History and the Will to Power in the Alzheimer’s Field

It is a strange time to be a historian interested in Alzheimer’s disease.

On the one hand, since the putative one hundredth anniversary of Alzheimer’s disease, which was confusingly celebrated in both 2006 and 2010, the Alzheimer’s field seems completely enamored with its storied past. Virtually every major book, conference or news articles on contemporary Alzheimer’s research contains at least a brief account of the origins and development of the basic concepts of the Alzheimer’s disease field. On the other hand, as history, these accounts are typically superficial at best, and are often distorted and misleading. The Alzheimer’s field remains so distressingly unaware and uninterested in its actual past that one could wonder about whether it is afflicted with some sort of memory disorder—except that this alienation from a meaningful engagement with history is  quite typical of  contemporary society.

My quarrel with the way the Alzheimer’s field represents its history is grounded in what I see as the core value of historical scholarship. If being a historian means anything, it is a commitment to the complexity of the past. Our interest in history comes from questions and concerns we have in the present and the patterns we see in the past are inevitably shaped by this. But we must remember that the people of the past,  whose experiences we would try to understand and learn from, had lives fully as complex as our own, and did not necessarily know and share the concerns we have in the present. When we attend to the complexity of the past it can serve as a source of rich human experience to interrogate and learn from. But if we impose the concerns of the present too strongly, we silence the individual and collective voices we could learn from and produce a self-serving narrative that can only reinforce our own biases. Historians cannot accept facile, reductive accounts of the individual and collective lives of people in the past in order to serve our purposes in the present.

A recent infographic on the history of Alzheimer’s disease research has begun circulating that distills the field’s warped history of itself into a viral nugget. It’s a nice design that pulls together information on the prevalence and financial burden of Alzheimer’s, the growth in funding for biomedical research, a list of drugs that have been approved for treating Alzheimer’s, and a timeline of “breakthroughs in research” drawn from standard sources: the websites of the Alzheimer’s Association and other major organizations in the Alzheimer’s field and mainstream media sources like CNN and Consumer Reports. As a whole, the infographic makes it clear that this is, or soon will be, a history of  medical triumph:

It has been called incurable, and its diagnosis comes as a death sentence. But as research accelerates, new breakthroughs become the norm, and donations come pouring in, sufferers of Alzheimer’s and their families are finding new hope in the possibility of future research and treatment options. See the history behind Alzheimer’s disease, the milestones in its research, and the global push for a cure.”

Shorn of any clarifying or qualifying context, all of the information in the graphic is grossly oversimplified. But  the distortion of history is simply outrageous. The timeline begins with the early twentieth century work of Alois Alzheimer’s associating plaques and tangles in the brain with dementia, and Emil Kraepelin’s creation of the term “Alzheimer’s disease” in 1910. This is all true, but ignores the fact that their concept of dementia was quite different, reserving the term Alzheimer’s  to distinguish the rare cases of early onset dementia from the much more common form of senile dementia, which they seemed content to view as an extreme form of normal aging. Moreover, Alzheimer and Kraepelin did not view dementia  as a major public health issue, and they showed no interest in developing therapeutic interventions; rather, their interest in dementia was aimed at advancing the intellectual power and social authority of psychiatry.

Remarkably, the only “breakthrough” mentioned between 1910 and the 1980s is the  invention of the electron microscope that allows  “deeper study of the brain.” Inclusion of this in a timeline on Alzheimer’s research is inexplicable since its inventors had no interest in Alzheimer’s disease, and Alzheimer’s researchers would not use the electron microscope in their work until the 1960s.

But to anyone who has systematically studied the history of Alzheimer’s disease , even more inexplicable is that a major body of research on the dementias is ignored. From the 1930s through the 1950s, American psychiatrists wrote extensively about age associated cognitive deterioration from a psychodynamic perspective. While this work goes against the grain of more recent research on brain pathology, as I showed in my first book, it was highly influential at the time, challenging  the therapeutic nihilism that had characterized medical approaches to senility and contributing to a broader transformation in social expectations for old age without which the emergence of Alzheimer’s as a  major public issue would be impossible.

The creation of the National Institute on Aging n 1974 and the Alzheimer’s Association in 1980 are noted, but there is no explanation indication of  the  political machinations behind them. They are, it seems, the straightforward and inevitable  institutional forms that emerge to deal with a dread disease. These have indeed been important organizations, but suffice it to say the reality is a good deal more complex than this.

