I read this book with some eagerness, as I’m always glad to hear a whole-systems approach to medicine. However, I ended up being disappointed. I am sure that Dr. David B. Agus is a highly intelligent man who has made strides in his field of oncology, but I am unimpressed with the job that his ghostwriter did. The End of Illness relies very heavily on standard health advice—get plenty of sleep and exercise, eat whole foods, try to be less sedentary, etc. And even what’s offered as “new”—take baby aspirin and a statin drug after age 40, throw out your vitamin supplements, and wear comfortable shoes—are really not all that new. If you hadn’t heard about these debates and suggestions already, then you weren’t paying much attention.
That doesn’t mean that there aren’t good things about this book. I celebrate any physician who is trying to focus on preventive medicine and who believes in empowering people with information about their health. He is absolutely right that we need to do things differently in health care, and even in taking care of ourselves. He has some good ideas about what some of those things are. I do think his intentions are a step in the right direction. However, his orientation toward the wealthy and the celebrity aspects of his work lead him astray a bit. (Both Lance Armstrong and Al Gore endorse his book on the back cover, and Agus mentions several other well known people visiting him.)
This book is flawed in a few important ways and raises for me some questions that are relevant to our health care system in a way that Agus probably doesn’t intend. It reminded me of my constant (though usually low-level) mistrust because our medical system is oriented toward profit.
First of all, the entire first part of the book felt a lot like an infomercial for genetic testing. Dr. Agus admits that he is part owner of a genetic testing corporation, which he names, but that still didn’t ease my sense of having paid for a book that was a big promotion for his profit-making corporation. It was almost as if they sat around the corporate board room and asked, “How can we get more customers? Oh, let’s put out a book that is really an ad. We’ll have profits from the book AND more genetic testing customers.” It may also be that Navigenics is using the book to try to change the public attitude toward genetic testing, since it has recently been caught up in regulatory wrangles.
While Agus’s company is not a “bottom-feeder” or “scammer” corporation, as the regulatory article notes, it also doesn’t get the greatest reviews online. Even Wired, which generally supports the industry and introduced Navigenics as more user-friendly than others, noted that it is overpriced compared with similar companies. And most of us do not have health insurance that will help pay for it, nor do we have doctors that can interpret the information obtained. Dr. Agus’s fantasy of health care that is tailored to the individual based on genetic screening is both futuristic and out of the reach of most people financially (though obviously not of the likes of Armstrong or Gore).
Then, in his chapter on tossing out vitamin supplements, Agus notes two things: a) correlation is not the same as causation and b) animal and petri-dish studies don’t always apply to the whole human person. I couldn’t be happier for someone to say this. I have always had the sense that vitamin and supplement obsessions are inappropriate in this well-fed nation, just the same way the insistence on drinking bottled water is ridiculous and wasteful, when in the U.S. we have some of the safest public water in history.
Yet, as the book progresses and Agus turns to his causes, he uses the same kind of questionable study results as though correlation IS causation and as though animal and lab studies CAN be generalized to people. There are many examples, but, for instance, on p. 255, he uses a study of rats to claim that people need downtime. Now, I believe in downtime, but this study doesn’t prove its need for humans. He also does this with the issue of “positive” people living longer or surviving cancer longer—a chicken and egg question if ever there was one. And he notes in cavalier fashion that “study after study” shows that happier people live longer. Even if the research results were that clear, which they are not, that does not mean that the happiness causes people to live longer. This is a classic confusion of correlation and causation, which he criticized before. Maybe I’m missing something, and I certainly don’t have the same level of expertise at analyzing medical studies that Agus has. But, something is inconsistent here.
Lastly, Agus claims that we need to become personally responsible for our health, and I am certainly a person who has years of experience doing so. But taking good care of oneself and advocating for the right tests, medications, and other treatments can only go so far, and Agus hedges about the need for universal health care. While he does cite the brutal statistics involving our health care system (p. 296-297), he also states that “we need health-care reform at a much more basic and fundamental level before we can get to the financial end of it” (p. 279).
