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Comment by pmiller2 | Hacker News Reader

As a matter of public health, we should really be focusing the vast majority of our efforts on cancer and cardiovascular disease. Odds are that most people will end up dying of one or the other.

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I recently spent time in hospital, and came away convinced that the one thing that could reduce the greatest amount of human suffering would be a really good 24/7 painkiller without long-term side effects.

Time after time I saw patients pleading with a nurse for more pain relief, and the answer came back, "You can only have so many in a 24 hour period, so you have to wait for another hour before I can give you any more."

The number of people I saw on one small ward who had hours each day full of really bad pain convinced me that pain relief would be one of the best places a philanthropist could spend money. If you're in that much pain you can't think properly, can't enjoy life, and it's all ultimately unnecessary, because, once a doctor and a patient agree there's something wrong and what to do about it, additional long-term suffering doesn't add anything to the experience.

People can have cancer. They can have arthritis. They can have a bad back, or kidney stones, or pancreatitis. I do think all those should be cured if possible. But the one constant misery for so many people, even if someone simply has old age - is pain.

I've been a full time patient for 32 years. We've come full circle on pain management. Again.

Wait a bit, the next cycle of oversteer will start soon enough.

Not excusing it. Just explaining.

I encourage everyone to figure out what works for them proactively. Because eventually everyone will need it.

Mental health [1] should be on that list. The amount of suffering as well as economic losses from mental health issues are overwhelming.

[1] Ideally we should work towards broader / more fundamental goals such as "well-being" and "meaning", but that is even more difficult.

Psychology research is certainly important, but not in the same way as cancer research.

For mental health, what's primarily needed is more access to therapy.

We need better, safer, anti-psychotic medication.

We need better, more effective, treatment for entrenched eating disorder.

We need better treatments for treatment-resistant depression or anxiety disorders.

This.

Currently most mental health medicine is like throwing darts in the dark. We clearly don't actually understand why some medications work for some people but not others. If you go through the medicine path then I can only wish you the best of luck - finding the right medicine is life changing but it's a long arduous struggle to find it currently.

Not to mention the side effects...

> We clearly don't actually understand why some medications work for some people but not others.

There are plenty of psychoactive drugs where we have no understanding of why they work at all. Lithium is one of the oldest, most successful, and best known medications for bipolar disorder, major depression, and schizophrenia, and we have no idea which of the many effects it has on the body actually contribute to stabilizing mood.

Psychedelics and mdma seem to be very promising in this area.

First, mental health issues account for a huge amount of suffering and societal expense.

Also, this is a commonly misunderstood issue. We are increasingly finding that "psychological" issues have strong links to physiological issues. Here is one example (of many):

https://www.nimh.nih.gov/health/publications/pandas/index.sh...

Autoimmune disorders can lead to a huge variety of neurological/psychological issues. All work on better understanding of the immune system is going to help many overlapping disorders.

What have previously been seen as "psychological" issues are, for these disorders, only marginally improved by therapy. Therapy can help someone cope, but root causes might be based on immune system issues.

I could of course be wrong, but my own unfounded suspicion is that in a few years we will find that a lot of current mental health therapy was rather stone age. Much may be replaced by more fundamental treatments to eliminate the source of basal ganglia (or other structures) inflammation that led to the psychological disorder.

I disagree that simply access to therapy solves the problem. I don't think we have a good understanding of the many causes and factors that affect the wide variety of mental health issues people face.

citation on that? my understanding is that therapy is our best option but that's it's unreliable and about as good as our drugs.

Look up the side effects of common medications for severe mental illness and ask yourself why anyone would take them if therapy was a more effective alternative. If you have no idea, let's just say they can kill you in various terrible ways, or damage your body and brain irreversibly, including causing tumors, and/or put you in a living hell, not to mention cause diabetes, and yet, popular medications have been around for 25 years or longer. It's not because there is a conspiracy of doctors or drug companies, and it's not because there are good alternatives, and it's not because positive thinking fixes everything.

Well said. It's frustrating to be on a train of drugs that become less effective over time, necessitating the roulette wheel of trying new ones again. And when they work, you don't feel better, you just feel less worse. Furthermore, they work by deadening the edges of your personality, so while you don't feel worse, you're unable to feel as happy as you are when you're not on them. They're the worst, but they're why I'm still here commenting, so I take the good with the bad.

ah yeah, I wasn't talking about severe cases. For severe cases medication is better than therapy.

