Vioxx, the Scientific Method, and the Atheists

Lots of people, if you levied a $4.9 billion fine on them, might look for a bridge from which to jump. But when Merck, the pharmaceutical company, struck a deal with lawyers to settle 27,000 lawsuits for that amount, legal and financial types were ecstatic. It could have cost so much more. I've heard 25 billion. I've even heard 50 billion. This is how you do it! one market analyst gushed. This is how you come back from a defective product. You fight each case no holds barred for a few years to discourage plaintiffs. Then you offer to settle for a lowball amount. Merck's stock rose 2.3% the day they announced the move, even while the overall market was sharply down.

Medical and ethical folks were less enthused. Like Dr. Eric Topol, for example, the cardiologist who in 2001 co-authored a JAMA paper warning of heart attack risks associated with the drug company's Vioxx. “I think they’ve gotten off quite easily, frankly, for the problems that they’ve engendered,” he said. A large clinical trial that ended in 2000 showed that Vioxx was much riskier than Aleve, an older painkiller. Four more years were to pass before Merck took the drug off the market, pulling the plug on their Young Rascals jingle "It's a Beautiful Morning" when it seemed the morning might not be so beautiful after all.

But if Dr. Topol groused, you should have heard Dr. Katherine Di Angelis. "What people should learn from this is you don't believe anything, not one thing, put out by a pharmaceutical company. Just don't believe it," she said on National Public Radio. "You start from there." She estimated probably 5-10 % of the people who were taking it really should have been taking it. The other 90% raised their risk of a heart attack or stroke with no significant benefits. "When you want to make money by selling products to people who don't need it....then you're going to get into this kind of trouble"

Dr Di Angelis is Editor in Chief of the Journal of the American Medical Association.

Now, this sticks in my craw even more than it might normally because I've just been squabblingwith a flock of atheists who worship science. Of course, they would never use that term - I can hear them sputtering now - yet what they do so closely resembles worship that I can't tell the difference.

"You don't believe anything, not one thing, put out by a pharmaceutical company," she advises the public. Okay. Good advice. Did she have counsel more harsh for medical doctors? After all, you could not get this drug over the counter. A doctor had to prescribe it. The general public can be excused for being duped by drug hype. But what of medical doctors, those high priests of the scientific method? The atheists I mentioned positively gush over the scientific method, the ultimate test of truth. Yet here we see that it's foremost representatives in the medical field, doctors, are every bit as susceptible to error as the average Joe. They uncritically swallow any bilge handed down to them.

My skirmish with the atheists was with regard to alternative health treatments: chiropractic, acupuncture, homeopathy. All hoax, they insist. They know that because they and their scientific allies have subjected such techniques to the Scientific Method - double blind repeatable controlled studies - with very unspectacular results. The fact that more and more people are choosing these therapies over conventional medicine means nothing to them. Those folks have only testimonials to offer, say the atheists, or even worse, anecdotal evidence. Absolutely worthless, they insist rather dogmatically; it only goes to show how gullible people are.

Tell it to the 27,000 plaintiffs who allege injury or even death of their loved ones from Vioxx. If alternative therapies fail, they simply fail. It's very rare for them to do harm.

One alternative that has gone from cult to mainstream within my lifetime is chiropractic. It's every step forward was fought tooth and nail by the American Medical Association, (AMA) which attempted to use its science stature to label the competition quackery. It took a lawsuitwhich ultimately went to the U.S. Supreme Court to end the iron fist.

As burdensome as the "quackery" namecalling was the financial hit one incurred in seeking chiropractic care. Insurance rarely covered chiropractic. Patients paid out of pocket. Imagine: medical care could be had for free (or with small co-pay); chiropractic care you paid for yourself. People chose chiropractic care. (To this day, a cynical friend swears by the rule: if it works, insurance won't cover it.) It wasn't superstitious dolts choosing the alternative therapy, which I suspect the science camp would love to maintain. No, it was the more educated and well-heeled, the only persons who could ignore the financial implications of seeking chiropractic care.

To this day, devotees of medical science grouse that chiropractic fails their tests of proof. Some grudgingly allow that it can serve a limited purpose in the case of back pain, but nothing more. Meanwhile, one constantly runs across persons crippled for life by disc removal surgery, (I know some of them) the mainstream medical practice that dominated for years. (still does, I think) How did chiropractic become so well accepted? Largely through the avenues my atheists despise: testimonial and anecdotal evidence. Thirty million people in the United States seek chiropractic care. Are they all fools?

