hn-classics/_stories/2007/7801339.md

---
created_at: '2014-05-26T20:03:56.000Z'
title: Do We Really Know What Makes Us Healthy? (2007)
url: http://www.nytimes.com/2007/09/16/magazine/16epidemiology-t.html?pagewanted=all&_r=0
author: gwern
points: 44
story_text: ''
comment_text: 
num_comments: 15
story_id: 
story_title: 
story_url: 
parent_id: 
created_at_i: 1401134636
_tags:
- story
- author_gwern
- story_7801339
objectID: '7801339'
year: 2007

---
Faith in the protective powers of estrogen began to erode in 1998, when
a clinical trial called HERS, for Heart and Estrogen-progestin
Replacement Study, concluded that estrogen therapy increased, rather
than decreased, the likelihood that women who already had heart disease
would suffer a heart attack. It evaporated entirely in July 2002, when a
second trial, the Women’s Health Initiative, or W.H.I., concluded that
H.R.T. constituted a potential health risk for all postmenopausal women.
While it might protect them against osteoporosis and perhaps colorectal
cancer, these benefits would be outweighed by increased risks of heart
disease, stroke, blood clots, breast cancer and perhaps even dementia.
And that was the final word. Or at least it was until the June 21 issue
of The New England Journal of Medicine. Now the idea is that
hormone-replacement therapy may indeed protect women against heart
disease if they begin taking it during menopause, but it is still
decidedly deleterious for those women who begin later in life.

This latest variation does come with a caveat, however, which could have
been made at any point in this history. While it is easy to find
authority figures in medicine and public health who will argue that
today’s version of H.R.T. wisdom is assuredly the correct one, it’s
equally easy to find authorities who will say that surely we don’t know.
The one thing on which they will all agree is that the kind of
experimental trial necessary to determine the truth would be excessively
expensive and time-consuming and so will almost assuredly never happen.
Meanwhile, the question of how many women may have died prematurely or
suffered strokes or breast cancer because they were taking a pill that
their physicians had prescribed to protect them against heart disease
lingers unanswered. A reasonable estimate would be tens of thousands.

At the center of the H.R.T. story is the science of epidemiology itself
and, in particular, a kind of study known as a prospective or cohort
study, of which the Nurses’ Health Study is among the most renowned. In
these studies, the investigators monitor disease rates and lifestyle
factors (diet, physical activity, prescription drug use, exposure to
pollutants, etc.) in or between large populations (the 122,000 nurses of
the Nurses’ study, for example). They then try to infer conclusions —
i.e., hypotheses — about what caused the disease variations observed.
Because these studies can generate an enormous number of speculations
about the causes or prevention of chronic diseases, they provide the
fodder for much of the health news that appears in the media — from the
potential benefits of fish oil, fruits and vegetables to the supposed
dangers of sedentary lives, trans fats and electromagnetic fields.
Because these studies often provide the only available evidence outside
the laboratory on critical issues of our well-being, they have come to
play a significant role in generating public-health recommendations as
well.

The dangerous game being played here, as David Sackett, a retired Oxford
University epidemiologist, has observed, is in the presumption of
preventive medicine. The goal of the endeavor is to tell those of us who
are otherwise in fine health how to remain healthy longer. But this
advice comes with the expectation that any prescription given — whether
diet or drug or a change in lifestyle — will indeed prevent disease
rather than be the agent of our disability or untimely death. With that
presumption, how unambiguous does the evidence have to be before any
advice is offered?

The catch with observational studies like the Nurses’ Health Study, no
matter how well designed and how many tens of thousands of subjects they
might include, is that they have a fundamental limitation. They can
distinguish associations between two events — that women who take H.R.T.
have less heart disease, for instance, than women who don’t. But they
cannot inherently determine causation — the conclusion that one event
causes the other; that H.R.T. protects against heart disease. As a
result, observational studies can only provide what researchers call
hypothesis-generating evidence — what a defense attorney would call
circumstantial evidence.

Testing these hypotheses in any definitive way requires a
randomized-controlled trial — an experiment, not an observational study
— and these clinical trials typically provide the flop to the
flip-flop rhythm of medical wisdom. Until August 1998, the faith that
H.R.T. prevented heart disease was based primarily on observational
evidence, from the Nurses’ Health Study most prominently. Since then,
the conventional wisdom has been based on clinical trials — first HERS,
which tested H.R.T. against a placebo in 2,700 women with heart disease,
and then the Women’s Health Initiative, which tested the therapy against
a placebo in 16,500 healthy women. When the Women’s Health Initiative
concluded in 2002 that H.R.T. caused far more harm than good, the lesson
to be learned, wrote Sackett in The Canadian Medical Association
Journal, was about the “disastrous inadequacy of lesser evidence” for
shaping medical and public-health policy. The contentious wisdom circa
mid-2007 — that estrogen benefits women who begin taking it around the
time of menopause but not women who begin substantially later — is an
attempt to reconcile the discordance between the observational studies
and the experimental ones. And it may be right. It may not. The only way
to tell for sure would be to do yet another randomized trial, one that
now focused exclusively on women given H.R.T. when they begin their
menopause.

