Background on author
Han S Chiu, MD [email protected] www.vavici.com
Dr. Chiu is a Stanford-trained physician, venture capitalist, and former pharmaceutical executive. He is an advisor to Stanford’s Clinical Excellence Research Center and leads Malin Burnham’s San Diego based Obesity/Diabetes Working Group. He currently serves as the founder and CEO of VAVICI, a start-up seeking to pilot a root-cause-based physician platform for obesity and diabetes. What follows is an application of root-cause-based principles to challenge and improve our approach to COVID-19 policy and treatment.
Donations can be made to VAVICI FOUNDATION, a 501c3 public charity. For more information please contact Ron Bissinger at [email protected].
COVID-19: FROM CRISIS TO OPPORTUNITY –TAKING BACK OUR LIVES – PART 1 AN INTRODUCTION
COVID-19 is one of the most dangerous pandemics we have faced. Now we find ourselves on a precipice.
Is this really a once in a lifetime tragedy? One that will never happen again.
Or is it a warning?
A once in a lifetime opportunity for us to change the way we do health care;
so that we are never again so unprepared;
so that we can take back our lives.
The choice is ours, but unless we open our eyes and act, it will be gone. It will be replaced by a new “normal”.
The status quo would have us believe that this will all go away with social distancing and the new drugs and vaccines our biotech and pharmaceutical companies will invent.
The status quo would have us believe that in the meantime it is okay to have our ER doctors and hospital physicians toil night and day to save us when we get sick.
The status quo would have us believe that this nightmare will never happen again and that we don’t have to do anything more.
But what if we truly are at the precipice, a breaking point where what we are doing is no longer enough?
Many of us sense that something is not right.
In a world where in almost every industry, technological change has driven innovations that have improved the lives and reduced costs for millions, why has this not happened in healthcare? Instead, we are less healthy and costs have spiraled out of control.
How can we do any good?
When we are all so focused on doing no harm by avoiding any harm.
How can we do what we can and should for ourselves?
When we expect our healthcare workers and companies to do it for us.
We have forgotten a critical element. We have forgotten ourselves and with this we have forgotten the root-cause approach to health care that requires our participation.
This may be the first time that our modern healthcare system has been brought to the brink. There are very real limits to what can be accomplished with avoidance and social distancing. There are even harder limits on what we can expect from our companies, healthcare workers and hospitals. But instead of recognizing this and doing something about it, many of us continue to hope for more.
We hope that a new vaccine will come or that this pandemic will simply burn itself out. Effective herd immunity for COVID-19 the measure by which an epidemic can be stopped requires an estimated 55-82% of the population be immune[1] [2]. It’s hard to imagine getting anywhere close to this level of immunity with current social distancing efforts. Even with a COVID-19 vaccine it’s hard to imagine getting there when the average flu vaccine only works 40-60%[3] of the time and is used by less than half of the population. It is even harder to see how this would happen when COVID-19 has mutated[4] making vaccine development more challenging and bringing us closer to the situation we face with the flu and with colds. These are infections that recur and re-emerge year after year. After all, COVID-19 belongs to the same class of coronaviruses that cause 20% of all colds[5].
We hope that a new miracle drug or a repurposed drug will be developed, but drug development takes time, and ramp up for production takes even longer. A typical drug for an infection can be approved with well under 50% efficacy. For a disease with a fatality rate estimated at ten times the standard flu (0.9%-10% vs 0.1%)[6] we will need closer to 90% efficacy. Even so the standard flu kills an estimated 12-60,000 Americans annually[7]. Mutations don’t just affect vaccines, they can make existing drugs obsolete too. Mother nature fights back and it’s not just us humans she is protecting.
We hope that we will return to a normal way of life, but even many of our leaders recognize that we are in uncharted waters and do not really know how best to restart the economy or what level of testing and social distancing will be with us to stay. So, the new normal may not be that different from what we have now, with social distancing, masks, quarantines and testing.
Even if it isn’t this bad, have we really dodged the bullet or have we simply postponed the inevitable?
None of what we are doing now directly addresses the risk of another pandemic. In fact, with recent SARS and MERS epidemics (both coronaviruses) recurrent pandemics hardly seem like a once in a lifetime problem.