Many areas of alternative medicine are more art than science. Didn't we once refer to all medicine as "healing arts"? They draw on the subtle uniqueness of each individual, not on the broad similarities which we all share. But therein lies a problem for scientific verification. If every single patient is different and your health care is attuned to those differences, that's a problem for the scientific method, which is most useful when there are common attributes readily grouped and measured. Alternative medicine is more like your child who does something irresistibly cute, so that you want to show him off. Will he do the same thing for relatives or friends or camera? Not a chance. How do you apply the scientific method to individual attributes, when it is those very attributes that form the basis of this or that treatment? Insisting alternative medicine conform to the scientific method is a bit like playing an away game, on someone else's turf with all their fans booing you. Better to play on your own field.

Then again, it could be that conventional science simply ignores what is too contrary to prevailing wisdom. This apparently happened withthat studyconcluding the placebo effect is overhyped. It made front page news one day in 2001, then it vanished without a trace, like a mafia don with concrete boots. Nobody ever mentioned it again. Might this be the case with alternative treatments, whose supporting evidence is ignored by the AMA people?

Inconceivable, says my science-adoring atheist: "The vast majority of scientists revel in what they don't know because it provides them with an opportunity to find out what's happening and explain it. Prove one wrong and he or she will be ecstatic," he tells me.

No, I don't think so. Science does not purge humans of human nature. Max Planck the physicist offers a more realistic assessment: "People think new truths are accepted when the proponents are able to convince the opponents. Instead, the opponents of the truth gradually die, and a new generation comes along who is familiar with the idea."

I'm not opposed to conventional health care. I'll see a doctor when sick (unlike Pop). But it's not the monopoly on truth that it would like us to believe. Alternatives work too well. I've seen, heard, and experienced it. When testimonials become overwhelming, you don't reject them simply because it's not the type of evidence you would prefer.

Vincent McCabe's book Let Like Cure Like (1997) discusses principles underlying most alternative therapies (homeopathy in his particular case): These philosophies, both thousands of years old, have yet to be proved scientifically because of the limitations of science, not because they are not true. p 17

Awake!, on the other hand, the JW publication, stays above the fray. Often it discusses matters of health. Invariably it states it does not endorse any specific treatment, but discusses what it does for informational purposes only. In other words, let's not have anyone take my views and think it represents all of Jehovah's Witnesses.

********************************  The bookstore

 

Comments

[Romulus Crowe]

Hi Tom

Atheists and science don't mix - they have an agenda, and the real scientific method can't disprove what (or rather, who) they want disproved. Religion and science clash only over evolution and geology. I know several biologists, mathematicians, chemists, who are devout Christians, Muslims, Buddhists. There's no conflict for them because their area of work doesn't conflict with their religion.

Atheist scientists, too, are unaffected unless they're in certain specific areas.

There was a report on an evolution conference where some of these 'general-public' atheists - James Randi was at the head of them - insisted that the scientists refer to the LAW of evolution rather than the theory. The scientists tried to point out that, in science, evolution is not a law.

Gravity is a law. If you throw something up, it comes down. It always happens. That's a scientific law.

Evolution doesn't have to happen. Organisms don't have to evolve. (I know we'll differ on the details of this point but...) dinosaurs didn't evolve. They died out. So evolution is not a law.

Science doesn't like to be dictated to by anyone with a specific agenda - and the atheists needn't think they're a special case. Science, done properly, should plod along proving things. Never disproving anything. The only verdicts science can give are ‘True’ and ‘Not proven’. It can never return a ‘Can’t happen’ or ‘Doesn’t exist’ verdict.

The pharmaceutical industry isn't a branch of science, it's a business. There are scientific pharmacists, but ‘pharmaceuticals’ is run by suits, not by lab coats. New Scientist has slated them in the past for broadening the definition of illnesses such as bipolar disorder, so more people get diagnosed and they sell more drugs.

Sometimes I'm happy. Sometimes I'm miserable. Sometimes I fly into a rage, and sometimes nothing will crack my calm. If I went to a psychiatrist he could call that bipolar disorder. I call it 'life'. I won’t take any drugs to alter my mood. I can do that myself.