No one questions the value of these epidemiologic studies when they’re
used to identify the unexpected side effects of prescription drugs or to
study the progression of diseases or their distribution between and
within populations. One reason researchers believe that heart disease
and many cancers can be prevented is because of observational evidence
that the incidence of these diseases differ greatly in different
populations and in the same populations over time. [Breast
cancer](http://health.nytimes.com/health/guides/disease/breast-cancer/overview.html?inline=nyt-classifier "In-depth reference and news articles about Breast Cancer.")
is not the scourge among Japanese women that it is among American women,
but it takes only two generations in the United States before
Japanese-Americans have the same breast cancer rates as any other ethnic
group. This tells us that something about the American lifestyle or diet
is a cause of breast cancer. Over the last 20 years, some two dozen
large studies, the Nurses’ Health Study included, have so far failed to
identify what that factor is. They may be inherently incapable of doing
so. Nonetheless, we know that such a carcinogenic factor of diet or
lifestyle exists, waiting to be identified.

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[Continue reading the main story](#story-continues-4)

These studies have also been invaluable for identifying predictors of
disease — risk factors — and this information can then guide physicians
in weighing the risks and benefits of putting a particular patient on a
particular drug. The studies have repeatedly confirmed that high [blood
pressure](http://health.nytimes.com/health/guides/test/blood-pressure/overview.html?inline=nyt-classifier "In-depth reference and news articles about Blood Pressure.")
is associated with an increased risk of heart disease and that
[obesity](http://health.nytimes.com/health/guides/symptoms/obesity/overview.html?inline=nyt-classifier "In-depth reference and news articles about Obesity.")
is associated with an increased risk of most of our common chronic
diseases, but they have not told us what it is that raises blood
pressure or causes obesity. Indeed, if you ask the more skeptical
epidemiologists in the field what diet and lifestyle factors have been
convincingly established as causes of common chronic diseases based on
observational studies without clinical trials, you’ll get a very short
list:
[smoking](http://health.nytimes.com/health/guides/specialtopic/smoking-and-smokeless-tobacco/overview.html?inline=nyt-classifier "In-depth reference and news articles about Smoking.")
as a cause of lung cancer and cardiovascular disease, sun exposure for
[skin
cancer](http://health.nytimes.com/health/guides/disease/skin-cancer/overview.html?inline=nyt-classifier "In-depth reference and news articles about Skin Cancer."),
sexual activity to spread the papilloma virus that causes [cervical
cancer](http://health.nytimes.com/health/guides/disease/cervical-cancer/overview.html?inline=nyt-classifier "In-depth reference and news articles about Cervical Cancer.")
and perhaps alcohol for a few different cancers as well.

Richard Peto, professor of medical statistics and epidemiology at Oxford
University, phrases the nature of the conflict this way: “Epidemiology
is so beautiful and provides such an important perspective on human life
and death, but an incredible amount of rubbish is published,” by which
he means the results of observational studies that appear daily in the
news media and often become the basis of public-health recommendations
about what we should or should not do to promote our continued good
health.

In January 2001, the British epidemiologists George Davey Smith and Shah
Ebrahim, co-editors of The International Journal of Epidemiology,
discussed this issue in an editorial titled “Epidemiology — Is It Time
to Call It a Day?” They noted that those few times that a randomized
trial had been financed to test a hypothesis supported by results from
these large observational studies, the hypothesis either failed the test
or, at the very least, the test failed to confirm the hypothesis:
antioxidants like
[vitamins](http://health.nytimes.com/health/guides/nutrition/vitamins/overview.html?inline=nyt-classifier "In-depth reference and news articles about Vitamins.")
E and C and beta carotene did not prevent heart disease, nor did eating
copious fiber protect against [colon
cancer](http://health.nytimes.com/health/guides/disease/colon-cancer/overview.html?inline=nyt-classifier "In-depth reference and news articles about Colon Cancer.").

Photo

The Nurses’ Health Study is the most influential of these cohort
studies, and in the six years since the Davey Smith and Ebrahim
editorial, a series of new trials have chipped away at its credibility.
The Women’s Health Initiative hormone-therapy trial failed to confirm
the proposition that H.R.T. prevented heart disease; a W.H.I. diet trial
with 49,000 women failed to confirm the notion that fruits and
vegetables protected against heart disease; a 40,000-woman trial failed
to confirm that a daily regimen of low-dose aspirin prevented colorectal
cancer and heart attacks in women under 65. And this June, yet another
clinical trial — this one of 1,000 men and women with a high risk of
colon cancer — contradicted the inference from the Nurses’s study that
folic acid supplements reduced the risk of colon cancer. Rather, if
anything, they appear to increase risk.

