19 November 2014

About evidence-based medicine, demography, epidemiology and much more

How epidemiology gets knowledge


Transcript of a lecture by Professor of the Higher School of Economics, President of the Society of Evidence-Based Medicine Specialists Vasily Vlasov, delivered on November 15, 2014 as part of the Festival of Public Lectures #KNOW – a joint project of the information and analytical channel "Polit.ru" and the Department of Science, Entrepreneurship and Industrial Policy of Moscow.

Boris Dolgin: Colleagues, we are continuing the Festival of public lectures #KNOW – a joint project of the information and analytical channel "Polit.ru" and the Department of Science, Entrepreneurship and Industrial Policy of Moscow. This is 20 lectures, we can say 20 exemplary lectures. We are trying to set a certain sample of the genre.

Today our second lecture is no longer devoted to humanities, but, one might say, almost natural science subjects, although they are on the verge of sociality. This is a problem of epidemiology, as well as what we will learn about in its framework. Our guest today is Vasily Viktorovich Vlasov, Professor at the Higher School of Economics and, as far as I understand, the First Honey…

Vasily Vlasov: They fired me from the First honey.

Boris Dolgin: Fired? Well, let them regret it. Vasily Vlasov is the head of the Society of Evidence–Based Medicine.

We work in the traditional mode. In the first part of the actual lecture. In the second one, you will be able to ask questions, make some remarks using a microphone and a raised hand. Please, Vasily Viktorovich.

Vasily Vlasov: Thank you very much. Dear sirs, I suspect that someone may have some misunderstanding during the lecture. For my part, I have a completely positive attitude to the fact that someone will raise their hand and say: "explain this to me."

Boris Dolgin: Okay, questions for understanding, not discussion…

Vasily Vlasov: I will be happy to clarify and explain something. Moreover, my speech today touches on a number of issues that are not so strongly related to each other. Related to each other by my interest and, I suspect, by your interest in the development of our wonderful knowledge about what we are and what we are sick of.

I would like to start by notifying you of a potential conflict of interest. In our medicine, I am not sure that in all other areas it is also customary to notify about a potential conflict of interest. Because a significant part of doctors, healthcare professionals in general, receive payments for the work performed from various manufacturers. And their presentations may reflect these conflicting interests. In this case, I do not have any problems of this kind, I can go to my first example, the first area that relates to epidemiology sideways. This is a demographic example.

On this screen you can see the curve of the projected population of the Earth. Note that in addition to the blue line, the most likely forecast, there is a red line – the maximum forecast – and a blue line – the minimum forecast. Pay attention to how much they differ in the perspective of 50 years. And 50 years is the life of one generation. How can this be? This may be because there are a huge number of powerful factors besides epidemics. For example, productivity, warm winter. If it is a warm winter, pathogens have overwintered, people have been bitten, mass diseases have arisen. Cattle died, famine arose. These factors are predictable with great difficulty. For example, this year, maybe those of you who are interested in nature know that ducks have bred a second offspring in Siberia. On Lake Baikal at the end of September, ducks have just flown from the north. And in Kamchatka at the end of November, the bears did not lie down for the winter. Such completely unpredictable global things can have a very strong impact. Scientists must somehow understand this.

Here's a look at what the English demographers manage to do. England is a country where population registration is very good, population movement is well taken into account. Look what's going on. In 1956, they give a forecast of the population, which is not justified already on a huge scale in 5 years. After that, they make a new forecast and fail again. New forecasts are being made, but the true population greatly exceeds them all. Every year there are new forecasts, a new leap. What explains this jump? I think each of you, after thinking, will guess: so these are immigrants! That's right, immigrants. But no demographers could predict this process. Because this is a political, social process. It is not displayed with demographic data.

Look what happened. This is the real number of immigration. And this is what was expected in 1976, in 1988. Please note, it was assumed that immigration would decrease. And it does not decrease and does not decrease. And that almost zero immigration to the UK, which was back in 1980, grew to 300 thousand a year in 2006. You know, now in the UK for many years the most common name for a newborn boy is Mohammed. In fact, these processes should be well predictable, because the birth rate of the population depends entirely on how many women will enter the fertile age. But this was already known last year and the year before last. It should be easy to calculate. And it is not calculated.

Look, here we are talking about mortality in the UK. Mortality could be well calculated: after all, it is known how people die, the basic structure is clear. And watch what happens. Mortality is calculated, this is a calculation made in 1975, this is made in 1984. And mortality is decreasing and decreasing. It is declining more than the calculations based simply on the age structure of the population suggested. About 15 years ago, a wonderful article was published in Nature, which compared data on how long people really live, and calculations by gerontologists about how long they can live. So it turned out that 15-18 years did not pass after the next announcement that people can live up to a maximum of 115 years, like bang! – and it turns out that, it turns out, they can live longer. And there were 5 or 6 stages of such scientific predictions about the maximum life expectancy of a person. And all of them did not justify themselves for a short time. It's amazing how little we understand even such simple processes as the dynamics of population mortality.

And here is a more medical example. Here we are talking about morbidity and mortality. Let me draw your attention to the fact that a lot of interesting things happened in the XX century. For humanity, the most interesting thing is the demographic transition. The demographic transition is so named by demographers. And we, epidemiologists and doctors, call it an epidemiological transition. What is it? Before that, people were sick mainly with infectious diseases and died mainly in childhood. Few people lived to be 30-40 years old. By the end of the XX century, almost the entire population of the Earth begins to suffer from chronic diseases of older age and die at a later age. The structure of morbidity is changing, the structure of mortality is changing. Hence, of course, healthcare should change. And this is another surprise at how little we know. The demographic transition took place, apparently, in the whole world. In China, it took place in the late 80s - early 90s. A huge country with its huge population. In Western Europe, in the USA, this happened before the Second World War. The World Bank published its remarkable report that chronic diseases of older age are the main health problem of the country's population in 2011. The World Health Organization put the prevention of chronic diseases at the forefront in 2013. Pay attention to how big the lag is between when the processes developed, when they were recognized by science, and when they began to be really taken into account in health policy.