All trials are flawed. Some drugs will cause a deadly reaction in 1 in a 1000 cases. If the trial tested 500 people, then that deadly reaction won't show up. Until the whole population starts taking the drug. Then, people start dying, and the suits try to cover their tracks.

Similarly, homeopathic effects can be subtle, and a small-sample trial won't show them.

It's possible, using the right number of people and the right statistical test, to prove what the hell you want to prove.

Pharmacuticals aren't tested by the scientific method. Those doing the testing have a vested interest in getting a specific result. They also have a vested interest in getting a non-result from non-patentable things like homeopathy. That's business, not science. It's not about curing people, it's about selling drugs. In fact, they don't want to cure anyone - because cured people stop taking drugs.

I know a veterinarian who has used homeopathic medications on animals. The animal doesn’t know what it’s getting. So, the whole ‘placebo effect’ is, in this case, wrong. Science does study homeopathy, but uses the term ‘hormesis’ to avoid setting off alarm bells in journal editors’ heads.

I don’t know what chiropracty is. I don’t think we have it in the UK. Currently I’m working up the nerve to visit a local Chinese doctor to see if he can help me stop smoking. Perhaps it’ll work – the threat of a second session of needles might be enough to do the trick.

"Give up the cigars or I'll stick you full of pins again". Hmmm...

[dikkii]

Howdy Tom.

Enjoyed your post on Dylan, by the way.

Now. Vioxx. Many times I've had discussions that were near fist fights with various woo merchants about how the scientific method is useless because Vioxx, Thalidomide etc have snuck through.

It raises an interesting point, though. Scientists admit that bad ethics and/or bad research got these over the line initially.

But scientists admit these mistakes all the time. When was the last time you heard a homeopath or acupunturist admit that their research field was wrong about something?

And if they did, could you also tell me an instance of where this was discovered by means other than the scientific method?

Down the page you wrote this:

"Then again, it could be that conventional science simply ignores what is too contrary to prevailing wisdom. This apparently happened with that study concluding the placebo effect is overhyped. It made front page news one day in 2001, then it vanished without a trace, like a mafia don wearing boots."

Did you ever think that it might have been because, it wasn't news?

BTW for your reference, the news article is here:

http://www.usatoday.com/news/health/2001-05-23-placebo.htm

And the journal article that vanished (your words) is here:

http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&uid=15247500&cmd=showdetailview&indexed=google

Incidentally, I was one of the "science-adoring atheists" in that discussion at Plonka's Blog. Except, I'm not an atheist. I'm agnostic.

While I reluctantly accept that your views of science and CAM are somewhat at odds with how science would like to view them, I have to pull you up on this one as it is, rather a cavalier approach to alternative therapies:

"If alternative therapies fail, they simply fail. It's very rare for them to do harm."

The best response to this comes from a surgeon who saw this patient once:

http://scienceblogs.com/insolence/2006/08/the_orange_man_1.php

Cheers, Dikkii.

[tom sheepandgoats]

Romulus:

If it weren’t for pesky soreheads (perhaps even you) who would carry on about plagiarism, I would replace my post with yours. It’s very well stated.

“Organisms don't have to evolve. (I know we'll differ on the details of this point but...) dinosaurs didn't evolve. They died out” My friend Tom Pearlsenswine mutters about the “wiles of Satan” every time he sees dinosaur bones in a museum, but I have no problem with them, nor with their dying out. And were they long gone before humans ever came about? Scientifically, that seems like a done deal. I’ve no problem with that, either.

Dikkii:

Thanks for your thoughts as well. Sorry for the atheist label. Sure enough, I read on your own blog you’re an agnostic. I think that’s what Romulus is. Incidentally, given his field of research (which I won’t tell you, you must go yourself and find out if you’re interested) you two might find fertile grounds of conversation, or would it only be debate?

Did I take a cheap shot or two with regard to doctors & the S.M? Maybe. I don’t really fault the Scientific Method in itself. Only that business or professional interests can supersede it, so that it isn’t necessarily the protection people imagine it is. I think you mentioned in one of your posts/comments that doctors down under are not known for pushing drugs. I don’t know about Australia, but they certainly are that way here. Insurance reimbursement may have something to do with it. Prescribing a drug is a quick way to get rid of someone who may otherwise chew up a lot of time.

