Sunday, January 20, 2008

Getting to the Heart of Heart Disease

BusinessWeek recently ran a nice article on the actual benefits of cholesterol drugs. They discuss the scientific flimsiness of the entire lipid hypothesis as well. It's interesting (and good) to see the mainstream press picking up on this discussion, because despite appearances, there really has never been anything close to scientific consensus as to the role of fats and cholesterol in causing heart disease.

The behavior of people is remarkably consistent. We previously saw in the context of the AIDS/HIV hypothesis how the "pro" group simply heaped scorn and anger on any critics, rather than presenting the supposedly "overwhelming" scientific evidence supporting their position. Those in favor of the lipid hypothesis engage in similar behavior, as we see in this excerpt from the BusinessWeek article:

Add it all together, and "current evidence supports ignoring LDL cholesterol altogether," says the University of Michigan's Hayward. In a country where cholesterol lowering is usually seen as a matter of life and death, these are fighting words. A prominent heart disease physician and statin booster fumed at a recent meeting that "Hayward should be held accountable in a court of law for doing things to kill people," Hayward recounts. NECP's Cleeman adds that, in his view, the evidence against Hayward is overwhelming.

Great, except that one supposes in order to prevail in a court of law, you'd actually have to supply said evidence. I don't know whether the evidence exists in the AIDS/HIV case, but I'm about 99.999% sure it ain't there for the lipid hypothesis.

I'm not going to go over the case against the lipid hypothesis in detail, since it has been covered in many other places. Here's a few books and links you can check if interested:

Taubes' book dismantles the whole business in detail, providing a lot of scientific and sociological insight. Kendrick's book is less scientifically dense and an easier read, and quite funny. Try dropping some of the info you learn on your doctor next time he recommends a cholesterol test (or statin treatment). You'll likely witness a great example of cognitive dissonance, much as Nigel Tufnel did when asked to explain why his guitar amplifier "goes to 11".

What I want to talk about today is a sort of mental exercise I undertook after reading some of the above material, along with the Robert Sapolsky's most excellent book Why Zebras Don't Get Ulcers. The idea is to start with physical phenomena that are likely directly causative for heart disease, then try to find whatever might cause those things, and keep working backward until we hit causes (like diet or infectious agent) which originate outside of the body. We can then make a graph of sorts, where the various phenomena are connected by arrows to show how they are related (an arrow from one box to another means that the thing in the first box potentially causes the second).

Click on the image at the left to see what I came up with in the case of heart disease. I'll be the first to admit this is far from complete, but it should at least be thought-provoking. It proves nothing per se, but the kind of logical relationships shown here should at least be reflected in any theory of the cause of heart disease, as I believe the relationships shown are well-established in the scientific literature (and if you have different information or something to add, please post a comment).

Okay, enough disclaimers. What does this mess mean? The red boxes are supposed to represent the direct causes of heart disease, i.e. those conditions which directly lead to plaque formation. I picked these because it seems fairly clear at this point that arterial plaques form as part of the body's response to injuries of the endothelium. The endothelium is a very thin layer of cells which line the entire circulatory system, and amongst many crucial functions, it controls the passage of material in and out of the blood. Even a tiny injury requires repair, and it is thought that the "patch" is actually the beginning of an atherosclerotic plaque.

I don't know if there exists any direct evidence for this phenomenon, but the indirect evidence is pretty compelling. First of all, plaques only form in arteries, where blood pressure is high. Indeed if you transplant a vein to replace a damaged artery, the newly transplanted vein will itself begin to show plaque formation. The plaques themselves are localized. People often think that "clogged arteries" is just junk building up over time, much like a clogged drain. But the plaques form in local spots, preferentially in areas where the blood pressure is the highest, and/or the blood is forced to change direction, like where arteries fork off.

When your skin gets a little cut or nick, a blood clot or scab forms. The skin grows back underneath the scab, which eventually falls off. But this wouldn't be a good idea for repairing blood vessels. If a scab formed and then fell off when the underlying endothelium had grown back, that scab would likely travel down the artery until it got lodged, causing stroke or heart attack. It's also important that the integrity of the endothelium is preserved, so whatever patches up the injury should be water resistant, so material does not leak across at the injury site. hat is thought to happen is that various blood proteins quickly rush to the injury site, forming a water-resistant patch. One of the main players is low-density lipoprotein, or LDL, the so-called "bad cholesterol". Special enthothelial progenitor cells, which are always circulating in the blood, then grab hold and form a new endothelium on top of the patch. In a healthy individual, the plaque may then be slowly absorbed by the body.