These are US statistics. Their statistics are better than ours, so in many cases we will focus on it. This is mortality from cardiovascular diseases. At the beginning of the XX century, you see, it was very low. There are thousands of cases just here. Please note that the diagnoses of patients who were diagnosed at the beginning of the XX century correspond to today's. By making the best corrections, you can make a more or less plausible picture. This is the best available version of the truth. Look what's going on. In the middle of the XX century, it seems that humanity will soon die out from cardiovascular diseases. There are a huge number of them, they grow and grow. And this is where the epidemiology of chronic diseases arises. And the whole epidemiology, which used to be only about infections, begins to switch to the study of non-communicable diseases. It was an absolutely wonderful period in the development of medical science, because this is where attention to cardiovascular diseases appears, here they begin to be actively studied. Here they begin to develop the technique of vascular surgery, and so on and so forth. Only in the middle of the XX century. Then there is such a downward trend. It is believed that it was a huge discussion in the 70-80 years, why this declining trend arose. Doctors who receive money for treatment say we have started to treat well. I see, right? Specialists involved in prevention – we do prevention well. People who like the infectious theory, they say – it was an epidemic of an unknown disease that manifested itself with cardiovascular problems. And by the way, this hypothesis has not yet been completely rejected. But what happens next? Further, more effective interventions are being developed. It was in the middle of the XX century that the statistical methods that allow us to assess these realities were developed. In the classroom we have masters of statistical methods who do this every day. Because without performing calculations on these large volumes, it is impossible to see what is happening there. Epidemiology, as a science that understands these processes, has become a participant in these huge shifts. And I will cover several such areas of these big shifts in understanding what is happening in the world, in understanding what is happening to a person, and I will cover further.

My own research field is clinical epidemiology. More narrowly – the problem of obesity. In general, clinical epidemiology is the science of clinical realities. When we say clinical, we mean medical, just such a tracing paper from English. This means that we, the doctors in the clinic, are not studying metabolism, hormones, microbes, viruses. And we study what happens to a person. We link the intervention and the outcome. We link the diagnostic technology and the chosen method of treatment. That is, clinical realities, medical realities. This is what clinical epidemiology is doing. This field of activity appeared as a real one, realized only in the 1980s.

The first fairy tale is a fairy tale about cohort studies. Cohort studies were developed as an idea and were first applied specifically to the study of cardiovascular diseases after World War II, at a time when a huge number of people in the Western world were dying. These studies, by and large, were conducted only in the richest countries, because they are terribly expensive. What are these studies?

They take a set of people and distinguish from them those who are exposed to some unfavorable factor, and those who are not exposed to this unfavorable factor. For example, a classic example is smoking. These smoke, but these do not smoke. And these people are being watched for a long time. And they find that those who smoke are more likely to develop symptoms. Some do not develop, but these develop more often. Those who do not smoke also develop, but rarely. And this difference in the frequency of symptoms of the disease in those who are at risk, and those who are not, is the basis for the connection of smoking with a harmful outcome.

The largest study of this kind was launched after World War II in the city of Framingham, near Boston. It was aimed at studying what factors determine the development of coronary heart disease in people. The whole population of a small town was involved in this study. And today – in the XXI century, 60 years later – the research continues. Now the children and grandchildren of those people who were included in this analysis continue to be observed. And they revealed very interesting things that are now the property of the whole world. This is a great achievement of the development of modern medical science – not only medical, but, above all, medical – the data collected in such studies become available to any researcher from all over the world. That is, any researcher, from Russia or Japan, can access this data, analyze, study and get answers to some of their questions. Physicists have worked this out for a long time, it is more or less an everyday practice. In medicine, this has been formed only in the last 20 years.

And here is the classic result from this Framingham study. Please note that these columns correspond to groups of people with certain characteristics. See, here's one package, here's the second package. How do they differ? Here we have people who have glucose intolerance, and these have high blood pressure. These don't smoke, these smoke. And for each of these groups, the concentration of cholesterol in the blood is shown. From low to high. Here we see that in a certain group of people who have high cholesterol, high blood pressure, a tendency to diabetes, glucose intolerance, who also smoke, they have such a huge risk. This was shown in the Framingham study. But interestingly, there are very few such people. There are less than one percent of them. But the picture looks very convincing. And it is thanks to the persuasiveness of such a study, on the basis of such a connection, such a correlation between cholesterol and the occurrence of cardiovascular diseases, the idea that less cholesterol should be consumed appeared.

Those of you who are older probably remember the idea of the 60-70s, she lived to the 80s, that you need to consume less cholesterol. And still on some products, on bottles with vegetable oil, they write that there is no cholesterol in it. It's an echo of that old idea. For at least the last 30 years, it has been known that cholesterol consumed with food has no significance for cardiovascular risk. But the advertising idea was picked up, and today you can buy vegetable oil, in which, hooray, there is no cholesterol. In fact, I emphasize, this connection served for the idea of prevention, useless, and the idea that was picked up for marketing. While there was no ice cream on the shelves of our stores at all – it was sold by peddlers in boxes, at that time in the USA there were already whole walls in supermarkets filled with ice cream in stores. And it was possible to observe Americans who went and looked for which bank had the lowest concentration of cholesterol. And they paid extra money for this ice cream. Thus, marketing began to support this idea, and it lives on to this day.

Does this mean that these connections are false? Nothing like that. It turns out that by reducing the concentration of cholesterol in a person's blood, you can really reduce his cardiovascular risk. But with medicines. It is impossible to do this with a diet. The idea that came from here, from this cohort study – about the effect of food – was not confirmed, but drugs and statins appeared, which, although not highly effective, nevertheless reduce cardiovascular risk. Here's a look at what happened thanks to who knows what. Cardiovascular mortality in the United States, here is no longer the total mortality, but per 100 thousand of the population, began to decline after the 70th year. And it is still declining. There is an impression that soon it may come to zero. Of course, that's not going to happen. But nevertheless, this process is absolutely fantastic.

However, I must say that in the USA a little later, somewhere from the 70s, mortality from other conditions, including cancer, began to decrease. This is generally a common property of human populations. My grandmother, the deceased, loved to say: "it's good when everything is good, and as bad as it is, everything is bad." When people's mortality decreases, it decreases from all causes approximately the same. There is no separate reason, by disabling which, you can disable the process, does not occur. So it is here. If there is an improvement in the health of the population, then it goes in different directions. And cardiovascular mortality is decreasing, and cancer. It may not be a simultaneous process, but it is happening. By the way, in our country, in which changes in mortality are mysterious, but if life expectancy is increasing now, then, accordingly, cardiovascular and oncological mortality, mortality from stroke and rectal cancer are decreasing. Roughly parallel. This is one of the mysteries. What factor works here? There are many hypotheses, there are no exact explanations. This is the state of our population today in terms of cardiovascular mortality. These are the EU countries, they have about the same as in the USA, even a little better. And this is our cardiovascular mortality. Cardiovascular mortality is the main component of mortality for the population – most of the population dies from cardiovascular diseases. This does not mean that it is so at all ages. In fact, there are different causes of death at different ages. If you single out young people, they are more likely to die from injuries related to drunk driving and so on. And, let's say, at the age of 5 to 15, the biggest cause of death of children in our country is suicide. That is, if we take different ages, there will be different reasons. But in general, cardiovascular mortality is the main cause of our demographic catastrophe.

