Outrageous Fortune: The Probability Of Prevention
For those who knew and loved Dr. Ather Ali, the first naturopathic physician ever to join the faculty of the Yale School of Medicine– and I proudly count myself among them- a light has gone out in the world. Dr. Ali died this week at the absurd age of 42 only a few months after what at first seemed an innocent irritation in the chest proved to be a cancer that defied all treatments. I am sharing shock and sadness and a sense of something like dizziness with many of the best people I know as we figure out how to react to this hole torn in the world.
Many of you, of course, won’t know Dr. Ali, but he’s important to you just the same. He represents the very best of what modern medicine could, and should be.
The credential most prominently associated with Ather is the ND degree, a doctoral degree in natural medicine, or naturopathy. In certain quarters, that evokes a warm glow of appreciation, but as I know well- it evokes something else entirely among the more staunchly conventional. The concern espoused there is that an emphasis on natural medicine pulls us away from science and evidence.
To be fair, those critics are not always wrong; there are misguided excesses in either direction. Some practitioners subordinate evidence to personal belief or preference, just as some subordinate the human art of medicine to unduly rigid interpretations of science applied to the uncertainties of clinical care.
Ather was neither of these. He had an undergraduate degree in psychobiology (the biological basis for psychology, essentially neuroscience) from UCLA, and two masters degrees, both from Yale. One of these was in chronic disease epidemiology, the other in patient-oriented research.
So, yes, Ather was devoted to kinder, gentler, and more holistic treatment options whenever possible, but never without regard for scientific evidence. Over the bridge of modern healthcare’s troubled waters, where the competing priorities of art and science, reductionism and holism, evidence and empathy roil- Ather was the bridge.
We met nearly a decade and a half ago, shortly after Ather completed his training in naturopathic medicine (a 4-year program) at Bastyr University. He was at first my resident in one of the nation’s few post-graduate training programs in integrative medicine, ours specifically in evidence-based integrative medicine, and exclusively for naturopathic physicians. The rather famous program long overseen by Dr. Andrew Weil at the University of Arizona trains conventional health practitioners in the various approaches to natural medicine. Our intent was to come at this issue from the other direction, training naturopaths to appreciate conventional, modern approaches, and the underlying evidence.
In both cases, the goal was and is to offer patients a wider spectrum of responsible options, and to help more people get better.
Ather epitomized the possibilities in this still rarefied space, and with credentials even those most inclined to consign all but the most orthodox of conventional practices to the realm they derisively call “woo,” would find hard to disparage. We published our first peer-reviewed paper together more than a decade ago. Ather went on to publish dozens of peer-reviewed papers, playing a lead role in NIH-funded research demonstrating the effectiveness of massage therapy for osteoarthritis. He secured a coveted K Award from the National Institutes of Health, funding dedicated to his personal development as a clinical researcher. Just a month ago, Dr. Ali and colleagues published results of an important study of individualized diets for irritable bowel syndrome, which garnered high profile, and well-deserved media attention.
Among the many roles he was playing at Yale at the time of his death (I confess, I have trouble even typing that), Ather was Medical Director of Integrative Medicine at the renowned Smilow Cancer Hospital. Ironically, and seemingly in the blink of an eye, he became a patient in the very program he helped establish, and oversaw.
Why tell of this to those of you not privileged to know Dr. Ali? For two reasons.
First, when a genuine trailblazer falls, in the fullness of time or long before their full measure of it as in this case, it falls to the rest of us to keep the trail open. Ather worked tirelessly to renounce the false choice between responsible use of evidence, and responsiveness to every need of the patient. He worked to broaden the spectrum of treatment options, while resisting the inclination to fall fatuously in love with any. He worked hard at the intricacies of science, and to be consummately gentle in all the intimacies of patient care.
The trail is still there. It falls to us to tend it.
The other, general message in this tale of both triumph and disaster has to do with the probabilities of prevention, and the potential primacy of outrageous fortune.
I routinely write about the incredible power of lifestyle over our medical destinies, the potential to add years to our lives and life to our years. I write about our capacity to use what we know to prevent some 80% of all chronic disease and premature death, to slash our personal risk of the same. All of this is true. I am board certified in my convictions in the power of prevention.
But that power is not absolute. Dr. Ali and I were friends. I know that he never smoked, and did not drink. He ate a wholesome diet. He exercised routinely. He was quite expert at stress reduction methods, and natively peaceful. He gave sleep the respect it warrants, and had a large, strong, diverse network of friends and a loving family- his beautiful wife and two children. He did everything right, and got the wrong outcome anyway.
This is a reminder and a reality check for us all. Prevention is powerful, but imperfectly so. Health outcomes are not merit-based. We are reminded not to blame the victims of calamity, not to think people get what they “deserve.” We are reminded to be humble, to respect our ineluctable fragility. Prevention, and lifestyle as medicine, are ultimately arbiters of probability, not certainty. We should not forsake their power, for most of us will be beneficiaries of it. But no one of us will ever get a guarantee.
Perhaps that tells of the need to strike the right balance between protecting tomorrow, and relishing today. In the turbulence of strong emotion, I am still seeking for lessons and meaning.
All I know for sure right now is that too soon, too young, a bright light has been extinguished from the world. The rest of us must strive for the light of meaning in it, to defend against the darkness.
Director, Yale University Prevention Research Center; Griffin Hospital
Immediate Past-President, American College of Lifestyle Medicine
Senior Medical Advisor, Verywell.com
Founder, The True Health Initiative