The years I have spent studying the medical industry have made me appreciate how often economic principles can allow one to understand its complex and contradictory behavior.
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For example, I believe many of the inconsistencies in medical ethics (e.g., “mothers have an absolute right to abort their children” and “mothers cannot refuse to vaccinate their children because it endangers their child’s life”) can be explained by simply acknowledging that whatever makes money is deemed “ethical.”
Sales Funnels
The sales funnel concept is crucial to understanding the modern medical industry. This method involves initially targeting a broad audience and then gradually narrowing down to more expensive products or services for the captured customers. There are typically two overlapping sales funnels in medicine:
The first funnel involves prescribing innocuous drugs to many people and then selling increasingly expensive pharmaceuticals to treat complications. For example, this often occurs with medications given to girls, leading to harmful consequences.
Note: Sources for the above graph can be found in this article about the dangers of SSRI antidepressants.
The second funnel involves framing preventative medicine as screening individuals for potential health risks and then using these results to justify selling medical services like drug prescriptions. As these screenings become normalized, the industry expands the range of services offered, often leading to overdiagnosis and overtreatment. For instance, guidelines for “safe” blood pressure and cholesterol levels have been continuously lowered, hence putting more people on medications.
Note: The folly of this approach is highlighted by a trial that found removing on average 2.8 non-essential drugs from the elderly at one facility caused their 1-year death rate to go from 45% to 21%.
DEXA Scams
One common way mass screenings are conducted is by giving many patients X-rays and then funneling those with abnormal imaging into being treated. For example, women over 50 get mammograms every two years to detect breast cancer early. However, studies show these screenings often lack overall benefit because fast-growing cancers are usually not caught early, while false positives are common and frequently lead to harmful treatments.
Note: Many medical specialists depend upon repeatedly performing the same billable service (e.g., vaccinating a child, performing a female pelvic exam, or reading a mammogram).
Another common universal screening practice for women is dual-energy X-ray absorptiometry (DEXA) scans, which measure bone density as an indicator of bone strength. The results are compared to the average bone density of a 30-year-old, producing a T-score. Medical students learn that a T-score of 0 to -1 is normal, -1 to -2.5 indicates osteopenia, and -2.5 or worse signifies osteoporosis, prompting urgent treatment.
However, considering natural age-related bone density loss, most individuals will have lower bone density than a 30-year-old. Thus, the current approach to managing osteoporosis acknowledges inevitable bone loss with age and focuses on prevention, as regaining bone density later in life is challenging.
How reliable are DEXA scans? Results vary significantly based on machine, operator, and measured bones, with studies showing a 5% – 6% difference in bone density. This variation can alter T-scores by 0.2 – 0.4, leading to misdiagnoses of osteoporosis.
Is repeated scanning necessary? A study of 4124 older women found no additional useful information gained from repeating DEXA scans over 8 years. Yet, guidelines recommend scans every 1-2 years, with Medicare covering one every 2 years, despite costs ranging from $150 to $300 per scan.
Do DEXA scans accurately predict fracture risk? While generally predictive, studies show discrepancies between scan results and observed bone strength under a microscope. Additionally, scans often underestimate strength loss in deliberately weakened bones.
Note: I recently learned from Dr. Mercola that a faster and more accurate method of diagnosing bone strength (which does not expose patients to ionizing radiation) is beginning to be used in Europe. REMS technology works by sending ultrasound waves into the bone and then analyzing the spectrum created to assess the health of the bones.
As this presentation shows, it accurately predicts bone density, and additionally, predicts bone strength. In short, this may be a dramatically superior approach to Dexa scans, but it faces stiff resistance in the United States because of how heavily invested many already are in performing DEXA scans. For those interested, more information can be found at EchoLight’s website.
Note: This comment was affirmed in an NPR article.
Bisphosphonates
Once osteoporosis is diagnosed, the initial treatment often involves starting a bisphosphonate, which may continue for 3-5 years depending on the administration method. A variety of factors influence the development of bone.
Two of the most important ones are the cells that build bone up (osteoblasts) and the cells that break bone down (osteoclasts). Bisphosphonates, (e.g., Fosamax or Actonel), concentrate in bones and inhibit osteoclasts, leading to increased bone density by shifting the balance towards bone building. However, this approach faces two major issues:
•Bisphosphonates are associated with numerous side effects, such as stomach irritation, severe muscle and bone pain, flu-like symptoms, osteonecrosis of the jaw, unusual hip fractures, atrial fibrillation, hypocalcemia, fatigue, and kidney problems. Remarkably, the American Dental Association even cautioned its members to avoid working on patients who are taking bisphosphonates.
•Bisphosphonates disrupt the body’s natural bone-building process, resulting in the preservation of “old bone” rather than promoting healthy bone formation.
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Note: In addition to the bisphosphonates, there are other problematic osteoporosis drugs which also target the osteoclasts.
Bone Remodeling
One of the key adaptive processes in the body is its response to stresses and loads placed upon it. An often-overlooked marvel of the body is its continual reshaping of bones to bear loads optimally. While we seldom think about this process, its significance becomes apparent in certain scenarios. Consider space travel: astronauts, deprived of gravity’s weight signals, experience rapid bone loss, posing serious fracture risks upon returning to Earth.
In this bone-building ballet, osteoclasts play a crucial yet under-appreciated role. They sculpt bones to withstand gravity’s demands, but when blocked by drugs like bisphosphonates, bones become denser yet more brittle and less flexible. This is important because less flexible bones are much more likely to break when an impact occurs (and since that flexibility is lost from normal processes of aging such as declining hormone levels) fractures are more common in the elderly.
This underscores a common issue in medicine: focusing on treating numbers (e.g., lowering cholesterol) assuming it equates to health improvement. Studies often assess benefits through value changes (e.g., vaccine-induced antibodies), overlooking actual patient outcomes (e.g., in Pfizer’s COVID vaccine studies, antibody production didn’t correlate with decreased deaths).
In short, I would posit that while bisphosphonates may be effective at improving a DEXA score, they aren’t necessarily good at improving bone health.
