GUEST: Dr. Isadore Rosenfeld
I’m Richard Heffner, your host on THE OPEN MIND. Probably the best received programs we’ve done on this series have related to medical matters. Indeed some months back we did two OPEN MINDs with Dr. Isadore Rosenfeld, the distinguished internist, cardiologist whose very successful book, Second Opinion focused our attention on what he calls our “medical alternatives”. And indeed your response was explosively positive. You liked him, respected him enormously, wanted him to come back, and I agreed. And what I’d like most to discuss with Dr. Rosenfeld today is the matter of medical futures. No one of us after all is immune to the ravages of illness. And now still early in the last quarter of our medically rather amazing 20th century I think most of us want very much some sense of where we’ll soon be in terms of the diseases that have so long plagued mankind. What can we look forward to in the realm of medicine? That’s the question that I’d like to put today to Dr. Rosenfeld. Fair question?
ROSENFELD: Yes, and a small question.
HEFFNER: Just a small one.
ROSENFELD: Yes, and one that we can discuss very completely in half an hour.
HEFFNER: Why don’t you begin? Seriously, what can one anticipate? Take your own field, cardiology.
ROSENFELD: Well, I tell you it depends on whether you want to anticipate immediately, anticipate over the short term, or anticipate ultimately.
HEFFNER: I guess the best answer is, I’m 56 years old. You judge for yourself.
ROSENFELD: In terms of cardiology we’ve made enormous progress, and we are continuing to make it. Now, this is the beginning of 1982. It is my expectation that throughout the course of this year we will see the release of several new types of drugs for the treatment of very common heart conditions. Now, this isn’t the kind of explosive answer where I’m talking about the cure of this or eradicating that. But there are millions of people around, in this country and around the world, who suffer today and now from various forms of heart disease that need treatment. You’ve read recently in the last two or three weeks about his drug and that drug being released for the prevention of second heart attacks, in the so-called beta blocker group. I expect that in 1982 there will be at least three or four new and different members of this family to help control the symptoms of angina pectoris, which as you know is the heart pain that so many people have due to narrowing of the coronary arteries.
Another area that I think will explode in the United States with respect to the treatment of heart disease is the availability of the calcium-blocking drugs. This is another group of drugs which will be used for patients with hardening of the arteries in the heart. They are completely different from anything else we have. Some people are already getting them. These drugs have been released elsewhere in the world, in Europe, some in Canada and the Soviet Union. Our FDA’s been very careful about giving permission for a drug to be used in this country until they’re absolutely convinced about its safety and efficacy. They are now satisfied. They’ve given approval to these drugs, and I expect that they will be released in 1982. And it’s very interesting what this particular group of drugs does. And anybody who is listening to this program who has angina will understand it. We, angina is the pain that people have when a coronary artery that nourishes the heart is narrowed. So we always think of the disease in terms of a blockage. But there is another component to this disease, and that is spasm. A coronary artery may not even have a lot of actual blockage, or may have a considerable amount. In any event, that artery goes into spasm from time to time for reasons that are not clear. These calcium blockers prevent that spasm. And I expect that when these drugs are released there will be a much more effective control of many cases of angina, and I think it may even reduce the incidence and the need of coronary bypass surgery.
HEFFNER: That, I guess, is the question that is uppermost on my mind. What are the implications for those who are watching and listening who are sitting by waiting, considering the possibility of surgery? What’s the meaning for them of your assumptions that in 1982 explosive paths will be uncovered?
ROSENFELD: Well, I wouldn’t want to interfere in an immediate decision for bypass surgery. If somebody has had a lot of symptoms and has been investigated with radionuclide cineangeograms and coronary arteriograms, and the decision has been made that these people are immediately vulnerable to having a heart attack or to sudden death, and surgery has been recommended, I would not in those individuals recommend that they wait for these new drugs to make their appearance. I think for them it may be too late. But for the vast majority of people who have chronic, stable angina, and who perhaps dread that sometime in the future they will have to undergo this operation, there is a possibility that a substantial number of them would be spared the operation.
HEFFNER: You’re not talking about correction now, you’re talking about controlling or handling a situation, aren’t you?
ROSENFELD: Yes. We don’t have any drug at the moment. We don’t have a chemical roto-rooter that will clean out the artery. But now of these drugs are pain killers. They all work on improving the efficiency of the heart, of having the heart extract as much oxygen from a narrowed vessel as possible, from preventing spasm, so that these are not only palliative; these are drugs to improve the circulation. I think they will be important.
Another area that I think bodes as very exciting and perhaps not next year but certainly within a couple of years, is the matter of drugs to regulate the rhythm of the heart. Now, this is something that very few people know and appreciate. The greatest public health problem in this country is sudden death. It’s not the heart attack of the patient, in the patient who ends up on the coronary care unit in a hospital. It’s the patient who sits on a television set doing a program one minute, and keels over the next.
