Anxiety about what is true

Robin links to an article about apparent manipulation of the medical process by drug manufacturers, dealing particularly with the drug Fosamax which is supposed to improve bone strength. The article raises the possibility that many modern diseases don’t exist at all but are the creation of the pharmaceutical industry to give them tools to sell more drugs.

My wife used to take Fosamax, so this was a topic of interest to me. To learn more, I did a search on for “fosamax hip-fracture”. It looks to me like most of the hits are pretty favorable to the drug, but how much does that really prove?

From the 1st hit: “Therefore, for postmenopausal women with low bone mass, alendronate is well tolerated and produces significant, progressive increases in BMD at the lumbar spine and hip in addition to significant reduction in the risk of nonvertebral fracture.” From the 3rd hit, a recent meta-analysis: “We conclude that therapy with alendronate is associated with significant and clinically important reductions in the incidence of hip fracture in women with postmenopausal osteoporosis. The overall reduction is consistent among different patient populations.” From the 5th hit: “These data demonstrate that treatment with alendronate reduces the risk of multiple symptomatic fractures during a treatment period averaging 4.3 years. The reductions were consistent across prespecified subgroups. This effect is evident early in treatment and is sustained.”

The issue that bothers me is, how are non-specialists to know what is true? What is the best methodology to follow for a lay person to reach the truth? In this case, should he go to the primary sources, study medical textbooks to learn the details of bone dynamics, read all the recent research to get up to date, look at results from the various drug studies, learn about the pharmaceutical industry and the incentives governing research and publication, weigh all this evidence and come to his own conclusion? That would be a big job. And it is not at all clear that this method is likely to succeed, given that there is substantial disagreement among people who have in fact performed all these steps.

Or should he do as I did, a quick perusal of a sampling of results, reading through a few abstracts to find key sentences in the conclusions, to get a sense of the overall consensus in the field?

Or should he rely on the various exposes and/or rebuttals which float about on the web, perhaps focusing on those which best fit into his individual prejudices, preconceptions and ideological biases? That seems to be what most people do.

For a lot of “big” issues it doesn’t really matter; the individual’s opinion has no effect. But for questions of personal health, nutrition and similar issues, this kind of information could make a big difference in many individuals’ lives. Nobody wants a hip fracture in old age, but OTOH they don’t want their jaw to dissolve or whatever other horrific side effect may manifest. Our lack of a social consensus on a good mechanism for approximating the truth on controversial issues seems to me to be a major stumbling block in improving health and welfare.

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  • There are also interesting meta-questions: why don’t more people perceive they have a big problem here, and why isn’t there more interest in trying to solve it? If they think about the problem at all, most people seem to think it sufficient to just believe their doctor because he is licensed by the government.

  • Grant

    In my ideal libertopia fantasy land, doctors (and by doctors I mean highly-trained specialists) don’t physically see the patient unless they need to. Technicians who specialize in bedside manner and diagnosis interact with the patient and post pertinent information on a sort of online market. Doctors (or really anyone the market allows; the term ‘doctor’ would have a looser meaning) can then question both the patient and technician, and place bets on both possible diagnosis and cures (which could include placebos). The technician would then present the patient with his options, their costs, and odds of success. Collusion between the technicians and doctors would be possible, but if the prediction market’s contracts were decided by patient feedback, I think the incentives for significant corruption would be small.

    Who do we have to lobby to make prediction markets completely legal? How else can groups of people estimate the truth? Unless you can use prices to aggregate medical knowledge, I think the information asymmetries are always going to be a big problem.

    IMO, YMMV.

  • One of my standard resources for questions of this type is Wikipedia. The “discussion” tab on Wikipedia is very useful for getting insight into the debate and controversy behind a Wikipedia entry. So I went to Wikipedia and typed in “fosamax”. There is indeed a Wikipedia entry on fosamax, but it does not discuss the apparent manipulation of the medical process by drug manufacturers. Even the “discussion” tab does not mention any controversy. I’m tempted to add a section to the “fosamax” Wikipedia entry about this issue, to see what reaction it gets.

  • Tom

    Grant, another advantage of your system would be that computers could be programmed to look for specific combinations of symptoms and make diagnoses/place bets on specific diseases automatically. This would be cheap, near-instantaneous, the information the computers used to make their decisions could be updated as new studies came out and it would free up real doctors to deal with the more subtle and difficult cases.

  • George Weinberg

    I think there are two distinct concepts being mixed here. Robin seems to be asserting that osteoporosis is an imaginary disease because the cutoff level for diagnosis seems arbitrary and because bone loss appears not to be a result of something like an infectious agent but is a natural result of the aging process. But so what? If loss of bone density leads to an increased chance of bone breakage and hence a decrease in the quality of life, why not try to reverse it? Aren’t we pretty much all agreed here that medications that make people healthier than normal would be a good thing?

    Now if the manufacturers of Fosomax have been engaging in shenanigans to overstate its benefits and understate its risks, that’s clearly bad, but it’s a separate question from the “fakeness” of the disease it purports to treat

  • The Washington Post link above says:

    ‘The panel’s first step was to define “normal” bone density as that of the average 30-year-old woman. Next, the experts chose as their cutoff for osteoporosis a statistical point that was slightly below the bone density of their normal 30-year-old — a definition they admitted was “somewhat arbitrary.” Finally, they came up with a completely new disease — osteopenia — for bone density that fell somewhere between that normal 30-year-old and their arbitrary definition of osteoporosis.’

    The Wikipedia article on osteopenia discusses the controversy about the definition of osteopenia:

    ‘An osteoporosis epidemiologist at the Mayo Clinic who participated in setting the criteria in 1992 said “It was just meant to indicate the emergence of a problem,” and noted that “It didn’t have any particular diagnostic or therapeutic significance. It was just meant to show a huge group who looked like they might be at risk.”‘

    ‘The definition has been controversial. Dr. Steven R. Cummings, of the University of California at San Francisco, said in 2003 that “There is no basis, no biological, social, economic or treatment basis, no basis whatsoever, for using minus one.” Cummings also said that “As a consequence, though, more than half of the population is told arbitrarily that they have a condition they need to worry about.”‘

  • Patri Friedman

    I think this is an important general question – how do smart laypeople interpret controversial data in an unbiased fashion? I have this issue with medical/diet/exercise questions all the time. For those questions which will be resolved in the future, I think prediction markets is a good answer. But that doesn’t really apply to people trying to solve the problem today.