The remainder of the timeline is devoted to breakthroughs in drug treatment or that contribute directly to dominant trends in current research, such  as the identification of the beta amyloid and tau proteins, the discovery of gene associations, or  the development of the transgenic mouse model of Alzheimer’s disease. Each of the drugs that have been licensed in the United States for treatment of Alzheimer’s is noted, but the now out-of-date  “cholinergic hypothesis” on which they were based is ignored, as is the controversy that surrounded tacrine and the fact that all of these drugs have proven to provide little if any benefit to patients. The 1999 success of an Alzheimer’s vaccine in transgenic mice is noted, though not the fact that initial human trials proved a disastrous failure when it caused fatal swelling of the brain. The timeline culminates with the  use of a cancer drug to reverse Alzheimer’s in mice earlier this year.

Those not  afflicted with the sensibilities of the professional historian might wonder why this is so bad. Is oversimplification of the past really so bad if it encourages public support for research and provides hope for people who are struggling with Alzheimer’s disease?

My response is that an oversimplification of history encourages naive thinking about our present situation. This is a winner’s history, in which scientific developments in the past are included only if they contributed directly to the  research agenda that is dominant in the present. It is a history that serves the interest of the leaders in the Alzheimer’s field today, suppressing contingency, complexity, and uncertainty so that the discovery of a prevention or cure seems inevitable if only we will make the necessary investment  in their work. On this account,  a crude version of Nietzsche’s will to power not Alzheimer’s research on plaques and tangles in the brain, seems to be the real foundation of the Alzheimer’s field.

Such history inevitably leads to an inflated sense of the efficacy and importance of dominant social institutions like medicine, and ignores or marginalizes the importance of other social and cultural resources like art or spirituality that can and should be part of our understanding of the problem and part of our response. In the case of Alzheimer’s, this distorted history helps to rivet  attention on faulty molecules in the brain and to foster a desperate hope in the power of biomedicine to produce a cure.

We need to create richer, more profoundly optimistic understandings of dementia and how we might respond to it. Attending to the complexities of the history of Alzheimer’s research is a good place to begin.

Confusingly celebrated in both 2006 and 2010. Alzheimer described the case of Auguste Deter at a small, regional conference of German psychiatrists in Tübingen in 1906, and Kraepelin created the eponym Alzheimer’s disease based largely on this case in the eight edition of his influential textbook Psychiatrie, published in 1910. 

Nietzsche’s will to power. The nuanced version of the will to power, which can be found in Nietzsche’s original work, did not condone a simplification of history  to fit the wishes of those seeking to exert power and remains an important concept in history and theory. 

Medical Journalism in the War on Alzheimer’s

They say that truth is the first casualty of war. So how is the truth doing in news coverage of medical research on dementia now that we have finally declared War on Alzheimer’s?

ImageThe question is prompted by the recent major article on the genetics of early onset Alzheimer’s disease by New York Times science reporter Gina Kolata in last week’s NYT Magazine. The article immediately generated a lot of positive buzz in the Alzheimer’s research and caregiver communities. It’s the kind of piece that usually garners awards, not opprobrium. So let me begin by saying what Kolata does right before making the case that she gets the most important things very, very wrong.

Kolata’s writing is a beautiful, and she tells a compelling story of the members of a family struggling to live with the burden of knowing that they may have a gene for early onset Alzheimer’s, and their sometimes enthusiastic and sometimes ambivalent involvement in medical research that can tell them for sure. She also describes some complicated genetic science with commendable clarity.

The problem is that Kolata uncritically accepts the perspective of Alzheimer’s researchers in a way that violates the fundamental value of systematic skeptical inquiry that ought to be at the heart of both journalism and science. There is nothing new or exceptional in this, of course. Frankly, Kolata’s many articles in the Times hyping the latest Alzheimer’s research, like so much of medical reporting in general, reminds me of the sort of journalistic failure, most egregiously by Judith Miller of the Times, that led so many to accept the Bush administration’s claims about weapons of mass destruction in Iraq. Just as uncritical reporting of the Bush administration’s false claims about the presence of WMDs, and its rosy assessment of how American troops would be received by the Iraqi people after dislodging Saddam, influenced the public and congress to support a war in Iraq, uncritical reporting of the sorts of claims made in the article about the imminence of therapeutic breakthroughs will influence the public and congress to continue supporting the war on Alzheimer’s and the growth of the biomedical industrial complex behind it.