And here is another way of analysis – ecological. It also became widely used in the 50s and 60s and also applied to cardiovascular diseases. Indeed, the idea is very simple. Let's compare different countries in terms of mortality from different diseases. And where will the lowest mortality be, will we look at what people are doing there? Maybe they do something magical there and live longer. Such an analysis was carried out, there was a huge study. This study drew attention to the Mediterranean diet. I understand that you all know more or less about the Mediterranean diet. The Mediterranean diet has attracted attention precisely because there is a small cardiovascular mortality. And, interestingly, with not such a long lifespan. And based on this, the Mediterranean diet has been promoted for 50 years. And interestingly, for 50 years there has not been a single experimental confirmation that the Mediterranean diet really reduces cardiovascular mortality. 15 years ago, an Indian scientist published a study in a British scientific journal that experimentally proved that if some patients with coronary heart disease were given a Mediterranean diet, and others would eat ordinary Indian food, then those on a Mediterranean diet would have a better condition, and repeated heart attacks would occur less often. The study was impressive, everyone cited it for three years. Three years later, it was proved that the data had been falsified. But we live, still trusting the idea of a Mediterranean diet.

This picture reflects the mortality from breast cancer. We see that prosperous countries have a high mortality rate from breast cancer. This pattern is illustrated here by data from 2007. But even earlier, 50 years ago, it was described in a wonderful book by Richard Doll, an outstanding specialist in cancer epidemiology, based on statistics from the 60s. See what correlation he found. The more fat is consumed with food, per day, the greater the mortality rate per 100 thousand population. The connection is so close that it rarely happens in experiments. Hence the recommendation to eat less fat. And then there will be no breast cancer. However, in order not to return to this picture, pay attention to which countries are here, and which countries are here. Can the difference between these countries lead only to how much fat they consume? No, of course, these are completely different countries, completely different hereditary structures, completely different living conditions. But the idea was very strong. And here, too, it had a huge impact on social practice. Doctors often said that it was necessary to limit fat, because fat causes cancer. But, fortunately, other studies have been given in relation to this pathology. Here we see data from cohort studies that you already know, from data from comparison studies with controls.

Since not everyone can know what a comparison study with a control is, I will explain this matter on my fingers. The comparison study with the control looks something like this. A woman who has been diagnosed with breast cancer is matched. A woman of the same age who does not have breast cancer. And they are interviewed about how they eat. And if it turns out that a woman who has breast cancer eats a lot of fat, then, accordingly, it turns out that fat is associated with breast cancer. Here is such a study. These studies have a lot of disadvantages, but also many advantages. Disadvantages, for example, are that sick people remember better what they did wrong before. And healthy people are not inclined to remember what they did wrong before. And this displacement of memories has a huge impact on the result. Please note, in a controlled study, fat consumption increases the risk of breast cancer by about one and a half times. It is revealed significantly. And in a cohort study, remember, a cohort with smoking, some smoke, others do not smoke. If you observe women who eat little fat and a lot of fat, it turns out that there is no connection. Identically. Cohort studies are more reliable. Therefore, we conclude that there is no connection between the occurrence of breast cancer and fat consumption.

But I would like to draw your attention to one circumstance of this picture, which is relatively new for medical literature, has probably been used for the last 20-25 years only. Pay attention. I said here that the risk of cancer is increased by about one and a half times. This is a point estimate. You see, these "mustaches" are drawn here? These moustaches have been painted only for the last 25 years. Maybe a little more. These "whiskers" determine the interval in which the true estimate probably lies. This estimate is most likely, but we are not sure about it. Because the data is always inaccurate. Remember, I showed from the very beginning how inaccurate everything is with us. These tendrils show us the confidence interval. Usually with a 95% probability, this means that the true estimate lies there. Here we see that here the true estimate is rejected, but here it is not rejected. Since we trust cohort studies more, we are convinced. Limiting fat intake is pointless if we want to prevent cancer by doing so.

I must say that the research arsenal for understanding what is happening is not limited to these two methods. The method of so-called controlled tests has attracted the most attention over the past 60 years. We say "trials", trial, meaning that this is one of the research options. There are some areas, for example, areas of legal regulation in medicine, where the word "research" is used in relation to tests. We are analyzing science with you. According to science, we are talking about tests. Why testing? Because it's a terribly important joke. There is such a disease, prostate cancer. Men have a gland under the bladder that is highly dependent on male sex hormones. Over the years, it increases and over the years, tumors and prostate cancer appear more and more often in it. This cancer is not too vicious, but it also has the property of spreading through the body, giving metastases. Here you can see the picture obtained from a patient whose prostate cancer has metastasized to the bone.

Bone metastases are a very unpleasant thing, they hurt very much. This picture is obtained by scintigraphy. That is, a substance emitting radioactive rays is injected into the human body. It accumulates in the tumor cells. If a person is then, roughly speaking, examined with a photographic film, then these dark areas appear in the places of accumulation of the drug. We see that there are quite a lot of these areas, they are intense. We treated this person with a certain new drug, and look what happened: the metastases practically disappeared. Fantastic result. This is the result of one of, in my opinion, five patients who were allowed to use this new drug by the American Agency for Drug and Food Control. Thus, it was shown that this drug is promising, it should be further tested. Why should we continue testing? After all, such a wonderful result. But because we don't know what the result will be for the next patient. After all, people do not want to know specifically about this patient Sidorov, but what happens to such patients. And if I have such a disease, how will this drug affect me? And in order to get an answer to this question, you need to conduct tests. These tests are conducted using a technology that is not new at all. For the first time, the technology of controlled tests is described in the prophet Daniel. He was the son of the king of Judah. And after the capture of Jerusalem, Nebuchadnezzar took him to serve at the table with his brothers. And the eldest eunuch was instructed to feed the children from the royal table so that they would look good. The children, and above all the eldest son, the heroic Daniel, said that it was not kosher – in these conditions, you can only eat vegetables, fruits and drink only water. The servant was afraid that the king would cut off his head. Daniel persuaded him: "Lock us in a room for 10 days and give us only vegetables, fruits and water. And in 10 days you will see." He agreed, locked them in a room, fed them vegetables, fruits and gave them water. And then compared with other young men who served in the palace, and found that they look very good. This was enough for him to allow them to eat the food that they consider correct in their faith. Please note that there is the most important thing here. There is a comparison. He didn't just observe them, he compared what the results would be.

This idea of comparison, it appeared in scientific form in the XVIII century. The English doctor James Lind gave calvados to some sailors suffering from scurvy, gave cabbage to others, and gave limes to others. In Soviet literature it was written about "lemons", but in reality they were limes. You can easily guess why in Soviet literature they were lemons. Because Soviet people didn't see limes. This had such a huge impact that within a year all the English ships went to sea only with a supply of limes. Even the English sailors themselves began to click "limes". And then, in general, all Englishmen began to click like that. Even that movie that you all probably know called "The Englishman", it's called "Limey" in the original. That is, the cultural significance of the discovery of randomized controlled trials is so great.

