prevents pancreatic cancer? Instead of waiting 10 years for a prospective study of 20,000 nurses to conclude (of whom 20 may get pancreatic cancer), our researcher would look back 10 years in the NSA data and have the answer in a day, based on 200,000 cases of the cancer. The researcher would need only to define an estimator of spinach intake, based on grocery-store purchases and dining-room conversations.

Next, consider a person who already has cancer. Is the best treatment surgery, chemotherapy, radiation, or prayer? The NSA data would be able to tell you the statistical results of each choice, in patients matched for your age, sex, tumor extent, and background medical history.

Or, a simple question: My vitamin D level seems to be low – is there really any benefit to taking a supplement or should I get more sun? The data would tell me what the experience of others has been.

Of course, I have overstated the depth and extent of the NSA’s data, and, to a lesser extent, the epidemiological principles involved. But there is no question that medical researchers could do wonderful things with data elements that the NSA is in a position to capture and categorize, whether from Germans, Americans, or whoever.

Obviously, none of this will come to pass. But, it does illustrate the priorities of national governments. Their mission, according to the Declaration of Independence, is to “effect [the] safety and happiness” of the governed. Whether your safety and happiness is threatened more by cancer or by terrorists would seem easy to answer.

First published on on Sept. 15, 2014
In response to the question: What health issue will millennials have to deal with that their parents didn’t?

I feel bad for the Millennials. Born into a golden age of human biological history that started after World War II, they could witness its end – if they live as long as their parents.

The first threat is illustrated by President Calvin Coolidge’s 16-year-old son, Calvin Jr., who one day in 1924 made the trivial mistake of not wearing socks while playing tennis on the White House court. A week later, he was dead. Penicillin and other highly effective antibiotics did not yet exist, so the infection that started in a foot blister spread unstoppably throughout his body. The President’s ability to summon the world’s best medical brains and care mattered not at all.

Today, antibiotics are losing effectiveness faster than new ones are being discovered. For 70 years the antibiotic safety net has kept our mistakes and bad luck from becoming fatal or crippling. Long may it endure, but don’t bank on it.

The second threat is illustrated by Richard Preston’s gripping novel, The Cobra Event, in which a single malevolent individual invents, manufactures, and distributes a new virus combining the contagiousness of the common cold with the lethality of smallpox – all from within his city apartment. Whether the requisite technology and knowledge is available today is immaterial. It will certainly be available in 30 years, given the still-accelerating pace of the biotechnology revolution. What happens then, when brilliant, but socially frustrated teenagers start engineering human viruses instead of computer viruses?

It is deeply ironic – and tragic – that the same tools that hold so much promise for advancing medicine and preserving human life could so easily kill most of the planet’s human population. Preventing this catastrophe is the strongest justification I’ve heard for the National Security Agency’s intrusive information monitoring.

Rejected by the New England Journal of Medicine in September 2014.
Co-authored with Dr. Dean Winslow and Dr. David Walton.

To the Editor:

Smith and colleagues’ [1] sound arguments for a tobacco-free military underemphasize the military’s culpability in creating tobacco users.

Since 1987, Department of Defense regulations have prohibited any tobacco use during the 8 weeks of basic military training [2]. Because physical addiction to tobacco lasts only 2-4 weeks [3], all members of the U.S. military for a generation have departed for their first duty station tobacco-free and physically unaddicted.

At this first active duty station, troops initially live on base. Deliberately-inculcated esprit de corps ensures a troop’s social network remains rooted there for years. Given the importance of social networks in promoting the initiation of tobacco use [4] and given that 90% of smokers start at ages no later than these years [5], the social environments on our military bases are, inescapably, what generate the military smoking rate that will ultimately kill >15% of all troops – dwarfing combat deaths.

As officers, we break faith with young troops by putting them into such toxic, risk-laden environments without cause. Tobacco should be banned from U.S. military installations worldwide.

These opinions represent the views of the authors alone and do not reflect official views of the Department of Defense or its components.

[1] Smith EA, Jahnke SA, Poston WS, Williams LN, Haddock CK, Schroeder SA, Malone RE. Is it time for a tobacco-free military? N Engl J Med. 2014;371:589-591.

[2] Johnson L. Military restrictions. New York: Philip Morris USA inter-office correspondence. January 11, 1988. Accessed on-line Sept. 2, 2014 from:

[3] Hughes JR. Effects of abstinence from tobacco: valid symptoms and time course. Nicotine Tob Res. 2007;9:315-327.

[4] Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. N Engl J Med. 2008;358:2249-2258.

[5] Bondurant S, Wedge R (eds.). Combating Tobacco Use in Military and Veteran Populations. Washington: National Academies Press, 2009. Page 37.

First published on on June 11, 2014
In response to the question: How should patients use the increasing amount of data available on prices and quality of care at competing hospitals?

It may seem paradoxical at first, but the more complicated the medical problem, the less important are price and quality data. There are lies, damn lies, and data.

First, price. If one’s back is to the medical wall, no sane person is going to skimp when extra expenditures will buy a chance at a better outcome. Price-consciousness should, therefore, be reserved for commodity medical services.

Ideally, quality data would tell us where to go for that chance at a better outcome, but, here, too, the data are only useful for commodity services delivered to a broad, homogeneous population.

For example, Johns Hopkins, where I spent many years, is never going to have the quality performance numbers that good community hospitals will, because half of Hopkins’ patients come from long distances as very difficult cases, and because the other half are from its impoverished east Baltimore neighborhood. These challenging populations inevitably drag down quality scores, which then compare unfavorably to hospitals serving healthier patients. However, one’s chances at Hopkins for many serious or unusual conditions are going to be better than in a community hospital.

Thus, before making decisions based on data comparisons, be sure you understand the limits of the data, and how they really apply to you.