Offense and Defense
In baseball if your team is up to bat you’re on offense; if you’re in the field you’re on defense. In football if you have the ball you’re on offense; if you don’t you’re on defense. Your job on offense is to score. Your job on defense is to prevent the other side from scoring. Good teams try to excel at both. Games are good for both sides, and for society, but they can turn into wars when the other side becomes the enemy and eliminating them becomes the goal. Such wars may be good for profits, but they are not good for society.
Offense and Defense in Healthcare
As a practicing family physician I have been on the front lines in our battle with microbes. It’s a battle that has been almost entirely offensive where the focus has been attacking the microbes seen to cause the burden of our illnesses. Every patient with a possibility of an infectious process got an antibiotic. It was a tactical decision, but, “In our tactical decisions we are operating contrary to our strategic interests.” That’s what Moshe Yaalon said in 2003 about Israel’s Palestinian policy while he was Chief of Staff of Israel Defense Forces. That statement, reported in the Washington Post on October 30, 2003, jumped out at me because of its truth in Israeli policy, but also from its application to our use of antibiotics.
Strategy has to do with the goals we set while tactics are the moves we make to get there. Israel’s stated goal is coexistence with the remaining Palestinians living in Israel as well as their neighbors. It’s essentially the same as ours with microbes—reducing the threat and living together. But both Israel and our medical establishment seem to want dominance in their respective games and the tactics used to get there are unequivocally and uniformly offensive. The game has recently changed in Israel, but ours with microbes amounts to warfare—we want them dead. It is not true that the best defense is a good offense; they are fundamentally different approaches.
In all of our games there are aspects of both offense and defense. The offense seeks to score against the opponent while the defense tries to prevent the opponent from scoring. Life is not that different; we try to live in control and disease free while microbes try to recycle us. We have offensive weapons provided by our doctors and defenses learned from public health. Both teams are needed for success. But in healthcare and many of our other wars the offensive model is the only one seen. It’s like what happens when you give a hammer to a child—everything looks like a nail.
Louis Pasteur, the father of the germ theory, began the offense against the microbes when he showed us weak and defenseless microbes as the cause of our diseases. His argument won the day and our paradigm—the way we think about microbes—was formed by it. Unfortunately for us they are neither weak nor defenseless. Their offensive and defensive aspects are both in their ability to rapidly mutate to get around our offensive tactics. They are the unquestioned champions in variety, penetration into regions of the earth, and sheer volume. More than any other organism they deserve the title of the Titans of life on this earth and our battle with them is as close to a Cosmic War as we are likely to get. With our mounting problem of antimicrobial resistant organisms it is increasingly clear that this is a battle we are not likely to win. In cases like that we negotiate and that is what our defenses do, and if we want to win in this war we call life we need both teams to be working well and cooperating.
Paul Ewald, in his book Evolution of Infectious Disease points out that using all of the defenses that prevent the spread of disease push the microbes to adapt commensally—to be more friendly to us. That’s how we negotiate with microbes. Virtually all of the advances in life expectancy over the past century have been due to improvements in these defenses. As beneficial as these have been it is unfortunate that all of the methods used—from window screens and bed-nets for malaria, clean water for cholera, condoms for STDs, to gowns, gloves and face masks for our medical facilities and us in public places—stop at our skin and ignore the physiologic defenses inside us that we are born with. These defenses developed over thousands if not millions of years and are likely the best available.
They are those pointed to by Claude Bernard, Pasteur’s contemporary and father of modern physiology, who argued with Pasteur that the soil where the microbe is planted is just as important in who gets sick. We are the soil where these microbes are planted and the defenses inside us are strongest where we are most vulnerable—at the openings of our bodies—with the major ones being for eating and breathing. Bernard’s soil is the environment where the seed either withers—if our defenses are adequate—or grows—if they aren’t. If we are to win our wars we need these defenses.
In the course of our lives we have many episodes where we eat or drink something that our bodies don’t like. In some cases our primary GI defenses—the acid and enzymes in our stomachs and all of the friendly commensal bacteria, which are routinely crippled by antibiotics and antacids—are not able to handle the insult. The back-up defense, for when the primary defenses are inadequate, is called gastroenteritis; it’s the bothersome washing defense that attempts to get rid of the problem via both ends of the GI tract. It too is crippled when we use drugs to stop the washing. It is enabled and the defense is optimized when we use oral rehydration for GI upsets instead of our crippling drugs. Oral rehydration is the mixture of salt, sugar and water in proportions that activate a transport system in the stomach and small intestine which pumps water into the body. It optimizes the washing defense simply by keeping our tank of water full. Its use is recommended by both the WHO and the CDC for GI illnesses. If used in standard care in the United States it would save up to a billion dollars annually and many lives. But it isn’t; it’s not in the current offense oriented paradigm so it isn’t even seen. And if it is there is also the realization that it would cost that much for our hospitals and doctors, so a decision is made not to use it.
