Are we losing our faith in the future?  If we do, what are the likely consequences?

September 2010 --In 2005 and in 2007, I and my colleagues carried out national studies to assess the perceptions of people about their own future, the future of their country, and the future of the world.  The respondents were divided into four age groups – 18 to 24 years, 25 to 44 years, 45 to 64 years, and over age 65. In every age group, more than 80 percent were optimistic about their own futures, but, in every age group, the majority were pessimistic about the future of the United States and the world.  Importantly, the majority in each of the four age groupings believed we are not able to solve or significantly mitigate the major problems facing us (such as terrorism, global warming, the potential for nuclear or biologic warfare).
These studies suggested strongly that Americans of all ages are well on their way to losing faith in the future.  Since our last survey, more than two years ago, a number of events have occurred that almost certainly will accelerate that loss of confidence in the future, reduce optimism about one’s own future, and increase the pessimism about the future of the United States and the world.

• There has been a severe recession and, with it, a terrible toll in lost jobs and diminished confidence.
• There is increasing distrust of a Congress that seems unable to deal effectively with our most serious problems.  The cynicism about our political system is likely to be profoundly magnified as a result of the Supreme Court decision to allow unlimited and uncontrolled direct political advertising by corporations and unions (and others) in congressional and presidential elections.
• The countries of the world, including the United States, appear unwilling to take the necessary actions to avoid catastrophic consequences of global climate change.
• We are told that unless health care costs are contained, our healthcare system will eventually bankrupt the country.  Yet, despite an extended and acrimonious debate, there is nothing to suggest our government has figured out a way to cope with or prevent this looming disaster. 

I fear we are now in great danger of a large percentage of the public having their hopes for the future battered, being overwhelmed by feelings of hopelessness in regard to our ability to cope with the major problems facing the society.  If that occurs, there are substantial societal and individual consequences.

• There will be a dramatic increase in the frequency and severity of anxiety and depression.
• There will be a much greater focus on hedonism with increased risk taking and pleasure seeking, including the use of mind-altering drugs, both legal and illegal (alcohol included).
• There will be little attention paid to preventing or mitigating future problems and threats; politicians, even more than now, will focus almost entirely on present issues, thereby making the future even more bleak.
• The depression epidemic will have physical and other consequences with increased incidence of suicide and heart attacks, marital discord, inability to function effectively, and overeating (a well known response to depression) that will exacerbate our obesity and diabetes epidemics.

Make no mistake about it.  Loss of faith in the future is very serious business – if widespread enough, it is society threatening.  There is, in my judgement, only one preventive: people, especially young adults, must be convinced that we as a society are still meliorist, that is able to solve the major problems facing us by the dint of our own efforts.  That, in turn, means our politicians and leaders must give the perception they are approaching major issues in potentially effective fashion.  To do so, they must know when to use and how to use what I have called societally-connected systems thinking.  That is why I wrote the book “reThink: A Twenty-First Century Approach to Preventing Societal Catastrophes.”
Now, the questions for me are:

• Will my recommendations about how to approach major societal issues be implemented by educational institutions and the political establishment?
• Will the book be read by sufficient numbers of people to give societally-connected systems thinking a chance? Will anyone even care?

Extraordinary longevity -- new technologies

August 2010 -- The scientific attempts to extend human longevity can be divided into two overlapping sets of technologies. The first is focused on disease prevention and health promotion. If we could prevent or successfully treat the diseases that afflict people as they age, life expectancy could be increased in the United States from the current 78 years to between 90 and 95 years. The second set of technologies focuses on either modifying the aging process itself or replacing worn out tissues or organs by use of stem cells. If these technologies are successful, life spans could reach 110 to 120 or more years. All these technologies are moving ahead with amazing speed.

One of the new technologies for preventing, detecting, and treating disease is nanotechnology, which may well be as important and society-changing as the industrial revolution. Nanotechnologists work at the molecular and atomic levels. By manipulating atoms, they can create molecular machines that are as small as 10 to 80 atoms in size. The field is in its infancy, but medical applications should start to be available within the next decade -- and the breadth of the potential applications is mind boggling.

Nanoparticles could combine with cholesterol and reduce or prevent arteriosclerotic plaques in the coronary artery blood vessels of the heart.

Nanoparticles will be devised that can selectively bind to cancer cells and can deliver cancer cell-killing materials.

