My Cardiovascular Risk Conundrum

In the last couple of weeks I have had two vigorous healthcare conversations that I am having trouble figuring out how to reconcile with each other. Both were related to how we best predict cardiovascular disease, and both were incredibly compelling and engaging and involved super smart people — experts at the top of their field. And both had some really interesting “Aha!” moments in them. But in some ways, they are polar opposites of each other and I am confused about how to think about them as an integrated set, though I know they are related.

I’m going to lay this out for you and will be interested in your thoughts. Just to preempt the obvious, yes I know these things can be interrelated, but that is not the way they exist in the real world.

The first conversation took place between me, David Shaywitz (my podcasting partner in crime at “Tech Tonics”) and Dr. Sek Kathiresan, one of the nation’s foremost experts on the genetic predictors of cardiovascular risk. You are lucky in that you can actually listen to the entire conversation since it occurred on David’s and my “Tech Tonics” podcast found here and on iTunes.

Sek is truly lovely and engaging and is so human it’s hard to imagine he’s a hard-core Harvard scientist. No offense to the myriad of wonderful people I know that meet that definition (love you David and Zak and Christine), but his description of his first interaction with McDonald’s French fries was pure gold and I so loved listening to him talk about his work figuring out the polygenic “smoothie” of cardiovascular disease risk. FYI, “polygenic” means derived from multiple genes.

Basically Sek’s life’s work is finding the mix of tiny genetic nudges that, together, create a numerical cardiovascular risk score that tells you whether you are more or less likely to have to worry about having a heart attack at a young age, much like many of his own family members did. Sek has done years of research to refine an analysis of 500 people who survived heart attacks at an early age (people in their 30s, 40s and 50s) and is in the process of creating/disseminating a diagnostic algorithm that can use genetic testing, such as that available to consumers through Ancestry.com or 23andMe, and tell you where you are on the ”write a will” vs. “go ahead, have the second order of French fries” spectrum. Let’s call this the Biologic Determinants of Health for a moment (my term not his). Now put that on hold for second.

My second conversation took place at my Aspen Health Innovators Fellowship reunion, held last week in Detroit. Quick detour: If you haven’t been to Detroit lately, you haven’t been to Detroit. I was amazed by how nice it was, how safe it felt and how hipster it has become. Seriously — ironic beards and funky lofts everywhere. They are well on their way to kombucha on tap. Thanks Patrick Hines! But I digress….

But because you can only drink for 12 hours, not 24, we alumni include in our reunions a period of time where we read interesting, evocative works of writing (sometimes old, sometimes new) and talk about them seminar-style, like you would in college. We appoint someone the moderator and we take turns debating the meaning of the articles, the implications, the pros and cons — the whole megillah, as my grandma would say. This time we read a story that first ran in The New Yorker called “The Poverty Clinic.” Wow. If you are in healthcare and haven’t read this article by journalist Paul Tough, you need to do so right now.

The article is specifically about Dr. Nadine Burke, a Bay Area physician who, through her work in a clinic in a deeply disadvantaged and underserved community in the Bayview-Hunters Point area of San Francisco, realized how directly childhood trauma leads to adult physical illness. Yes, there is a ton of work out there talking about Social Determinants of Health, but this is highly specific, highly researched and deeply disturbing data about how people who score high on the ACE test, which is a “a tally of different types of abuse, neglect, and other hallmarks of a rough childhood,” are far more likely to experience serious physical illnesses, like cardiovascular disease, later in life. Specifically, Burke’s work showed that the prior work of Vincent Felliti and Robert Anda, both from Kaiser and authors of the ACE Study that was the seminal evidence for this theory, was the real deal in her everyday doctoring experience. And here’s what the work on the ACE test has found: If you have an ACE score of four or higher, you are twice as likely to have cardiovascular disease later in life than someone who scores under four. If you score seven on the ACE test, even if you are a person who does not drink, smoke or overeat (in other words, who doesn’t have behaviors that would cause heart disease), you have a predictive risk of ischemic heart disease that is 360 percent higher than those with an ACE score of zero. Well that sucks.