The implication of this track record seems hard to avoid. “Even the
Nurses’ Health Study, one of the biggest and best of these studies,
cannot be used to reliably test small-to-moderate risks or benefits,”
says Charles Hennekens, a principal investigator with the Nurses’ study
from 1976 to 2001. “None of them can.”

Proponents of the value of these studies for telling us how to prevent
common diseases — including the epidemiologists who do them, and
physicians, nutritionists and public-health authorities who use their
findings to argue for or against the health benefits of a particular
regimen — will argue that they are never relying on any single study.
Instead, they base their ultimate judgments on the “totality of the
data,” which in theory includes all the observational evidence, any
existing clinical trials and any laboratory work that might provide a
biological mechanism to explain the observations.

This in turn leads to the argument that the fault is with the press, not
the epidemiology. “The problem is not in the research but in the way it
is interpreted for the public,” as Jerome Kassirer and Marcia Angell,
then the editors of The New England Journal of Medicine, explained in a
1994 editorial titled “What Should the Public Believe?” Each study, they
explained, is just a “piece of a puzzle” and so the media had to do a
better job of communicating the many limitations of any single study and
the caveats involved — the foremost, of course, being that “an
association between two events is not the same as a cause and effect.”

Stephen Pauker, a professor of medicine at Tufts University and a
pioneer in the field of clinical decision making, says, “Epidemiologic
studies, like diagnostic tests, are probabilistic statements.” They
don’t tell us what the truth is, he says, but they allow both
physicians and patients to “estimate the truth” so they can make
informed decisions. The question the skeptics will ask, however, is how
can anyone judge the value of these studies without taking into account
their track record? And if they take into account the track record,
suggests Sander Greenland, an epidemiologist at the University of
California, Los Angeles, and an author of the textbook “Modern
Epidemiology,” then wouldn’t they do just as well if they simply tossed
a coin?

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As John Bailar, an epidemiologist who is now at the National Academy of
Science, once memorably phrased it, “The appropriate question is not
whether there are uncertainties about epidemiologic data, rather, it is
whether the uncertainties are so great that one cannot draw useful
conclusions from the data.”

Understanding how we got into this situation is the simple part of the
story. The randomized-controlled trials needed to ascertain reliable
knowledge about long-term risks and benefits of a drug, lifestyle factor
or aspect of our diet are inordinately expensive and time consuming. By
randomly assigning research subjects into an intervention group (who
take a particular pill or eat a particular diet) or a placebo group,
these trials “control” for all other possible variables, both known and
unknown, that might effect the outcome: the relative health or wealth of
the subjects, for instance. This is why randomized trials, particularly
those known as placebo-controlled, double-blind trials, are typically
considered the gold standard for establishing reliable knowledge about
whether a drug, surgical intervention or diet is really safe and
effective.

But clinical trials also have limitations beyond their exorbitant costs
and the years or decades it takes them to provide meaningful results.
They can rarely be used, for instance, to study suspected harmful
effects. Randomly subjecting thousands of individuals to secondhand
tobacco smoke, pollutants or potentially noxious trans fats presents
obvious ethical dilemmas. And even when these trials are done to study
the benefits of a particular intervention, it’s rarely clear how the
results apply to the public at large or to any specific patient.
Clinical trials invariably enroll subjects who are relatively healthy,
who are motivated to volunteer and will show up regularly for treatments
and checkups. As a result, randomized trials “are very good for showing
that a drug does what the pharmaceutical company says it does,” David
Atkins, a preventive-medicine specialist at the Agency for Healthcare
Research and Quality, says, “but not very good for telling you how big
the benefit really is and what are the harms in typical people. Because
they don’t enroll typical people.”

These limitations mean that the job of establishing the long-term and
relatively rare risks of drug therapies has fallen to observational
studies, as has the job of determining the risks and benefits of
virtually all factors of diet and lifestyle that might be related to
chronic diseases. The former has been a fruitful field of research; many
side effects of drugs have been discovered by these observational
studies. The latter is the primary point of contention.

While the tools of epidemiology — comparisons of populations with and
without a disease — have proved effective over the centuries in
establishing that a disease like
[cholera](http://health.nytimes.com/health/guides/disease/cholera/overview.html?inline=nyt-classifier "In-depth reference and news articles about Cholera.")
is caused by contaminated water, as the British physician John Snow
demonstrated in the 1850s, it’s a much more complicated endeavor when
those same tools are employed to elucidate the more subtle causes of
chronic disease.

And even the success stories taught in epidemiology classes to
demonstrate the historical richness and potential of the field — that
pellagra, a disease that can lead to dementia and death, is caused by a
nutrient-deficient diet, for instance, as Joseph Goldberger demonstrated
in the 1910s — are only known to be successes because the initial
hypotheses were subjected to rigorous tests and happened to survive
them. Goldberger tested the competing hypothesis, which posited that the
disease was caused by an infectious agent, by holding what he called
“filth parties,” injecting himself and seven volunteers, his wife
among them, with the blood of pellagra victims. They remained healthy,
thus doing a compelling, if somewhat revolting, job of refuting the
alternative hypothesis.

