Book Summary: Over-Diagnosis – Making People Sick In The Pursuit Of Health, by Dr. H Gilbert Welch

Imagine one morning you don’t feel right and go in WebMD (medical portal) to figure out what’s wrong, you browse around until you find the illness that catches your eye, Swine-Flu.

As you read through the list of symptoms you realize that you have all of them or in other words if you have all of the symptoms that you would have if you have Swine-Flu.  If we talk in term of probability, 95% of the people with swine-Flu have these symptoms. You began to freak-out and this is what happened to us most of the time. You search about any small symptom on the internet, you are sure to meet disaster. They will lead you to the any form of cancer or any dangerous disease. But this is not the truth sometimes, in fact, most of the times. Let us see how. If you know about Bayes Theorem, (a concept in probability. Don’t worry we are not dealing this in detail) you do further research and try to find out more facts to figure out the probability if you have swine flu or not. So, with little more googling you discover that the disease is extremely rare, only one in one hundred thousand (1/100000).Now, about the symptoms, like headache and runny nose, lots of people have those and google tell you one in a hundred (1/100). Putting everything into the place, now probability (using Bayesian theorem) of have Swine Flu is calculated as .00095, which is very-very small as compare to the probability we saw in first stance i.e. 95%. If we revisit the statement once again “…95% of the people with swine-Flu have these symptoms”, DOESN'T mean if you have these symptoms then 95% chances of you having Swine Flu.

In the book, Overdiagnosed: Making People Sick in the Pursuit of Health (Beacon Press), Welch and coauthors Lisa Schwartz and Steven Woloshin write about the hazards of looking too hard for illnesses in healthy people, including additional procedures that carry no benefit, but may cause harm, higher health care costs, and psychological detriments. “The biggest problem is that over diagnosis triggers over-treatment, and all of these treatments carry some harm,” says Dr. Welch.

There is an assumption that sooner is always better  but the hidden assumption states anything found early required intervention. OVER-DIAGNOSIS can be defined as the detection and treatment of an abnormality not destined to ever produce symptom or death.

This book is divided into twelve thorough chapters that do not only unveils the systematic conspiracy of the health care systems but also bursts the hypes created by popular media that promotes the fear of disease and perpetuates the myth that early and aggressive treatment is always better. Doctors have begun to leave no test undone, no abnormality overlooked. Profits are being made from screenings, medical procedure and pharmaceutical.

Chapter two; We change the Rules, highlights the clear traces of conspiracy at the institutional level. It shows how numbers get changed to give you diabetes, high cholesterol and osteoporosis. The author provides the end-to-end research to prove that over-diagnosis or early detection doesn’t help the population at large but only instills the fear of being died with the disease. Let us see how-

Who is diabetic? Before 19997, if you had fasting sugar over 140, then you had diabetes. But in 1997 the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus redefines the disorder. Now if you have fasting blood sugar over 126, you have diabetes. So everyone between 126 and 140 used to be normal but now has diabetes. That little change turned over 1.6 million people into patients.

Is that a problem? Maybe, or May not be. Because the rule has been changed, doctors now have to treat more patients for diabetes. That MAY mean that they have lowered the chances of diabetic complications for some of these new patients. But because these people have milder diabetes, they are at relatively at low risk of these complications to begin with. The author has proved through the research that people with mild abnormal blood sugar have less to gain from treatment. If patients are not getting benefited from the early diagnosis then who is?

These changes substantially increased the market for treatment and the money to be made from them. There are widespread concerns about the independence of the experts who set the cutoffs for all the conditions (whether it is diabetes, hypertension, osteoporosis or any other disease). The head of the diabetes cutoff panel was a paid consultant to Aventis Pharmaceuticals, Bristo-Myers Squibb, Eli Litty, GlaxoSmithKline, Novartis, Merck and Pfizer – all of which make diabetes drugs. Nine of the eleven authors of recent high blood pressure guidelines had some kind of financial ties – as paid consultant, paid speaker, or grant – to drug companies that made high blood pressure drugs. Similarly, eight of the nine experts who lowered the cholesterol cutoff were paid consultants to drug companies making cholesterol drugs.

With over-diagnosis, a few may be helped but a lot more will be over treated and some of them will be harmed. The conventional ethos of medical is to focus of potential benefits for the few and to downplay the rest. Dr. Welch proved via randomized trials that the treatment on ‘new’ patients (with mild abnormality) does not improve the chances of not getting better. However, over diagnosis will increases the chances of plethora of other diseases.

In the graph on the left (fig. 1a), the rise in cancer diagnosis is accompanied by a rise in the feared outcome of cancer -  death. This suggests that the new diagnoses are destined to be meaningful and that this is a true increase in the underlying amount of cancer that matters.

