an ounce of prevention is worth a pound of cure

which is why the people who sell cure by the pound never want to talk about it

there was once a longstanding truth:

“an ounce of prevention is worth a pound of cure.”

your grandma knew this. everyone did.

but consider the incentives this creates for a modern pharmico-medical complex whose living hinges upon selling cure by the pound.

now consider how those incentives may diverge from your own.

yeah, that gets pretty ugly pretty fast, doesn’t it?

because that ounce costs them the ballgame.

truly, this meme is destined to be evergreen:

(and we would all do well to remember it)

it is not my intent to malign all pharma. there are good companies and useful drugs and lots of life and world changing technology that has come out of this space. you would NOT want to live in a pre-pharma world. but like any commercial sphere, incentives matter and when the incentives are perverse so too are the results and that which maximizes power and profit may not be what maximizes your welfare.

from private actors subject to market forces and consumer sovereignty this is fine because they cannot run unchecked, but when these forces are short circuited or outright abrogated by, say, government agencies that fund studies, give grants, and approve products as part of the endless revolving door of staff from public to private sectors and back again and therefore constitute captured game preserves of complicit co-conspirators in the place where “public servants” are supposed to be, well, then we land in altogether more treacherous terrain where bad ideas persist and good ones can be ignored forever.

the companies that sell insulin and GLP-1’s like the hot new drug ozempic have no interest in your learning about “good diet and exercise.” sugar and sloth are the core of their market size expansion. the folks selling hypertension and cholesterol drugs feel the same way. those selling anti-depressants have a truly dark set of market size optimizers.

to a great extent, your self control and independent knowledge/agency stand in opposition to their profit lines. that makes “trusting the experts” a bit fraught, no?

and these people buy A LOT of advertising and when you pay so many pipers, you sure get to call a lot of editorial tunes.

gone is “feed your kids right and keep them active.”

let’s normalize putting them on drugs instead.

the whole thing has gotten wildly out of control and become some sort of bad take singularity from “you cannot lose weight by just counting calories” to “exercise is white supremacy.”

truly, the mind boggles.

but this is also so obviously stupid that not many fall for it.

but there are other, more insidious manners in which this same game is played and one of the nastiest is around alzheimer's (AZ), a truly awful disease that creates truly desperate patients and caregivers and has become a big business of junk products many of which are premised on modalities that look like they may have been fraudulent from the start but that make it to market through complicit regulators aiding and abetting semi-scrupulous (at best) drug co’s as they prey upon people at the end of their wits and the end of their rope.

this ill effect is amplified by the fact that desperate people tend to band together into active and aggressive advocacy groups who demand that the FDA “do something” and clamor for the very drugs that will cost them much and give them little because it feels better to act than not to. and regulators are happy to comply and service the perverse incentives.

NIH has become a fiefdom funding the hobbyhorse of “reducing amyloid plaques” to mitigate and prevent alzheimer’s but it looks increasingly like this was pure capture and gold giving. “science” blew the lid off this last year with demonstration that the foundational work in the space had used doctored images and was outright fraud.

this likely led to decades of lost time and who knows how many millions in misapplied research on pointless endpoints. it sucked all the rest of the air out of the room and near monopolized federal grants.

but reality is not optional.

and the fact of the matter is that we have made very little progress on curing or even mitigating AZ and certainly far less than we should have.

but the “new drugs” keep on coming and most of them look like junk with poor risk/reward profiles.

johns hopkins med school professor marty makary has a good discussion of some of the new compounds here. worth a read.