Severe cases are the only ones where treatment matters. Anything works for problems that aren't severe. Preferring therapy to acupuncture is just a personal preference.

The way you identify a serious case is where the forming and/or maintenance of normal relationships is seriously impaired. Therapy is a way of providing needed human contact. It's just not addressing the underlying problem.

> Anything works for problems that aren't severe

That's measurably not true.

The consequences of not working (so long as it's not counterproductive) on an non-severe (so long as not also progressive) case may be less than a severe case, but that doesn't mean that everything works in those cases.

Usually the phrase is "severe and persistent". Things that aren't severe and persistent are tolerable and get better and worse, so whatever you do or experience, it can appear to help.

There's a difference between “help” and “appear to help”, and measuring to distinguish the two is a central function of clinical science.

> Therapy is a way of providing needed human contact. It's just not addressing the underlying problem.

citation needed.

Which part of that needs a citation?

All of it?

There are two sentences that appear to be separable. So I don't know what you mean by "all of it". You think therapy does not provide human contact?

well therapy can be administered online or in a self-directed manner and still be shown to work.

Edit: Further you implied that the purpose of therapy is to provide human contact not just that it involves human contact.

I think the rates of depression and anxiety are indicative of a problem, and the answer isn't just to throw resources at it.

This view, that mental illness is about psychology is kind of like what people refer to as the "god of the gaps" defenses of theism. Far too little is understood about mental illness, but no matter how much we learn about metabolic, autoimmune, or other disorders that affect mental function, there will always be some cases that aren't understood and people will still say that there are psychological explanations. By definition, essentially, mental illness is everything that can't otherwise be classified as a physical or neurological disorder. But all that it is, is a drag on actual efforts to solve problems.

As far as comparing to cancer, it seems plausible to me that some measurement like "quality adjusted years lost" (or impaired) could show it's more significant than cancer. I hesitate to say we need more research for anything, because unlimited funding leads to garbage research. But good research is needed. One of the most interesting developments in the last couple decades, I think, was "optogenetics" - techniques that allow scientists to manipulate neurons in a living subject by using light. But just funding more research may just mean torturing a few more mice to no purpose.

https://en.wikipedia.org/wiki/Optogenetics

In terms of reducing DALYs, I agree. Depression and anxiety disorders are the most common mental health conditions[0], and most respond quite well to psychotherapy.

But, we also need better access to addiction treatment (decriminalization would be a huge step here), more drug research, and a huge push to remove the stigma of mental health conditions in general.

---

[0]: https://www.nimh.nih.gov/health/statistics/global/global-dal...

Yes. Mental disorders account for many years lost to disability. https://www.nimh.nih.gov/health/statistics/disability/us-lea...

I hold out a lot of hope that the resurgence in psychedelic research may lead us out of a large part of our mental health crisis.

I agree mental health should be allocated higher priority than it is. I can't find a great source, but this listicle[0] claims the top categories of conditions in terms of disability adjusted life years (DALYs) lost are:

  1. Arthritis.
  2. Heart disease.
  3. Stroke.
  4. Cancer.
  5. Mental health conditions.
  6. Diabetes.
  7. Nervous system disorders.
  8. Pregnancy.
  9. Accident.
  10. Developmental disorders.

Whereas the top causes of death in the US[1] are:

  1. Heart disease.
  2. Cancer.
  3. Accident.
  4. Chronic lower respiratory disease.
  5. Stroke.
  6. Alzheimer's.
  7. Diabetes.
  8. Influenza and pneumonia.
  9. Kidney disease.
  10. Suicide.

Given that heart disease, stroke, and cancer top both lists, IMO, it makes sense from a pragmatic POV to focus on those two.

Side note: I was surprised to see arthritis at #1 on the DALYs list. Seems like more research is needed here, as well.

---

[0]: https://www.cheatsheet.com/health-fitness/this-awful-disease...

[1]: https://www.medicalnewstoday.com/articles/282929.php

I think one thing that's overlooked in Cancer research is how much ground has been, and will continue to be broken in terms of basic biological research to solve the problems required.