How are they conducted today? In the simplest version, this is a comparison of two methods of treatment, active treatment and control. The so-called placebo, that is, a pacifier, is used as a control. A tablet that looks like an active treatment, but in reality does not contain an active substance. People who need to be tested, for example, such patients who have metastatic prostate cancer, are informed about the test, and their consent is obtained. This is also a new technology, it appeared after 1946. The Nuremberg Tribunal tried doctors, and the court ruled that people can be experimented on only on the basis of their informed consent. This is a new technology of the second half of the XX century. And when they get their consent from them, then people are randomized, that is, they are distributed into one of two groups. The simplest method of randomization: if we have two groups, we throw a coin, who has heads, who has tails, fall into different groups. These groups are randomly formed, but the same. Why are they the same? Because they are random. At the same time, you can not examine these groups in any way. Because it is quite obvious that both men and women, and brunettes, and blondes, and smokers, and non-smokers in these groups will be about the same number, if there are enough of them. And after that, if we know that these groups are the same, and the outcomes will be better in some of them, we can attribute this to this treatment.

In fact, this research method was used two thousand years ago. An ancient technology, but in its new guise like this. These randomized controlled trials are very well available to us today. American taxpayers pay taxes, and the government maintains the national medical library. And today, each of us can go to her website and for any disease, for any medicine, type a request and get good information. The most reliable information, as I have already said, is obtained by the keywords "randomized controlled trials" (Randomized controlled trials). And we can find out there with you that for arbidol, for example, there are no randomized controlled trials that would be of interest to us. Therefore, we claim that arbidol is a medicine with unproven usefulness and people should not spend money on it. This is a wonderful tool that is available to all mankind, works effectively, and access to it works well. Since humanity really liked this tool, which was really used after the Second World War, then see how rapidly the number of randomized controlled trials in the world is growing. It's growing very fast. Because this is the best way to find out whether the medicine cures or not. Unfortunately, modern practice has not come to this everywhere. In our country, for example, some drugs are allowed to be used without randomized controlled trials. Here is one of such well–known and scandalous drugs - this is kagocel. It was allowed for the treatment of influenza on the basis that a certain number of people were simply treated, they recovered, and the drug was allowed for the treatment of influenza. Unfortunately, such things happen. And in this respect, our country differs very slightly from Nigeria or Bangladesh. As I have already said and I do not tire of repeating, all the data that we receive when studying people, animals, and all living things, they are all impermanent. That is, we measure once – we get one result, we measure again – we get another result. As a result, we seem to have intended 20%, but we don't know for sure whether it's 12 or 36. This confidence interval is often very wide. That's when they test different methods of treatment or diagnosis, they get slightly different results.

In the middle of the XX century, another statistical technology was invented. True, it was invented in the humanities, but doctors began to use it most of all since the 80s. This is called a systematic review. Systematic means conducted according to the system. It also includes statistical technology, which is called the word meta-analysis. Here we see one of such examples. Here we are talking about the use of beta-carotene for cancer prevention. There was such a wonderful idea in the middle of the 20th century, which, in particular, was promoted by the aforementioned Richard Doll, that since cancer develops from the epithelium, that is, from those cells that line the inner wall of the gastrointestinal tract, bronchi, our skin, from these cells. And since these cells feel good when there is enough vitamin A, then there was such an idea that if vitamin A is not enough, it can contribute to the development of cancer. So, you need to add vitamin A.

This idea is so popular that if we turn to dietary recommendations, sometime before the mid-90s of the XX century, we will find that it was specifically recommended to eat red and yellow fruits and vegetables there. Carrots, tomatoes, persimmons. That is, the recommendation was to get this vitamin A in the form of its provitamin carotene. Accordingly, a bunch of dietary supplements with beta-carotene were released to the market, huge sales. Subsequent studies were still carried out. And look what happened. Here we see with you a picture of very good quality. These are cohort studies. For example, health workers, men. Men, social workers. Etc. And they have shown that those who consume more beta-carotene have a reduced risk of developing cancer. In this study, the effect is not detected, but in this one it is again detected. The line, as we know, is a confidence interval. There were few participants here, so the confidence interval is wide. And here there were a lot of participants, the confidence interval is narrow, a more accurate assessment. If all of them are combined using statistical meta-analysis technology, it turns out that the probability of developing cancer is reduced by a quarter. It's great to reduce the chance of developing cancer by a quarter. But these are cohort studies, here people simply chose their own food. Tests were carried out. In these trials, people in one group were given a tablet with beta-carotene, and others were given a tablet that was similar, but it did not contain beta-carotene. And it went on for many years. And look what happened. Smokers develop cancer even more often, in patients with skin cancer, cancer develops further more often – in former smokers. It turned out that beta-carotene does not prevent cancer, but even increases the likelihood of its spread. By about 10%. That's what controlled trials are giving at the moment. This is a wonderful technology that allows us to study whether something should be done. We still do not know by what mechanism this is determined. And we may not find out in the foreseeable future. But it is very important that thanks to the tests we know that beta-carotene does not benefit, and maybe even harms. For public health, for the healthcare organization, it is extremely important to know what not to do. If you do not do this, then you can save money, which is terribly needed by sick people.

Unfortunately, a lot of unnecessary things are being done in many healthcare systems, including ours. As a result, we do not have enough money for health, including. Epidemiology, first of all clinical epidemiology, has an interesting form – the so-called evidence-based medicine. We have already mentioned today the Society of evidence-based medicine specialists. This is a form of medical practice, characterized by the use of only those methods of treatment that are scientifically justified. And the best scientific justification is the conduct of controlled clinical trials. What has not been tested in controlled clinical trials should not be used in normal medical practice. This is evidence-based medicine. I must say that today people, at least people who read in English, have very good opportunities to find out how scientifically justified the intervention that is recommended to them. The National Health Service of Great Britain has created a wonderful website where every visitor can find out information about almost all common diseases, how to treat them correctly, what is scientifically justified, and get information about medicines that are allowed for use in the UK. In the UK, almost all modern drugs are allowed. Russian Russian, unfortunately, does not have anything like that, so I can not recommend such sources in Russian. Google translate to help you, you can use the information from this site.

(Obviously, we are talking about a website NHS.uk ; we recommend another patient–oriented website, the American MedlinePlus - VM.)