The ACE test is, by the way, a list of 10 questions that anyone could take in less than three minutes and it asks you nothing about your medical history and specifically nothing about your genetic makeup. You can take the ACE test here. It asks about your childhood home, whether anyone beat you, ridiculed you, ignored you, drank to excess, was abusive to you or your parent, etc. It asks you not one single question about your actual “health,” unless you consider these signs of mental health (which of course they are). And yet, the ACE test may well be as good a scientific predictor of cardiovascular risk as the polygenic risk test derived by Sek Kathiresan during his profoundly important work at Harvard.

What to think about that?!? So many things. The first is this: What is the right treatment to avoid cardiovascular disease? Clearly the answer includes a mix of pharmaceuticals (statins, beta blockers, etc) and behavioral changes (don’t eat those damn French fries). But what I came away with after the ACE conversation was this: Holy shit, by the time we are adults, assuming we had a tough childhood, it may be too late — we have already made a mess. Broken hearts lead to, well, broken hearts, and the real treatment people need is psychiatric/psychological, not biological. For those who wonder about whether the social determinants of health matter, the research around ACEs should give you clear evidence how important these things are. For those of you who spend all your time in the medical model, you may be missing something fundamental.

The other thing I was thinking: Do you know how much money pours into basic research, clinical research and drug discovery around cardiovascular disease? Squillions. Bazillions. So much and it’s still not enough to really get us where we want to be. I think I now know why far more clearly than I really had let crystallize in the past. Yes, all this biology stuff is essential too, but if you come to the game with a loaded psychological deck, you have a much higher burden to overcome and that is likely to suppress the value of the “traditional” treatments. Science is essential, but so is social science and psychology. Can medical treatment even work if psychological treatment isn’t attended to? That is my conundrum.

Maybe we should be matching the medical dollars spent on research and clinical development with the dollars spent on interventions in the social determinants of heart disease. We might actually get a lot farther. We are nowhere close on that measure. There are great organizations trying to get at this, including the American Heart Association, Robert Wood Johnson, Health Leads, Kaiser, etc. But are there any massive for-profit organizations pouring money into finding “cures” for childhood trauma? Please tell me, because I’d really like to know. Talk about a blockbuster opportunity if you could figure out how to productize it. If you had organizations thinking about interventions for childhood trauma the way Pfizer and Amgen think about discovery and commercialization and earnings per share, I bet we would get much further.

So why doesn’t this happen? Many reasons, but one was articulated so well by my Aspen fellowship colleague, Dr. Eric Leuthardt: “The problem lies in the fiction we have created that separates the brain from the mind.” In other words, most of the people in the medical/biological world think that we can treat organs, like the brain, with drugs and other medical interventions and that the mind is a different thing altogether with uncertain boundaries, separate from the true medical treatment process and not susceptible to science in the same way. That’s some pretty deep stuff, but then again Eric is a neurosurgeon/neuroscientist who has spent large parts of his life thinking about the intersection of biology and psychology, so no surprise. You can listen to some of Eric’s thoughts on this “Tech Tonics” podcast. But Eric went on to say, as does The New Yorker article, that there are actual biological changes in the brain and the human body (even the DNA) that directly result from unresolved childhood trauma and which can directly affect the development of the cardiovascular system, the metabolic system, the regulatory system, inflammation, even fetal development. The list goes on and on. The mind-body connection is very real from a biological standpoint, and yet we try so hard not to remember that in our healthcare system. Once again, the psychological and the medical are intrinsically intertwined and one must not be ignored in favor of the other.

In other words, American cardiologists should all be expecting to see a wave of patients in a few years who got to have the childhood experience of detention at the Mexico border, assuming they get to stay.

What is particularly worth nothing is that ACEs are found in every segment of the US population, across every type of community and ethnicity, rich and poor, etc. ACEs are not the purview solely of the Black community or the Latino community or the “bad neighborhood.” They are the story of all people from all walks of life who are dealt a hand that will make them struggle medically and, potentially, financially, given how the costs of using the healthcare shifting are rising for people across the country. No one whose childhood truly sucked is safe. There is lots of good information in this article, which shows that one in 10 children across the United States have experienced three or more ACEs.

