A while ago, I read a figure that was something like, “In the entire history of medicine before the invention of antibiotics, doctors killed more people than they saved.”

Of course, this is impossible to really prove. There’s no way to get those statistics. But it seems about right. We all know the stories of the bleeders and leechers of medicine in the past: George Washington bled to death by his doctors after he caught pneumonia; King Charles II bled, blistered, and purged until he slipped into a coma he never woke up from; even the obstetricians of Semmelweiss’s time infecting their patients by refusing to ever wash their hands.

I often think about what people in those times must have thought of their men of medicine and science. They must have seen that going to the doctor was, at best, a roll of the dice. A doctor’s visit might get you better, the same, or worse. There was no way to tell in advance.

And yet they kept going to the doctor! Not only that, but they actually paid those doctors, and gave them honors and places in their highest halls. Why? Is someone who’s willing to confidently take action, even if that action is sorely mistaken, so highly valued?

And what about all the privileged young men who then chose to become doctors themselves? Surely they must have noticed that the people they were learning from had no idea what they were doing. They must have been able to tell that, despite their professors’ grave pronouncements that they knew exactly what was wrong with the patients, they somehow were unable to consistently fix the problems, and frequently made them worse.

Didn’t that ever stick in those young mens’ craws? Did they ever stop their gray haired professors in the midst of their grave diagnoses and say, “Wait a minute, I saw you kill a guy last week by giving him enemas until he collapsed, so why am I listening to you about how to fix this new guy?”

This has all been swirling through my mind as I read that the FDA has now officially approved lecanemab, the newest Alzheimer’s treatment from Eisai. Lecanemab is the newest and greatest anti-amyloid antibody. Unlike the previous approved one, aducanumab, it even has a mild clinical beneft. Also unlike aducanumab, it’s been approved for Medicare coverage, which means that Eisai is almost guaranteed to start earning billions of dollars a year from the US taxpayer for this drug, given that there are around a million Medicare patients eligible for it and the sticker price is $26,500. 

An approved, publicly available drug for Alzheimer’s should be a time of rejoicing. It should be as exciting as the approval of penicillin, where patients on the brink of death were brought back to life within hours. And yet somehow, it’s not. 

This probably has to do with the fact that this multibillion dollar drug’s greatest effect is to slightly slow down decline in cognitive function over the course of 18 months, resulting in a decline of about 1.21 points instead of 1.66 points on an 18 point scale. This comes at a time cost of an hour spent on an IV every two weeks, and a health cost of a 20% chance of “flu-like symptoms” and a 10% chance of brain swelling. This doesn’t feel like a miracle drug. It feels a lot more like a slight step up from bleeding.

NPR ran an inadvertently interesting piece after the approval of lecanemab. The piece itself is mostly just fluff, but what I find interesting is that, in their search for “balance”, they had the following quotes:

1. From a doctor with a prestigious title: “[Lecanemab] will not stop or reverse [Alzheimer’s], but it may slow progression…it is very exciting that we are targeting the pathology of the disease.”

2. From the well-paid CEO of a nonprofit that’s heavily funded by Eisai: “[To be talking about a treatment] is an incredible point for the Alzheimer’s cause.”

3. From the husband of a patient who received treatment: “There’s been some [cognitive] degradation. But, we don’t have enough experience, like the medical folks do, to know what would have happened without the drug.”

So, a doctor who acknowledges that this isn’t even close to a cure, but is still confident that he knows the pathology of this disease, a paid booster, and a patient who sees that this drug is barely working, but decides to trust in authority.

Maybe this is how the medicine men of centuries past kept their position in the halls of power. They themselves were unwarrantedly confident, supported by hangers on who benefited from their cures and prognoses, and their patients had to simply trust that these august men knew better than they did.

In the words of Faulkner: the past isn’t dead. It’s not even past.

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