Doctors, in turn, as a result of the development of evidence-based medicine, received new literature. If earlier literature was only in the form of books, now this literature has appeared in electronic form. Doctors have wonderful reference books that are in their pocket, from which they can get information via the Internet. And what is most interesting, today the best reference books are updated as new scientific data becomes available. The book can stand on the shelf, it was published in 2004, it is still on someone's shelf. And it's been 10 years. A significant part of it is outdated. And if you open it, you don't know what's outdated in it. And there are such systems that, in fact, within a month, all the new scientific data that appear include. At one time, I was impressed by Stanislav Lem's story about the encyclopedia of the future, written in the form of a preface. In this preface it was written that if you are reading the text and your letters have become blurry and unreadable, wait a bit, this is an update of the text. And this updating of scientific medical texts today is a perfect reality. Any publications that are not updated in accordance with the latest research can cause significant harm to patients. I cannot give such an example here, but in the USA in 1988 the first verdict of a medical organization was passed, not to a doctor, but through the fault of a doctor. The doctor, consulting the patient, did not check his knowledge of scientific periodicals. At that time, as the plaintiff's lawyers showed, studies had already been published that required him to take other actions. As a result, the organization he worked for paid a rather large fine. That's the pressure medicine is under today in the sense of responsibility. Unfortunately, not in our country.

In the end, we come to the question that our science, epidemiology, feeds not only the clinic, but also feeds the health organization. If we are going to talk about the organization of healthcare, popularization interventions, then I will simply say that the ways of organizing work in hospitals, the ways of paying for the work of a doctor are also all checked in controlled trials. Indeed, there are experimental data that show, for example, that incentive payments in a doctor's salary should not exceed 15-20%. In our country, incentive payments from a doctor are 50-60-70%, and the basic salary is only 30%. This is ineffective, such stimulation does not work, on the contrary, it has a negative impact on the quality of the doctor's work.

Take such interventions as medical examination in general. They have never been tested. And what was tested? Annual medical examinations were tested. Several long-term studies have been conducted. They showed that it is pointless to invite people for a medical examination once a year. It does not bring any health benefits. What is important? It is important that people have easy access to a doctor, so that they can come to the doctor if necessary, when it occurs. If there is access to a doctor, then the doctor will help solve these problems.

Here is another example of such a massive intervention, which has been well tested. Breast cancer is known to be detected by X-ray. And so when portable X-ray machines and fluorographs appeared, the idea arose that women should periodically photograph the mammary gland in order to detect growing cancer in it. Then it will be possible to operate on him early and there will be no negative consequences, the woman will not die of cancer. The idea is simple. But in some countries it was blindly applied, and in some they began to conduct controlled tests. How were they conducted? In some countries, they took the regions of the country and distributed them. In some regions, universal mammography was performed, while in others it was not performed. And compared what would happen. In other countries, women were randomized. Some women were offered mammography once every two years, others were not. And then they compared the mortality rate of these people. And there have been many such studies. Here are three studies of good quality and three studies of poor quality. I will not go into the details of the quality assessment, but it is very important that if you look at the overall mortality after 13 years, it turns out that X-ray mammography has no effect on the mortality of women. That is, from the point of view of life extension, it is useless. This is proven. But mammography is not about general mortality, it is about mortality from breast cancer. Calculations from the same study show this sad truth. Indeed, if mammography is carried out systematically, it is possible to prevent a certain number of deaths from breast cancer. But at what cost? If 2,500 women undergo mammography for 10 years, then one of them will not die of breast cancer in these 10 years. At the same time, thousands of women will initially receive a diagnosis of breast cancer by mammography, will be subjected to biopsies, and 15 will be treated, surgical, radiation, toxic, chemotherapy. They will be greatly harmed. How to treat it? Today, in countries where medicine has the best grounds, society does not make a decision whether to do mammography or not. But what was the decision made? All women who are interested in mammography, do preventive examinations, should receive this information. They should weigh themselves and decide whether they need to receive such a probable benefit, 1 in 2500, at such a price. And in countries where such information began to be presented, this led to great satisfaction of women. Some of them began to consciously refuse mammography, and some began to continue to do mammography. It is very important that, as it turns out, normal people, when providing them with information, can make normal, balanced decisions in relation to themselves.

And this is a very important lesson. It turns out that epidemiological data, clinical epidemiology data are not so abstruse. It turns out that normal people can deal with them, they can adjust their behavior in relation to their health. If only we had more of this good knowledge. And then we would be able to achieve much greater success even with the small resources that we have. Thank you very much for your attention. I'm done and I'll be happy to answer your questions.

Question from the audience: A lot of questions, I don't even want to ask them. For example, what to eat so that there is no cholesterol?

Vasily Vlasov: As I said, cholesterol in the diet does not matter, because the human body itself produces a thousand times more.

Question from the audience: That is, a diet is a useless thing? Any?

Vasily Vlasov: No, not any. It is known that all diets are equally useful. In recent years, several controlled trials have been conducted in which 5-6 of the most popular diets were compared. Mainly designed to lose weight. I understand why you're asking, I have the same problem. It turned out that they are all about equally effective.

Question from the audience: That is, there is no difference at all?

Vasily Vlasov: There is practically no difference.

Boris Dolgin: I'm sorry, are they equally effective or equally ineffective?

Vasily Vlasov: The glass is half full… In general, it is more correct to say that they are equally ineffective. That is, they lead to a certain decrease in body weight, but the decrease is clearly insufficient for a person who has an extra 20-30 kilograms. It doesn't help, unfortunately. Every person is a blacksmith of his own happiness.

Question from the audience: Not on science answered.

Vasily Vlasov: I understand that I answered badly. The trouble is that complex problems, as you know, have simple solutions, usually incorrect. With regard to weight loss, an acceptable simple solution is a diet. Unfortunately, it does not help most people, or it helps, but very little. There is a radical solution, such as surgical treatment, which leads to a very large decrease in body weight. They have been used for 50 years. Some of them turned out to be catastrophically harmful, leading to the fact that people died a few years after successful weight loss. The methods that are used now are more effective, but the experience of those countries where they are provided widely shows that people are very wary of this surgery. That is, even people with a large excess weight, when an extra 50-60-100 kilograms, they are still afraid of surgery. And I understand them.

Boris Dolgin: I think I'll wait with my question.

Question from the audience: Vasily Viktorovich, what is your point of view as an epidemiologist, the prognosis regarding Ebola?

Vasily Vlasov: I spoke about Ebola recently. Fortunately, the situation is not developing catastrophically fast. It develops in much the same way. And according to statistics that the World Health Organization publishes almost daily, it turns out that the situation has stabilized. That is, in some places the incidence decreases, in others it increases, and so on.

Here we must distinguish between risks and danger. The risk of Ebola in developed countries, including Russia, we will consider it developed, is not high. But the danger is very high. I believe that the danger of Ebola is very high in our country, because we have an infectious department in a very poor condition, providing infectious care. That is, I think that if one person was treated in Spain, two got sick, and the same story is in the USA, then we may get it so that when such a patient appears, the entire medical staff will get sick within a week.

