Obesity; Immune Mediated Inflam D; Addiction; Iatrogenic: 4 Horsemen Modern Poor Health Apocalypse

Obesity; Immune Mediated Inflammatory Disease (IMID- includes Gadolinium Deposition Disease-GDD); Addiction; and Iatrogenic Disease represent the 4 horsemen of the Modern Poor Health Apocalypse. They all share the common root cause of Genetics and Environment combination. For the most part the Genetics is not an inevitability that the poor outcome will arise, but a predisposition, that with correct environmental intervention poor outcome can be avoided.

The traditional horsemen of death still exist, and in many respects the modern contributions assist them. So war, famine, infection all still are doing well as causes of death, facilitated by greed and stupidity (Stephen Hawking's observation). Cancer, dementia and toxin exposure have also gained ground over the century - in part a reflection of overall longer life spans.

But herein I am discussing the truly modern poor health horsemen, which do not lead inevitably to an early death, but do contribute to overall poor health, physical and mental. Longer lives, but lousier longer lives.

Obesity. The genetic predisposition has always existed, but the difference is the environment. In broad brush-strokes: poor diet, increased sugars (carbonated beverages a major culprit), increased chemicals in foods especially ultraprocessed foods, and decreased physical activity. We have understood these issues for easily a half century, but these factors have all accelerated in modern life . There are now nuances to diet: lecithins, gluten, and other allergies/ intolerances, but most of the problem can be handled by large brush-strokes. These include stopping subsidizing harmful calorie production, such as corn; and start subsidizing healthy calorie production such as broccoli, other vegetables, berries such as blueberries, other fruits, and subsidize better distribution of quality foods with little post-processing to low income communities.

A major focus of mine is presently the observation of upper GI inflammation as the root cause for many abdominal diseases, including obesity. Abdominal pain is the most common clinical complaint in the general public, and this can be seen as increased inflammation in the esophagus, stomach, duodenum, jejunum, and ileum..

Obesity leads then to a chronic low level of inflammation. Inflammation is an important cause of malignant transformation, such as in the liver, with Non-alcoholic Steatohepatitis [NASH] an outcome primarily from obesity becoming the most common cause for hepatocellular cancer, even though percentage wise the incidence of cancer is much lower in NASH than in toxic liver disease like Hepatitis C, but numerically the number of individuals with NASH is much more enormous.

Chronic low level inflammation from obesity increases the risks of many cancers (classic example endometrial cancer), but also the risk of dying from infections of all kinds, most recently in the public attention, COVID-19.

Prevention through education will have by far the greatest impact. My opinion is that the most important school class in K-12 is Health and Wellness (diet and exercise). To continue the theme of education, followed by critical thinking in the sciences; communication; and rounding out the important list: humanities that emphasizes tolerance and understanding.

2. Immune Mediated Inflammatory Diseases. (IMID). This entity also combines a genetic predisposition with environment. GDD is what I have focused on, but the general principles apply to all of them. A general principle is that toxic exposures that disturb our immune system, can result in their mishandling of antigen management. A simple but pervasive one has been excessive use of antibiotics, primarily on ourselves, but also in the foods we eat; and effects from other toxic chemicals. If we consume an antibiotic, such as ampicillin, because we feel somewhat sick or in our infant children they have a fever and are tugging on their ear, and by taking the antibiotic (without lab evidence it should be beneficial, hence unnecesssary) we wipe out half of our native intestinal bacteria, that then get replaced by foreign and potentially harmful bacteria.... what do we think is going to happen? Our native intestinal bacteria form one of our most important immune defenses. Excess antibiotic use leads to famous lethal infections: noteworthy the family of multiple antibiotic resistant bacteria (now called MultiDrug Resistant Organisms [MDROs]).

I have not previously described this but it is interesting that morphologically the low level chronic inflammation related to the upper GI tract predisposes to obesity; whereas the great majority of GDD sufferers are not obese, but slim to medium build. This reflects that the immune perturbation of these two sets of chronically inflamed individuals result in a fundamentally different response in the body shape. The upper GI inflammation leads to a set of biochemicals that try to correct the disturbance by a more increased and constant food intake, whereas the T-cell dysregulation of GDD does not stimulate what I would call these cibi cherubitas (food craving) axis biochemicals, hence most individuals are thin to normal weight.

Probably a toxin-created too sterile environments (meaning using excess chemicals to create a clean, bacteria deficient environment) creates a trigger happy immune system in many of the IMID group.

3. Addiction. The classic addictions that have been killing us in great numbers over the last century have been excess alcohol intake and excess smoking of tobacco. Progressively highly addictive drugs over the last 30 years have been increasing in importance, and now the king of addictions that are killing us is fentanyl, although alcohol and smoking may be still more common causes of death, but they are more protracted and silent, and not so sudden and dramatic as potent illegal drugs in the opiate family and other families.

There is no doubt that there is an important genetic component to addiction, but again it is a predilection and not an inevitability. It may be the most important impact will be Health and Wellness education K-12. Consumption of drugs is far too alluring, that without early preventive eduction it is too easy to fall into their trap. The spiral of negative effects of pervasive social media on cell phones, feelings of worthlessness and hopelessness, that social media helps to instill, is a toxic fertile ground for addiction.

4. Iatrogenic Injury. This refers to injury from health care. A number of credible reports from credible investigators and agencies have described that health care errors are the 4th most common cause of death in the US. A somewhat competing narrative is that atleast 50% of health care expenses arise in the last 6 months of life. What this informs me, is that many of the deaths related to errors are really occurring in preterminal individuals... too much given of a drug they are on, or too little in individuals in fundamentally poor health.

