Seth’s blog

I’m fond of arguing that the Ten Commandments was a very political document. Notice it’s aimed at men? Notice that women aren’t protected, much less children? That’s because men had all the power. No one has said they already knew this or that I was wrong.

I thought of the Ten Commandments when a friend from Amsterdam wrote me about a recent experience of hers:

A very old man asked me to come to his apartment, and he would donate a bike to the project.  I went over to get it, and it was half a bike, and it was locked to a pole…had obviously been there for years.  The temperature was well below zero.  It became clear that he was in fact super-lonely, and torn between usual Dutch suspicion of strangers… and desperation for human contact.  He finally pleaded with me to come up to his apartment (where he obviously lived alone) but not before we spent 15 minutes trying to saw that rusty old bike loose, with his World War II-vintage hacksaw with missing teeth.

You may know that Dutch people are the tallest in the world, reflecting a very high standard of living. But — if this old man is not unusual — alleviating the loneliness of old people isn’t part of the Dutch social contract, admirable as it may be.

I recently watched the Frontline program Sick Around the World. It suggested that that old man isn’t unusual. In England, where doctor visits are free, a doctor said he has several patients who come weekly, purely because they’re lonely. In Japan, some patients have their blood pressure measured very often — presumably for the same reason. In Taiwan, if you see a doctor 20 times in one month someone from the government will come to talk to you. Not about loneliness — about overuse of medical care. The Frontline program made nothing of any of these facts, which were included to show that access was easy. That’s not all they show. What if the British doctor had said that several patients visit him often because they need water? Then we’d be shocked. Yet the idea that everyone needs human contact isn’t mysterious or controversial.

My explanation is there’s a double whammy: Not only do lonely old people have little power, it’s also clear that their problem (loneliness) isn’t caused by a “chemical imbalance”. So no drugs can be sold to treat it. And there’s no diagnostic category. It’s another example of gatekeeper syndrome. When these lonely old people exert what little power they have by visiting their doctor, the doctor — I’m assuming — doesn’t do anything to get rid of the loneliness. Even if you visit 20 times in a month.

In the 1960s, Richard Bernstein, an engineer and a Type 1 diabetic, pioneered the use of blood glucose self-monitoring. Using it, he was able to greatly improve his glucose control and thereby his health. No one doubts it helps Type 1 diabetics. With Type 2 diabetics, whose blood glucose is better controlled, the benefit is obviously less clear — but to many Type 2 diabetics, unmistakable.

A recent literature review, however, begged to differ:

Contrary to the widely-held belief, there is no proof that non-insulin-dependent patients with type 2 diabetes benefit from glucose self-monitoring. Moreover, it remains unclear whether an additional benefit is displayed by the blood test compared to the urine test or vice versa, in other words, whether one or other of the tests might offer an advantage to patients. The current data are quantitatively and qualitatively inadequate: the few trials that are suitable for investigating these questions have not included or have insufficiently reported many outcomes important to patients. Owing to their short duration, it is also not possible to draw any conclusions on the long-term benefit of glucose self-monitoring. This is the conclusion of the final report of the Institute for Quality and Efficiency in Health Care (IQWiG), [which is in Germany,] published on 14 December 2009.

Which is even more ridiculous than dermatologists concluding that acne isn’t due to diet. At a forum for diabetics, the report was roundly criticized:

Telling a Type 2 Diabetic not to measure his/her BG is like telling an overweight person not to weigh themselves…Ignorance is NOT bliss.

Totally agree! I was told by a nurse the other week not to measure my blood pressure at home as ‘home testing can cause patients to get worried”!!!

I have recently been diagnosed with type 2, and without the regular testing i did whilst i was going though my diet change, I would have no idea which foods caused high or low readings. I definitely think regular testing gives you the ability to control your diabetes 100% more than with no testing and using the 3 month HBA1c tests.

[impressive self-experimentation:] For my own edification, I discovered that chromium, zinc, and vitamin B1 added to my diet were benficial. I discovered that cinnamon, selenium, Omega 3, and some other quack remedies being touted on the web did nothing for me except empty my pocket. I was about to start investigating CQ10 enzymes, but the doctor [who said “don’t self-test”] stopped that trial in its tracks.