Do we really believe that the reason we are seeing new pandemics is that practices, that have occurred for centuries, have suddenly now unleashed new viruses? Or is it more plausible that we, as a people, are less healthy and so more vulnerable to disease?
We are not in this crisis because of a failure to develop better vaccines and drugs more quickly. We are in this crisis because of a failure to create the kind of health care that protects us from diseases that require these treatments and because we have failed to realize the potential of what we can and should do now.
The idea that we might be more vulnerable isn’t that far-fetched. Chronic diseases that were once uncommon like obesity, diabetes, and heart disease are now so commonplace that even our children are affected. Life expectancy in the US hasn’t just plateaued, it has declined[8]. We might believe we live longer than we did decades ago, but are we healthier?
Is it possible that the Western world and the US in particular, where these changes are more pronounced, is at greater risk? Is this why we have been more adversely affected? Or is it really all just because we took this less seriously, acted too slowly, or just weren’t prepared?
The heroes who save our lives with drugs and ventilators together provide what we might call sick care. It is reactive care provided by others when we are sick and need their support. It focuses on disease symptoms. It is important care, which can and does save lives.
It is not, however, proactive care that makes us stronger and healthier. It does not protect us from future infection. This, in contrast, is what we might call “healthy” care, however, since this goes beyond traditional health and wellness it might be better thought of as “beyond care”. This kind of care focuses on root cause. It is care we can and should be doing now; care that can work better than the drugs and vaccines we are waiting for.
We cannot take back our lives, if our entire focus is on sick care. Sick care works best only when we also try to treat root cause. But can “beyond care” reverse disease? Can it really do so as well or better than drugs?
We have known for decades that chronic diseases like obesity and type II diabetes aren’t just preventable[9], they are reversible[10] using evidenced based root cause approaches (“beyond care”). Yet instead of effectively implementing these approaches we have allowed type II diabetes to become the single biggest driver of healthcare costs, largely because none of our drugs reverse this disease. They treat disease symptoms. Type II diabetes which was uncommon just decades ago now represents an estimated one in seven US healthcare dollars spent[11]. An alarming 40% of the US population is obese[12] and 50% of us have either prediabetes[13] or diabetes[14]. Most of us don’t even know it. Chronic diseases as a whole now represent an estimated 75% of healthcare costs[15]. It isn’t just the western world that has become more vulnerable to disease, China now has one of the fastest growing diabetes rates in the world[16].
Our symptom-based bias is deeply embedded. Over ninety percent of our health care public and private investments, research and development and even the treatments we currently provide do not address root cause. Root cause approaches that include many natural therapies often don’t have a regulatory pathway, let alone a way to achieve patent protection[17]. As a result, they rarely get the support they need to generate the clinical data caregivers are taught to look for.
The NIH budget for complementary therapies, the only NIH section that clearly includes root-cause-based approaches, is less than one half of one percent of its $40 billion annual budget[18] [19]. Venture capitalists, private companies and foundations spend even less on such therapies. An often-cited section of Medicare guidelines (section 225.13) as recently as 2014 read:
“A treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition is deemed NOT medically necessary”.
We are spending most of our resources on symptomatic therapies that enable chronic conditions to exist, when the most impactful results come from root cause treatments that reverse them. When root cause therapies don’t have the resources to generate the clinical data we demand, we assume they don’t work.
If we want our lives back, the only way this will happen is if we as individuals do our part. We will have to do this by taking this opportunity to restore our focus from sick care to healthy “beyond care” and from treating symptoms to treating root cause.
This isn’t about traditional health and wellness using lifestyle verticals to prevent disease. It is healthy care designed to go “beyond” this to encourage our caregivers to use root-cause-based approaches to treat and reverse disease. Instead of using such methodologies for simple wellness and prevention, it’s about pushing the limits of what can be done by applying the same level of critical thinking and technological expertise we use for symptom-based therapies.