Smoking and lung cancer is the emblematic success story of
chronic-disease epidemiology. But lung cancer was a rare disease before
cigarettes became widespread, and the association between smoking and
lung cancer was striking: heavy smokers had 2,000 to 3,000 percent the
risk of those who had never smoked. This made smoking a “turkey shoot,”
says Greenland of U.C.L.A., compared with the associations
epidemiologists have struggled with ever since, which fall into the tens
of a percent range. The good news is that such small associations, even
if causal, can be considered relatively meaningless for a single
individual. If a 50-year-old woman with a small risk of breast cancer
takes H.R.T. and increases her risk by 30 percent, it remains a small
risk.

The compelling motivation for identifying these small effects is that
their impact on the public health can be enormous if they’re aggregated
over an entire nation: if tens of millions of women decrease their
breast cancer risk by 30 percent, tens of thousands of such cancers will
be prevented each year. In fact, between 2002 and 2004, breast cancer
incidence in the United States dropped by 12 percent, an effect that may
have been caused by the coincident decline in the use of H.R.T. (And it
may not have been. The coincident reduction in breast cancer incidence
and H.R.T. use is only an association.)

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Saving tens of thousands of lives each year constitutes a powerful
reason to lower the standard of evidence needed to suggest a
cause-and-effect relationship — to take a leap of faith. This is the
crux of the issue. From a scientific perspective, epidemiologic studies
may be incapable of distinguishing a small effect from no effect at all,
and so caution dictates that the scientist refrain from making any
claims in that situation. From the public-health perspective, a small
effect can be a very dangerous or beneficial thing, at least when
aggregated over an entire nation, and so caution dictates that action be
taken, even if that small effect might not be real. Hence the
public-health logic that it’s better to err on the side of prudence even
if it means persuading us all to engage in an activity, eat a food or
take a pill that does nothing for us and ignoring, for the moment, the
possibility that such an action could have unforeseen harmful
consequences. As Greenland says, “The combination of data, statistical
methodology and motivation seems a potent anesthetic for skepticism.”

The Nurses’ Health Study was founded at Harvard in 1976 by Frank
Speizer, an epidemiologist who wanted to study the long-term effects of
oral contraceptive use. It was expanded to include postmenopausal
estrogen therapy because both treatments involved long-term hormone use
by millions of women, and nobody knew the consequences. Speizer’s
assistants in this endeavor, who would go on to become the most
influential epidemiologists in the country, were young physicians —
Charles Hennekens, Walter Willett, Meir Stampfer and Graham Colditz —
all interested in the laudable goal of preventing disease more than
curing it after the fact.

When the Nurses’ Health Study first published its observations on
estrogen and heart disease in 1985, it showed that women taking estrogen
therapy had only a third the risk of having a heart attack as had women
who had never taken it; the association seemed compelling evidence for a
cause and effect. Only 90 heart attacks had been reported among the
32,000 postmenopausal nurses in the study, and Stampfer, who had done
the bulk of the analysis, and his colleagues “considered the possibility
that the apparent protective effect of estrogen could be attributed to
some other factor associated with its use.” They decided, though, as
they have ever since, that this was unlikely. The paper’s ultimate
conclusion was that “further work is needed to define the optimal type,
dose and duration of postmenopausal hormone use” for maximizing the
protective benefit.

Photo

Only after Stampfer and his colleagues published their initial report on
estrogen therapy did other investigators begin to understand the nature
of the other factors that might explain the association. In 1987, Diana
Petitti, an epidemiologist now at the University of Southern California,
reported that she, too, had detected a reduced risk of heart-disease
deaths among women taking H.R.T. in the Walnut Creek Study, a population
of 16,500 women. When Petitti looked at all the data, however, she
“found an even more dramatic reduction in death from homicide,
[suicide](http://health.nytimes.com/health/guides/disease/suicide-and-suicidal-behavior/overview.html?inline=nyt-classifier "In-depth reference and news articles about Suicides and Suicide Attempts.")
and accidents.” With little reason to believe that estrogen would ward
off homicides or accidents, Petitti concluded that something else
appeared to be “confounding” the association she had observed. “The same
thing causing this obvious spurious association might also be
contributing to the lower risk of coronary heart disease,” Petitti says
today.

That mysterious something is encapsulated in what epidemiologists call
the healthy-user bias, and some of the most fascinating research in
observational epidemiology is now aimed at understanding this phenomenon
in all its insidious subtlety. Only then can epidemiologists learn how
to filter out the effect of this healthy-user bias from what might
otherwise appear in their studies to be real causal relationships. One
complication is that it encompasses a host of different and complex
issues, many or most of which might be impossible to quantify. As Jerry
Avorn of Harvard puts it, the effect of healthy-user bias has the
potential for “big mischief” throughout these large epidemiologic
studies.