If this decision is made it is unfortunate, for all physicians take an oath to do no harm, primum non nocere in the old Latin version of this oath. It’s why we trust our doctors. But our defenses work; they save lives. That’s why we have them; they are there because of natural selection, and using drugs that cripple them is harmful.
Our Respiratory Tract goes from the nose to the lungs and, like eating we pick up a lot of pollutants as we breathe, both microbial and allergic. The respiratory defense we have to cope with this is a well functioning mucociliary process—the combination of mucus, which holds on to all the pollutants we inhale, and the microscopic hairs (the cilia) that sweep it out, down the throat where it’s all recycled in the stomach. Key to this process is the airway surface fluid. This microscopic layer of fluid provides a space in which the cilia sweep, as well as the water for the concentrated secreted mucus to absorb to become the mucus that works to bind with all of the foreign material we inhale.
Anthony Arundel, a computer science researcher from British Columbia, showed us how easy it is to make this process optimal in 1986 by just living in a more humid environment. British Columbia is on the cool side of the temperate zone. He was aware, as was I in my practice, of a link between respiratory infections and turning the heat on in the winter, and his study is a collection of the data from the existing studies looking at this connection. Warming winter air makes the water in the air much less available to our noses and this is harmful for us all. His research was published in the U.S. Government journal, Environmental Health Perspectives in which he shows an optimal zone where the humidity in the indoor air—the air that we breathe—is between forty and sixty percent and all respiratory conditions, both allergic and infectious, are minimal in this zone. If the humidity is greater than fifty percent respiratory infections are insufficient to count. COVID-19 is a respiratory infection and the protection seen from outdoor air is likely via the greater humidity found there and that of masks may be from their capturing the moisture we breathe out, which increases by an estimated 100 percent that which we breathe in. Arundel showed us that adequate humidity in the air we breath is enough to keep the airway surface fluid sufficient.
If western medicine was interested in preventing rather than profiting from our many respiratory conditions they would find a way to get us all back into Arundel’s optimal zone and that’s what I found more than twenty years ago when I began using the sugar like substance xylitol in a nasal spray to prevent my granddaughters chronic ear infections. I added a teaspoon of xylitol to a bottle of saline nasal spray and had parents and caregivers spray her nose prior to every diaper change and ear infections disappeared. I gave it to a grandson and he could visit his other grandmother with a cat to which he was allergic. I gave it to a cousin with asthma and after two weeks her asthma disappeared.
Xylitol works osmotically to pull water into the airway surface fluid and the osmotic pressure of a teaspoon of xylitol in 45 mls. of saline is double what is normal for the body, which is how it pulls water into the nose. In this way using such a spray regularly puts us in the optimal zone.
I told the FDA I had a good way to clean the nose and they were impressed, at least verbally, by my safety profile: a person could use this spray every hour, both nostrils, twenty-four hours a day and get about half a plum’s worth of xylitol, which is not absorbed in the nose, but delivered with the mucus to the stomach. But without demonstrating efficacy with million dollar clinical trials I could not advertise the spray for what it did. If I borrowed the million and did the studies I would have to charge more and people would make it themselves. That is essentially what I learned from the ‘not interested’ pharmaceutical industry. So we sold a nasal wash.
As with oral rehydration wide spread use of this spray would prevent most upper respiratory conditions and save many billions of dollars as well as lives. Around the world the WHO estimates that 1.6 million people die annually from infections with Streptococcus pneumoniae. These infections begin in the nose and xylitol has the ability both to clean the nose as described above and to block the adherence of these microbes in the nose. It has also been shown in laboratory studies to do this with the virus behind COVID-19.
Both cleaning the nose and blocking microbial adherence do not attack the microbe; they are defensive tactics that work by further blocking microbes from getting access to us. They fit into Ewald’s strategy of negotiating with the microbial world and Bernard’s by manipulating the soil to be less hospitable.
But this war is very profitable to our current healthcare system, which is why many providers are not interested in this means of prevention. We can likely counter this and gain their help by ending another war that is just as costly: our war on illicit drugs.
War on drugs.
This war too has been singularly offensive with its focus on eliminating the drugs and all who are involved with their growing, transporting and delivery. This has driven all these people underground into illegal, but very profitable networks. We have exported this war to other nations and paid for their militarization in the hopes of preventing drugs from entering our country. The cost of this war is in the range of a trillion dollars annually. Change occurs in such situations when the cost of continuing is more than the cost of changing and evidence suggests we are there.
The Organization of American States is unanimous in their recommendation that the problem would be greatly helped if the United States would address the problem of the drug users as a health problem. This argument is the same as that of defense medicine; it looks at the soil where the drug is planted rather than at the drug.
Were our healthcare system given the responsibility to deliver drugs to those wanting them in a safe way and at less cost than what is now the street cost our drug related deaths would disappear and an illegal and profitable industry would be moved to the formal economy where the taxes would be in the billions. Much of the money spent in this illegal industry would then go to healthcare.