Instead of limiting our ability to find new solutions to the handful of companies working on drugs and vaccines, it’s about unleashing the combined might of over 200,000[20] of our brightest minds working together. Instead of limiting our frontline defenders to the much smaller numbers of ER doctors and hospital physicians who normally form our second and final line of defense, it’s about enabling all of our primary care doctors to reach us BEFORE we need such urgent care. Instead of limiting ourselves to specific drugs and lifestyle modalities it’s about leaving no stone unturned and opening our hearts and minds to approaches and treatments that otherwise might never see the light of day. It’s about recognizing that, when we do this kind of healthy “beyond care” we can get results now that are as good or better than we might get from the therapies we are waiting for.
Table 1 Comparison of Health Care Approaches for COVID-19
| Drugs | Vaccines | Traditional Health and Wellness | “Beyond Care“ | |
| Prevents disease | – | +++* | ++ | +++++ |
| Treats disease | +++ | – | – | +++++ |
| Curative potential | +++ | – | – | ++++ |
| Available now | +/- | – | +++++ | +++++ |
| Engages doctors | +++++ | +++ | + | +++++ |
| Empowers patient | – | – | +++ | +++++ |
| Collaborative | – | – | – | +++++** |
| Comprehensive | – | – | + | +++++*** |
It can do things traditional drugs and vaccines do not.
* Vaccines may not protect if a virus mutates. Root cause modalities provide broader protection.
** Seeks collaborative innovation among all primary care doctors instead of fostering competition.
*** Supports using all legitimate modalities including drugs, vaccines, and lifestyle verticals.
To do this requires that we truly understand the limits of avoidance and of the system of research and development that has defined what we call modern medicine. It requires that we understand what is missing and that we open our hearts and minds to the kinds of approaches and therapies that have often been ridiculed and scorned.
Louis Pasteur was originally ridiculed for his thesis that germs cause disease and
Dr. Semmelweis’s original suggestion that hand washing reduces infections didn’t fare much better.
The greatest strides in health care never came from doing the same thing over and over again and expecting a better result. Instead, they came from having the courage to explore those avenues that no one else thought to consider or worse that others scorned and ridiculed.
This is how all major scientific breakthroughs have happened. This is how we can take back our lives.
[1] https://academic.oup.com/cid/article/52/7/911/299077
herd immunity = 1-1/R0, where R0 (a measure of infectivity). For COVID-19 R0 is estimated between 2.2 and 5.7. Therefore, herd immunity requires between 55% to 82% of the population be immune.
[2] https://www.forbes.com/sites/tarahaelle/2020/04/07/the-covid19-coronavirus-disease-may-be-twice-as-contagious-as-we-thought/#2482999429a6
[3] https://www.cdc.gov/flu/vaccines-work/vaccineeffect.htm
[4] https://www.newsweek.com/sars-cov-2-coronavirus-mutate-study-china-1499503
[5] https://www.webmd.com/cold-and-flu/cold-guide/common_cold_causes
[6] https://www.livescience.com/new-coronavirus-compare-with-flu.html
[7] https://www.health.com/condition/cold-flu-sinus/how-many-people-die-of-the-flu-every-year
[8] https://www.cnn.com/2019/11/26/health/us-life-expectancy-decline-study/index.html
[9] https://www.nejm.org/doi/full/10.1056/NEJMoa012512 The DPP study was the impetus for many preventative programs, but many thought leaders immediately recognized it paved the way for reversal of disease.
[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520897/
[11] https://www.diabetes.org/resources/statistics/cost-diabetes
[12] https://www.cdc.gov/nchs/products/databriefs/db360.htm
[13] https://www.cdc.gov/diabetes/basics/prediabetes.html
[14] https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
[15] https://www.chronicdisease.org/page/whyweneedph2imphc
[16] https://www.who.int/china/news/detail/06-04-2016-rate-of-diabetes-in-china-explosive-
[17] https://www.hematologyandoncology.net/archives/june-2016/challenges-of-conducting-clinical-trials-of-natural-products-to-combat-cancer/
[18] https://www.nccih.nih.gov/about/budget/nccih-funding-appropriations-history
[19] https://www.niaid.nih.gov/grants-contracts/budget-appropriation-fiscal-year-2020
[20] https://www.ahrq.gov/research/findings/factsheets/primary/pcwork1/index.html