HEFFNER: Please, no such funny comments.
ROSENFELD: (Laughter) And this is the situation where somebody is in a restaurant or is in a totally neutral environment and, you know, keels over. To give you the magnitude of the problem, there are about a million heart attacks every year. Of these, among these there are some, oh, 600,000 deaths. So 600,000 people die of heart attacks each year. In that 600,000, 350,000 at least go like that. That is the problem of sudden death in this country. It’s one that’s not appreciated. It happens so quickly that an ambulance can’t get to the patient. His only chance of course is if he’s fortunate enough to be in the presence of somebody who knows CPR, cardiopulmonary resuscitation, or a trained doctor or nurse or paramedic.
HEFFNER: So for the rest of this half hour I’m okay.
ROSENFELD: You’re okay. Yes.
HEFFNER: I’m sitting next to you, but…
ROSENFELD: It would be a great show, wouldn’t it?
HEFFNER: If you’re talking about sudden death, how can you also be talking about something that will be, you’re not talking about a preventative step?
ROSENFELD: No, no, that, now let me…Yes. The point is that it’s then too late to treat sudden death inn moist cases except if that person happens already to be in the hospital for something else of happens to be in the presence of someone who can resuscitate him or her. So the key in this area is to find, identify those among us who are vulnerable. How do we know if we go look at the first hundred people we meet on the street, who among them is a candidate for sudden death? That’s a very important question. And we now have techniques for identifying these people, more or less. Now, having identified them, how do you intervene? How do you give them the medication or whatever to prevent them from dying suddenly? Most of these deaths are due to acute disturbances in heart rhythm. The heart suddenly beats like crazy. And instead of 80 or 90 or 100 times a minute, it suddenly beats in a countless, I mean, the heart looks like a bag of worms. It doesn’t even really contract; it just does this. That’s called ventricular fibrillation. And that is the mechanism by which sudden death occurs. Now, what we’ve got to do is to find a drug that we can give somebody whom we have identified as vulnerable for that condition…
HEFFNER: You say “What we have to do”. Are you not suggesting that we are on the edge of that discovery at the moment?
ROSENFELD: Yes, I am suggesting that we are on the edge. We have several drugs available already. There are some new ones just coming out. It is my expectation that there will be more in 1982. There are drugs in usage in other countries. There are drugs now being evaluated in this country. And I expect that some of them will be available toward the end of 1982 or early 1983. If they fulfill their promise in preventing this kind of crazy heart rhythm which can cause death, then we will see a significant impact on the death rate from heart disease. That’s a very, very exciting area.
HEFFNER: Are there secondary effects to the better living through chemistry that you’ve been talking about?
ROSENFELD: You mean secondary effects to the medication?
HEFFNER: Indeed. You’ve been talking about ways in which drugs are going to help us here and there. Now, what price do we pay?
ROSENFELD: Well, Dick, I don’t know how many years ago Hippocrates lived, but he said something that I never forget in my practice: “In every medicine there’s a little poison”. And you’ve got to weigh the potential benefits against the risks and the side effects and the toxic effects. Of course every medication has toxic effects. Indeed, the problem with the drugs that are now on the market and for which we are seeking substitutes is the fact that the drugs we do have now are very, very toxic. And so not many people can take them, or not enough people can take them. We have drugs to suppress dangerous rhythms. The problem is that they too are accompanied by side effects. And it is our expectation that the new generation of anti-arrhythmic drugs, which is what we call them, will have fewer of these side effects. But I have never seen a drug or a vitamin or any medication that anybody takes that is available that is free of side effects.
HEFFNER: What about some of the other fields in which we are all concerned?
ROSENFELD: Well, there’s the question of aging. Now, I don’t think that we will, at least in my lifetime, perhaps in yours, but not in my lifetime…
HEFFNER: That’s a very, very funny remark.
ROSENFELD: (Laughter) I don’t anticipate that there will be a significant prolongation of life. But I think that one, oh, I mean a couple of years here and there. I think it would be a program…
HEFFNER: You mean we’ve made so many steps already?
