Hippocrates knew it. Galen knew it. EVERYBODY knows it! (So why are we still paying for research on it?)

It is totally fair to say that everybody knows that exercise is good for you, and overindulgence isn't.  Not all the details are known and they probably change over time and place, because there are various ways to exercise and various ways to eat, drink, and be merry.

But around 400 BC Hippocrates (whoever he/they was/were) clearly observed, knew, and stated that moderation in all things is good for health and longevity, and that exercise is part of that.  500 years later (yet still 2000 years ago), Galen was also very clear about the same points, and this from his own very extensive observation.  Yes!  "Evidence-based medicine" isn't new!

Hippocrates; Rubens engraving; Wikipedia

If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health. 

Eating alone will not keep a man well; he must also take exercise.                   -Hippocrates

And, Galen's view, as described by Jack Berryman in "Motion and rest: Galen on exercise and health" (The Lancet, vol 380:9838, pp 210-11):

Galen (c 129—210 AD), who borrowed much from Hippocrates, structured his medical “theory” upon the “naturals” (of, or with nature—physiology), the “non-naturals” (things not innate—health), and the “contra-naturals” (against nature—pathology). Central to Galen's theory was hygiene (named after the goddess of health Hygieia) and the uses and abuses of Galen's “six things non-natural”. Galen's theory was underpinned by six factors external to the body over which a person had some control: air and environment; food (diet) and drink; sleep and wake; motion (exercise) and rest; retention and evacuation; and passions of the mind (emotions). Galen proposed that these factors should be used in moderation since too much or too little would put the body in imbalance and lead to disease or illness.

Galen; Wikipedia

So, if we all already know this, and have known it for millennia, why are we as societies still paying for researchers to design even more studies so they could show this yet again, and again, and again, and...?  The latest instance is covered in a recent NY Times story reporting a study published in the British Medical Journal in October ("Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study", Naci and Ioannidis, BMJ 2013:347).

The authors looked at studies of the effect of exercise on mortality from heart disease, chronic heart failure, stroke or diabetes and found that exercise was either as good as the standard drug treatment or better, except in the case of chronic heart failure.  The results show that exercise can be very effective, although medicine is the usual treatment prescribed (naturally).   

The results also underscore how infrequently exercise is considered or studied as a medical intervention, Dr. Ioannidis said. “Only 5 percent” of the available and relevant experiments in his new analysis involved exercise. “We need far more information” about how exercise compares, head to head, with drugs in the treatment of many conditions, he said, as well as what types and amounts of exercise confer the most benefit and whether there are side effects, such as injuries. Ideally, he said, pharmaceutical companies would set aside a tiny fraction of their profits for such studies.

But he is not optimistic that such funding will materialize, without widespread public pressure.

The bottom line is that we already know exercise is good for you, don't we?**  It is problematic that we yet need 'far more information', the usual researcher's plaint.  How many details do we need to know about, already knowing that they are largely ephemeral, when there are actual serious unanswered disease questions that we might study?  If half or more of diseases are in a sense treatable, preventable, or delayable with exercise rather than drugs, MRIs and CAT scans, surgery or other approaches, then why do we still allow doctors to meddle as much as they do?  Why do we still have to spend public funds, essentially to feed schools of public health, to keep on doing what are essentially retreads of the same old studies (with fancier and costlier statistical packages and other exciting technologies to make us seem wise and innovatively insightful)--when there are real, devastating disease problems with real unknowns that could be addressed more intensely? 

This is not to mention how much disease would be reduced if we had the societal guts to address poverty.  Real unsolved disease problems may be harder to design studies to understand, actually requiring new thinking rather than just designing some new sampling and questionnaires and the like.  But at least it would be a more real kind of 'research'.

One answer is that this is how the system, and what is basically its rote means of self-perpetuation works.  Science is a social phenomenon not just an objective one.  An institutionalized system doesn't insist on moving beyond essentially safe problems that we have a sufficient knowledge of, to face up to ones we don't yet understand.  That's riskier for professors needing salaries and publications, and administrators needing the overhead funding.  It's part of the fat in the system.

And fat, as we've known since Hippocrates, isn't good for you!


