Well Being: Four Forms of Numericide

Medicine confuses surrogate markers with actual health outcomes

Dr. Robert W. Malone

Sep 03, 2026

Executive Summary

Alan Cassels has written an important essay for the Brownstone Institute about something modern medicine rarely stops to question: our growing obsession with numbers.

Blood pressure. LDL cholesterol. Hemoglobin A1C. BMI.

We are increasingly taught that health can be reduced to whether these four numbers fall on the correct side of an officially sanctioned line. Cross that line and, almost overnight, a healthy person can acquire a diagnosis, a prescription, regular laboratory testing, and perhaps a lifetime relationship with the medical system.

Cassels calls this “numericide.” It is a provocative term, but the underlying argument deserves serious consideration.

His central point is not that blood pressure, blood glucose, cholesterol, or body composition are meaningless. They clearly are not. These measurements can provide useful information, particularly in people with established disease or substantial cardiovascular or metabolic risk. His argument is that medicine has increasingly confused surrogate markers with actual health outcomes.

That distinction matters.

The question should not simply be, Can we lower the number? Modern pharmaceuticals are often very good at doing that. The more important questions are: Does lowering that number meaningfully reduce heart attacks, strokes, disability, or death? By how much? In which patients? And what are the harms and tradeoffs required to achieve it?

Cassels walks through four of the most familiar medical targets.

With blood pressure, he challenges the idea that 120/80 should function as a universal dividing line between health and disease. Blood pressure varies considerably with age, circumstance, measurement technique, stress, and underlying cardiovascular risk. Aggressively lowering it may benefit selected high-risk patients, but treatment also carries risks, particularly in older people, including hypotension, falls, kidney injury, and adverse drug effects.

With LDL cholesterol, he makes a similarly important distinction between primary and secondary prevention. Someone who has already suffered a myocardial infarction is not the same patient as an otherwise healthy person whose LDL happens to exceed 100 mg/dL. Yet public messaging often collapses these very different risk categories into a single mantra: lower is better. Cassels points to the relatively small absolute mortality benefit found in primary-prevention statin trials and argues that patients deserve to hear those absolute numbers rather than simply being told that their cholesterol is “too high.”

His discussion of HbA1C and “prediabetes” raises another problem: the medicalization of risk itself. There is an enormous difference between uncontrolled diabetes capable of causing blindness, kidney disease, neuropathy, and vascular injury and a metabolically healthy person whose laboratory value has drifted slightly across an administrative threshold. Cassels is right to remind readers that aggressive glucose lowering has not invariably produced better outcomes and, in some circumstances, can produce real harm through hypoglycemia and medication effects.

Finally, there is BMI, perhaps the crudest of the four measurements. BMI cannot distinguish muscle from fat, tells us little about fat distribution, and can classify two people with profoundly different metabolic health as essentially identical. Cassels points to large observational studies showing that the relationship between BMI and mortality is considerably more complicated than the familiar “25 equals overweight” threshold suggests.

There is much here that I agree with.

https://www.malone.news/p/wellbeing-four-forms-of-numericide