Now I am not saying that the motivations of medical researchers in Alzheimer’s or other fields are the same as warmongers in the Bush administration On the whole, I am a fan of Alzheimer’s and other medical researchers and the work they do. But good journalists, whether they are covering the war on terrorism or the war on disease, should be skeptical of sources that have an obvious self-interest. And medical researchers have an obvious self-interest in presenting their research in the most favorable light possible. Thus it should be no surprise, even to people familiar with the daunting complexities of understanding, treating and preventing dementia, that the researchers profiled in the article “say that within a decade there could be a drug that staves off brain destruction and death.” But Kolata should have raised questions about this claim, and talked to experts not directly involved in the research who are far less optimistic about its potential to so quickly lead to effective treatments.

Kolata’s article uncritically reiterates two other important aspects of the perspective of many Alzheimer’s researchers: a warped view of history, and an oversimplification of the disease.

Fairytale History

Regarding history, Kolata spends about 800 words connecting German psychiatrist Alois Alzheimer’s first encounter in 1901 with a patient with what we would today call early-onset Alzheimer’s to contemporary research. Alzheimer brilliantly described the pathological features of the disease, but lacked the scientific tools needed to understand what caused it let alone how to do anything to stop it. “There matters stood until the latter part of the 20th century,” when contemporary researchers heroically enter the stage with powerful new technologies to penetrate the mysteries of the brain and will soon, we are assured, be able to set things right.

Alois Alzheimer (1864-1915)

While it is attractively simple and flattering for researchers to think of themselves as part of a unified, continuous research enterprise stretching back more than a century in which they finally are able make progress on the medical mystery Alois Alzheimer unearthed in the brain of his patient more than a century ago, the truth is a good deal more complicated than that. Scientific and clinical research on dementia has never been a unified enterprise. The goals and approaches of researchers and clinicians are strongly shaped by the historical contexts in which they practice, and given the dramatically different context in which Alzheimer practiced, it is highly unlikely that he shared our concerns about age-associated cognitive decline. Though no one has done a serious historical study focusing on Alzheimer and his lab, I have looked at the available evidence enough to conclude that Alzheimer and his contemporaries simply did not view the disease that was named for him as terribly interesting or important. When he died in 1915, none of the admiring colleagues who eulogized him – not even Emil Kraepelin who named the disease for him in 1910 – listed the discovery of Alzheimer’s disease as one of his major accomplishments.

Moreover, the claim that nothing of significance happened regarding the medical understanding of Alzheimer’s disease and senile dementia between Alzheimer’ and the latter twentieth century ignores a major historical development. In the middle decades of the twentieth century, a group of American psychiatrists developed a psychodynamic framework for understanding and managing dementia and made sweeping claims about how it finally removed some of the mystery shrouding the condition and would soon lead to efficacious means of preventing cognitive deterioration in old age. It is perhaps understandable that contemporary researchers, trained in biological psychiatry and neuroscience and focused on pathology in the brain, have forgotten this chapter in the history of Alzheimer’s research. It is unfortunate though, if only because considering the now largely forgotten work of researchers who thought themselves on the cusp of being able to prevent dementia just might lead today’s researchers to consider the virtues of humility and circumspection in making claims about imminent progress.

While it might be presumptuous of me to suggest that Kolata should have known all this by making herself familiar with my work, she need not perpetuate a history of the field that is so obviously driven by the biases of contemporary researchers. It should not take a historian to recognize a self-serving fairy tale.

Simplifying Alzheimer’s

Regarding the oversimplification of the disease, there are a couple of points to make. First, the many scholars, clinical professionals and caregivers who have been working to lessen the stigma and despair associated with dementia – whom I am proud to count myself among – might take issue with the unremitting grimness with which Kolata represents having dementia. Without denying or diminishing the very real losses and challenges imposed by dementia, we have been working in different ways to show that a life cannot be reduced to a disease, even a disease that brings profound cognitive deterioration. Possibilities for human flourishing remain. Kolata’s story, like so much reporting on Alzheimer’s, represents people with dementia as pure victims – unable to comprehend or resist in any way a disorder that takes everything from them.

But I am willing to cut Kolata some slack here. While we need more stories about living well with dementia, that is not the story Kolata set out to write, and the one she did is important. Her story is about the dread associated with early-onset, familial Alzheimer’s disease, the very rare form of dementia that is associated with several autosomal-dominant gene mutations. Frankly, early-onset familial Alzheimer’s does seem more dreadful to me than the much more common variant that occurs at much older ages. Some may regard this as ageism, but developing a profound cognitive disability in your fifties or even forties does seem much worse than developing it in your seventies, eighties or nineties. And living with the sharp either/or risk of a Mendelian gene for dementia in one’s family seems much more dreadful to me than the gradually increasing risk for dementia associated with the normal vicissitudes growing older.