There are two possibilities by which a plaque (technically called an atheroma) might grow. The first is that the endothelium which overlies the existing plaque sustains an injury, causing another patch and new endothelium to be laid down on the first one. The second can actually occur from the inside. LDL is prone to oxidation, as are certain kinds of lipids that LDL typically carries, namely cholesterol and unsaturated fats. Oxidized stuff will provoke an immune reaction, with white blood cells "eating" the oxidized LDL. What happens next is less clear, but for some reason it seems a lot of these white blood cells die before leaving the plaque, causing a buildup of "foam cells". If a plaque filled with all of this junk undergoes a major rupture, spilling its contents into the blood, you get an immediate strong clotting reaction, potentially leading to heart attack or stroke (most likely further up the artery as it narrows).

So we see the two main phenomena at the root of plaque formation and subsequent "bad" outcome (heart attack or stroke) are injury to the endothelium and inflammation in the form of immune response and clotting. Thus any conditions which promote endothelial injury will cause more plaque to form. Any conditions promoting inflammation can cause the plaque to grow faster, or a more severe clot to occur when the plaque ruptures.

What promotes endothelial injury? High blood pressure is a biggie, no doubt, and high blood pressure is generally a sign of systemic inflammation. Of course anything that damages the integrity of the endothelial cells also likely promotes damage. This would include glycation, a process where sugars damage proteins (fructose is one of the major culprits promoting glycation damage), or oxidation damage from free radicals in the blood. And we keep working back from those causes until we start hitting the root exogenous (from outside the body, basically stemming from "lifestyle") causes, and we've got the headache-inducing graph I posted above.

Now as I said, that picture is probably incomplete. For example, I later learned about B-vitamins and homocysteine, and for simplicity I left out the effect of cigarettes. But what I find interesting is that for all of the internal complexities, everything ultimately traces back to a few root causes, really two, if you ignore cigarettes or other drugs: psychosocial stress and crappy food.

It's worth talking a bit about stress. We usually think of stress like "my job is really stressing me out." But stress is fundamentally a hormonal response, governed by the master glands of the sympathetic endocrine system: the hypothalamus, pituitary, and adrenal glands. Together, these form what is known as the "HPA axis", and activation of the HPA axis (regardless of the source) fundamentally defines the stress response.

The stress response is evolution's way of dealing with major crises that potentially threaten the survival of the organism. Suppose a cave bear decided to snack on one of your distant ancestors. Physical responses like increased heart rate and blood pressure, clotting response, immune response, etc. could come in handy, assuming said ancestor avoided actually being eaten. Most of the physical reactions caused by stress are detrimental over the long term; the system is designed to act in emergencies only, where the presumed trade-off is between bad (e.g. short-term increase in arterial damage) and worse (death). This point is illustrated nicely by the title of Sapolsky's book Why Zebras Don't Get Ulcers: zebras don't get ulcers because they only "stress out" when required, like when being chased by a lion. Otherwise, they're cool.

Humans, on the other hand, seem to be very adept at ramping up the stress response in the absence of a life-threatening situation. The major modern source of stress is termed psychosocial, originating from many sources, like unhappiness in a job, divorce, money troubles, etc. The problem with psychosocial stress is that it tends to occur over long time periods, and causes the same physiological responses that your distant ancestor experienced while trying to avoid being cave bear food (this actually suggests one way of dealing with stress: compare your problem with that of being eaten alive, and adjust accordingly). The negative effects of stress are then visited upon the body of an extended time period, and the damage starts to pile up.

Oddly enough, certain foods can actually reduce stress in the short term, but increase it in the longer term. Insulin is the "master" metabolic hormone, and comes from the parasympathetic endocrine system. The sympathetic (HPA) and parasympathetic systems are generally antagonistic: when the sympathetic system is activated, the parasympathetic system is inhibited, and vice versa. During the stress response, insulin is inhibited, allowing the blood levels of energy-giving macronutrients (glucose, fats, and proteins) to increase, making them available as necessary for, say, leg muscles so you can run away from a hungry bear. Interestingly, it works the other way as well. If you eat food that raises your insulin, the HPA axis will be suppressed. In short, sugary food reduces stress, which nicely explains why most "comfort foods" are high in refined carbohydrates.