ROSENFELD: Yes. I think that our life expectancy now, you know, early seventies, 72 or whatever it is, 73, is the result of the averages, so that kids, the fact that children don’t die very young of infections and so on and so forth, skews the curve to the left. I think that, I personally think, I’m not a geneticist; I think that our cells are programmed for a certain length of time. Now, it may be in the future that with genetic manipulation we’re going to be able to change that. But I think for a more realistic objective should be the attainment of old age with satisfaction, with, I mean, to enjoy, for people to enjoy old age. One of the very greatest problems that we have now is that we can keep people live, you know, their hearts may be good, their limbs may be good, but they are senile. They have no memory, they can’t take care of themselves, they’re a burden to society, to their children, to themselves. And this question of aging of the brain is one that is very much in focus now, and an area which I think will be productive in the next few years. And the reason I’m optimistic about this is precisely because of the way we introduced this topic, by calling it “aging”. I don’t think that this, the changes, the chemical changes that occur in old people’s brains are due to hardening of the arteries. That is a common misconception. I know somebody, a relative of mine in fact, who is 94 years old. And she thinks she’s on a cruise boat all day. She’s not with it. Yet her arteries must be very good for her to attain an age of 94. No, the appreciating now, the key thing now, and the research that’s being directed now is toward the belief, is the belief that what happens in senility, in confusion and poor memory loss an in paranoia, in all the things we recognize among our very old citizens, is that these are chemical changes that may be reversible. Now, there is already in research at the National Institute of Mental Disease or Aging in Washington under the direction of Dr. Butler, they are testing new compounds which will act on enzymes in the brain which will affect the metabolism of the brain that are really independent of hardening of the arteries. This is not the same thing as stroke. People with this condition don’t necessarily have stroke, although some of them may. The senility problem in our society is not one of arteriosclerosis. I think if one looks to the future, in the near future it is my expectation that inroads will be made in that area, and I think that’s very exciting. Because it’s wonderful to give people bypass surgery and control their blood pressure and improve the quality of life and at the same time give them the intellectual capacity to live.
HEFFNER: Once again we’re talking about chemistry.
HEFFNER: That’s very interesting. And the field that everyone skirts or plunges into, cancer, the same kind of optimism in terms of chemistry or other modalities of treatment?
ROSENFELD: You know, we have mad a lot of progress in cancer. It’s a dread word and a dread disease. It seems that the more types of cancer we’re able to control or to cure, the more there appear to be. The numbers of cases appear to be increasing, although there are certain kinds of cancers that we can control.
HEFFNER: Excuse me, tell me what you meant by that formulation. I really didn’t understand.
ROSENFELD: Well, I think that more and more doctors every day are seeing patients with different kinds of cancer who 15, 20, 30 years ago would have died quickly. These people are now able to live longer in greater comfort. Some of them are being cured. We’re able to cure more cancers with early detection, by surgery, some by radiation, and the addition of chemotherapy, immunotherapy, various treatment forms. But it seems like despite this there’s such an enormous increase, apparent increase in the number of cases that one is discouraged about it. The total number of cases appears to be increasing.
HEFFNER: How do you account for that?
ROSENFELD: I don’t know. I think it’s probably environment. I think there’s pollution. I think it may be in our food, in the air we breathe, in the clothes we wear, and in, I’m not…I mean, women for example, I can account for a cancer of the lung in women very well. You know, even when I started the practice of medicine 30 years ago, to see a lung cancer in a woman was very unusual. Today there’s virtually an epidemic of lung cancer in women. And that’s because of tobacco smoke.
HEFFNER: Is there any validity to the notion that the more cardiologists are able to deal with diseases of the heart the more that specialists in other areas are able to control those disease areas, by definition the more cancers we’ll see?
ROSENFELD: No. Cancer is not a degenerative disease, although cancer does occur for the most part in older people. There are many important cancers of children. So I don’t think one has to view cancer as an inevitable accompaniment of aging. Cancer is a disease. Now, where we stand with cancer is this: we have made tremendous progress in early detection. For most cancers at the moment, because we don’t understand the basic underlying mechanism, it’s very important to pick them up early. Now, hand in hand with the early detection we have very sophisticated surgery, we have very sophisticated radiation where very high-energy beams can be really pinpointed down so that the thing you’re burning out, the cancer you’re burning out is hit hard by a narrow beam, and the rest of the body is much less affected than it used to be in the older methods. The new CAT scanners, the sonograms that can evaluate every part of the body, go deep inside the body without invading the patient, can identify tiny cancers at their earliest stages. Now, one of the things that is very exciting, and I think will see the light of day certainly within two years, is a test, a blood test which will indicate in an apparently healthy individual the presence of a cancer somewhere. Some change in the proteins of the body, in the antigens of the body, whatever one they measure with these tests, the fact that there is a cancer brewing somewhere. Now, if you’ve got that information and if you refine the test so that you can tell where, I think that will also yield a tremendous result in terms of controlling the disease.