If we learned anything from our experience with prohibition it is that the best way to handle black markets that thrive because of human desire is to make them legal. In that case criminal ‘mobs’ profiting from the alcohol trade were hamstrung and had to move to drugs. Ending the war on drugs and moving it to a focus on the individual user would allow for safer use and more referrals to treatment centers. It should also allow for more use of currently illegal psychoactive drugs that do not have the addictive potential of narcotics and may actually be therapeutic in controlled therapeutic settings. This approach would make unnecessary the exporting of this war.
Indeed it would help resolve some of our other wars. Part 6 of the Washington Post’s Afghanistan Papers is entitled “Overwhelmed by Opium.” The other parts of the Papers tells how our offense there did not work out as expected. The part on opium deals with the parts that offensive tactics don’t see. Opium is a primary crop of Afghan farmers and has been the financial source for the Taliban since we invaded their country in 2001 to get rid of Al Qaida. It is an integral part of the environmental soil in this war. In his report Craig Whitlock looks at how our efforts to deal with their opium in our war on drugs failed on all accounts. In Afghanistan poppies have to do with the agricultural population and addressing those people and their agricultural interests is a defensive tactic not visible for those consumed with offense.
If we could have bought their poppy harvest in a legal market the Taliban would have been robbed of its funding source as well as much of its control over the citizens. The war would have been much different. Which introduces us to the uses of defense medicine in our global conflicts.
Kalev Sepp teaches at the U.S. Naval Postgraduate School in Monterey, California and is the author of the historical study “Best Practices in Counterinsurgency.” In it he looked at insurgencies over the past century and concluded that if the state relied only on force—the offense—they tended to lose, but if they addressed the underlying issues—the defense—they tended to win. A good example of this process is seen in Max Boot’s book The Road Not Taken, the story of Ed Lansdale’s work in the Philippines and Vietnam as an operative for the earlier version of the CIA. Charged with helping to develop democratic states he was able to help Ramon Magsaysay in the Philippines achieve a semblance of unity by getting the disputing tribal factions to agree to a clean and fair election as a way to resolve their underlying issues. This beneficial resolution of differences is contrasted with Lansdale’s attempts to do the same in Vietnam where military thinking—focusing on offensive tactics—prevailed, and there was no one with Magsaysay’s democratic orientation
Insurgencies begin when a group is frustrated in gaining their goals as we in the United States ourselves saw on January 6th. Addressing the underlying issues in insurgencies requires coping with the underlying issues, like Afghan poppies, or in our case simpler and more verifiable elections, or by electing leaders who don’t subvert them.
The issue behind insurgencies is a larger scale of what child psychologists know as counterwill: the instinct we all have to resist outside control. In children dealing with dominant parents it shows up in passive resistance in areas where the child can maintain some control, as in eating and potty training. In adults and our larger systems the responses are more complex, but if there is a dominant power in our relationship with others (spouses, coworkers, bosses, or government) which the person sees as threatening their responses are more than likely those of Daniel Kahneman’s ‘System 1’ rapid response thinking, which arise in the midbrain and largely trigger the fight or flight response rather than the more peaceful thought out responses of the cortex. This is why Yaalon was correct: tactical decisions more often come from the primitive midbrain’s fight or flight while strategy is cortical and thought out.
This instinct plays a role in our drug addicts as well as our children and punishment or time out, the honored—offensive—ways of making others conform to our social norms, do not work. What does work, according to the American Academy of Pediatricians, is spending enough time with the other to reach agreement on the best path forward. How to do that is explained by reading about Dialectical Behavior Therapy in DBT for Dummies, a new book by Harvard therapists Gillian Galen and Blaise Aguirre. This is not a dictatorial process; its aim, as Lansdale achieved in the Philippines, is consensual agreement between the parties looking for the best path forward. That demands hearing both, or all persons involved as independent agents worthy of pursuing their own self interests—it’s dialectical—and it’s the only effective way to deal with counterwill—in children as well as nations.
At the beginning of the cold war, in February 1946, George Kennan, the ambassador to the USSR, wrote a long telegram to the Secretary of State George Marshall explaining his opinion about world affairs at the time. It was not couched in terms of offense and defense or counterwill but looking at it in those terms clarifies the message. The USSR, he pointed out, was surrounded by capitalist countries and their counterwill was in full force. He cautioned about the offensive tactics of increased confrontation that would make their counterwill worse and push them toward the midbrain option of fight. Rather than that he concluded with the advice to cope with our own divisions and lead by example. Our real power comes from our ability to:
create among the peoples of the world generally the impression of a country which knows what it wants, which is coping successfully with the problems of its internal life and with the responsibilities of a world power, and which has a spiritual vitality capable of holding its own among the major ideological currents of the time.
Showing the world the best path forward is the best defense.