The problem is that Kolata’s story tends to conflate this very rare form of early-onset dementia, which is estimated to account for only one to five percent of all cases of Alzheimer’s, with the category as a whole. The story acknowledges this explicitly at only one point, nearly 700 words into a 5,400 word story, when it describes the rationale of the Dominantly Inherited Alzheimer Network (DIAN) project:

Though as much as 99 percent of all Alzheimer’s cases are not a result of a known genetic mutation, researchers have determined that the best place to find a treatment or cure for the disease is to study those who possess a mutation that causes it. It’s a method that has worked for other diseases. Statins, the drugs that are broadly prescribed to block the body’s cholesterol synthesis, were first found effective in studies of people who inherited a rare gene that led to severe and early heart disease.

Alzheimer’s is the sixth leading cause of death in this country, and is the only disease among the 10 deadliest that cannot be prevented, slowed or cured. But DIAN investigators say that within a decade there could be a drug that staves off brain destruction and death.”

Throughout the rest of the story, Kolata drops the qualifiers “early onset,” “familial” and most importantly, “rare” and simply uses the term “Alzheimer’s disease.” In the online version of the story, the first reference to Alzheimer’s disease is even linked to the NYT Health Guides general entry for Alzheimer’s disease. The elision of this important distinction has undoubtedly fueled the needless fear many people often have of being at greatly increased risk for dementia because a relative developed cognitive problems in their seventies or eighties, which can be seen in some of the many comments from readers to the online version of the article  It also reinforces the central dogma of the contemporary Alzheimer’s field – that it is a single disease, distinct from aging, caused by some unified patho-physiological mechanism that can be isolated and addressed with a linear therapeutic intervention.

As Kolata must surely be aware, many if not most researchers in the Alzheimer’s field will acknowledge privately though not so often in public that this central dogma is shaky.  In this case, some closer attention to the real history of Alzheimer’s research would be helpful. The term Alzheimer’s disease was originally created to describe cases of dementia – such as the 51-year-old woman Alzheimer encountered in 1901 – where the clinical and pathological features of senility appeared at a relatively early age. Though Alzheimer and his contemporaries had no inkling of the genetic basis, they thought that early onset was sufficient grounds for a separate disease category. In the late 1970s, a group of American researchers, government officials within NIH and activist caregivers lobbied successfully to drop the distinction. Their goal was to generate awareness and funding for biomedical research into dementia, and they were very savvy about the political ramifications of disease categorization. Since there was no meaningful clinical or pathological distinction between Alzheimer’s and senile dementia, they argued that the two should be considered a single entity – and that entity, crucially, should be called Alzheimer’s. By combining the two categories, they could claim that the condition was a major health problem afflicting millions of people; by calling it Alzheimer’s rather than senile dementia, they could claim it was not aging, but a dread disease worthy of a massive, publicly funded research initiative to understand its cause and discover a means of effective treatment or prevention.

Ironically, among the most important research findings generated by the torrent of funding that was unleashed by the political power of the re-conceptualization of Alzheimer’s was the discovery of the genes associated exclusively with the early onset form – which would logically seem to support a return to the original distinction made by Alzheimer and his contemporaries. But the concept of Alzheimer’s as a single, unified disease distinct from aging remains too powerful to abandon. So at the level of policy advocacy and popular news accounts at least, most researchers continue to talk as though Alzheimer’s disease were quite a clear-cut thing, when the reality is much more complicated.

Researchers in the DIAN project and others described in the article are exploring the distinction between presenile and senile dementia, and hoping that the ability to identify and follow subjects from families with early onset genes to test the use of drugs at much earlier stages in the development of Alzheimer’s will be quick route to a drug that can effectively prevent the disease.

I hope this strategy pays off, and that in a few years we will see more big stories of successful drug trials from the DIAN project – though even then I hope they will be stories that more accurately represent the complexities of medical research on Alzheimer’s. But given the complexity of dementia and the difficulty of identifying efficacious patho-physiological targets for drugs in a disorder with multiple, inter-related causal mechanisms, I think it much more likely that the drugs tested in these trials will be of limited value. In that case, if we read about it in publications like the NYT at all, it will likely be a much smaller item buried in the back pages. Meanwhile reporters like Kolata will be on to writing splashy front page articles about the next imminent breakthrough.

That’s how we roll in the War on Alzheimer’s.