At its simplest, the problem is that people who faithfully engage in
activities that are good for them — taking a drug as prescribed, for
instance, or eating what they believe is a healthy diet — are
fundamentally different from those who don’t. One thing epidemiologists
have established with certainty, for example, is that women who take
H.R.T. differ from those who don’t in many ways, virtually all of which
associate with lower heart-disease risk: they’re thinner; they have
fewer risk factors for heart disease to begin with; they tend to be more
educated and wealthier; to exercise more; and to be generally more
health conscious.

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Considering all these factors, is it possible to isolate one factor —
hormone-replacement therapy — as the legitimate cause of the small
association observed or even part of it? In one large population studied
by Elizabeth Barrett-Connor, an epidemiologist at the University of
California, San Diego, having gone to college was associated with a 50
percent lower risk of heart disease. So if women who take H.R.T. tend to
be more educated than women who don’t, this confounds the association
between hormone therapy and heart disease. It can give the appearance of
cause and effect where none exists.

Another thing that epidemiologic studies have established convincingly
is that wealth associates with less heart disease and better health, at
least in developed countries. The studies have been unable to establish
why this is so, but this, too, is part of the healthy-user problem and a
possible confounder of the hormone-therapy story and many of the other
associations these epidemiologists try to study. George Davey Smith, who
began his career studying how socioeconomic status associates with
health, says one thing this research teaches is that misfortunes
“cluster” together. Poverty is a misfortune, and the poor are less
educated than the wealthy; they smoke more and weigh more; they’re more
likely to have hypertension and other heart-disease risk factors, to eat
what’s affordable rather than what the experts tell them is healthful,
to have poor medical care and to live in environments with more
pollutants, noise and stress. Ideally, epidemiologists will carefully
measure the wealth and education of their subjects and then use
statistical methods to adjust for the effect of these influences —
multiple regression analysis, for instance, as one such method is called
— but, as Avorn says, it “doesn’t always work as well as we’d like it
to.”

The Nurses’ investigators have argued that differences in socioeconomic
status cannot explain the associations they observe with H.R.T. because
all their subjects are [registered
nurses](http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/nursing_and_nurses/index.html?inline=nyt-classifier "Recent and archival health news about nursing and nurses.")
and so this “controls” for variations in wealth and education. The
skeptics respond that even if all registered nurses had identical
educations and income, which isn’t necessarily the case, then their
socioeconomic status will be determined by whether they’re married, how
many children they have and their husbands’ income. “All you have to do
is look at nurses,” Petitti says. “Some are married to C.E.O.’s of
corporations and some are not married and still living with their
parents. It cannot be true that there is no socioeconomic distribution
among nurses.” Stampfer says that since the Women’s Health Initiative
results came out in 2002, the Nurses’ Health Study investigators went
back into their data to examine socioeconomic status “to the extent that
we could” — looking at measures that might indirectly reflect wealth and
social class. “It doesn’t seem plausible” that socioeconomic status can
explain the association they observed, he says. But the Nurses’
investigators never published that analysis, and so the skeptics have
remained unconvinced.

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A still more subtle component of healthy-user bias has to be confronted.
This is the compliance or adherer effect. Quite simply, people who
comply with their doctors’ orders when given a prescription are
different and healthier than people who don’t. This difference may be
ultimately unquantifiable. The compliance effect is another plausible
explanation for many of the beneficial associations that epidemiologists
commonly report, which means this alone is a reason to wonder if much of
what we hear about what constitutes a healthful diet and lifestyle is
misconceived.

The lesson comes from an ambitious clinical trial called the Coronary
Drug Project that set out in the 1970s to test whether any of five
different drugs might prevent heart attacks. The subjects were some
8,500 middle-aged men with established heart problems. Two-thirds of
them were randomly assigned to take one of the five drugs and the other
third a placebo. Because one of the drugs, clofibrate, lowered
[cholesterol](http://health.nytimes.com/health/guides/nutrition/cholesterol/overview.html?inline=nyt-classifier "In-depth reference and news articles about Cholesterol.")
levels, the researchers had high hopes that it would ward off heart
disease. But when the results were tabulated after five years,
clofibrate showed no beneficial effect. The researchers then considered
the possibility that clofibrate appeared to fail only because the
subjects failed to faithfully take their prescriptions.