I think he has it backwards. In fact, Agus calls on all of us to gather our own health data and share it fearlessly and openly so that large-scale analysis of such data can be conducted. That is a great idea, but it is not likely to happen as long as the health insurance industry is able to disenfranchise any of us at a moment’s notice and as long as people are discriminated against because of their health standing, and, in fact, can’t get independent health insurance with certain pre-existing conditions. Agus notes that many corporate fitness programs do collect data anonymously and preserve individuals’ privacy. Would that I trusted that would always continue. But I know full well that those policies can change with the political climate. As long as profit is the motive for the health insurance industry, then some individuals will always have the potential to have their health information held against them. To assert otherwise is unrealistic.
In fact, Agus’s claim that if you do what he suggests, you can “live robustly to a ripe old age of one hundred or more” and “die peacefully in your sleep after your last dance that evening” (p. 2) seems way overblown. And this brings me to my Joyous Crybaby theme of authenticity. Why do people feel such a need to exaggerate their claims so, especially in the realm of health? Because I have a hard time believing that Agus really believes the exaggerated nature of his claims, my lack of trust is heightened. What, I wonder, does he really have in mind here? Do his goals really have to do with helping me live longer and better? Or is he more interested in promoting his genetic testing business and pushing for the establishment of open medical records for research purposes?
I know that there are some people who don’t feel those last two purposes would in any way conflict with a passionate interest in my own personal health. The right-wing argument about the “superiority” of the U.S. health care system is based on there being no conflict between the financial gain of physicians and the health insurance, medical device, and pharmaceutical industries, on the one hand, and consumer-patients on the other.
But this is demonstrably false, as the following relatively brief list of links demonstrates:
This rich list of studies and reports includes several that show physician denial about their own lack of objectivity in the face of profit motives.
Here is a terrific article about the corruption of medical research by the profit motive.
The government has had to step in repeatedly because of the failure of professional self-regulation.
Even within the field of medicine, the potential for corruption is acknowledged.
Even since regulations have been tightened regarding conflicts of interest, physicians are not accurate in their self-reporting.
And, even though individual research studies are now required to reveal any potential conflicts, the meta-analyses that most physicians rely on to stay current in their fields are not required to do so and often do not reveal such conflicts.
Questionable and patient-threatening research is reported in numerous sub-fields:
And in terms of the daily practice of medicine, even as far back as 1997, Harvard researchers reported conflicts between the profit motives of health insurers and patient care. These conflicts have only increased in the past 15 years, and they are likely much worse in HMOs.
If you want to talk about research that is definitive, the research about the lack of objectivity of privately funded researchers and physicians is what is crystal clear, far more so than the research about cheerfulness supposedly making you healthier. The evidence has been so undeniable and the results of these conflicts of interest so deadly that even anti-government right-wingers have not stood in the way of increased regulation and prosecutions by the Justice Department. Yet, in spite of decades of social science research that demonstrates profit is not the main motivator for creative and complex problem-solving (as summarized by Daniel Pink and mentioned on this blog before), our medical industry is still largely dominated by the assumption that wealth should be its main goal and that innovation will cease without scientists and physicians having the prospect of great riches as their primary reward.
I think that assumption is hogwash. I myself believe that most scientists and physicians go into their fields with a genuine desire to help humanity. And I believe that the industry emphasis on profits turns them into hollow and unhappy practitioners of half-science in the laboratory and half-medicine in the hospital. Certainly, if they can’t survive financially while practicing medicine compassionately, the financial reward grows more and more important. It is all, perhaps, that they are left with, and a sour reward it must be.
This is why I greet something like Dr. Agus’s book with such mixed feelings. He wants to help people—I truly believe that—but he ducks out on the hard issue of trust in a profit-oriented system. And, even though I will take a suggestion or two of his such as walking around while I’m talking on the phone, I can’t trust him and I don’t think this book will change people’s, and certainly not the nation’s, health outcomes.
A shorter version of this review was originally published on Goodreads.