Public health (heart) lung cancer

by Carl V Phillips

Tobacco control and “public health” have the same attitude toward lung cancer as homophobes do toward AIDS. In both cases, they are motivated by “moral” objections to particular behaviors and are desperately frustrated that people fail to just stop doing what they personally consider sinful/disgusting/unappealing (those are fairly interchangeable concepts for this sort of person). Thus many of them are happy that there is a disease that disproportionately punishes the sinners. Of course gay bashers (as well as also those who object to all sexual promiscuity and the relatively smaller group who hate injection drug users) do not pretend to care about the physical health of the targets of their opprobrium, so they are merely vile; “public health” people are also hypocrites.

About ten years ago, I coined the term “anti-tobacco extremists” to refer to those who take the most extreme view of tobacco use. This was an attempt to push back against anti-THR activists being inaccurately referred to as public health, given that they actively seek to harm the public’s health. I have since given up on that, and recognize that “public health” is an unsalvageable rubric, which should just be relegated to being a pejorative. But the extremist concept remains useful. The test for anti-tobacco extremism is the answer to the following question: If you could magically change the world so that either (a) there was no use of tobacco products or (b) people could continue to enjoy using tobacco but there was a cheap magic pill that they could take to eliminate any excess disease risk it caused, which would you choose? Anyone who would choose (a) over (b) takes anti-tobacco to its logical extreme, making clear that they object to the behavior, not its effects.

Of course, something approximating that magic pill exists — using smoke-free alternatives rather than smoking — and that was the point of the thought experiment. It was designed to separate the pseudo-scientific rationalizations (e.g., inaccurate claims the alternatives are not really low risk) from actual extremist goals. Those who oppose THR are generally extremists, interested in moral cleansing, and do not care about health or people.

But opposition to THR is not the only evidence that anti-tobacco extremists dominate tobacco control and “public health” more generally. There is also their effort to prevent development of better treatments for lung cancer. On a research-spending-per-death basis, lung cancer is practically an orphan disease. Despite it being the leading cause of cancer deaths in the USA and most rich countries, it receives far less research spending than less common cancers. Those in power even take pains to try to hide this fact in their statistics, almost invariably splitting up cancers by sex so that it comes in second on both lists. (There is more lung cancer than either breast or prostate cancer, but the latter top a list that is limited to only women or men.)

[Update: It was pointed out to me that I failed to note that even worse than this is that even this cooking of the numbers depends on reporting diagnosis rather than mortality from the various cancers. Prostate cancer is relatively seldom fatal and likewise breast cancer, though not to such an extent (a large portion of breast cancers detected by screening mammography would never even have caused detectable symptoms, let alone mortality). By contrast, due to the late detection that almost always occurs, most diagnosed lung cancers are fatal. If we consider mortality, lung cancer is worst even when dividing by sex.]

Public health’s love affair with lung cancer was evident in a report from a couple of months ago, about research on a lung cancer vaccine. This got a lot of press only because researchers at Roswell Park will be testing a drug developed in Cuba, and anything about thawing relations with Cuba generates breathless news stories. The medical reporter and Candace Johnson, president and CEO of Roswell Park and oncology professor at SUNY Buffalo, teamed up to create this gem:

These forecasts are years from real-world application, but their implications are worth considering. One such challenge is how to resolve the tension between creating a lung cancer vaccine and keeping the smoking rates low. The U.S. has made tremendous strides since the mid-1960s in eradicating cigarettes, but fears of cancer and disease serve as driving forces of that change. If scientists take them off the table, Johnson admits, there may be less incentive to quit.

“It’s a fine line,” she said of the public health dilemma. In conquering one major form of burden — lung cancer — researchers could unintentionally spark a new one. More  important to her is keeping the rest of the world in mind. “Globally, there’s going to be a need even if we have great results here in this country in smoking cessation.”

So basically she is apologizing for possibly making smoking less unhealthy. As I said, public health loves lung cancer. Now some might think they would believe that making people immune to a disease is even better than preventing people from engaging in the behavior that causes the disease. But that would be the error of believing that “public health” is about health.

Moreover, contrary to the “may” in the quoted passage, of course there will be less incentive to quit if the harm is reduced. It is not exactly hard to understand that if  the cost of something drops, then more people will do it. I know that medics tend to be really bad at economics, but come on! They are at least human actors who make decisions, and so ought to be able to figure that much out. Then again, medical and public health education seem to train the ability to think scientifically out of people. After all, the public health types were astonished to discover that when HIV treatments became available — such that catching the virus was no longer a rapid death sentence — there was a dramatic increase in behaviors that caused a risk of catching the virus. Every economist who weighed in on this issue pointed out that this was inevitable. Indeed, anyone with any common sense could have predicted it. But “public health” denied it would happen and were astonished when it did.

Astonished and also dismayed. Perhaps not quite as much as the gay bashers were, but the similar response does make clear the very fine line that separates “public health” from being a hate group. “Public health” were genuinely unhappy that people took advantage of better technology to live their lives in a way they preferred, rather than continuing to obey the diktats. HIV treatments did not eliminate the costs of risky sexual behavior, or course, nor even the costs of having HIV, just as a magic cure for lung cancer would only eliminate a fraction of the risks from smoking. But in both cases the costs become substantially lower, and so the willingness to accept the costs in order to get the benefits of the behavior is going to be higher. This is only a problem for someone who considers people’s welfare to be unimportant, who only cares about whether people obey the moralistic rules they would impose on the world.