As it turned out, those men who said they took more than 80 percent of
the pills prescribed fared substantially better than those who didn’t.
Only 15 percent of these faithful “adherers” died, compared with almost
25 percent of what the project researchers called “poor adherers.” This
might have been taken as reason to believe that clofibrate actually did
cut heart-disease deaths almost by half, but then the researchers looked
at those men who faithfully took their placebos. And those men, too,
seemed to benefit from adhering closely to their prescription: only 15
percent of them died compared with 28 percent who were less
conscientious. “So faithfully taking the placebo cuts the death rate by
a factor of two,” says David Freedman, a professor of statistics at the
University of California, Berkeley. “How can this be? Well, people who
take their placebo regularly are just different than the others. The
rest is a little speculative. Maybe they take better care of themselves
in general. But this compliance effect is quite a big effect.”

The moral of the story, says Freedman, is that whenever epidemiologists
compare people who faithfully engage in some activity with those who
don’t — whether taking prescription pills or vitamins or exercising
regularly or eating what they consider a healthful diet — the
researchers need to account for this compliance effect or they will most
likely infer the wrong answer. They’ll conclude that this behavior,
whatever it is, prevents disease and saves lives, when all they’re
really doing is comparing two different types of people who are, in
effect, incomparable.

This phenomenon is a particularly compelling explanation for why the
Nurses’ Health Study and other cohort studies saw a benefit of H.R.T. in
current users of the drugs, but not necessarily in past users. By
distinguishing among women who never used H.R.T., those who used it but
then stopped and current users (who were the only ones for which a
consistent benefit appeared), these observational studies may have
inadvertently focused their attention specifically on, as Jerry Avorn
says, the “Girl Scouts in the group, the compliant ongoing users, who
are probably doing a lot of other preventive things as well.”

Another complication to what may already appear (for good reason) to be
a hopelessly confusing story is what might be called the prescriber
effect. The reasons a physician will prescribe one medication to one
patient and another or none at all to a different patient are complex
and subtle. “Doctors go through a lot of different filters when they’re
thinking about what kind of drug to give to what kind of person,” says
Avorn, whose group at Harvard has spent much of the last decade studying
this effect. “Maybe they give the drug to their sickest patients; maybe
they give it to the people for whom nothing else works.”

It’s this prescriber effect, combined with what Avorn calls the
eager-patient effect, that is one likely explanation for why people who
take cholesterol-lowering drugs called statins appear to have a greatly
reduced risk of dementia and death from all causes compared with people
who don’t take statins. The medication itself is unlikely to be the
primary cause in either case, says Avorn, because the observed
associations are “so much larger than the effects that have been seen in
randomized-clinical trials.”

If we think like physicians, Avorn explains, then we get a plausible
explanation: “A physician is not going to take somebody either dying of
metastatic cancer or in a persistent vegetative state or with end-stage
neurologic disease and say, ‘Let’s get that cholesterol down, Mrs.
Jones.’ The consequence of that, multiplied over tens of thousands of
physicians, is that many people who end up on statins are a lot
healthier than the people to whom these doctors do not give statins.
Then add into that the people who come to the doctor and say, ‘My
brother-in-law is on this drug,’ or, ‘I saw it in a commercial,’ or, ‘I
want to do everything I can to prevent heart disease, can I now have a
statin, please?’ Those kinds of patients are very different from the
patients who don’t come in. The coup de grâce then comes from the
patients who consistently take their medications on an ongoing basis,
and who are still taking them two or three years later. Those people are
special and unusual and, as we know from clinical trials, even if
they’re taking a sugar pill they will have better outcomes.”

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The trick to successfully understanding what any association might
really mean, Avorn adds, is “being clever.” “The whole point of science
is self-doubt,” he says, “and asking could there be another explanation
for what we’re seeing.”

Until the HERS and W.H.I. trials tested and refuted the hypothesis that
hormone-replacement therapy protected women against heart disease,
Stampfer, Willett and their colleagues argued that these alternative
explanations could not account for what they observed. They had gathered
so much information about their nurses, they said, that it allowed them
to compare nurses who took H.R.T. and engaged in health-conscious
behaviors against women who didn’t take H.R.T. and appeared to be
equally health-conscious. Because this kind of comparison didn’t
substantially change the size of the association observed, it seemed
reasonable to conclude that the association reflected the causal effect
of H.R.T. After the W.H.I. results were published, says Stampfer, their
faith was shaken, but only temporarily. Clinical trials, after all, also
have limitations, and so the refutation of what was originally a simple
hypothesis — that H.R.T. wards off heart disease — spurred new
hypotheses, not quite so simple, to explain it.

Photo

At the moment, at least three plausible explanations exist for the
discrepancy between the clinical trial results and those of the Nurses’
Health Study and other observational studies. One is that the
associations perceived by the epidemiologic studies were due to
healthy-user and prescriber effects and not H.R.T. itself. Women who
took H.R.T. had less heart disease than women who didn’t, because women
who took H.R.T. are different from women who didn’t take H.R.T. And
maybe their physicians are also different. In this case, the trials got
the right answer; the observational studies got the wrong answer.

