19 Jan Sugar + Pain = N of 2
When you see, or hear, the word “science,” what do you think of? Do you picture pristine labs with gleaming black counters, bright lights, powerful microscopes and workers in white coats? Does the word give you more of a feeling than an image? Does it make you think of the concept of discovery, knowledge, or of truth? When we think of a word or a concept, our brain accesses files of information, much as a computer does, but in a blindingly complex way, constructing and understanding from a myriad of sources. While our interpretation of a word is often connected to what other people think, it is also wholly unique, and built from various personal experiences that we alone have had. We use words to tell stories – to ourselves and to others. For many people, a very tight concept of science is foundational to their being. In fact, many people will point to an understanding of science that demands absolute proof of a concept, as their reason for rejecting all spiritual or religious concepts as “woo”. Through this frame, only if something can be “proven” does it exist. I would argue that this is a naive way of viewing the world. I do not believe in a god with a white beard, but I do not doubt that there is “something” that connects us all. I had to think carefully about the word to use there as words like “energy” or “spririt” carry baggage – “something” is hopefully a bit more neutral (if wishy-washy).
It might not surprise you that I was a Religious Studies major in college. I had no interest in “going into the field” of religious studies. I simply found the classes interesting, and when it was time to declare a major, I had completed it. I have always been someone who did not want to be a part of a system because I’ve always felt that systems are inherently corrupting. Nearly 30 years after college, I realize that almost all of my work as a filmmaker has been about systems and outsiders who challenge them – so in a way all of the work has been somewhat personal. However, only in our newest film, “All The Rage,” am actually present. Even still, the film isn’t really about me, instead I kind of play a character who, despite my best efforts, still has to navigate the medical system in order to get better. I do so by finding a doctor who works within the system, but who has been shunned by that system for challenging accepted practice.
The foundation of scientific practice is data. Without data, we are left with anecdotal evidence or “n of 1” information. Individual bits of data are seen as separate stories with little value unless that data bit is combined with a pool of other bits that exist within a similar vacuum of information. There is no doubt that the scientific process has brought us great advances. There is also no doubt that this process often creates dangerous blind spots as well. There is no such thing as “pure” science. Science does not exist in a vacuum of thought, but instead it exists within a framework of power, hierarchy and social values. It’s important to recognize this framework, and to name it, so that we might look at the forces that drive the science that we rely on more critically.
Like all systems – in fact, more so than many others – the process of organized scientific research is hierarchical. The research that gets funded and published has to have the financial and intellectual support of that hierarchy or it will not get completed or studied. Research that has more direct practical applications is more likely to get supported. Like all systems, the actual practice of science requires resources. In a capitalist-based system, resources are less likely to be invested in any scientific research that does not return resources, or in any scientific research that disrupts the flow of resources. If scientific data tell a story that challenges a system with resources (the tobacco industry, the oil and gas industry), then that industry will produce scientific data that challenge the original data. The previous example combines two n of 1 stories into a more complex tale, but it still isn’t “science” until somebody is able to tell a compelling story with the data. If one were to add in a third industry, we might be getting somewhere. So let’s talk about sugar.
Last month Gary Taube’s book “The Case Against Sugar” hit the shelves, causing a minor stir. His op-eds were published in the Times and the Wall Street Journal as well. Mr. Tabues builds on the recent work of Dr. Robert Lustig as well as the much earlier findings of the British nutritionist John Yudkin to make the case that sugar is killing us. In the process, he also illuminates how Science so often misses important data that should be obvious because this data falls outside what the researchers are looking for (or it falls outside what is seen as “established science”). While working on “All The Rage,” I came across Jonah Lehrer’s 2011 Wired article “Trials and Errors: Why Science Is Failing Us”, which incisively illuminated how – and how often – this scientific blindspot occurs. It clarified so many ideas that I had been struggling to understand but had been unable to articulate. The article pointed out that science, like any system, can quite easily be impaired without anyone realizing it. In short, Science too can fall victim to its own hubris and hierarchy.