But in the graph on the right, the rise in cancer diagnoses is not accompanied by a rise in cancer death. This suggest that while there is more diagnosis, there is no change in the underlying amount of cancer that matters.

Over-Diagnosis can also be understood as an attempt to look harder to find the abnormalities without any symptoms. This has been seen in cases of prostate cancer, breast cancer and other abnormalities which required scanning. Fear has taken place of understanding the disease. The simple rule of thumb that can be deduced from the findings of the author is that -  diagnosis is important but it should follow the symptoms not the other way around.

Author cautions in the end that it’s tempting to conclude that the solution is simply to avoid doctors. But that would be the wrong conclusion. Medical care offers ill patients a great care. The question is about when you are well. How hard doctors look for things to be wrong?

Book Review: ‘I am a Troll: Inside the Secret World of the BJP’s Digital Army’ by Swati Chaturvedi

The name of this book made me understand more about the term ‘Troll’.  A message that someone leaves on the internet that is intended to annoy people is troll. Lacking logic and perhaps even decency, these most often nameless, faceless but sometimes wholly visible people attack those they don’t agree with.

I am a Troll: Inside the Secret World of the BJP’s Digital Army is Swati Chaturvedi’s two year research. Her investigation as she calls it, is ‘inspired’ by her own experiences and those of her ‘fellow citizens’ who have been on the wrong side of trolling.

When any writer writes against the political party (BJP), which is not only ruling the country but came into power with huge majority and continuously spreading its presence in whole country, then, for sure, the writer is very courageous.

The veteran journalist, in this quick-read, maps out how some of the most venomous handles on Twitter are those that are ‘“Blessed to be followed by PM Modi”. The PM follows them, they follow him, and they also follow those who speak against him – attacking them at any given opportunity in what looks like a fully organised, coordinated game plan.  Through her conversations with BJP social media volunteers and Sadhavi Khosla (a former BJP social media cell member), the author takes us through how social media attacks are planned.

It reveals the BJP’s strong social media cell and its vast online support. Sadhavi Khosla claims that the BJP’s media cell pressurize the Snapdeal to drop Amir Khan is its brand ambassador after Amir’s strong comments about intolerance in 2015. Another undercover story states that the same unit trolled Shahrukh Khan and provoke its online support to boycott his movie Dilwale.

Ms Charurvedi alleges BJP for carrying out organized trolling on social media platforms to conveys a sense of the mood to the masses.

In her telling, the Bharatiya Janata Party (or the larger Sangh Parivar) uses volunteers and paid employees to function in concert and to execute centralised directives to “constantly peddle hate tweets and conspiracy theories and slander journalists”. Worse still, she claims, the hate-filled tweets are packed with communally volatile misinformation (a mythical exodus of Hindus from Kairana in UP, for instance) and contain threats: Hire so-and-so and we will boycott your company/paper/channel/product or  even worse.

Mr. Modi is followed some cyber bullies Twitter accounts (like LutynInsider, which I could not find on twitter. May be it got deleted after the row) that regularly tweet abusive language or obscenities, she claims. On the same note, Derek O’ Briain raised Ms Chaturvedi’s claims in the legislature, questioning why Mr Modi followed cyber-bullies.

Ankit Lal from AAP, who Chaturvedi says “tracks the ruling party’s social media as part of his work”, presents information on the same, casting doubts about how either the “BJP social media control centres have started using virtual private networks (VPNs) to hide their location and identity… The other possible explanation is that the BJP has hired a marketing agency in Thailand to do their online work.”

Moreover, this books gives the impression that BJP is the only single party that is using social media power to influence the behavior of the people which doesn’t seems a balanced view.  Other parties and people are let go scot-free, even when we know that everyone plays a dirty game – on Twitter and off it.

Huffington post  calls this book as a missed opportunity as of the seven short chapters that make up Swati Chaturvedi's work, almost entirely devoted to the testimony of Sadhavi Khosla, a former volunteer with the Bharatiya Janata Party (BJP), who has been responsible for the most explosive revelation in the book.  ‘While her mission to expose these trolls -- an army of men and women who thrive on misogyny, Islamophobia, hatred and bigotry -- is incredibly brave, urgent and necessary, the execution of the project could have been much better.’

On the factual front, I found little inconsistency in the facts; One, it was told I the book the flesh from the Akhlak’s home was not beef, which is incorrect. It was confirmed I the reports that the meat was found to be beef. Secondly, the picture is not black and white when she claims that Sadhavi Khosla  is the former volunteer with BJP as BJP denies the claim. Thirdly, with certainty, she says, Mr. Modi is handing its twitter accounts. It is very hard (but not certain) that the PM is so attached to his twitter account when he handles this by himself.

This book is less about trolls in general and more about what she claims is “the BJP’s digital army”. Chaturvedi has taken an interesting look at a topic of growing relevance to India and other democracies but should be researched without bias.