A second explanation is that the observational studies got the wrong
answer, but only partly. Here, healthy-user and prescriber effects are
viewed as minor issues; the question is whether observational studies
can accurately determine if women were really taking H.R.T. before their
heart attacks. This is a measurement problem, and one conspicuous
limitation of all epidemiology is the difficulty of reliably assessing
whatever it is the investigators are studying: not only determining
whether or not subjects have really taken a medication or consumed the
diet that they reported, but whether their subsequent diseases were
correctly diagnosed. “The wonder and horror of epidemiology,” Avorn
says, “is that it’s not enough to just measure one thing very
accurately. To get the right answer, you may have to measure a great
many things very accurately.”

The most meaningful associations are those in which all the relevant
factors can be ascertained reliably. Smoking and lung cancer, for
instance. [Lung
cancer](http://health.nytimes.com/health/guides/disease/lung-cancer/overview.html?inline=nyt-classifier "In-depth reference and news articles about Lung Cancer.")
is an easy diagnosis to make, at least compared with heart disease. And
“people sort of know whether they smoke a full pack a day or half or
what have you,” says Graham Colditz, who recently left the Nurses’ study
and is now at Washington University School of Medicine in St. Louis.
“That’s one of the easier measures you can get.” Epidemiologists will
also say they believe in the associations between LDL cholesterol, blood
pressure and heart disease, because these biological variables are
measured directly. The measurements don’t require that the study
subjects fill out a questionnaire or accurately recall what their
doctors may have told them.

Even the way epidemiologists frame the questions they ask can bias a
measurement and produce an association that may be particularly
misleading. If researchers believe that physical activity protects
against chronic disease and they ask their subjects how much
leisure-time physical activity they do each week, those who do more will
tend to be wealthier and healthier, and so the result the researchers
get will support their preconceptions. If the questionnaire asks how
much physical activity a subject’s job entails, the researchers might
discover that the poor tend to be more physically active, because their
jobs entail more manual labor, and they tend to have more chronic
diseases. That would appear to refute the hypothesis.

The simpler the question or the more objective the measurement the more
likely it is that an association may stand in the causal pathway, as
these researchers put it. This is why the question of whether
hormone-replacement therapy effects heart-disease risk, for instance,
should be significantly easier to nail down than whether any aspect of
diet does. For a measurement “as easy as this,” says Jamie Robins, a
Harvard epidemiologist, “where maybe the confounding is not horrible,
maybe you can get it right.” It’s simply easier to imagine that women
who have taken estrogen therapy will remember and report that correctly
— it’s yes or no, after all — than that they will recall and report
accurately what they ate and how much of it over the last week or the
last year.

But as the H.R.T. experience demonstrates, even the timing of a
yes-or-no question can introduce problems. The subjects of the Nurses’
Health Study were asked if they were taking H.R.T. every two years,
which is how often the nurses were mailed new questionnaires about their
diets, prescription drug use and whatever other factors the
investigators deemed potentially relevant to health. If a nurse fills
out her questionnaire a few months before she begins taking H.R.T., as
Colditz explains, and she then has a heart attack, say, six months
later, the Nurses’ study will classify that nurse as “not using” H.R.T.
when she had the heart attack.

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As it turns out, 40 percent of women who try H.R.T. stay on it for less
than a year, and most of the heart attacks recorded in the W.H.I. and
HERS trials occurred during the first few years that the women were
prescribed the therapy. So it’s a reasonable possibility that the
Nurses’ Health Study and other observational studies misclassified
many of the heart attacks that occurred among users of hormone therapy
as occurring among nonusers. This is the second plausible explanation
for why these epidemiologic studies may have erroneously perceived a
beneficial association of hormone use with heart disease and the
clinical trials did not.

In the third explanation, the clinical trials and the observational
studies both got the right answer, but they asked different questions.
Here the relevant facts are that the women who took H.R.T. in the
observational studies were mostly younger women going through menopause.
Most of the women enrolled in the clinical trials were far beyond
menopause. The average age of the women in the W.H.I. trial was 63 and
in HERS it was 67. The primary goal of these clinical trials was to test
the hypothesis that H.R.T. prevented heart disease. Older women have a
higher risk of heart disease, and so by enrolling women in their 60s and
70s, the researchers didn’t have to wait nearly as long to see if
estrogen protected against heart disease as they would have if they only
enrolled women in their 50s.

This means the clinical trials were asking what happens when older women
were given H.R.T. years after menopause. The observational studies asked
whether H.R.T. prevented heart disease when taken by younger women near
the onset of menopause. A different question. The answer, according to
Stampfer, Willett and their colleagues, is that estrogen protects those
younger women — perhaps because their arteries are still healthy — while
it induces heart attacks in the older women whose arteries are not. “It
does seem clear now,” Willett says, “that the observational studies got
it all right. The W.H.I. also got it right for the question they asked:
what happens if you start taking hormones many years after menopause?
But that is not the question that most women have cared about.”