** Actually, despite this post, no, we don't really know this that quite as clearly as you might think!  We do certainly have lots of good mechanistic and physiological reasons why exercise is good, but some fraction of the association of exercise with health may be due to confounding: those who exercise are already healthier than average, or know or care more bout health, or they wouldn't do it (e.g., if they were too overweight, or had troublesome joints, etc.).  So those who exercise are not a random sample. Is it the exercise itself that does them good?   In any case, Galen thought so: he went to the gym regularly because he knew it was good for him!

From scroll to screen: the 500 year academic speed-up

How do academics deal with the chaos of online publishing these days, when it comes to evaluations for professional performance?  Deans, chairs and grant reviewers must make hiring, tenure, promotion, and funding decisions based on academic track records.  But what should be in that record?

We have been advocating our view that the social media, including things like blogs, Twitter, and so on as well as online publishing and open reviewing should count.  Indeed, perhaps the successful professor should be expected to work in this rapid, open mode of spreading his/her ideas, results, and influence.

How that could be done is an important question.  Chairs and deans tend to be conservative.  They want to be fair, and not to be bowled over by chaff and resume-padding.  We know some of the  issues that relate to 'peer' review and so on that lead to just that.  But the online world is chaotic, even as it's exciting, breathtaking, and vibrant.  Many are and more will be considering ways to get away from simple bean-counting (publications, citations, etc.) and move towards more substantial criteria (we've posted on this before, e.g. here).

Galen. De pulsibus. (Manuscript; Venice, ca. 1550). This Greek manuscript of Galen’s treatise on the pulse is interleaved with a Latin translation.  Wikimedia Commons

Nothing New
Today we wanted just to put this in a different perspective.  I am reading a very fine new book by Susan Mttern, called The Prince of Medicine, which is a life of the classic Greek physician Galen.  This sentence, in its context, struck me:  "Almost all significant medical writers had, apparently, commented on Hippocrates..."

Hippocrates of Cos; Rubens, 1638, Wikipedia

Why this struck me is this:  Galen's time (130-200 AD) was roughly 500 years after Hippocrates (and here we skip over who Hippocrates actually was, or wasn't).  By then, all scholars worth their stethoscopes had commented on the works of the great master of Cos.  His ideas had been lauded, picked on, updated, and debated. Various schools of thought, often as vitriolic as differences about selectionism or genetic determinism, chimed in to advocate their view, and critique Hippocrates, and over those five centuries, to critique each other.

It was a vigorous field of play, and must have included a lot of chaff along with the ideas that stuck around.  One would have to know what's what to be able to evaluate who should be listened to, and  who was just ranting or hacking away gratuitiously at the great founder of medicine.

Sound familiar?

We're lucky.  The same is going on now, but we get to enjoy its variegated flavors every day.  We don't have to wait five centuries and only judge retrospectively over the misty generations.

Actually, this is nothing new and it's not specific to the sciences.  The humanities are going online as well, if more slowly.  But in the last thousands of years the idea of descending trees of commentary were certainly part of western culture.  This, as I understand it at least, was the Talmudic and Scholastic and Koranic scholarship through the millennia since the separation of these religions.  It is likely also characteristic of Asian thought, but that's not something I know about.

Again, this took place over centuries, with the usual back and forth, sometimes polite, sometimes vitriolic. Just as science develops its schools of thought, so have religion and philosophy, based on their respective commentariats. But as with science even back in the classical days, things took generations.

We are lucky to live in our faster age, even if it can be too fast sometimes.  Our professional world will have its shakeout.  Ideas will come and go, win or lose in this arena.  But we may all live to see it.  If we can learn to use it creatively.

The death of privacy: an anthropological perspective

For most of the world's creatures now and ever, life is a naked phenomenon. Organisms, their phenotypes and their behavior, were lived entirely in the open. Mating, selection, survival and so on all occurred that way. Those were the kinds of groups in which we too evolved as a species. So, how did privacy become so important to us? We can imagine a scenario; human history at warp speed.

For tens of thousands of years, predominantly small ancestral bands of close kin made their living by hunting and gathering, dwelling around a camp (and, eventually, a campfire). Local groups moved around frequently, abandoning sites and finding new ones--for example, to follow food resources. All must have been public, and basically nothing private. That included the shared and basically equal nature of material possessions, as well as the nature of each person's physical and behavioral traits. Everyone was related to everyone else, in known (indeed, prescribed) ways. It was, perhaps, a gossiper's heaven, since everything was known about everyone by everybody.