The problem is that all of the insulin that gets released when you eat said comfort foods ultimately drives much of the energy nutrients out of the blood and into the cells, resulting in insulin-induced hypoglycemia, or low blood sugar. Your body interprets this state as starvation, and as you might imagine, starvation induces stress (see this article for more info). So now you've not only got your original psychosocial stress, but additional stress from eating junk food, which then induces you to eat more junk food to get a temporary fix, and around and around you go. And to make matters worse, all of that sugar you're dumping into your blood is promoting glycation damage of the endothelial cells, so it's a double-whammy.

One final piece falls into place from junk food as well: bad fats. Junk food tends to be replete in vegetable oils. Most vegetable oils are polyunsaturated, which makes them prone to oxidation. Ever notice how the top of your bottle of "healthy" vegetable oil gets sticky? That's the result of oxidation. Fats are generally transported in the blood via LDL, and if that fat in the LDL is oxidized, it can in turn oxidize the LDL, and we've already seen what kind of mess that creates. Further, most of these vegetable oils are high in omega-6 fatty acids, which the body tends to use to create pro-inflammatory hormones. They are deficient in omega-3 fatty acids, which the body uses to make anti-inflammatory hormones, and high insulin further inhibits conversion of any vegetable omega-3's (alpha linolenic acid) into the forms required by the body. So the net effect is to further increase the inflammation already present from chronic stress, as well as increase the problems associated with oxidation.

Alright, that's a lot of information. Let me just leave with one final observation. You might note in the picture that there are some boxes that don't have arrows leading out of them, namely the following:

  • Increased LDL/decreased HDL
  • Increased triglycerides
  • Obesity

These are all identified as "risk factors" for heart disease, yet the causal connection is weak, at best. For example, you might argue that increased serum LDL implies that more LDL will be deposited in the arterial patch; but if the rate of endothelial damage is low, it's pretty much irrelevant, since you won't be making many of these patches in the first place. It seems to me (and this is strictly my opinion) that the traditional risk factors are symptoms of the underlying cause. It is well-known that chronic stress increases LDL and decreases HDL. Triglycerides are formed by the liver from excess blood sugar, i.e. when you eat refined carbohydrates. And everything that is known about fat storage at the molecular and cellular level indicates that obesity arises from some combination of stress and consumption of refined carbohydrates. If this is true, then current treatment recommendations like low-fat diets and statins do nothing but mask the symptoms while the underlying disease continues to progress for exactly the reasons that caused it in the first place.

So relax, and have a steak.

Tuesday, January 15, 2008

Not Another Health and Nutrition Blog

Yes, it's true. I don't know if we really need another health and nutrition blog, but for reasons I'll explain in a moment, I felt the need to speak (and I like hearing myself talk). Hopefully I can add something. The "manifesto" of this blog was placed in the inaugural post. It's a little high-falutin' (reading Ivan Illich will do that to you), but I think it makes the point: individuals need to make decisions which maximize their health (or wealth, or any other goal). In order to make those decisions, people need information. If you trust others to hold the knowledge and make the decisions for you, you're doomed. It sounds pessimistic, I know, but as we'll see in the course of my blogging, the evidence strongly supports this viewpoint.

Let me start by briefly telling you how I arrived here. About three years ago, my wife and I tried the South Beach diet. We lost weight easily with the low-carb approach (which we quickly expanded from the original South Beach prescription), without starving, and eating food that didn't taste like cardboard (tonight's dinner will be a large steak, smothered in Bordelaise Sauce). This piqued my curiosity, because the result flew in the face of everything that doctors and the media were telling me about weight loss. I began by investigating the relationship between diet and heart disease, because low-carb diets are inevitably "high-fat", at least by current standards. I was really bothered that while on the one hand, obesity was supposedly a "risk factor" for heart disease, on the other hand, the only way I had ever lost any significant fat was to eat more fat; and of course, dietary fat was also supposedly a risk factor for heart disease. It didn't add up.

So I developed the hobby of researching evidence underpinning current health and nutrition dogma, mainly related to diet. What I found, and continue to find, is that most of what we're told is complete crap, bad science and politics driving public health recommendations affecting the lives of hundreds of millions people. I probably shouldn't have been surprised. I spent several years as a professional scientist, and was quite familiar with how "the system" works. Yet I had not previously extrapolated that experience to the arena of public health, probably because I (like most people) felt that such obviously important issues would be treated with due concern for the actual health of the population, rather than petty politics, careerism, and general money-grubbing (the norm in science, I'm afraid). Sadly, it doesn't turn out to be the case.