Question from the audience: Vasily Viktorovich, thank you for the lecture, for the data that you have prepared. My question is the following. I am related to the diagnosis of women for breast cancer. I am interested in whether there are any data at the moment on the degree of reliability of cytogenetic research, on blood analysis? The theory of heredity naturally takes place. So, these latest tests that allow us to assess the risk, the degree of probability of developing cancer, how much do they make sense?

Vasily Vlasov: Let me start by drawing everyone's attention to the fact that in this case we are talking about diagnostics, not screening, but diagnosis. Preventive examinations of hundreds of thousands of women are one thing. And when a woman comes, and she has a node in the mammary gland, and you need to make the right diagnosis, it's completely different. Here we are in a situation where one of the forms of breast cancer, determined by the cytogenetic method, indicates the possibility of using special drugs that have relatively high efficacy. If this gene is not present, then the treatment is less effective. But there is another aspect, you have further clarified your question. There is another aspect. Some women have a genetic defect that increases the likelihood of developing breast cancer. Fortunately, it turned out that there are not so many such women. It turned out that there is no reason to get attached to this genetic defect in mass screening. The idea that we have such a sign, so we need to look for it and act on it is wrong. Initially, this idea was very popular, as such ideas are often popular… I think many of you remember, three years ago they discovered some kind of obesity gene, five years ago they discovered some kind of homosexuality gene. That is, such connections between individual genetic traits and conditions are constantly being revealed. But very often they turn out to be either fake or weak. That is, unnecessary for use in practice. What is it about in the first place? We are talking about a family history. It turns out that the family history works much better for the prognosis than these genetic defects. Because genetic defects can manifest themselves in different ways, to a greater extent or to a lesser extent. And the family history is more effective. I think that's how I should answer this question.

Boris Dolgin: Now I will still allow myself a question. Can all medicine become evidence-based? And does it all need to become evidence-based? What prevents her, if it is possible and necessary?

Vasily Vlasov: I think that all medicine should try to become evidence-based, but it will not be able to become such because it is primarily a social practice. That is, I define medicine as a social practice to help people in their suffering, which doctors call diseases. Medicine is constantly trying to expand and remains in some of its territory.

For example, there were periods when they tried to treat criminals. Fortunately, it turned out that this does not work, so medicine no longer encroaches on this territory, at least serious medicine. And in this sense, it turns out that there should be a lot of things in medicine that are difficult to verify by experimental methods. Secondly, there are simply no resources for this. Thirdly, there is a huge mass of traditional components that have not been tested, despite the fact that they have been in circulation for a long time. A classic biblical example. Thick chicken broth for the treatment of colds. It is recorded in the Talmud that people have been using it for 3,000 years, no one has conducted controlled tests so far. If any of you haven't tried it, try it, it kind of works. In this sense, there are a lot of such things that exist in medical practice, but they, like that Elusive Joe, are not needed by anyone, they continue to exist.

Boris Dolgin: Once again. Let's say medicine is part of social work. No problems. Why can't all social work be built on this kind of scientific foundation? Is it just too expensive, no customer? Or is it pointless?

Vasily Vlasov: This aspiration is meaningful, it would be good if it were so. But the history of the development of scientific medicine shows that there are not enough resources for this. And since this is a social practice, it turns out that there are a huge number of forces that prevent this. For example, in our country there is a certain political interest in the prevention of diseases, medical examination.

Boris Dolgin: Political?

Vasily Vlasov: Yes, political. The national leader has determined that we need medical examination. There are such rumors.

Boris Dolgin: If I understand correctly, this idea is based on the experience of our medical examination. Does it have any grounds?

Vasily Vlasov: It has theoretical prerequisites. But it has not been tested. Specifically, the medical examination that I was talking about was tested. And it is shown that it does not work. In addition, how does our medical examination differ from the main medical examination? It includes a whole package of laboratory tests. These laboratory studies lead to the fact that a huge number of supposedly sick people are identified. Just statistically.

A person, for example, today for some unknown reason has an increased concentration of sugar. I passed a blood test, they told him, so you have diabetes, and they started treating you. Manufacturers of antidiabetic drugs are terribly interested in this. Endocrinologists are terribly interested in this. Endocrinologists like to have a lot of diabetic patients. These are their jobs, this is the love of pharmaceutical companies, and so on and so forth. Urologists have the same story. They want all men over the age of 30 to be tested for prostate-specific antigen and have prostate cancer detected early.

As a result, when it was introduced in 2006, in all regions where there was money for it, the number of detected prostate cancer patients increased 2-4 times. That is, this is how people would live for themselves, they would not grieve, as I said, cancer is not very deadly. There are special studies that show that if a man at the age of 70, even in long-lived Sweden, is diagnosed with prostate cancer, then he does not need to be treated, because this does not increase his life expectancy. Cancer develops slowly, and he dies from other causes. But these people are beginning to be identified, and they are creating a market for services. Urologists stand with their surgical robots, ready to accept 200, 300 thousand rubles from each to be operated on.

This is a normal situation in which we live. Normal in the sense that pus flows normally. It's raining. This is the situation we live in. It cannot be ignored. However, it seems that these social forces are very influential. Is it possible for science? Can. But there is the influence of some chief specialist, for example, the chief specialist for some infection, who owns the production of a vaccine against this disease. As the chief specialist, he makes a recommendation to purchase the vaccine from his company. Naturally, he is interested in being vaccinated with this vaccine. There are a lot of such social interactions in medicine that interfere with the use of scientifically based technologies.

Boris Dolgin: But is it beneficial for society to increase evidence?

Vasily Vlasov: Yes.

Question from the audience: I wanted to ask about the plague epidemics. What kind of a disease was it that mowed down the population of many capitals in Europe? Why did it stop then? Did this infection disappear later? Somehow extinct?

Vasily Vlasov: It is believed that it was the plague. As you can imagine, there is a big problem in making sure that it was a plague 400-500 years ago. There were no photos, there were no tests. There are different hypotheses, but it is still more plausible that it was the plague. The plague, as is known, still persists in natural foci, including on the territory of our country. Rodents get sick, they are checked, destroyed. Rodents with plague are constantly found, sometimes people even get sick. But it is under control.

Why was there a decrease in that incidence? There are different hypotheses. As you know, what happened a long time ago, we can explain in different ways. Someone will explain the intervention of higher forces. The most plausible explanation from the point of view of natural science is that the population density has decreased as a result of the mass pestilence. It has decreased so much that there have even been colossal changes in social relations in all European countries. Incomes have increased for all segments of the population who used to be like Indian untouchables. Housing conditions have improved. As a result, infection control has improved. This process seems to be the main one.