Nanomachines potentially could circulate in the blood stream acting as physiologic and biochemical sensors, detecting abnormalities in their earliest stages when they are easiest to treat.

Nanoparticles will be used for incredibly precise tissue imaging, providing much more information than current computerized scans and magnetic resonance imaging.

And that will just be the beginning.

Nanotechnology will make a major contribution to markedly extending life spans. That would seem, at first glance, to be an unqualified blessing. But, in actuality, it is a mixed blessing if that profound increase in longevity results in major societal consequences and disruptions. I have detailed these potentially worrisome consequences in Chapter 3 of "reThink: A Twenty-First Century Approach to Preventing Societal Catastrophes."

For now, nanotechnology is focused on extending life spans by preventing and treating risk factors for or diseases themselves. But, in the not-too-distant future, the molecular nanotechnologists will almost certainly use the technology to attempt to interfere with the aging process itself – and they are likely to succeed. That will make it even more important to think carefully about the consequences (good and potentially bad) for individuals and for our society.

Time to change drug abuse policy?

July 2010 -- For the last forty years, from the time I wrote “The Drug Scene” and “Overcoming Drugs” and chaired (for seven years) the New York State Council on Drug Addiction, I have urged, as the primary action to reduce the frequency of illicit drug use, that schools and communities get young people involved in activities they felt were exciting and interesting. In schools, the major focus should be on extracurricular involvements, including sports. I argued this would help protect them against the sales pitch of their drug-using peers. I still believe that approach makes sense and have decried the budget slashes that include elimination of sports and other extracurricular programs. I have also argued that meting out jail sentences for illicit drug users and even small time sellers will not solve or even significantly lessen our societal drug problem; nor will “treatment” of drug users have significant impact on the overall problem (see my new book, “reThink: A Twenty-First Century Approach to Preventing Societal Catastrophes”).

The current slaughter in Mexico is forcing me into rethinking my approach. The horrendous situation gets worse every month. In the first six months of 2010, there were more than 5,000 drug-related murders, far more than in any other year. This carnage is driven by the insatiable drug appetite of Americans. If American drug use is the crux of the problem, then users of cocaine, heroin, methamphetamine, and even marihuana, have to accept their complicity in Mexican (and other drug cartel) violence. No longer should they be allowed to claim their drug use is a personal choice, unrelated to the hideous violence it spawns. Users and small time sellers should be held accountable.

The following is my four-point approach; two of the four represent, for me, a dramatic change. As a preface, I should acknowledge that marihuana might, in the near future, be separated from the other currently illegal drugs. However, we still have not had the necessary national discussion concerning the number of legal drugs of pleasure we wish to accept. No society can thrive with no limitations on the number of such drugs that are legalized. We now have alcohol and tobacco. With the reduction in tobacco use, perhaps legalization of marihuana would be okay, but we need that debate.

1. There should be a one-year extensive national education program focused on the link between American illicit drug use and drug cartel violence in Mexico and elsewhere, emphasizing that individual users and small time sellers bear a measure of responsibility and, after the one-year period, will be held accountable.
2. After the one-year period, law enforcement should vigorously pursue illicit drug possession and small time selling. Those convicted should be assigned to a national corps devoted to the badly needed repair of infrastructure (roads, bridges, tunnels, etc). Sentences would range from one to three years, the longer sentences for small time sellers and repeat offenders. Payment for the work would be nominal. That is a real change in approach to possession and small time sellers, but it meets a need (infrastructure repair) yet makes it clear that contributing to a murder epidemic is not acceptable.Of course, this approach would have to be structured so it did not apply to using marihuana products grown in the United States and unrelated to international drug cartels.
3. Sellers of and trafficking in large amounts of illicit drugs would, as now, be treated with harsh sentences.
4. There should e a greater focus on providing young people with alternatives to the drug scene (school extracurricular and community activities). The current restriction of funds for such activities during our recession is pure folly.
   

The bottom line is that we can no longer tolerate the illegal drug use in America that drives ever-increasing violence in other countries and we can no longer accept the rationalization that such use is a personal choice to seek pleasure or relieve some sort of psychological pain and nothing more than that.

_________________________________________________________

Omega-3 fatty acid reduce biologic aging and increase longevity.  Those are the claims.  Is that what the evidence really shows?