But the thing which really started to motivate me to actively blog on these topics was my reading of Peter Duesberg's book "Inventing the AIDS Virus". Duesberg makes a fairly convincing argument that AIDS is not caused by HIV, and that the Centers for Disease Control, National Institute of Health, and other organizations are basically generating a lot of hysteria to justify their own existence. Now it's always dangerous to draw conclusions from a single person's viewpoint, and in particular, Duesberg clearly harbors some bitterness towards the establishment. Duesberg carries some impressive scientific credentials, but ran into considerable career difficulty once he became a vocal opponent of the AIDS/HIV hypothesis. I had seen that kind of thing happen during my own scientific career. I'd also seen individuals whose career went in the toilet because they were lousy scientists, but who then blamed "the establishment" for screwing them. The only way to distinguish is to dig into the actual science, survey the totality of the evidence, and decide if someone like Duesberg is telling the whole story, or cherry-picking evidence to support his position, embarrass his enemies, etc.

I haven't gotten to the root of all of this yet, but I must say at this point that at least some of the leading scientists supporting the AIDS/HIV do not appear to be acting in a manner conducive to good science. Consider this exchange between a group of AIDS "dissidents" known as the Perth Group and Professor John Moore. You don't have to read the whole thing if you don't want to - it's lengthy and technical. But here's the point: the Perth Group makes detailed scientific arguments on 16 points, supported by no less than 72 literature references, many to peer-reviewed publications in respected scientific journals. Here was Moore's response:

You have gone through 21 drafts and a considerable amount of effort to say absolutely nothing that is of any conceivable interest to me. I'm glad you wasted your time though, as communicating with me (or trying to) is harmless, compared to the damage you AIDS denialists do to innocent people you attempt to confuse and thereby cause top be harmed. So, continue to knock yourself out, so to speak. All you will receive from me is my continued contempt, and derision.
John Moore.

Rather nasty and personal, don't you think? And if the evidence for the AIDS/HIV hypothesis is so overwhelming, would it not be simple for Moore to quash to Perth Group with said evidence and logic? Indeed, this is what the Perth Group requested:

You wrote: “All you will receive from me is my continued contempt and derision.”

As an academic surely you must pursue scientific discussions and don’t your students learn by your example? Don’t you teach your students that science progresses through scientific debate?

To which Moore replies:

You are confusing me for someone who is interested in what you have to say, and you are confusing yourself for someone who merits a more detailed response. Kindly correct yourself of those delusional tendencies. I despise you and your fellow AIDS denialists, and I regard your level of “scientific analysis” as pitiful and laughable.
John Moore

And after a final plea from the Perth Group to provide any scientific evidence of any kind, Moore replies:

Plead away, but I'll simply ignore your pleas, as will any bona fide scientist.
John Moore

I'm not sure what "bona fide" scientist means. From the above, it either means you're a total prick, or that you hold uncritical belief in the prevailing dogma. Neither is good for science, especially when that science is regarding something as important as AIDS. Indeed, I have had zero luck finding any actual scientific evidence against the points made by the AIDS "denialists". Instead you get a lot of "the evidence is overwhelming" with nobody ever presenting said evidence (if you can find it, please post a link here). That doesn't mean the evidence doesn't exist, because rather unfortunately even when there is "overwhelming" evidence for a given hypothesis, scientists behave in an essentially dogmatic fashion, accepting the truth of the hypothesis while not actually knowing the evidence which supports it. For example, I doubt you could find many professional physicists who can recite the experimental evidence supporting quantum electrodynamics (QED); yet to date, QED remains the most accurate physical theory ever devised, a status it has maintained in the face of 50 years worth of experiments with ever increasing accuracy. But a good scientist will at least find the evidence when a hypothesis is questioned, rather than just bleating "but everyone knows".

So back to the point: do you really want somebody like John Moore making decisions that affect your health? His goal seems to have more to do with securing his position in the status quo, as opposed to increasing your state of health. Further, he shows no desire to propagate information that is critical to making good decisions. It's like playing blackjack where you don't get to see any of the cards. You're guaranteed to get screwed.

Before calling it a day, lets talk about another example, that of the "benefits" of legal, prescribed drugs. Here's an excerpt from the linked article:

While approximately 10,000 per year die from the effects of illegal drugs, an article in the Journal of the American Medical Association (JAMA) reported that an estimated 106,000 hospitalized patients die each year from drugs which, by medical standards, are properly prescribed and properly administered. More than two million suffer serious side effects. [3]

An article in Newsweek [4] put this into perspective. Adverse drug reactions, from "properly" prescribed drugs, are the fourth leading cause of death in the United States. According to this article, only heart disease, cancer, and stroke kill more Americans than drugs prescribed by medical doctors. Reactions to prescription drugs kill more than twice as many Americans as HIV/AIDS or suicide. Fewer die from accidents or diabetes than adverse drug reactions. It is important to point out the limitations of this study. It did not include outpatients, cases of malpractice, or instances where the drugs were not taken as directed.