Does Anyone Still Care About Data?

lilly’s new trial showed a 40-60% slowing of disease progression (not a cure, not a remission, just a slower pace of getting worse), but it also had a 24% rate of brain swelling and a 31% rate of brain bleeding. not exactly “minor” side effects.

leqembi, approved 2 weeks ago had a paltry 12% slowing of decline vs 13% brain swell and 17% brain bleed.

this is not great stuff nor good risk/reward. but desperate people will grasp for anything. and markets like that attract the worst sorts of merchants.

but what if there was a drug that was affordable, widely available, had NO adverse side effects, actually prevented disease, and had numerous other life benefits to boot?

what would a drug candidate like THAT be worth?

how much money should be allocated to researching it?

piles, right?

wrong.

despite proven efficacy, it gets nothing because, wait for it, there is no money in it and preventing disease is not profitable for the key constituents here.

but you don’t need them to help you prevent alzheimer’s.

you just need to educate yourself.

studies show that eating a mediterranean diet greatly reduces AZ risk (and there is a more than slightly provocative linkage between eating lots of good fats and keeping your noggin running well and perhaps a nasty link between the awful “low fat” fads of the 80’s and the current state of the oldster brainpans)

others link to exercise, cognitive activity (instead of watching TV) and good sleep as preventatives.

and yet NO ONE talks about this. a drug this effective at actually stopping alzheimer’s would be one of the biggest pharma products in the US bar none, but because instead it’s a practice that eliminates the need for high price, high risk, low reward cash cow products, it’s memory holed.

marty outlines it well. (bold mine)

The National Institutes of Health (NIH) will spend $3.6 billion this year on Alzheimer’s research, yet only 2% of NIH-funded Alzheimer’s clinical trials are studying the role of food. Given the rising prevalence of Alzheimer’s, we should be investing more on studying causes, such as environmental toxins, and the role of food. A Neurology study published two months ago found that people on a Mediterranean diet had a nearly 40% lower odds of having Alzheimer’s associated plaques in the brain. And a study by my Johns Hopkins colleagues and I found that chronic poor sleep may also be a contributing cause. Other factors that have been suggested in the literature include cognitive training, social engagement, and exercise.

Unfortunately, lifestyle changes that can reduce the risk of Alzheimer’s and related dementias are rarely discussed and are dwarfed by media coverage of new Alzheimer’s drugs. It’s time to study how to prevent Alzheimer’s, not just indiscriminately push pharmaceuticals.

one dollar in fifty gets spent on studying food. essentially zero dollars is spent publicizing this. and there is a better way:

you can solve a lot of problems with the same simple solutions.

this same mediterranean diet has long been associated with better heart health as well.

so has exercise.

and yet doctors push pills and not push ups and faucis instead of burpees.

they prescribe drugs and not food. very few doctors have better than even rudimentary knowledge of nutrition. and this is becoming a serious problem.

the western medical focus on “fixing that which has gone wrong” and “treating disease” instead of “prevention” and “building healthy people who don’t get sick” is a disaster of bad outcomes and run-away costs.

the 80’s diet debacle and the truly horrendous food pyramid marketing schemes may well be the source of most of our current travails from obesity to cognitive decline to depression to heart disease, diabetes, and who knows how many other maladies.

it’s an epidemic of lack of self care.

approximately zero people would be surprised if when you took a formula one car and filled the oil pan with peanut butter, it broke the engine.

and yet large chunks of america seem to think you can fuel a human machine with fritos, ding dongs, deep fried processed meat goop, and 64 oz of raspberry mountain dew and magically expect nothing bad to happen.

if we’re going to have public health agencies (and one can easily argue that we should not) then surely they should focus on the health of the public.

doing so means promoting healthy people, not acting as the marketing arms for the pills that maybe sorta compensate for the cavalcades of bad decisions about food and lifestyle these agencies seem increasingly inclined to enable.

an once of prevention of worth A LOT more than a pound of cure it’s just that the benefits accrue to you and not to those who hire bureaucrats when they leave the NIH or FDA as part of the revolving door of regulatory capture and complicity.

they are not going to help you, but the good news is that for the most part, you don’t need anything from them anyhow.

if you would take charge of your own health and maximize your likely outcomes, it’s really pretty easy.

2 steps and you’re most of the way home.

the doctor is thin