Dikkii, I’ll readily concede that the alternative therapies don’t do well by the S. M. Furthermore, I don’t really know why; I’ve hazarded a few guesses, but I don’t really know. Nonetheless, I’ve no doubt that they work, and sometimes work dramatically. I’ve seen, heard, and experienced it too many times to naysay it. So I tend to blame limitations of the Scientific Method, even if I can only guess at what they may be. Why would I not do so? I’ll go with what works. I don’t have to know everything. I’d prefer to know exactly why & how it works, but if I can’t do that, I’m still willing to go with something that works. Countless times scientists have made new discoveries that completely overturn old ideas, even old ways of looking at ideas. Why should I assume that will never happen again?

[Screech]

I've used a rule to help me sort out information.

Is someone trying to sell me something?

If I see an ad on TV about the newest drug, they are obviously trying to sell me something. If I get an email or a friend of mine gives me a photocopy of an "article" about some treatment, and I see a blurb about some product being sold, it is fair to conclude that someone is trying to sell me something. Any time money is involved, the bias in the information provided seems to be exponentially related to the money to be made. In my view, that's a strike against the "information."

Case in point: Tobacco.

The scientific method is only a tool. Much as a Bible or Koran is a tool. They are all used to test information against a set of beliefs. The Bible or Koran (holy books) are used as ways to find truths. The Scientific Method is also used as a way to find truths. Even though these ideas explore different domains (most of the time), the principles are the same.

You use these tools to help organize a sequence of logic. If we accept A, and the data supports A, then B and E must necessarily follow. However, in this example, D is missing. Yet the person in this line of logic may not be aware that D even exists. Their assumption is true, but they are missing an important piece of the puzzle.

Does this matter? Am I rambling? Perhaps, but it seems to me that in either case (religion or science), one is taking a "leap of faith." One is trusting that those teaching are correct in assuming that B and E follow A. They are hoping that D isn't missing. They are also hoping that A is the right place to start the assumption.

[dikkii]

Hi Tom,

I'm rather shocked to discover that US doctors just prescribe and nothing else. The Declaration of Geneva (which is really the revised Hippocratic Oath) plainly states that, "The health of my patient will be my first consideration."

I have seen Sicko, but I never realised that the insurance situation in the US was skewing medical advice so badly.

While I suspect that your lack of confidence in the scientific method
is probably due more to misconceptions than anything else, this bit of your response caught my attention

"Countless times scientists have made new discoveries that completely overturn old ideas, even old ways of looking at ideas. Why should I assume that will never happen again?"

Such an argument is effectively saying that we should accept all ideas, no matter how wacky, because maybe, just maybe, there might be something there.

This approach is fraught with all sorts of problems. The most obvious one being that it reverses the burden of providing evidence.

For example - if I say that snake oil cures cancer, this approach says that it is up to science to prove me wrong. It is currently accepted, and far more practical, for us to accept that snake oil does not cure cancer, unless evidence is provided to suggest that it does.

In which case, we can justifiably change our minds about snake oil.

I'm not sure if you've heard of an classic error called the Galileo gambit? This is kinda similar to that.

[plonka]

Hi Tom, sorry it's taken a while and thanks for the link...:)

But I really don't see why would it stick in your craw any more than say, Union Carbide and Bhopal and why atheism or religion should even rate a mention here? The executives that caused the Bhopal disaster were all good god fearing christians for instance. But we're talking about a business that is only interested in profit. Ethics is the issue here, not religion or a lack of it.

And bad ethics are just as prevalent in christian business circles. Let's face it, Ted Haggard made his money denouncing and trying to "cure" homosexuality, so where's the difference?

[plonka]

Tom: Forgot to mention...

Science is what proved Vioxx to be a killer, so what's the problem? If it's just the size of the settlement, then I agree with you 100%

Now to tame exception. I don't tend to sputter, but if that's your view...

"Science" is a very general term. Now, it's very easy to see exactly what it is you worship, but I'm having trouble pinning something down in "science" that's specific enough to warrant that kind of devotion. Perhaps you could explain?

[tom sheepandgoats]

Dikkii & Plonka: Guys, thanks for stopping by. I appreciate your observations, even where I do not agree.