According to another AMA publication, drug related "problems" kill as many as 198,815 people, put 8.8 million in hospitals, and account for up to 28% of hospital admissions. [5] If these figures are accurate, only cancer and heart disease kill more patients than drugs.

Jesus wept. The article goes on to suggest that a good deal of heart disease and cancer could be caused by legal drugs as well. I suspect you have to broaden the net, and that nutritional and other recommendations (like avoiding sun, leading to Vitamin D deficiency) play a major role. In all of these cases, however, we again see a large organization (government + drug industry + doctors) acting in a manner which has greater benefits to them than you. This organization has the information (side effects, toxicity, etc.) and makes the treatment decisions; the public just does what it's told.

I'm not proposing that this is any sort of organized conspiracy theory. It's just how human nature shakes out in the behavior of social organiations. Just like organisms, organizations adopt strategies which maximize their chances for survival and growth. Drug companies have to sell medicine to survive. Any strategy that doesn't sell more drugs tends to die off, while those strategies increasing revenue persist (this includes development of new drugs that really do save lives). Further, it is to the benefit of all involved parties to cooperate for their mutual benefit. For instance, it's better for doctors to prescribe medicine than to simply send you home to get better on your own, because then the patient feels like the doctor did something, has to return for more medicine, etc. So obviously it's good for both the people who make drugs and the those who dispense them to push as many of them as possible for as long as possible, regardless of the outcome. The role of government should be to balance this tendency with the goal of optimizing health of the population, and it currently fails miserably.

I know, I know, I sound like a raving paranoid. But again, I think we can find plenty of evidence to support this view. Let's first return to the whole AIDS debacle. This page contains an excerpt from a Harper's article by Celia Farber questioning the ethics of clinical trials testing the drug Nevirapine to treat AIDS in pregnant women. It also contains a response from Robert Gallo, the scientist who supposedly proved the existence of the HIV virus and that it causes AIDS, along with responses to Gallo.

I believe Gallo's response makes his priorities abundantly clear; saving lives is not high on the list, unless it is done with AIDS drugs (by the way, the best you can say about AIDS treatment is that it extends life a bit; patients still suffer early death in the end). Joyce Ann Hafford, the victim in this case, showed no signs of illness until she began taking Nevirapine, which ultimately resulted in her death and nearly that of her unborn child; but that death seems to be nothing but an annoyance to Gallo. Farber's response hits it on the head:

To date, no remorse has been expressed to Hafford's family from any of those responsible for her death, and no compensation has been offered. The only additional shock the family could possibly receive is to now learn that international AIDS "treatment activists" have declared Joyce Ann's death not "relevant to the science of HIV." That statement is sociopathic – bereft of all empathy. This is what I have long suspected AIDS treatment activists to be and this is what they say, in their own words, when given a chance to say something about this tragic death.

Gallo's evidence as to the benefits of the anti-retroviral medications used to treat AIDS patients was a single meta-analysis, and pretty thoroughly dismantled. Meta-analyses are a subject I'll discuss further in another post, but they're usually done as a way to take a bunch of studies which don't give the desired result, gang them together, and perform a little black magic so that they now give the "right" answer, albeit one that is usually marginal at best. In other words, take a bunch of little piles of crap, put them together into one big pile of crap, plant a daisy on top, and declare it no longer crappy. Meta-studies are almost always scientific and statistical nonsense, and even when done with the greatest care and honesty should be viewed with considerable skepticism.

One final example, oh gentle reader, and I shall release you. This one is great, both because it is timely (just came up today), and because it hits one of my favorite subjects: the prevention and treatment of heart disease. Michael Eades has a great writeup on the recent release of results from the Enhance trial, which tested the efficacy of a drug combining Zocor (a statin, which reduces cholesterol) and Zetia (blocks absorption of cholesterol in the intestines). The manufacturer of Vytorin withheld the results of this trial for two years, which ought to raise some red flags. Why? The New York Times gives us the answer:

In a press release, Merck and Schering said that not only did Zetia fail to slow the accumulation of fatty plaque in the arteries, it actually seemed to contribute to plaque formation — although by such a small amount that the finding could have been a result of chance.