To even define and understand the problem properly we have to solve a bunch of things. Then to get to a solution a bunch of other things need to be figured out and can be integrated into humanities knowledge base. On top of that things can be dragged in from other fields to get a sense of how biology responds at various scales: genetic, tissue, organ, system, whole person. It's a perplexing and fascinating disease to grapple with.

It's worth mentioning that just because something tops a list of conditions, doesn't mean money/effort is best spent there. The true measure is expected benefit per $ spent. Some conditions prove particularly resistant to research efforts, while others might be comparatively cheap to cure or alleviate. In those cases you are better off focusing on the 'easy wins' and moving to the more difficult problems once the biggest and fastest gains have been made with the comparatively easier conditions.

Sort of, but not smoking, diet, and exercise get you pretty far on cardiovascular disease.

And cancer for that matter.

But from a brutally pragmatic point of view, the point holds.

Does diet and exercise really get you that far against cancer though? My sense is that it helps but only a fraction of the amount that it does against cardiovascular disease, is that right?

> Overweight and obesity are associated with at least 13 different types of cancer.

https://www.cdc.gov/vitalsigns/obesity-cancer/index.html

Obligatory reminder that correlation is not causation.

Of course, avoiding obesity is advisable for everyone where possible, for all kinds of reasons.

But there are cases where a complex physiological problems (particularly autoimmune issues) can contribute to obesity and cancer risk.

Such cases are quite possibly more frequent than is generally understood, given how many people try and fail to lose weight through diet and exercise.

I doubt any disease will grant you more energy than what you've eaten nor conditions that substantially improve the bodies efficiency. It's important to remember that exercise alone won't burn off that many calories. It's diet that is primarily responsible for that

It’s an argument that is as old as the hills and relies on the assumption that the body functions like a simple furnace, which of course is false.

Metabolic rates vary significantly, and rates of absorption of nutrients and consumption of energy vary a lot as a result of factors such as inflammation and endocrine function.

Calories in/calories out may still ultimately be true when you boil it down far enough, but the factors influencing and intervening in those processes are vastly complex and strongly affected by diseases and dysfunctions that are very common.

Thyroid disorder (which can include cancer or a precursor condition) is probably the most common/known, but just one of many.

Is "exercise" just a euphemism for not being overweight then? You can be skinny and not exercise, or be overweight and regularly exercise.

The short answer is yes, they can make a meaningful difference to risk, but as ever with cancer, the long answer is that there are a lot of risk factors and they aren't the same from one type of cancer to another. I'm not a medical expert, just someone who's supported cancer research for a long time and has a lay person's understanding of the issues, so I'll leave it to more knowledgeable people to comment any further.

I asked this as well, literally Googling up "Does exercise prevent cancer", and what I found isn't all that great:

https://www.cancer.gov/about-cancer/causes-prevention/risk/o...

>Nearly all of the evidence linking physical activity to cancer risk comes from observational studies, in which individuals report on their physical activity and are followed for years for diagnoses of cancer. Data from observational studies can give researchers clues about the relationship between physical activity and cancer risk, but such studies cannot definitively establish that being physically inactive causes cancer (or that being physically active protects against cancer). That is because people who are not physically active may differ from active people in ways other than their level of physical activity. These other differences, rather than the differences in physical activity, could explain their different cancer risk. For example, if someone does not feel well, they may not exercise much, and sometimes people do not feel well because they have undiagnosed cancer.

I would really like to see some proper studies done. Unfortunately, seeing friends and otherwise healthy, physically active people passing away from cancer at a relatively young age does not inspire hope at the moment.

Not that I'm disagreeing with the limitations of observational studies, but it's not quite that simple. Cancer Research UK describes being overweight or obese as the second biggest preventable cause of cancer (after smoking):

https://www.cancerresearchuk.org/about-cancer/causes-of-canc...

In particular, there appears to be a causal link between being fat and an increased risk of some cancers via several identified mechanisms, though of course this whole area is a subject of ongoing research.

Given the well-understood links between a healthy diet, getting enough exercise, and maintaining a healthy body composition, it's important to pay attention to both diet and exercise in order to minimise cancer risk, even taking into account the other effects.

I don't really like the idea of abandoning people suffering from "rare" diseases. ALS sucks so much. It is a horrible thing to be told you have ALS, you'd wish you were diagnosed with cancer or cardiovascular disease instead.

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