July 2010 -- The many reports on television and in newspapers were wildly enthusiastic. Investigators had supposedly shown that a high intake of omega-3 fatty acids, found particularly in fatty fish such as salmon, mackerel, and tuna and in fish oil supplements, reduced biologic aging and could make you live longer.

Heady stuff -- if true.

The study provoking all the enthusiasm was published in the January 20, 2010 issue of the Journal of the American Medical Association. The investigators studied 608 men and women, average age about 66 years. At enrollment, blood specimens were obtained and blood levels of the two most important omega-3 fatty acids were determined, as was the telomere length in the white blood cells. Telomeres are at the ends of our chromosomes. They protect the chromosomes from damage; they also shorten as we age. That shortening has been correlated both the occurrence of chronic diseases and with likelihood of death. It is not clear whether the shortened telomeres are a cause of chronic diseases and mortality or just a marker of these events. Telomere length and shortening are now regarded as, in essence, biologic clocks; a derivative notion is that, if by administering drugs or enzymes, we could keep telomeres from shortening, we could prevent a lot of disease and increase life span substantially.

In this study, the investigators divided the 608 participants into four groups from lowest to highest blood omega-3 fatty acid levels. They then compared telomere length in white blood cells at enrollment and five years later. They found that those with higher omega-3 blood levels at enrollment showed significantly less telomere shortening five years later. That finding caused all the ebullience about slowing the aging process, increasing longevity, preventing disease.

Does the evidence actually support the enthusiasm? In my judgement, it does not.  Indeed, I believe the study is virtually uninterpretable. Here is why. 

1. The four groups (lowest to highest omega-3 levels) were very different from each other. Those with the highest omega-3 blood levels were: older; more likely to be white; better educated; higher in income; less likely to have diabetes; less likely to smoke; less likely to be fat; less likely to have evidence of inflammation. These groups were so different, it is hardly surprising those with higher omega-3 levels would show less telomere shortening at followup -- and no amount of statistical legerdemain can correct adequately for those big group differences.
2. At neither baseline nor five year followup was there a statistically significant correction between blood omega-3 levels and telomere length. That does not make much sense. If telomere shortening at five years is related to omega-3 fatty acid blood levels, then telomere length at baseline and followup should also be correlated. It was not.
3. Everybody in this study had severe coronary heart disease. Any results cannot be generalized to people without established coronary artery disease.
4. There should have been an additional analysis, namely omega-3 fatty acid level at followup related to telomere shortening. The study is incomplete without that.

In sum, the idea that a good omega-3 fatty acid intake might slow biologic aging is an interesting one that, as the authors noted, does merit careful and critical additional study. Even if slowing of telomere shortening in humans can be achieved, it would be necessary to demonstrate clearly that this actually prolonged good quality life. To suggest that this study "proves" anything about omega-3 fatty acids and slowing biologic aging -- or even strongly suggests it -- is plain wrong.

More on mammograms - and a few simple words left out

June 2010 -- In trashing mammograms for women ages 40 to 49 and changing the recommended screening from annually to every other year for women ages 50 to 74, the United States Preventive Services Task Force report included, now widely quoted, estimates of the number of women who need to be in a screening program to avoid one death from breast cancer.

According to a November 23, 2009 article in The New York Times, "1,900 women ages 40 to 50 must be screened to prevent one death from breast cancer up to 20 years later." That statement agrees with figures used generally by the media. The exact figures in the Task Force report are:

1,904 women to prevent one death ages 40 to 49

1,333 women ages 50 to 59 to prevent one death

377 women ages 60 to 69 to prevent one death

There is one big problem with the media statements. The Task Force did not say how many women in each age group had to be screened to prevent one breast cancer death. They indicated how many women in each age group needed to be invited to screening to prevent one death.

That is a huge difference. It is intention to treat all over again. Those figures include women who, despite urging, would not go for mammograms or would not get the mammogram on the recommended schedule (which is now annually, but, if the Task Force report is followed, would be every two years). There is nothing wrong with telling us how many women need to be invited to screening to save one life; but, more important in evaluating mammography, is a figure for each age group indicating how many women need to be actually screened with regular mammograms to save one life. That figure for each age group would be significantly smaller than the figures given for how many need to be invited.

The Task Force seems intent on stacking the deck against mammograms. At the very least, we should be given both figures for each age group, the larger number needed to be invited and the smaller number to be actually screened to prevent one breast cancer death.