It was a couple of years later that I came across Margaret Heffernan’s book “Willful Blindness”. The book explains how so often we fail to see facts that are right in front of us. Some of us don’t see them because of fear – we are afraid we might lose a job, or get in trouble, or not advance in our career if we point out problems. Sometimes, we remain blind because we feel helpless. In the TED talk below, she talks about people who knew that the justification for the Iraq War was specious couldn’t bring themselves to protest or speak up because they felt like it would do nothing; that it was better to just put one’s head down and ignore it. She talks about our concepts of whistle blowers. We tend to perceive them as a bit crazy. In fact, most whistle blowers are people who are deeply loyal to and enmeshed in a system. They believe in the system and find their attempts to address problems rebuffed. Rather than leave, they fight against the problems, not to destroy the system, but to save it.
Dr. Sarno does not see himself as a whistle blower, nor does he see himself as an alternative medicine practitioner. Instead, when he found that what he had been taught about treating back pain was not working, he looked at the science that supported the standard care and found it profoundly lacking. He did what any scientist would do: he looked at the data in order to come up with a hypothesis about what the problem was. He went through his patients’ charts and found that over 80% of them had a history of two or more issues or illnesses that were thought to have a psychosomatic basis. He then asked the question: could back pain also be related? He began talking to his patients, asking questions, in order to find a connection. Over the course of many years, he came to see that the vast majority of his patients were what he came to call “goodists”: people who put themselves under a great deal of pressure to achieve, to be good husbands, mothers, children. Often, the standard that they set for themselves was emotionally difficult, and he postulated that perhaps the repression of painful emotions played a role in the their pain. He began to explain his theories to the patients. The ones who bought the concept tended to rapidly improve and he continued to develop and refine his practice. Soon he had a robust rate of success in treating problems that he had previously been unable to help. As he describes it, once he understood the true cause, the suppression of emotions rather than a “physical abnormality,” there was the possibility of healing.
As you might imagine, when he told his colleagues about it, they were not so enthusiastic. Soon, he realized that talking to them wasn’t useful. He was a practitioner rather than a research scientist, so he didn’t have the time or resources to do a double blind study. However, he did get a resident to help him do a follow up study on his patients. Years after treatment, the vast majority of them were still better. Instead of trying to work within the field that didn’t want to hear about his work, he took it directly to the people in the form of a series of books about mind body medicine. One of those books saved my father, a psychologist, from years of debilitating whiplash pain. My father, who had almost died of a bleeding ulcer, another illness with known emotional causes, began to share the book with everyone he knew. Then when I had back problems, the book saved me. Many years later when I found myself in his office after a horrifying bout of pain, we started to make our film. Unfortunately, we ran into the power of willful blindness. No one wanted to hear about our film. Only after the problem had gotten so bad that it was costing the country more than heart disease and cancer combined, we found that the awareness had begun to shift. It had become undeniable that whatever we were doing to treat pain wasn’t working, and people were more stressed out than ever. While Dr. Sarno’s work is not embraced by the medical industry still, a growing number of practitioners have begun to accept the power our emotions have on our health.
As mentioned above, the population has seen over and over again that industry-funded science often supports the story that industry wants to tell. If we go back to the question that started this article – when you think of the word “healthcare” what do you picture? I’ll jump to the point. Healthcare is both a practice and an industry. As an industry, it is often willfully blind to problems with practice. Dr Sarno saw this with pain, Dr David Clarke saw this with gastroenterology, Dr. Gabor Mate saw this with auto-immune issues. All of them saw that our repression of emotions has a powerful affect on us in a physical manner. Dr. Robert Lustig saw this in regards to the science of diet and challenged the overriding paradigm that fat is the cause of heart disease. He did research that found that sugar was the cause. When he presented his case at a conference, one of the attendees asked him what he thought about John Yudkin’s work from the early ’60’s, which was quite similar. Not only had Lustig not heard of him, it took him months to find a copy of his work. We don’t want to believe it, but science is often a zero sum game, in which there are competing visions of cause. One paradigm wins and the other work is lost.