So what to do, what to do? Do we seek out teens with high ACE scores and start them early on medical interventions known to have a prophylactic effect? Do we figure out how to fix our pathetic mental health system to ensure that people who need it actually get treatment that is preventative in nature, not just when they are already in crisis? (Or never; would never work for you?) Do we figure out how to train the next generation of physicians to actually think of a whole person risk score that includes not just genetics, biological symptoms and current behavior, but also childhood experiences? I think the answer to all of those may be yes. But how and who pays? Dear Lord, I wish I knew the answer to that one. There are all sorts of companies and organizations trying to tackle little pieces of this puzzle like the blind guys feeling an elephant, but there are few coordinated efforts on this front that really take into account a whole person from childhood to adulthood, brain and mind, body and spirit.

I am deeply puzzled by the clear resistance that still exists when one brings up the importance of treating people’s mental health to get to their physical health. Yeah, yeah, everyone pays lip service to the idea, but few in the business are acting on it. Burke’s clinic in Hunter’s Point is a great example of one that is really trying to do this on purpose. I love the work that Sachin Jain is doing here at Caremore around loneliness. But in general there are few that try, much less get this right, and our insurance system is designed not to think about it this way at all.

And worse, there are people who still question the science around social determinants, even the original ACE study and what has followed. I found it fascinating to learn that the original ACE study done by Felitti and Anda included 17,000 patients enrolled at Kaiser. 17,000 patients. Not a whole lot of clinical trials include 17,000 patients. And because their work took a look at the patients from a retrospective angle (e.g. You have heart disease, so let’s ask questions about your past childhood trauma), skeptics pooh pooh the results, saying that patients will misremember/misreport their experiences. The fact is, most of the time people underreport their traumatic experiences (witness the current eruption of women talking about 30-year-old sexual trauma). And seriously folks, if it weren’t for retrospective data sitting in EMRs we wouldn’t have any healthcare-focused artificial intelligence products at all right now. Every one of those AI monsters is loading up retrospective data that is well-known to be riddled with error, ranging from self-report errors to recording errors to physician errors to lord knows what. But we like those retrospective studies because they are “technology” and investors and large companies are throwing money at AI innovators. What I say to that is this: 17,000 patients. And many, many confirmatory studies have followed the original ACE study, including those by Burke, and even a 30-year-long prospective study undertaken in New Zealand (the Dunedin study). Each time, the same results. So skeptics — wise up.

My thinking is that we really need to increase the value we place on pediatricians and early childhood development experts. We need all kids to take ACE tests in some safe setting and figure out ways to help educate parents about the impact of their behaviors — I know, yeah right, but there has been work done like this in some communities, and even a few kids saved is a few kids saved from an early heart attack or disabling congestive heart failure diagnosis. Maybe we should pair ACE tests with physical fitness tests and think about prevention in a much more expansive way. It’s not just our genes that can determine our outcome, and it’s not just our crappy food and bad behavior. We are the sum of all our characteristics and experiences. We are, as Sek so beautifully put it, a big smoothie of inputs. Let’s recognize that and act accordingly.

How do we create a healthcare system that can respond? I wish I knew but I’m going to keep working on it. I do want to call out many of my Aspen Institute and other colleagues who have made it their life’s work to integrate both the medical and psychological needs of people. There are too many to name but I am so honored to be among them. I am also grateful to people like Sek, my many dedicated colleagues affiliated with the American Heart Association, Dr. Lonny Reisman at Health Reveal and other cardiovascular physician scientists who so clearly are trying to improve the lives of patients by helping them prevent the misery of cardiovascular illnesses. Cardiovascular disease is the leading killer of Americans and yet money has flowed rapidly away from innovation, discovery and intervention here as it has shifted to oncology. Oncology clearly also needs attention — it all does. FYI, ACEs also dramatically increase your risk of cancer.

For all of you involved in the healthcare field, my call to action is this: Your work cannot be an island — please make a concerted effort to build that bridge between the biological determinants of health and the social determinants of health as you go about your everyday lives. If we really want to improve the healthcare system, both sides need each other or the efforts are futile. Focusing only on either biology or psych/sociology is building a bridge to nowhere. And you know who hates bridges to nowhere? Venture capitalists! So you guys with the money, if you actually want to make the world a better place, please join in and think more expansively about what constitutes a good healthcare investment.