The most dramatic of these deaths in individuals in poor health are those caused by the likely self-described 'angels of merciful death'. Most of these are nurses, some other technologists such as respiratory, and comparatively fewer are physicians (although the image of Doctor Death captures the blood lust allure of the public more than the other lesser trained health care workers). In these perpetrators, this pattern of distorted perception, cognition and conduct is difficult to pin down the mental disturbance, probably a spectrum of schizotypal personality disorder to frank psychopaths. I suspect the majority of these perpetrators (even in the neonatal intensive care nursery setting, and not just old age retirement facilities) consider themselves 'angels of merciful death', and a much smaller percentage are true devils of death (true psychopaths), that are simply happy to have the opportunity to kill other people. Overall these numbers are small and I will write a more directed blog in the future on 'deliverers of death'.

Most of the errors that occur in the fundamentally extremely sick, although unfortunate, are not in my estimation, truly tragic. Most of these errors are likely secondary to health care workers simply being overworked and with the carelessness that arises from that, and a smaller number are due to true incompetence.

The iatrogenic injuries that should be considered tragic, that compensation to the victims and/or their families seems justified, are ones where the individuals was essentially young and ok, or older and well, they go in to seek health care, and then get injured and or die. There is a considerable overlap in this category with the above mentioned Addiction Horseman.

What has been essentially completely overlooked to the present time is the integral and dire role that management plays in this category. This certainly is true in the case where health care workers are devils of death, and senior management choses to ignore and cover this up, and send the perpetrators along to other health care facilities, if they can accomplish that goal.. Staying with the religious theme, on these senior administrators the sword of the Avenging Archangel Michael should smite them upon their heads. Overworked providers can be remedied by increasing staff, so errors from being overwhelmed are minimized, this also generally requires paying higher salary to staff.

What is completely inexcusable is senior administration that allow dangerous health care workers to continue to practice, or to allow dangerous health care workers to leave and go on to other health care systems without providing any warning. The most dramatic examples are health care workers that are psychopaths, being sent off with good recommendation, because management does not want to create any publicity that may reflect badly on their institution, and to their financial bottom line. This is relatively uncommon but not rare. An overwhelming legal settlement against them, would curb this impulse for other centers in the future to ignore or cover-up devils of death. As with many things, generally the largest category of misconducts is not the dramatic ones of psychopaths killing innocent victims, but the mundane, non-exciting, non blood lust allure cases of simple incompetent practitioners causing injury. Competency as a category of misconduct can often be difficult to judge. Notably the sexual misconducts reported committed by gynecologists across the US (this would be a world-wide phenomenon). Is this too much interest or time spent examining the vaginas of young women? This can be difficult to tell in many cases.In other settings, is the surgeon just a below grade surgeon- a C- or D surgeon. This can be difficult to judge. What is not a difficult situation to understand, individuals operating on patients should never be imparied by drugs or alcohol. This is clear-cut. It is likely in many institutions over the years a blind eye has been turned to doctors operating drunk on patients. Certainly a few, but probably the minority, of the physician-drunks have been stopped from operating. To my knowledge, never have the administrators in charge been held to account for allowing drunks to operate. As long as this status quo is maintained there is no incentive for change. One overwhelming legal settlement against administrators and the institution where a drunk has been allowed to operate, may suffice to change this malpractice across the country. If there is no strict accountability to any organization or set of administrators who have allowed alcohol- or other drug- impaired doctors from practicing then there is no impetus for change to this mundane but likely very common and pervasive cause of poor health outcome.

Summary:

We are on a path of devastating general-public poor health from the new 4 Horsemen of the Poor Health Apocalypse. Changes necessary are actually quite straightforward, but in a fractured political environment perhaps impossible to correct, maybe until it is too late - as with global warming, nuclear war and gun violence.

Prevention is always the most effective, smartest, and most affordable approach. Why in the US we spend so much more on health care than any other nation and yet have such poor outcome, is we spend the great majority of the money on disease management, which is extremely expensive and of overall limited value, and very little on effective prevention. By far the best investment is on preventive education in school from K-12 in Health and Wellness. One of these classes can be centered at noon where the children take active part in creation of a nutritious meal for themselves with healthy food. This would also have the important side benefit of getting a healthy meal in children from underprivileged settings. In very poor neighborhoods this program could be done for breakfast and dinner as well. This would be also the most palatable form of restitution for individuals with an ancestral history of enslavement in the US and for the first nations individuals who have been the most of all groups injured by the original white society. They all get free healthy meals at school that they take part in creating, so they have this foundation of eating healthily. Also of critical importance: a separate class where they engage in physical activities they enjoy (which may be Tai Chi, or dancing to music they like- as opposed to doing chin-ups or climbing a rope in a gym).

Education would probably have the largest impact on both obesity and addiction.

Changing IMIDs involves more effort. Thoughtful cautious use of drugs such as antibiotics. The move from excess use of chemicals, back to more simple and healthy methods of maintaining sanitation. For GDD, less use of imaging procedures unless they are essential, and paying attention to what patients are telling us health care workers.

With iatrogenic injuries, the primary target is to hold the administrators personally responsible for failures in the maintenance of safety for patients. They should be held responsible when 'devils of death' are allowed to practice health care, and especially when they allow these devils to leave and be given good recommendation or no warning to future health centers, as happened in the recent famous case in the north east US (I will deal again on this in the future), This type of misconduct, the lower level of administrators in addition to higher levels must be held to account.

Sick old people who die because a dose of drug is not administered correctly, is sad but not tragic, and this, and more serious errors of this type, can be largely avoided if the working environment is a positve one for the health care workers. This failure is also what senior administrators must be held to account for. This type of malpractice is often above the level of the primary administrators, and may be the parent organization should be held to primary account.

Richard Semelka, MD