There was a researcher Ivan Illich, he has a book called "Medical Nemesis". There he describes how really, apparently, ineffective medicine is. The greatest achievements in prolonging human life, in reducing human mortality have arisen as a result of its gradual cultivation, material well-being, improvement of housing conditions, water supply, sewerage. Medicine only helped a person to worry.

That's why I think it's right to define medicine as a social practice. She helps people in suffering. Sometimes it can help. But globally, it does not seem to have influenced many processes in the history of mankind. However, I must say that in the history of mankind, medicine has not had such means as it has now. After all, let me remind you, it was only in the XX century that effective drugs for the treatment of infections appeared, before that they simply did not exist. At the beginning of the XX century in Russia, and indeed in Europe, every 20th person had syphilis.

Question from the audience: Vasily Viktorovich, earlier epidemiology was engaged in organizing some mass events, the same fight against the plague. Thousands of patients, some kind of state prohibitions. Now you say that evidence-based medicine comes to the level of an individual to go down, give all the information, and let him make decisions. In our country, less money is allocated for medicine now, yes. And at the same time, the Internet appeared, it became possible for each person to determine how to be treated, what to drink, what not to drink. Do you think this is good from the point of view of evidence-based medicine?

Vasily Vlasov: I think you didn't quite understand what I said correctly, or I didn't say it clearly enough. You've probably noticed that I'm a liberal. I am a supporter of people being free, so that they do not interfere with anyone and are themselves as free as possible, determine their own destiny. But this does not mean that population interventions are not needed. For a healthy society, public goods are necessarily needed, which are distributed to the entire population. For example, clean water is a collective good. It is extremely important for people to live for a long time. They are all interested in it.

Let's say breastfeeding is a terribly important thing in Africa, but it is well shown that in developed countries it does not matter to anyone. Why? Because there is clean water in developed countries. The mixture is diluted in clean water and the children do not get sick. And in Africa they breed in a dirty one, and children get sick with infections and die. A lot of things that determine our health are not necessarily perceived by us as healthy.

Here is an example with clean water. The second thing is vaccination. Some vaccines are very effective. After all, there is actually no diphtheria. And why? Because mass vaccination. And let me remind you that for diphtheria, vaccination does not work against the spread of the microbe, but protects every vaccinated person from the toxin of this microbe. This mass vaccination has led to the fact that we have practically no mortality from diphtheria, and people rarely get sick. There are a huge number of population-based programs that are scientifically grounded, which must be promoted. Interestingly, the most effective programs are programs of social well-being, like clean water.

Question from the audience: Hello, thank you very much for the lecture. And here is a question, in continuation of the conversation about vaccination, that not all vaccines help in fact. For example, in the case of Ebola, we need to say that there is no reliable test that helps distinguish Ebola from other diseases that have the same signs. Like fever, decreased kidney function, and so on. The test that people are using now, it only says with 50% accuracy that yes, it is the Ebola virus. But also with a 50% probability we will say no. And we will never be able to determine from those 10 thousand people who got sick, died, from what they actually died.

Statistical methods used in epidemiology try to be as impartial as possible. And scientists try to be as impartial as possible. But it seems to me that the scale of the problem here is very large. A lot of research is being lobbied by vaccine manufacturers. And independent research, in my opinion, is not carried out at all. What is your opinion on this?

Vasily Vlasov: You have asked several questions here at once. Your last question sometimes takes a certain form, but did the pharmaceutical companies come up with this Ebola or did the CIA come up with this pathogen? Since there are people in this audience who are not asking questions in this form, I will accordingly say the following, which, it seems to me, best corresponds to the truth.

Medical practice is always practice in conditions of uncertainty. Unless a person has not five fingers on his hand, but six, then yes. Polydactyly will be his diagnosis. An extra sixth finger. Such diagnoses can be counted on the fingers. Most of the diagnoses that doctors make are more or less correct. According to a critical analysis that was published once in the United States and has since been widely quoted around the world and attached to Russia, it turns out that almost every third patient is treated for the wrong disease that he actually has. This uncertainty is great even in the clinic, where you can do all the tests. What can we say about the early detection of a patient with an infection.

You are right to say that Ebola is really different in that there are no specific symptoms. That is, until a severe form develops – nonspecific symptoms. But this does not mean that uncertainty prevents us from taking any action. Still, it is possible to limit the spread of the disease if patients with nonspecific symptoms of fever are not missed. This does not mean that we are guaranteed to eliminate all of them, but we will reduce their number. Here modern epidemiology uses the term "containment".

The main thing in the spread of such epidemics, which have already lost a certain focus, and Ebola has already spread to the whole of West Africa, is to contain its spread so that it does not spread further. It does not give guarantees, but it gives a probability. If the epidemic exists in the form in which it is now, then I do not rule out that it will be possible to prepare some vaccines during this time. Let me remind you that the trial of the first vaccines has already begun. That is, after some months, the first results will already be available. It's not a fact that they are positive, but deterrence gives time. That's how I'll answer your question.

Question from the audience: I also wanted to ask about AIDS? How overblown is this problem? In general, is this a fiction?

Vasily Vlasov: There is a theory that there is another, much larger one inside our Earth. People who adhere to this theory also adhere to the fact that AIDS was invented by Americans or that it does not exist at all. AIDS is an absolute reality, by the way, it was also revealed by epidemiological methods. That is, at first they identified it as some kind of strange disease, and then, after a long time, after years, they discovered the virus. And they began to develop a medicine. It is now known that people began to get sick at the beginning of the XX century, in the 20s there were the first cases. But people did not notice them, medical science did not notice them. A lot of people die with some kind of fever, from some unknown reasons.

In general, a lot of things happen that we don't notice. For example, in Moscow, if I remember correctly, every 14th person who is buried is unknown. Because they found a corpse, buried it. And who is unknown. In this sense, everything developed very well with AIDS. As soon as he was determined in mass quantities, medicines were made very quickly. Today, medications are so effective that people infected with the immunodeficiency virus live almost as long as people without the immunodeficiency virus. Only they need to take these medications all the time. But it costs a lot. Therefore, in relation to countries like ours, scientific decision-making is very important.

For a long time, we have maintained an attitude towards people infected with AIDS as perverts and drug addicts. God has punished them, let something happen to them. But it was stupid from the very beginning. Because this disease tends to develop first in the most vulnerable part of the population, among drug addicts and homosexuals, and then it necessarily comes out of this part. And it becomes a common problem of the population. Hubby went to the left, his wife got infected from him. This begins, it becomes a problem of the people. It was obvious from the very beginning. But, unfortunately, our country has not really come to understand this yet. We still do not have all AIDS patients provided with medicines. And what is most important, we are not currently conducting preventive work. We stopped allocating money to AIDS prevention last year. As a result, we have one of the highest rates of increase in the incidence of AIDS.