Dikkii: on drug prescribing in the U.S:

Remember in that "placebo" post the 600 drugs in 1960 that became 9000 in 2002 (+ over the counter). This was not online or I would have linked to it. It was a letter from NYS board of Regents to state medical schools. But the expenditures ($2.7 billion to $162 billion is online and cited) Obviously, with that many drugs, somebody has to be doing a lot of prescribing.

Evening network news in the U.S is, after commercials, about 18 minutes per night. Frequently a fourth or so of that time might be devoted to matters of American health. Pharmaceutical companies are among the major sponsors of such newsscasts. They bombard viewers with ads for prescription drugs. "Ask you doctor if Vioxx or whatever is right for you." We hear it ad nauseum. One might think medical doctors, persons of science that they are, would see though the hype. They don't. Mind you, I'm not saying science causes the problem. I'm simply saying it does not solve it, when it is in position to do so. All doctors have to do is prescribe in moderation and the matter is alleviated.

On another matter you said: "Such an argument is effectively saying that we should accept all ideas, no matter how wacky, because maybe, just maybe, there might be something there."

No. Were it a few handfuls of people here and there, that argument might be valid. Here we are speaking of hundreds of millions of people who maintain that this or that treatment is effective. I'm not so disrespectful of them to say they're all full of crap only because my tools cannot detect the results. Instead, when that many people are involved, I tend to question my tools.

Plonka: "Science is what proved Vioxx to be a killer, so what's the problem? "

Granted, it did prove Vioxx a killer, but don't forget the 27,000 lawsuits. If a baseball team allowed 27,000 runs before finally ending the inning, I think you would not be praising their defense.

As for "sputter," that's just me being playful. Don't take it personally. I am confident you will not.

As for "worship," I qualified the term: "...what they do so closely resembles worship that I can't tell the difference." Chalk it up to my perception if you like.

But this is why I perceive it as I do: Among the atheists, I've encountered a great many who are insistent that only their approach is valid and they are absolutely intolerant of what is not their approach. These discussions about alternative medicine have well illustrated that, IMO. There is no conciliatory "well, if according to their own words, it works for them...." No! It is absolute intolerance of what hundreds of millions maintain through their own experience. These attitudes of absolute truth and intolerance are often associated with religion.

Plus, this statement from my post strikes me as downright idolizing:

"The vast majority of scientists revel in what they don't know because it provides them with an opportunity to find out what's happening and explain it. Prove one wrong and he or she will be ecstatic."

To which I replied:

"Science does not purge humans of human nature. Max Planck the physicist offers a more realistic assessment: 'People think new truths are accepted when the proponents are able to convince the opponents. Instead, the opponents of the truth gradually die, and a new generation comes along who is familiar with the idea.'"

[dikkii]

Tom:

"Remember in that "placebo" post the 600 drugs in 1960 that became 9000 in 2002 (+ over the counter). This was not online or I would have linked to it. It was a letter from NYS board of Regents to state medical schools. But the expenditures ($2.7 billion to $162 billion is online and cited) Obviously, with that many drugs, somebody has to be doing a lot of prescribing."

I'm not sure that's a relevant comparison. Remember, there were tons of illnesses back then that didn't have pharmaceutical remedies for which we have now.

Also, the expenditure figures you have quoted for reflect an increase of just a little over 10% per annum. This is about the same as average US inflation over that 42 year period.

With this timeframe, I personally am a little disappointed that only 9,000 drugs are the figure quoted. I would have expected something like Moore’s Law to hold here, in which case that 9,000 figure in 2002 should really be about 1.25 billion.

On the drug advertising front, we don't get those ads over here. Advertising for prescription drugs is banned outright in Oz.

But I'll re-iterate - Doctors are breaching their own ethics by just prescribing and nothing else. And I think that you are forgetting some basic maths here: Simply put, the risks of something going wrong (in a prescription only approach) are so great and such a breach of medical codes of ethics that there would be a logjam in courts through the sheer volume of malpractice cases.

I think that you need to re-think this scenario a little bit – it’s not borne out by reality.

Here’s a project. The next few times you visit your doctor, try getting second opinions on everything. Remember to not tell the second doctor that you’ve already consulted the first one. Get the recommendations in writing – doctors should do this when asked to.

Then compare the two. If one recommends drugs and the other one doesn’t, or different ones, go back and ask why there have been different recommendations done.

