Angelina Jolie’s announcement that she had had a prophylactic double mastectomy prompted a thoughtful piece on NPR today. In it, Todd Tuttle, chief of surgical oncology at the University of Minnesota, discussed the motivations underlying such decisions. The number of women choosing this extreme form of preventive medicine has risen dramatically in recent years and is also much higher in the US than in Europe, although women there have the same access to surgery and reconstruction.

One cause, he said, was that women tend to greatly exaggerate their breast cancer risk when extrapolating from genetics or family history. Why is this? The NPR piece suggests that “the ubiquitous pink-ribbon campaigns may be fueling the rise in mastectomies.” We’d like to see the evidence, but it’s a profoundly ironic notion:

Could the campaign to “Save the Ta-Tas” in fact be reducing their numbers?

In an age of super-sensitive, ever more powerful diagnostics and a culture that favors preventive medicine, it becomes increasingly important for people to actually understand abstract concepts such as risk and probability.

A student* linked me to The Postnational Monitor, which features composite photographs of different racial, ethnic, and cultural groups. By superimposing many images (selected by unstated criteria) and centering them on the eyes and other key facial features, they produce visual “averages”. Here’s an average German male:

And here’s an average Irish female:

Some of the distinctions are pretty subtle. I had to look back and forth several times to make sure the Belgian and Dutch woman were not the same image. Can you tell which is which?

Statistics can be witty. Here’s “Ras’ average ex-girlfriend:

This lovely individual is the average South African female:

And the average Han Chinese man:

This fascinates me because in the 19th century, Francis Galton (Charles Darwin’s cousin and the inventor of eugenics and linear regression) invented this technique to uncover the “true” underlying features of different groups. His methods were cruder, of course, but the technique was basically the same. Here’s the essential Boston physician:

But for Galton, this was more than just visual play. He thought you could identify fundamental features of physiognomy, letting one get at the structural qualities of health and behavior. Composite photography could reveal the facial features of predisposition to disease (diathesis):

It could also be useful in crime prevention. Here are portraits of the kind of man who commits larceny (without violence):

Right! If you see any of these men, look for the nearest Bobbie.

Today, more sophisticated image-processing could be easily combined with DNA sampling and whole-genome analysis to find genetic correlates of these facial features. The Human Genome Project was, of course, a “composite” of a sequential sort—it comprised consensus sequences of numerous individuals to provide an image of “the” human genome. Today, much of personalized medicine relies on genomic composites of “Europeans,” “Africans,” and “Han Chinese.” Someday, similarly blurry visual portraits might even be made from genome data.

Consensus sequence, from bioinformatics.oxfordjournals.org

Think of the possibilities for preventive medicine and crime prevention! With sufficient data, it would be straightforward to produce “Wanted”-style posters of people predisposed toward illness or indiscretion, enabling the appropriate authorities to step in and save both the public and the individuals themselves from suffering. 

There is a long-standing dialectic between the belief that individuality most faithfully expresses the real world and the belief that truth lies in averages–that variation is noise. Personalized medicine, which relies on “big data,” inches forward by the pushes and pulls of that dialectic, alternately claiming to tailor treatment to the individual and relying on racial categories considerably less differentiated than the composites above to parse disease and behavior.

The patron saint of this style of research is (or ought to be) a hybrid of Galton and Archibald Garrod, whose inborn errors of metabolism are often cited as the origin of the kind of individualized, biochemical-genetic approach so much in favor today. So we close with a portrait of that patron saint, Sir Francibald Galrod:

Sir Francibald Galrod

*h/t Dmitry Pavluk

Dear Valued Faculty Member:

It has been a challenging year for Kashkow Medicine. First, we completed the King Mullah Abdullah Medical Multiplex, the first healthcare resort to be attached to a major medical school. The KMAMM is a component of the Kaschkow International Strategy for Monetizing Yet Another Sector of Society (KISMYASS). Completing the KMAMM required purchasing one third of the land mass of our city, in addition to more than 20,000 sturdy cardboard boxes for relocating the residents who lived there. We are glad to report that the residents are enjoying the flexibility and simplicity of life in a cardboard box. That was only the beginning, of course. The twin 40-story towers of the KMAMM feature 5-bedroom luxury suites crafted to impress the most discriminating patient. Each suite comes with its own physical therapy facility, with pool, weight room, and ¼ mile indoor running track; a kitchen staffed by a gourmet chef; an occupational therapy facility, with potting studio and wood shop; a private staff of nurses; and sexual surrogates available on request, no questions asked. We designed these suites, in other words, to be like a home away from home for our most elite patients. The KMAMM also maintains three high-speed cruise ships, fitted with accommodations similar to the towers, that will make “house calls” anywhere in the world for patients who cannot come to Kashkow. We are entering an exciting age of personalized medicine. We understand that healthcare must be tailored to the unique needs of each individual. The most privileged patients, too, deserve to have their expectations accommodated, and meeting those demands is expensive.

Next, we received the news that an anonymous donor was giving us Chicago. Although this generous gift is an exciting opportunity, it comes with significant challenges. First, where will we put it? It is obviously in a bad location and besides, it is too far away. Further, maintaining a city of that size will require a major investment in infrastructure and staff. Nevertheless, with your help, we are confident that we can successfully extend the Kashkow brand to include this and other major metropolises around the world. Indeed, we are close to a deal on purchasing Greece, which is available for a song, comparatively speaking. But we can’t do it without you.

Dr. John Moneybags, the recently anointed Prince of Development at Kashkow, wishes to extend a special invitation to all faculty to be a part of these thrilling changes at our university by making a gift to the school. Although a recent article in Medical Money magazine ranks our School of Medicine faculty as among the lowest paid in American academic medicine, we remind you of the substantial fringe benefits we offer: a generous healthcare package including two free hospital stays of one night or less per year, partial tuition remission for one course per year in our Master’s program in Biomedical Business Administration, and a coupon for 5% off the full uninsured rate for a heart transplant (not to be used in combination with any other offer). These benefits amount to more than $105,000 in effective annual take-home pay. Seen in that light, our faculty are a significant resource to be tapped. In short, we value you and want to make more of you and from you.

We warmly thank all our faculty and staff for contributing to our Institutional Advancement Campaign by accepting a 10% involuntary pay cut for each of the next three years. But we think you can do more. We are asking, therefore, that you invest more of your salary by giving back to your institution through one of our many convenient giving opportunities. For those unable to commit to long-term support, a one-time gift of $1,000 will make a real difference in our inexorable rise to world domination in healthcare. The easiest option is an annual subscription of $5,000 per year, managed through our payroll deduction program (pretax!). These gifts will be acknowledged by a gold-tinted brick with your name laid in our “Walk of Fame,” which will connect Bank of America Hall to Saudi Arabia. Or consider our new “Life Member” program for junior faculty under the age of 35: pledge your firstborn child and receive a “Kashkow World” calendar, delivered to your door every year that you remain part of the Kashkow Family. Staff making less than $40,000 per year are encouraged to drop spare bills and pocket change in one of the many bright blue “I <3 KK” donation boxes conveniently located in every ward, laboratory, classroom, and meeting room on campus. They also accept MasterCard and Visa.

As the poet said, “Health is your most important asset.” It is certainly ours. Our “20×2020” campaign has set an ambitious goal of raising $20 trillion by the year 2020—which translates to roughly the amount of the national debt each year. We have never been willing to settle for “second best.” But we can’t do it without you, our third most important asset (after property). So please, dig deep and make your gift today. And again tomorrow.

I have a review, in today’s Science magazine, of The Annotated & Illustrated Double Helix. A must for serious Watsonologists and DNA Studies majors. “Novel features of considerable interest”