Screening for breast cancer is not different from most other cancer or heart attack screening. You have to screen a lot of people who are not destined to get the disease to save the lives or add good quality years to the lives of a small percentage who, absent screening, will develop the full blown disease. That is why screening ordinarily does not save money. It costs money and the major question is how much we are willing to spend per life saved or to provide a specific number of additional years of good quality life. If the costs are reasonable, the screening tests should be embraced – and that is the case with mammograms, starting annually at age 40 and, even though we do not have adequate data beyond age 74, probably not ending until age 85.

The Dumb New Recommendations For Breast Cancer Screening

May 2010 -- The United States Preventive Services Task Force has recently released updated recommendations about screening for breast cancer. They now, unlike their previous recommendations, urge:

1. Screening mammograms every two years for women ages 50 to 74 years;

2. No routine mammograms for women ages 40 to 49;

3. No routine self breast examination.

Additionally, the Task Force takes no position on mammograms after age 74, though they suggest any benefit would be less than for women ages 50 to 74.

These recommendations have created confusion among some, anger in others, and have garnered very little support. Review of the data on which the recommendations are based shows a huge methadologic flaw. The mammography studies used for analysis were the randomized intention to treat type. In this type of study, women assigned to mammography, who never actually had a mammography, then developed breast cancer and died were considered mammogram failures. Those assigned to mammograms who never went for mammography are not mammogram failures; and including them in the evaluation is wrong and results in understating the value of screening mammography.

Statisticians will insist intention to treat is the gold standard; in this case, it is the lead standard.

If only those who actually went for mammograms are analyzed, the various data indicate that, for women ages 50 to 74, routine mammograms reduce breast cancer deaths by 33 to more than 50 percent. For women ages 40 to 49, the reduction in breast cancer mortality is less, in the 17 to 30 percent range.

Breast cancer death rates have fallen 30 percent since 1990, in part because of mammograms. Additionally, the occurrence of new cases of invasive breast cancer have also fallen in every age group, almost certainly due to mammographic screening. The recommendation of the Task Force is based on improper analysis and should be ignored. In addition, in the studies they used, for the most part, the interval between mammographies was 1.5 to 3 years instead of the currently recommended annually. That further understates the value of mammographies.

Breast cancer incidence increases with age and is highest in the 75 to 84 year age group, so there would be no logic in stopping at age 74 despite lack of specific studies on women in that age group.

In sum, the current recommendation for annual mammograms starting at age 40 should be continued; the US Preventive Services Task Force report should be emphatically disregarded.

The Pill To End All Pills - True, False, or In Between

Resveratrol is the new magic pill. Based on animal and test tube experiments, but almost no human data, here are some of the claims. Resveratrol, which in small amounts is found in red wine and grape skins, will be given in gargantuan doses and supposedly will prevent or treat:

• diabetes;
• coronary heart disease;
• cancer;
• degenerative nervous system diseases;
• and maybe also cataracts, osteoporosis, and stroke.

It will also interfere with the aging process and could result in marked increases in life spans

Are there adequate, or even good, preliminary studies documenting such claims in people? Answer: No

Are there any long-term, or even adequate, short-term safety studies on Resveratrol given at these huge doses? Answer: No

Could Resveratrol have real benefits in humans? Of course it could, but it also could have some worrisome side effects. Suppose this was a new antibiotic or a new anti-cancer drug that was very effective in experimental animals, but had never been studied in humans. Would anyone seriously propose that such drugs be approved for use by the general public in the absence of proper clinical trials to study effectiveness and toxicity? If this were done without clinical trials, there would be justifiable public outrage.

The Resveratrol entrepreuners are using a currently legal gimmick; they word any claims carefully and ambiguously with the help of lawyers and then make a statement that claims for the drug have not been reviewed by the Food and Drug Administration. As a result, Resveratrol will be marketed as virtually magic in the absence of any persuasive evidence of either effectiveness or safety in people.

The bottom line, in my judgment, is that Resveratrol is a very interesting and potentially valuable drug whose use, at present, should be restricted to clinical trials for as many years as it takes to determine:

(a) its effectiveness in treating established diseases such as diabetes;

(b) its effectiveness in preventing diseases such as diabetes and coronary heart disease. This could take five to ten, or more, years;

(c) whether its use is associated with significant adverse effects. This too could take five or more years.

If the drug interferes with the aging process, there would be, almost certainly, some very significant consequences for our society. These need to be discussed and debated before the drug is widely distributed to the public (see the chapter on the consequences of extraordinary longevity in my new book, "reThink: A Twenty-First Century Approach To Preventing Societal Catastrophes").

