Cardozo and Cholesterol

"The half truths of one generation tend at times to perpetuate themselves in the law as the whole truth of another." J. Cardozo, Allegheny College v. National Chautauqua County Bank, 246 N.Y. 369, 159 N.E. 173

I remember about 10 years ago, during a medical school interview, I was asked what contribution would I bring to medicine. My answer was not that well received. First, I expounded on the difference between causation and correlation, and how it appeared that much of today's research was based on correlative data and attempted to treat the symptoms of the condition, and not the condition itself. When I was asked to clarify my position, I should have gracefully backpedaled, but instead, I went on the attack, and began discussing the faulty logic behind the Framingham Heart Study which first introduced the relationship between cholesterol and heart disease. I tried to explain that perhaps a high cholesterol count was a result of a condition that caused heart disease. The interviewer looked shocked, that a college student was questioning decades of research. After all, it's easy to visualize cholesterol as some fatty substance that would clog the arteries if not reduced.

And yet even as new classes of drugs were shown to be effective in reducing cholesterol, the expected reductions in cases of heart diseases never materialized. To explain these inconsistencies, researchers began parsing the definition of cholesterol. We started hearing about HDL (good cholesterol) , LDL (bad cholesterol), triglycerides, and genetic conditions. Today, the conventional wisdom is that the increasing the level of HDL decreases the risk of heart disease. Unfortunately, study after study is showing that the relationship may not be valid. In this week's issue of the Journal of the American Health Association, a study showed that individuals with a genetic condition that resulting in decreased levels of HDL did not have an increased risk of heart disease.

After billions of dollars in research and treatment (estimated 20B/year), we really haven't come close to proving the "half truths" of a fifty year old study. But someone, this half-truth has become entrenched. And along the way, we've marginalize the collateral damage (e.g. Vytorin) that our cholesterol "cures" have caused; later this year, we may even insulate the manufacturers for the damage they cause. Sooner or later, somebody's got to shout that the emperor has no clothes on.