Over thousands of years, especially after the implementation of agriculture 10,000 years ago, large, permanently settled but no longer kin-based populations became our environment. Individuals increasingly lived in isolated nuclear (or perhaps 3-generation) families in separate dwellings. They acquired and could accumulate personal possessions, largely interacting with people unrelated to themselves in any known way. Close relatives knew a lot about their own affairs, but less about others'. Society became more unequal, and people developed increasingly private lives, as we know them today.

Very large societies require administrative structures (governments) for protections of all sorts, and to avoid the chaos of conflicts of interest and personal conflicts. This includes the protection of individuals' privacy from intrusion by others (which we name 'crime'). Industrial societies, at least in part because of the growing inequities they developed, came increasingly to recognize personal privacy, including ownership, as important or even fundamental.

Disputes, that traditionally were settled by the families involved, or by a local strong-man, became society's business, with standardized codes of acceptable behavior and of sanctions for violations, that is, laws. Probably beginning with property, society protected individual possession as well as individual rights not to disclose possessions.

Humans build their emotions and belief systems around their ways of life. So, associated with these societal privacy traits were senses of outrage or embarrassment if the traits became known. They may make a person vulnerable to social or material risks, by revealing weaknesses, or his deceits, greed, and the like.

Personal traits including health became largely private unless revealed by the individual or family, but physicians necessarily had to know. As a result, even in the Hippocratic oath around 2400 years ago, physicians promise that

"All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal."

There are many obvious reasons for this. The healthy could easily take advantage of the sick or even of health risks they know such people may face. Relatives would perforce know a lot, but could be trusted, at least comparatively. In modern times, the obvious reasons for health privacy include the possibility that disease may be used to discriminate against people in various ways (jobs, insurance, etc.), and this would go against the legalized sense of things-that-are-nobody-else's-business.

Medical genetic data on their surface can be viewed simply as another source of diagnostic or therapeutic information, like blood pressure or 'where does it hurt?' But there are several basic differences:

1. Genetic data about a person are also informative about his/her relatives
2. Genetic data can be informative about any of the person's characteristics, not just the currently-presenting disease, and including normal as well as disease traits
3. Genetic data may be of predictive value about a person's future, in a way that vested interests can use to discriminate among people to their detriment and the gain of the discriminator (e.g., HMO, insurer, employer, pension plan). Even police and the military get into the act in many forensic, security, or other ways.

It is for this reason that many are concerned about privacy issues in relation to 'personalized medicine' which, at its core means computerized storage and analysis of DNA sequence data for the purposes of assessing existing or potential phenotypes of the individual (not just a group).

There are many professional bioethicists thinking about this, as well as lawyers, journalists, legislators, and scientists. Indeed, we ourselves are happy to be helping train a graduate student who is both knowledgeable in modern genetics and a practicing lawyer. She should be an unusually qualified individual to help as society negotiates between science, society, and the law.

A lot of worry is being expressed, some of it professional angst (making careers out of the issues), given that it seems wholly inevitable that, barring some gross national trauma, personal DNA sequence data bases are inevitably going to proliferate. Unless we get bored with genetics, our technological age is in love with DNA and is widely embracing it, both to great profit and because of the accepted promise of major health advances.

Much of this debate is moot because the lid certainly cannot be kept on such a bottle. Data bases will increase, become more shared, computerized, coordinated, public, and difficult to contain. Interpretation of all sorts will accompany that growth. More and more people will learn more and more about more and more people--or at least will think they did.

How far this goes nobody can know, but it may be most useful to think ahead and stop knotting one's stomach about the details of regulation. Let's do something that is probably more useful to think about: let's assume that everyone's complete DNA sequence and its interpretation is entirely public, and can be known to anybody who wants to look. Let's further make the au courant assumption that DNA is the deterministic causal blueprint for who and what each of us is.

Such changes are to a great extent likely to occur, and in a way they spell the death of much of the sense of privacy that we have lived with for the roughly 10,000 years since the dawn of settled agricultural societies.

Younger generations will be born into this system, after us grouchy old goats pass the scene. For new generations this will just be how things are. The effects of such data, and how they're handled, will be worked out--fallibly, imperfectly and with abuses, as always in human affairs. But we will work them out! We know that, as humans, we can live publicly naked lives. That doesn't mean we can do it free of trauma, and history does not suggest we'll always do otherwise. In a sense, in regard to this particular issue, in shedding our privacy clothes, we'll be going back to our beginnings.