For the present, I urge that everyone avoid Resveratrol, except for those participating in properly designed clinical research trials.

Is Pre-paying Medicare the way to go?

Medicare is a huge healthcare success on a steady course to becoming a stunning financial disaster. 

Why? Since it was started in 1965 the number of beneficiaries has increased dramatically. Then there were about 19 million Americans over age 65. Today that number has doubled and, by the year 2050, it will more than double again to over 85 million men and women.

Our total annual Medicare expenditures today exceed $500 billion. Ten years from now the figure will be $1 trillion -- and there is no end in sight. Medicare has more than $30 trillion in future unfunded liabilities.

Something has to give. The currently proposed "solutions" include:  reducing waste and fraud; increasing the efficiency of care; better management of chronic diseases; greater focus on disease prevention; delaying the onset of benefits to age 70 (or beyond); increasing premiums for beneficiaries; increasing co-payments; and reducing payments to hospitals and doctors. 

Could these actions, taken together, succeed in restoring fiscal integrity to Medicare? Could they be a permanent solution? The answer is a very guarded "perhaps." But, there are three problems. 

First, it is unlikely that all, or even most, of these actions will be implemented successfully.  Second, it is unlikely they will reduce annual expenditures by an amount even close to the hoped-for 30% to 40%. Third, and most important, any combination of these actions is likely to be overwhelmed by a massive increase in the over-65 population (85 million by the year 2050 and 130 million by the year 2100). 

If the proposed solutions do not achieve financial stability, the Medicare system will eventually either collapse or place a gargantuan and unacceptable tax burden on the under-65 population.

Is there another approach? I believe there is.  The pre-payment of Medicare. 

Every child born in the United States, about 4 million a year, would be given by the government $1,000 a year for 18 years, to be placed in an untouchable trust account that would grow by age 65 to more than $300,000 and, if not used until age 75, to more than $500,000. This would be each person's healthcare fund (including long-term care), to be used for no other purpose. After death, any unused monies would be recycled into the program; potentially some of the recycled monies could be used to support the small percentage who would legitimately exceed the amounts in their healthcare funds.

The program would cost maximally $72 billion annually, potentially requiring a 1% value-added tax (or its equivalent), but after 65 years, most of the current Medicare payroll taxes and Medicare premiums (over $200 billion annually) could be abandoned. Radical? Not really, especially when you consider the long-range impact of the plan. The pre-payment of Medicare would have a much greater potential for permanently solving the Medicare crisis than the array of Band-Aids currently being debated by policymakers. At the very least, it deserves careful consideration.  To make sure pre-paying Medicare works as planned, it will still be necessary to correct some of Medicare's most egregious problems, including the need to markedly increase efficiency and coordination of care while reducing profoundly the fraud and waste that, in some cases, borders on the unbelievable.

Teach Young People to Rethink
Public health expert calls for societally connected systems thinking to be taught in nation’s schools

Nov. 30, 2009 NEWARK, N.J. -- There is a better way to think about the big issues of our time and it can be learned in 30 minutes, says public health expert and Chairman Emeritus of the Department of Preventive Medicine and Community Health at New Jersey Medical School Dr. Donald Louria. In his new book, reTHINK: A Twenty-First Approach to Preventing Societal Catastrophes, Dr. Louria calls on the nation’s educational leaders to adopt societally connected systems thinking into middle school and high school and college classrooms.

“Societally connected systems thinking is easy to learn and easy to teach,” said Dr. Louria, who has successfully taught the holistic approach to problem solving to a broad range of students including those enrolled in high school and medical school. He argues that no student should be allowed to graduate from high school unless he or she knows when it is necessary to approach a complex problem with systems thinking and how to create a systems diagram.

The bedrock of the societally connected systems thinking is the circular systems diagram. Problem solvers can tackle any issue by examining its causes and consequences, understanding patterns and identifying leverage points where even minor actions can produce dramatic, positive results.

“To learn systems thinking is to become engaged with the world and interested in improving its future,” Dr. Louria said. “This is a thinking tool that should be available to, understood by and even second nature to all graduates.”

reTHINK is Dr. Louria’s sixth book. It examines seven critical, public issues and using societally connected systems thinking, offers specific, provocative recommendations for solving or mitigating important issues.