I would also add to this to go to the doctor for check-ups as well, and not just when you’re sick – if you’ve clearly got a bacterial infection, then of course they’re going to prescribe antibiotics. A doctor would be criminally negligent not to.

By the way, I know someone who has done this with naturopaths. The results were, quite frankly, embarrassingly bad for the naturopaths in question. One of these days, I’m going to get his permission to put the results up on my blog.

Lastly, this:

“No. Were it a few handfuls of people here and there, that argument might be valid. Here we are speaking of hundreds of millions of people who maintain that this or that treatment is effective. I'm not so disrespectful of them to say they're all full of crap only because my tools cannot detect the results. Instead, when that many people are involved, I tend to question my tools.”

Millions of people swore by bloodletting for over a thousand years. Are you telling me that in spite of all the evidence to the contrary, because so many believed in it, bloodletting must actually do something?

This by the way is another classic error called an “appeal to popularity”. The appeal to popularity says that Britney Spears must be good because she’s sold so many albums. I think you’ll find reviewers have a somewhat different opinion on this matter.

So I’ll put this to you, just so I’m clear. You have suggested that we shouldn’t assume that something doesn’t work. This is a reversal of the burden of proof that throws up an enormous grey area but you seem to have taken a step towards alleviating this.

Are you proposing that the burden of proof may only be reversed on the grounds of popularity?

And if not, where do you draw the line?

[tom sheepandgoats]

$2.7 to 162 billion: Amazing what a little inflation will do. Who'd a thought it? Has it really been 10% per annum?

Moore's Law: Not so sure. Semiconductors are many times faster & many times smaller than a couple decades ago. Human life expectancy, on the other hand, has increased perhaps 10% & not necessarily all attributable to drugs.

I don't go to doctors (of any type) frequently enough to try your experiment.

I'm not sure bloodletting is a parallel, though there are some similarities. Was bloodletting an alternative therapy that thrived during the time medical science was offering viable alternatives? Or was it not merely a development within conventional medical circles? Once medicine replaced it, was there anyone who pined for the old days?

And Britney isn't any Mozart, or even a Bob Dylan. But, alas, if you maintain that the purpose of music is to entertain, then it probably has to be admitted that she "works" as well as the more refined alternatives.

[dikkii]

Bloodletting was conventional (not alternative) medicine. However, it was developed well before the scientific method, when testimonial and anecdotal evidence reigned supreme. Kinda like alternative medicine now.

Moore's law? Well maybe. My point though was pretty good - only 9,000 in 2002 is a fairly weak performance on the old results front.

10% inflation? Hard to believe alright in these days of 3-4%, but if you factorin the hyperinflation of the 70s and 80s, it's about right.

[mark's tails]

Tom, interesting post and a nice discussion. Although I am a late arrival here is my two cents FWIW.

I wrote a little about Vioxx and Vitamins on a post I called Vitamin Tails, October 22, 2007 which is linked to my name below.

Regarding drugs, alternative medicine and the scientific method I'll just say this.

Many of the drugs used, including chemotherapeutic agents, estrogens, antibiotics are "ALL NATURAL" in that many drugs are derived from things found in nature. One of the points that many people fail to understand is that 'all natural' does not mean 'without side effects'. Drug companies screen hundreds of thousands of natural plants etc in an attempt to find new therapeutics.

Theoretically the 'natural' plant estrogens beings used for the treatment of hot flashes can have the same risk of cancer as the traditional allopathic HRT. The problem is no large study on these drugs, such as the ones done with synthetic estrogens, has ever been done.

Yes, ignorance is bliss, but while there certainly are problems with the drug industry and allopathic medicine at least the effort is there to actually provide the patient with the best possible information regarding side effects and risk. Can that really be said of some Alternative therapies?

[tom sheepandgoats]

In general, the alternative field is much more "buyer beware" than is the conventional medicine field. Quality of products (and practitioners) is much more uneven. You do have to shop around. While that has its disadvantages, I'm not sure it's uniformly bad. It does encourage the consumer to educate himself and take charge of his own health. Americans are often in absurdly poor health, a fair amount of which is self-inflicted. I almost think you must applaud any development which encourages self-responsibility. Medical doctors can, and do, join in this crusade themselves (sometimes). Pharma tends to influence people the other way....after all, healthy people need less of their products or none at all.