Now in fairness to Johnson, she might not have proactively sought to apologize for making smoking less harmful. Reporters tend to like to report every story as if it were a sports match with simplistic rivalries, and so the reporter probably pushed the conversation in this direction. But it was Johnson who chose to recite the public health party line of not really wanting to do anything about lung cancer. She could have chosen to respond with something like:

Are you kidding me? Are you suggesting that we should not have improved the safety of air travel, leaving it as risky as it was in 1950, to avoid having so many people engage in this risky activity? Or that we should have avoided finding a cure for syphilis or treatments for HIV, because now more people engage in risky sexual behavior? Would you have us remove seat belts from cars? The reason smoking is bad is that causes diseases; if we take away a major disease that it causes, smoking is no longer as bad.

Of course, she is part of the public health establishment and so it is reasonably likely that she would not say this because she does not agree with it.

This absurdity brings to mind the Claudia Henschke debacle. For those who do not recall, Henschke was a medical researcher associated with Cornell/Weill who claimed to have discovered a method of using CT scanning for early detection of lung cancer, when it was still treatable. This became a debacle when the ANTZ figured out that the project got some grant support from a tobacco company. There was criticism that she was inadequately open about this (she disagreed). On the other hand, who cares? It is not as if that changed the results. It is not as if the funder — even if they had controlled the conduct of the research, which they did not — would want to make erroneous claims about the results. Such claims would quickly be discovered to be wrong (unlike, say, most of public health’s anti-tobacco pseudo-science, in which they make sure their rhetoric does not depend on any testable claims).

The real problem was that other research did not show similarly promising results, suggesting that the Henschke results might have been an error (random or otherwise). A 2007 analysis, seriously questioned her 2006 results, for example, well before the 2008 kerfuffle about the funding. There is also the fact that the value of cancer screening is easy to overestimate because it detects a lot of cancers that would not have actually caused health problems. Public health people do not really care about such matters of science (math is hard!). They avoid denouncing the similar problem of screening mammography — which is approximately worthless — because they do not really care whether people fear breast cancer. That fear does not motivate people to behave “properly”. But they tripped over themselves trying to denounce Henschke’s research when they found out about the funding. It was truly comical.

Some good ones that are still available online:

“How can you, as an institution that is based on promoting public health and medical research, take money from an industry that produces a product that causes health problems in the world?” commented Ruth Fadden, director of the John Hopkins Berman Institute of Bioethics, in a report on ABC News.

Um, as opposed to all those corporations that make products that cause no health problems at all? Besides, why not? Apparently these people think it is much better to make sure all the corporate profits enrich the shareholders, rather than skimming some off to fund research that the companies owe to the world. I am sure the rentier class would commend such sentiment.

But comedy aside, the real anti-health mission of public health came through in the more substantive reactions. By not prominently disclosing the source of funding, Henschke performed a very useful experiment of a different sort, pointing out how public health people do not care about accuracy of scientific research or its potential benefits. They only care about whether it was motivated by the extremist goals of their special interest group or by some real societal interest. Their criticism ignored the science that suggested the original study result was wrong because they only care about motives, not truth. For example,

‘Why did the tobacco company want to support her research?’ ” [Dr. Jerome Kassirer, a former editor of The New England Journal of Medicine and the author of a book about conflicts of interest] said. “They want to show that lung cancer is not so bad as everybody thinks because screening can save people; and that’s outrageous.”

Um, what? No, they wanted to make lung cancer genuinely not as bad as it has been. That is the “outrage” that public health did not like. Contrary to the ignorant prejudices of public health people, people who work for corporations are, on average, decent human beings who care about people’s welfare (with a few exceptions, of course — energy companies, banking, and military contractors come to mind). They strongly prefer that their products cause less harm.

Of course, they also like the idea that making their products less harmful would mean that more people will buy the products. But you know who else funds clinical research that is intended to help them sell more of their products? The pharmaceutical industry. It is basically that industry’s entire research business model. Funny that public health seems unbothered by this.

The thing is, if the public health people wanted to question this research based on conflict of interest, they had a good basis for doing so based on information that was prominently disclosed: Henschke owned the IP for the technology she was studying. Unrestricted research grants do not create much conflict of interest; making a middle-class living while doing grant-funded research is not going to motivate any competent and honest researcher to skew her results. Someone would have to have a serious lack of a moral compass for that to matter. Indeed, people who make a big deal about their lack of industry grants are the equivalent of people who tell you “I have not had a drink is over eight years”: The real message is a confession that they personally have a defect such that if they drank (or accepted such a grant) it would create serious problems. This is the speaker admitting there is something wrong with himself, and does not change the fact that most people can drink (or accept research grants) harmlessly.

But owning IP for a potentially breakthrough technology is a different story. It creates dreams of becoming a billionaire, and that is an incentive that poses a serious challenge to intellectual integrity, bigger even than drawing a salary from an organization with an interest in the results, let alone getting grants. But somehow these people who claim to care about conflict of interest — including the one who wrote a (presumably really bad) book on the topic — seemed to not understand the real conflict of interest. It is notable that more than a few anti-THR people own interests in other smoking cessation technologies, but this never seems to get mentioned.

Those who talk the most about conflict of interest seem to understand the least about what it really means. Is there a conflict of interest in a cigarette company supporting research to find a cure for lung cancer? No, not any more than if they supported research to find a cure for malaria. They have an interest in finding a cure for lung cancer, but that does not create any conflict with doing good and honest research. Of course, it does create a conflict with the goals of “public health” tobacco controllers because they do not want a cure to exist. A reduction in the toll from lung cancer would be a threat to their business model — threatening both their funding and their foundational myth of tobacco companies wanting their customers to suffer — and also represent undeserved relief for the sinners who they claim to care about, but really despise.

[Update: See more on this theme by Dick Puddlecote. It also ties closely to several of the themes in my “Why is there anti-THR” series.]