The basic question unfortunately with cancer is one that is not yet understood: Why one moment is a cell in an organ following a rational, orderly existence, or leading an orderly existence as are its cellmates, and then something suddenly triggers that cell to go crazy? And it grows all over the place, invades the bloodstream, goes to different parts of the body, and literally chokes the life out of a patient as it metastasizes. What the mechanism is that does that, we don’t understand. For example, I talked about tobacco a minute ago. We know that tobacco, I believe that tobacco is responsible for most cases of lung cancer. But there are many people who smoke and who smoke heavily who don’t have lung cancer. Now why? What is the difference? What is it in one person that makes him vulnerable and another not? And those are the questions we have to ask. Those are the questions that have not been answered. We have made very great progress in all kinds of drugs to kill these cells, to kill these bad cells, and the radiation and the surgery. Now we’re trying to stimulate immune responses, to have the body’s antibodies run and kill them and so on. That’s the therapeutic thrust. The true answer will come when we begin to understand the mechanism of cancer. And I don’t think we’ve made all that significant progress.
HEFFNER: It’s interesting, Dr. Rosenfeld, that you haven’t talked about preventative medicine.
ROSENFELD: Well, you haven’t given me a chance.
HEFFNER: All right. I’m sorry that I talk so much. But please…
ROSENFELD: (Laughter) Well…
HEFFNER: …throw some light on that.
ROSENFELD: You see, when we started to talk, I talked about the immediate effects, the short-range effects, and the long-term effects or expectations. Now, in heart disease for example, the long-term is to understand what causes hardening of the arteries. We now know that there are certain things that accelerate, that make an individual more vulnerable to developing a stroke or to developing heart attacks. Those things include cigarette smoking, the old evil back again, high cholesterol or other abnormal blood fats, high blood pressure, lifestyle, weight, exercise, personality factors, all these things. And they are all, as you know, called “risk factors”. But these risk factors are not the cause of the disease; they are things that accelerate the disease. The underlying cause is something we don’t understand. Now, we try to prevent the disease by controlling these risk factors, and we are only modestly successful, I must say. So that over the long term we will exercise prevention when we understand the fundamental underlying causes. Today we can only effect cosmetic prevention, in my judgment.
HEFFNER: Dr. Rosenfeld, are you saying, when you talk about “only modestly successful”, does that mean you’ve, the profession has not been successful in getting people to abide by preventative measures, or that the measures themselves have not really worked out?
ROSENFELD: Well, both. I think we have become, we have been progressively, I think, as people become educated they realize the importance of keeping physically fit and of watching what they eat and controlling their blood pressure and not smoking, and there has been an impact on public opinion in those areas. But quite frankly, given all that, the predictability of preventing a heart attack is not a hundred percent. I think one can reduce the likelihood of a heart attack for example, that’s the area we’re talking about. By…we can reduce a heart attack perhaps and have a 25% chance of doing it in the vast majority of cases. If I see somebody whose mother died of a heart attack, whose father died of a heart attack, whose brothers and sister, where there is a very strong family history, comes to me and says, “Now, look, I want to prevent this fate”, all I can do is give him this advice and watch him very carefully. But in the majority of cases we will not be able to prevent the heart attack. It will require careful watching so as to intervene with drugs and surgery and so on. The control of risk factors is far from a hundred percent effective.
HEFFNER: It’s interesting in terms of what you said just now and what you said before about aging, you seem to be rather much of a determinist in your application of medical techniques and medical knowledge.
ROSENFELD: Not at all.
ROSENFELD: No. Perhaps…No. As far as aging is concerned.
ROSENFELD: …I reject…Or you mean as far as lifespan…
HEFFNER: Well, now, that’s different from aging.
ROSENFELD: Lifespan, I am a determinist. But aging, the quality of life, I am not; I am an activist.
HEFFNER: Yes, but in this matter of those who have family histories of heart disease…
HEFFNER: …you’re going to watch and look carefully…
ROSENFELD: Yes, I’m not…No…
HEFFNER: …but you seem to be saying they’re going to…
ROSENFELD: Those are the facts. Those are the facts. I can’t, and no cardiologist can guarantee any patient that if he does this, that, and the other thing, he will surely be protected against a heart attack. We will reduce the risk in some people. But we cannot now interfere with the, I think, with the genetic expression of this disease until we understand the basic underlying cause of hardening of the arteries which we at this moment do. We do not understand it.
HEFFNER: Dr. Rosenfeld, we’ve come to the end of our time here. I’d love some day to continue the discussion of the genetic predispositions and what we have in our genes that relate to your practice of medicine. Join me again?
ROSENFELD: Will do.
HEFFNER: And I’ll be quiet next time to let you get a word in.
HEFFNER: Thanks so much, Dr. Isadore Rosenfeld.
And thanks, too, to you in the audience. I hope that you will join us again here on THE OPEN MIND. Meanwhile, as an old friend used to say, “Good night, and good luck”.