The most noticeable thing about this thread is how many people have either just joined or made a relatively “early” post after belonging for ages. Amazing! There is a depth of feeling aroused [by this report] that wasn’t apparent before!

Why have dermatologists claimed we can’t say acne is caused by diet (”there is insufficient evidence”)? Why did these diabetes researchers claim we can’t say home testing helps Type 2 diabetics? A big reason, I believe, is that these claims (if true, which they aren’t) would preserve their gatekeeper function. You don’t need to see a dermatologist to stop eating chocolate. Home testing will reveal all sorts of simple ways that you can control your blood sugar without medicine. The doctors who reach these ridiculous conclusions have a big conflict of interest that goes unstated. They are fine with the conclusion that home testing helps Type 1 diabetics because Type 1s will still need them. Because Type 1 diabetics inject insulin, they need doctors to prescribe it.

In a widely-emailed article about depression, Judith Warner, a former columnist at the New York Times, writes:

This is the big picture of mental health care in America: not perfectly healthy people popping pills for no reason, but people with real illnesses lacking access to care; facing barriers like ignorance, stigma and high prices; or finding care that is ineffective.

When Atul Gawande fails to mention prevention in a discussion of how to improve American health care . . . well, he’s a surgeon. Of course he has gatekeeper syndrome. What’s Judith Warner’s excuse? Judging from this article, the notion that depression might be prevented has not occurred to her.

Of course I loved this comment on a recent post of mine about how to flavor stuff:

I made a vegetable soup today spiced by small amounts of vegetable stock, hoi sin sauce, angostura bitters, lea & perrins worcestershire sauce, kikkomann soy sauce, maggi würze, marmite, maille mustard. I can honestly say it was the best tasting soup I, or any of my guests, can remember having been served.

I routinely make soups that taste clearly better than any soup I had before I figured out the secret (thousands). There is no failure (I’ve done it 20-odd times), no worry about over- or under-cooking. Something else odd: There seems to be a ceiling effect. The texture could be better, the appearance could be much better, the creaminess could be better, sometimes the temperature could be better, the sourness could be better, but I can’t imagine it could be more delicious.
Why wasn’t this figured out earlier? I’ve looked at hundreds of cookbooks and thousands of recipes. I haven’t seen one that combines three or more sources of great complexity, as I do and the commenter did. There may be more trial and error surrounding cooking than anything else in human life. Billions of meals, day after day.

I think it goes back to my old comment (derived from Jane Jacobs) that farmers didn’t invent tractors. Some people claimed they did but I think we can all agree farmers didn’t invent the engine on which tractors are based. You can’t get to tractors from trial and error around pre-tractor farming methods. Even though farmers are expert at farming. I think that’s what happened here. I am not a food professional or even a skilled cook. My expertise is in psychology (especially psychology and food). Wondering why we like umami, sour, and complex flavors led me to a theory (the umami hypothesis) that led me to a new idea about how to cook.

And this goes back to what many people, including Atul Gawande, fail to understand about how to improve our healthcare system. The supposed experts, with their vast credentials, can’t fix it — just as farmers couldn’t invent tractors. Impossible. The experts (doctors, medical school professors, drug companies, alternative healers) have a serious case of gatekeeper syndrome. The really big improvements will come from outsiders. Outsiders who benefit from change. To fix our healthcare system, empower them.

At a charity dinner in New York City to benefit the Food Allergy Institute, the president of the Institute told the guests that

Several promising treatments [were] in the works, including a Chinese herbal therapy being developed by the prominent allergist Dr. Hugh Sampson of Mt. Sinai (ready as soon as 2011) and a parasite “similar to those found in the stomachs of most citizens in developing countries,” which could someday be introduced into imperiled Upper East Side intestines, the theory being that “in the developed world, we live in too clean of an environment, so our immune system has nothing familiar to attack.”

Gatekeeper syndrome. How dare they not read this blog!