Blog | Thursday, May 8, 2014

What I would do if my foot caught fire

I know it seems like the obvious choice, but I would not run a randomized clinical trial.

I have recently lamented the pernicious influence, within my domain of public health practice, of hyperbolic headlines proclaiming “this,” followed unfailingly by equally and oppositely hyperbolic headlines reactively proclaiming “that.” But we are obligated to acknowledge that there are, generally, research studies underlying the headlines, however extreme the pop culture distortions of the actual findings. So to some extent, the problem originates before ever the headlines are a gleam in an editor’s eye, with our expectant anticipation of the next clinical trial, and the next, and the next.

By all means, bring on the clinical trials! They serve us well. They advance the human condition. I run a clinical research lab; my career is devoted to just such trials.

But still, I wouldn’t conduct one if my foot caught fire.

Of course, there is a very good case for running such a study, as many vitally important questions about the right response to a foot on fire are at present unanswered. What, for instance, would be the ideal volume of water? Should it be hard water, or soft? Fluoridated, or not? A controlled trial is very tempting to address each of these.

The vessel is even more vexing. What would be the best kind of bucket? What size should it be? What color should the bucket be, what composition, and what’s the ideal kind of handle? I think the variations here are the basis for an entire research career.

Perhaps the notion of running randomized, double-blind, controlled intervention trials to determine the right response to a foot on fire seems silly to you. But if so, you must be suggesting that science does not preclude sense. That’s rather radical thinking in some quarters.

I recall, in particular, a talk I gave some years ago to an academic audience in Washington, D.C. At this stage of my career, I have had the opportunity to honor more fully the sensible “trust, but verify” adage for which we have Ronald Reagan to thank, or the more recent “keep the faith, but get the data” courtesy of author Samhu Iyyam. Most of the convictions my colleagues and I have had about public health interventions have, over the years, traversed the gauntlet from hypothesis to protocol to published findings. We have been getting the data, and continue to do so.

But back then, I was younger, and I had fewer data and published papers to substantiate what I thought were very sensible ideas about combating obesity and chronic disease, such as engineering opportunities for physical activity into the school day and work day; teaching children and adults how to trade up their food choices; and more along those lines. So when I presented an overview of the problem and likened it to a flood, my academic audience indulged me with subtle nods of venerable heads. But when I then presumed to suggest that if the problem was a flood, the solution was a levee and I had some sandbags. The restive vibration of disapprobation shook the very air. Where were the clinical trials? How dare I propose solutions in their absence?

Not all academics are put together this way, of course. I have many colleagues every bit as inclined as I to roll up their sleeves, bend their backs, and stack sandbags. But the ivory tower crowd does tend to hold the most rarefied real estate in academia. And from what I can tell, if their feet caught fire, they would, indeed, await the scrupulously analyzed results of a whole sequence of randomized trials before doing anything about it.

But I would not.

Nor would I succumb to the almost equally seductive offerings of the foot fire fadists. This group has no need of clinical trials because they’ve got epiphanies. On the basis of such revelations, they might proclaim that the only way to put out the fire would be to use a green bucket. No, purple. Or, it would have to be a bucket made of hemp; or coconut fiber; or rawhide; or paper mache. Or maybe it would be that the handle would need to be blue; or a lanyard; or incorporate a twist to the left. Or perhaps it would be all about how to hold the bucket, with the left hand only, and just the right 3 fingers, revealed only to those who send in the first of three payments of just $29.95. Or maybe they would know the only proper mix of electrolytes in solution, and that would make all the difference.

Tempting options, all. But for the fact that they are utter nonsense.

And so we come to it. If my foot caught fire, I would not seek out the mystical insights of iconoclastic geniuses (self-proclaimed) regarding solute, or handle, or fingers. Nor would I hop (on the other foot) into an ivory tower to join in the number crunching.

If my foot caught fire, I would just go ahead and fetch a pail of water. Soldiering past the want of randomized clinical trials on the topic, and weirdly wonderful fad approaches would test me sorely, but I think I could deal with it.

And that, of course, is what today’s rant is really about. Let’s just deal with it! Let’s deal with using what we know about lifestyle and diet to fix the stuff that ails us. Let’s eliminate 80 percent of all chronic disease, because we can. Let’s allow for the complementary roles of science and sense. Let’s concede that simple isn’t the same as easy, that hard doesn’t have to mean complicated.

If my foot caught fire, I would fetch a pail of water.

We have comparably urgent matters at hand (if not foot). We have sufficient information to address them effectively -- protecting years in life, and life in years. Let those so inclined crunch numbers forever in their ivory towers. The rest of us should welcome the data as they come in; but we would be well advised to take action right now, based on sense as well as science as if our feet were on fire.