Yikes. The best thing you could possibly say is that Vytorin is draining the wallets of those taking it (or, since most of them probably have insurance, it's draining MY wallet, which is infinitely worse). The worst case scenario is that it potentially worsened patients' condition, while putting them at risk of well-known side-effects.

Now it should be clear why a drug company would behave this way: it's the money. What may be less clear is why doctors are so heavily bought into statin treatment, considering that there is no evidence that statins prolong life: they may slightly reduce heart attack risk in high-risk patients, but that risk reduction seems to be invariable offset by increased mortality from other factors, like cancer. But I doubt that most MDs know this. Doctors are not scientists. They treat disease, but they don't spend much (if any) brain space on understanding the origin of disease, the consequences of the currently accepted treatment, etc. Most doctors get their information from drug companies, the FDA, and organizations like the American Medical Association, all which which gave statins a big thumbs up.

Further, the doctor gets to be something of a minor hero. He gives a patient a cholesterol test, finds evidence of a "serious disease" as indicated by elevated "bad cholesterol". Doctor prescribes Vytorin, the next blood test shows significant reduction in the cholesterol, patient loves doctor for providing a "cure". Sadly, the cure must be maintained for the rest of the patient's life, at a significant expense, with continued oversight of the doctor, who also gets paid. And all of this is done in the absence of any evidence that the medication has any actual benefit in terms of improving the patients health (again, if you know of some, post it in the comments). All it really does is put money in the pockets of the doctors, drug companies, and blood labs.

The only way to avoid these kinds of outcomes is to get the information yourself. It can be difficult to understand, because it is often complex. But at the very least, get your information from a source that does not stand to benefit by getting you to make a particular choice, like taking some medication, eating a special kind of food, etc.

Monday, January 14, 2008

Lighting the Spark of Reason

"In Science the authority embodied in the opinion of thousands is not worth a spark of reason in one man." - Galileo Galilei

Most science is bad science, based more on flawed logic, poor statistical practices, and "the opinion of thousands" rather than sound evidence. Though critical thinking is supposed to be the cornerstone of science, it is rarely exercised by its practitioners, the media which reports science to the public, or the public itself. For much of science, this is simply an annoying sociological artifact; evidence ultimately prevails over dogma, though it may take a century or two.

Unfortunately, the same criticisms apply to medical sciences, often quite literally resulting in matters of life and death. Bad science is rampant in public health recommendations and current medical practice. The organizations and individuals charged with preserving our health, while perhaps having good intentions, tend to exhibit behavior which is more self-interested than altruistic.

I hope to provide a "spark of reason". Unlike most of those pushing health-related "science", I don't ask for your unconditional trust. I will provide information which I believe to be supported by scientific evidence and logical thought, but it's up to you to assess validity of what I say, and how it applies to your own health. Modern society increasingly places blind faith in scientists, doctors, government, and the media. Our reward has been continued decline in the health of the population. About the best thing you can say for modern medicine is that it does manage to stave off early death, extending life in the face of the poor health caused by modern medicine in the first place. Ivan Illich nicely expresses this idea:

A world of optimal and widespread health is obviously a world of minimal and only occasional medical intervention. Healthy people are those who live in healthy homes on a healthy diet in an environment equally fit for birth, growth, work, healing, and dying; they are sustained by a culture that enhances the conscious acceptance of limits to population, of aging, of incomplete recovery and ever-imminent death. Healthy people need minimal bureaucratic interference to mate, give birth, share the human condition, and die. Man's consciously lived fragility, individuality, and relatedness make the experience of pain, of sickness, and of death an integral part of his life. The ability to cope with this trio autonomously is fundamental to his health. As he becomes dependent on the management of his intimacy, he renounces his autonomy and his health must decline. The true miracle of modern medicine is diabolical. It consists in making not only individuals but whole populations survive on inhumanly low levels of personal health. Medical nemesis is the negative feedback of a social organization that set out to improve and equalize the opportunity for each man to cope in autonomy and ended by destroying it.

In other words, optimal health depends on you taking responsibility for managing yourself. Only you place your own interests above all else, and by placing your health in the hands of other individuals and organizations, you are doomed to a fate which serves their best interests, not your own. To put it bluntly, illness is money: optimal health in the general population puts a lot of people out of business.

The path to optimal health lies not in "the opinion of thousands", but instead must be lit by your own "spark of reason".