This last explanation is now known as the “timing” hypothesis, and it
certainly seems plausible. It has received some support from analyses of
small subsets of the women enrolled in the W.H.I. trial, like the study
published in June in The New England Journal of Medicine. The dilemma at
the moment is that the first two explanations are also plausible. If the
compliance effect can explain why anyone faithfully following her
doctor’s orders will be 50 percent less likely to die over the next
few years than someone who’s not so inclined, then it’s certainly
possible that what the Nurses’ Health Study and other observational
studies did is observe a compliance effect and mistake it for a
beneficial effect of H.R.T. itself. This would also explain why the
Nurses’ Health Study observed a 40 percent reduction in the yearly risk
of death from all causes among women taking H.R.T. And it would explain
why the Nurses’ Health Study reported very similar seemingly beneficial
effects for antioxidants, vitamins, low-dose aspirin and folic acid, and
why these, too, were refuted by clinical trials. It’s not necessarily
true, but it certainly could be.

While Willett, Stampfer and their colleagues will argue confidently that
they can reasonably rule out these other explanations based on
everything they now know about their nurses — that they can correct or
adjust for compliance and prescriber effects and still see a substantial
effect of H.R.T. on heart disease — the skeptics argue that such
confidence can never be justified without a clinical trial, at least not
when the associations being studied are so small. “You can correct for
what you can measure,” says Rory Collins, an epidemiologist at Oxford
University, “but you can’t measure these things with precision so you
will tend to under-correct for them. And you can’t correct for things
that you can’t measure.”

The investigators for the Nurses’ Health Study “tend to believe
everything they find,” says Barrett-Connor of the University of
California, San Diego. Barrett-Connor also studied hormone use and heart
disease among a large group of women and observed and published the same
association that the Nurses’ Health Study did. She simply does not find
the causal explanation as easy to accept, considering the plausibility
of the alternatives. The latest variation on the therapeutic wisdom on
H.R.T. is plausible, she says, but it remains untested. “Now we’re back
to the place where we’re stuck with observational epidemiology,” she
adds. “I’m back to the place where I doubt everything.”

So how should we respond the next time we’re asked to believe that an
association implies a cause and effect, that some medication or some
facet of our diet or lifestyle is either killing us or making us
healthier? We can fall back on several guiding principles, these
skeptical epidemiologists say. One is to assume that the first report of
an association is incorrect or meaningless, no matter how big that
association might be. After all, it’s the first claim in any scientific
endeavor that is most likely to be wrong. Only after that report is made
public will the authors have the opportunity to be informed by their
peers of all the many ways that they might have simply misinterpreted
what they saw. The regrettable reality, of course, is that it’s this
first report that is most newsworthy. So be skeptical.

If the association appears consistently in study after study, population
after population, but is small — in the range of tens of percent — then
doubt it. For the individual, such small associations, even if real,
will have only minor effects or no effect on overall health or risk of
disease. They can have enormous public-health implications, but they’re
also small enough to be treated with suspicion until a clinical trial
demonstrates their validity.

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If the association involves some aspect of human behavior, which is, of
course, the case with the great majority of the epidemiology that
attracts our attention, then question its validity. If taking a pill,
eating a diet or living in proximity to some potentially noxious aspect
of the environment is associated with a particular risk of disease, then
other factors of socioeconomic status, education, medical care and the
whole gamut of healthy-user effects are as well. These will make the
association, for all practical purposes, impossible to interpret
reliably.

The exception to this rule is unexpected harm, what Avorn calls “bolt
from the blue events,” that no one, not the epidemiologists, the
subjects or their physicians, could possibly have seen coming — higher
rates of vaginal cancer, for example, among the children of women taking
the drug DES to prevent
[miscarriage](http://health.nytimes.com/health/guides/disease/miscarriage/overview.html?inline=nyt-classifier "In-depth reference and news articles about Miscarriages."),
or mesothelioma among workers exposed to asbestos. If the subjects are
exposing themselves to a particular pill or a vitamin or eating a diet
with the goal of promoting health, and, lo and behold, it has no effect
or a negative effect — it’s associated with an increased risk of some
disorder, rather than a decreased risk — then that’s a bad sign and
worthy of our consideration, if not some anxiety. Since healthy-user
effects in these cases work toward reducing the association with
disease, their failure to do so implies something unexpected is at work.

All of this suggests that the best advice is to keep in mind the law of
unintended consequences. The reason clinicians test drugs with
randomized trials is to establish whether the hoped-for benefits are
real and, if so, whether there are unforeseen side effects that may
outweigh the benefits. If the implication of an epidemiologist’s study
is that some drug or diet will bring us improved prosperity and health,
then wonder about the unforeseen consequences. In these cases, it’s
never a bad idea to remain skeptical until somebody spends the time and
the money to do a randomized trial and, contrary to much of the history
of the endeavor to date, fails to refute it.**

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