Well before MRI’s “proved” that herniated discs were the cause of back pain, Dr. Sarno argued they were not. Even though MRI’s might reveal a “soft tissue abnormality,” when we subject that finding to the scientific method there is no solid correlation between herniated discs and pain. In fact, as many people with no herniations have pain, and those with herniations often have no pain.
Back pain is an epidemic. The numbers are sobering: There’s an 80 percent chance that, at some point in your life, you’ll suffer from it. At any given time, about 10 percent of Americans are completely incapacitated by their lumbar regions, which is why back pain is the second most frequent reason people seek medical care, after general checkups. And all this treatment is expensive: According to a recent study in The Journal of the American Medical Association, Americans spend nearly $90 billion every year treating back pain, which is roughly equivalent to what we spend on cancer.
When doctors began encountering a surge in patients with lower back pain in the mid-20th century, as I reported for my 2009 book How We Decide, they had few explanations. The lower back is an exquisitely complicated area of the body, full of small bones, ligaments, spinal discs, and minor muscles. Then there’s the spinal cord itself, a thick cable of nerves that can be easily disturbed. There are so many moving parts in the back that doctors had difficulty figuring out what, exactly, was causing a person’s pain. As a result, patients were typically sent home with a prescription for bed rest.
This treatment plan, though simple, was still extremely effective. Even when nothing was done to the lower back, about 90 percent of people with back pain got better within six weeks. The body healed itself, the inflammation subsided, the nerve relaxed.
Over the next few decades, this hands-off approach to back pain remained the standard medical treatment. That all changed, however, with the introduction of magnetic resonance imaging in the late 1970s. These diagnostic machines use powerful magnets to generate stunningly detailed images of the body’s interior. Within a few years, the MRI machine became a crucial diagnostic tool.
The view afforded by MRI led to a new causal story: Back pain was the result of abnormalities in the spinal discs, those supple buffers between the vertebrae. The MRIs certainly supplied bleak evidence: Back pain was strongly correlated with seriously degenerated discs, which were in turn thought to cause inflammation of the local nerves. Consequently, doctors began administering epidurals to quiet the pain, and if it persisted they would surgically remove the damaged disc tissue.
But the vivid images were misleading. It turns out that disc abnormalities are typically not the cause of chronic back pain. The presence of such abnormalities is just as likely to be correlated with the absence of back problems, as a 1994 study published in The New England Journal of Medicine showed. The researchers imaged the spinal regions of 98 people with no back pain. The results were shocking: Two-thirds of normal patients exhibited “serious problems” like bulging or protruding tissue. In 38 percent of these patients, the MRI revealed multiple damaged discs. Nevertheless, none of these people were in pain. The study concluded that, in most cases, “the discovery of a bulge or protrusion on an MRI scan in a patient with low back pain may frequently be coincidental.”
Similar patterns appear in a new study by James Andrews, a sports medicine orthopedist. He scanned the shoulders of 31 professional baseball pitchers. Their MRIs showed that 90 percent of them had abnormal cartilage, a sign of damage that would typically lead to surgery. Yet they were all in perfect health.
This is not the way things are supposed to work. We assume that more information will make it easier to find the cause, that seeing the soft tissue of the back will reveal the source of the pain, or at least some useful correlations. Unfortunately, that often doesn’t happen. Our habits of visual conclusion-jumping take over. All those extra details end up confusing us; the more we know, the less we seem to understand.
The only solution for this mental flaw is to deliberately ignore a wealth of facts, even when the facts seem relevant. This is what’s happening with the treatment of back pain: Doctors are now encouraged to not order MRIs when making diagnoses. The latest clinical guidelines issued by the American College of Physicians and the American Pain Society strongly recommended that doctors “not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain.”
Dr. Lustig has been a bit more active in regards to speaking publicly about his work than Dr. Sarno has. His evidence is equally as breathtaking as Dr. Sarno’s. In 2009, he did an academic talk that California Public Television put online. It went viral. He has continued to push this message with increasing levels of persuasion, and is still facing a great deal of push back.
In the end important ideas rise to the surface and willful blindness falls away.