Remark from the audience: And what is its quantity?

Vasily Vlasov: I'm not good with numbers. When this happens, it is dangerous not because patients appear, but because if we start treating these patients, it requires a lot of money. They live a long time, as I said. It's good that they live a long time. But they need to be treated with expensive drugs for life. If you prevent in this case, then this is a relatively cheap event, which can then lead to a lot of savings.

If the incidence of AIDS increases to catastrophic proportions, the costs of this will increase to catastrophic proportions. You yourself understand that it is possible to ignore patients with some kind of disease, while there are several tens of thousands of them there. If there are millions of them, in proportion as it happened and is still happening in Africa, they will not be ignored, they will become a social force. And you'll have to spend a lot of money on it anyway. Unfortunately, there is a lag in the application of scientific knowledge.

Question from the audience: Tell me, please, do you have any information in the field of research regarding our layer of disabled people? I will explain the question. There was a time when the government and the state could not give money to this group of people. A huge number of benefits were provided. A large number of people, roughly speaking, began to attribute themselves to this category of people in order to receive these benefits. The costs are huge. The money that is allocated to really sick people is very small.

Boris Dolgin: And the question is what?

Question from the audience: The question is as follows. Have any epidemiological studies been conducted that could determine how to reduce the number of these patients who really need help? The point is, for example, to increase the monetary assistance to really sick people and reduce the costs of those people who can be cured by some medical means. Or can benefits be replaced by some other methods of assistance? Numbers?

Vasily Vlasov: I won't tell you the numbers, I have already admitted that my head doesn't hold the numbers. I can hardly even remember my own phone. In this area, there are practically only comparative studies of current research practices in other countries. I do not know of any experimental research in this area. This area is under the terrible influence of political considerations. You correctly remembered that in the early 90s people were sent to retirement, disability was widely distributed to them. Then, in the early 2000s, they came to their senses, began to take away their disability. Natural benefits, which were widely given under the Soviet regime and in the 90s, in 2004, I remember the figure, were replaced with money. Now this money is depreciating. These are some techniques, of course, they are scientifically justified.

For example, it is known that the public debt does not matter, because it is still eaten up by inflation in 10-20 years. That's it, too. These monetary benefits that are given to citizens will be eaten up by inflation. This is, of course, some hyperbole, but it shows that in the field of this social security for disabled people, the power of political, economic considerations of the moment is very great.

It's the same abroad. The only thing is that the representative authorities there, which adopt laws, depend on the population, and they cannot afford to introduce pension reform once every 3-4 years, as we do. Therefore, this does not happen. But, nevertheless, they also adapt to the current situation. Let me remind you that in Europe, in countries where the economy has suffered in recent years, pensions have been changed, legislation has been changed.

Question from the audience: Thank you very much. Lev Moskovkin. Oddly enough, your lecture and Kirill Eskov's lecture today turned out to be connected with each other. Very strongly connected.

The graph that you showed of cardiovascular mortality in Russia. I just have the same schedule imprinted in my memory, if I'm not mistaken by year, the issues in general on the well-being of the population, suicidal data, dynamics, crises coincide. I would like to clarify this. And the second question. Ebola is, of course, not a fever, but an epidemic, it's a myth. Just like the avian flu epidemic, I apologize.

The question is that a very bad thing happened in 2008-2009, we still don't know what it was. Especially in Chita, in the Far East, in Moscow. According to my information, the Ambulance received a discharge against the flu literally. That's what it was then? Thank you very much. In general, thank you for the lecture, it is very positive, which is extremely important now.

Vasily Vlasov: Thank you very much, I don't really understand what is being discussed about the Siberian events, so I won't say anything about it. And as for the causes of deaths, researchers have tried many times to disassemble our mortality jumps into pieces, to find out the cause. The best expert on alcohol mortality, Alexander Vikentievich Nemtsov, was the first to discover that at a time when mortality is increasing in our country, at this time, mortality from alcohol poisoning is also increasing. Of course, the death rate from alcohol poisoning is small, but it gives the same characteristic peaks at the same time.

Because mortality increases in these periods and depends on increased mortality at a young age and up to 40-45 years. It is natural to assume that these are young people of working age, mostly men, crack vodka without looking back and thus they die. I am not a supporter of this hypothesis, because it is difficult for me to assume that periodically Russian people begin to crack vodka indefinitely.

What's it? Last year we didn't do it, this year we started doing it in unlimited sizes. Well, no, they're normal people. So there are some other factors. I think that alcohol consumption, alcohol mortality is the cause of what is called the epiphenomenon. It is one of the manifestations of a global process. What is the global process? It's a big mystery.

I discovered a year ago that, it turns out, our mortality peaks coincide with the peaks of solar activity. The activity of the Sun is more suitable for the root cause than Russian drunkenness. More like the root cause. This applies only to the period of these waves. We don't know yet whether these waves of high mortality have ended or not. This mystery has absolutely no analogues in the studied history of mankind.

Question from the audience: Vasily Viktorovich, a question about some points of your lecture. They showed that our health, in principle, directly depends on what we eat. Returning to dietetics, in your opinion, which organizations' data are the most recent and proven in the field of recommendations for the required minimum daily intake of certain vitamins, minerals and other trace elements? Thanks.

Vasily Vlasov: I think the expression "we are what we eat" is, in principle, correct. But it is wrong to assume that everything is determined by this. Still, a lot depends on other living conditions. In almost all normal countries, where there are their own recommended parameters for the consumption of food components, this was done at about the same time – in the middle of the XX century on the basis of the same scientific concepts of the so-called balanced diet. These concepts were greatly influenced by the hypothesis that it is possible to isolate the main components from nutrition, which must be strictly present in certain quantities, and the rest is not important. In general, fortunately, this concept almost died by the end of the XX century.

And today, as you rightly noted, there are only minimal requirements for certain components of food, for certain trace elements. And not to everyone, and they are not scientifically substantiated enough. For example, if such a component as ascorbic acid is very well studied, then if we are interested in the scientific literature on the evidence of the benefits of using selenium, it turns out that this literature is much more limited.

As a result, we can say that the national standards for the composition of nutrition, which were developed in the Soviet Union, and they are practically unchanged here, or which are recommended by the American FDA, are about the same, they can be treated about the same. I think we can discuss the differences in some details, but in principle I would not say that we should single out any one, the most trustworthy source.

Boris Dolgin: Thank you very much. Well, our time is up. Thank you very much, Vasily Viktorovich.

Vasily Vlasov: Thank you, gentlemen.

Portal "Eternal youth" http://vechnayamolodost.ru19.11.2014

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