The Health Culture

What is healthism? (part two)

Jan — Mon, 20 Feb 2012 23:20:10 +0000

In part one of this post I explained the most common meaning of healthism (an excessive preoccupation with healthy lifestyles and feeling personally responsible for our health) and described an authoritarian sense of the term. Here I discuss healthism as an appeal to moral sentiments and as a source of anxiety. I also note an unusual definition of the term as the desire to be healthy, which leads me to end with a personal disclaimer.

Moral healthism

The directive to be personally responsible for our health – whether it comes from a government health policy, the medical profession, or an advertisement – is often fraught with unacknowledged moral overtones. People who practice healthy lifestyles (daily exercise, a Mediterranean diet) and dutifully follow prevention guidelines (annual cancer screenings, pharmaceuticals to maintain surrogate endpoints for risk reduction) are overtly or implicitly encouraged to feel morally superior to those who do not. This includes the right to feel superior to those who ‘choose’ to be unhealthy – after all, isn’t smoking a morally indefensible choice? The implication is that those who fail to take responsibility for their health are undeserving of our sympathy or assistance (especially financial).

This quality of healthism – like the anti-authority healthism discussed in part one – is possibly more common in the US than elsewhere. It’s unfortunate but true that in the US there’s a tendency to blame the poor and disadvantaged for not being able to pull themselves up by their bootstraps. There is a decided unwillingness to acknowledge that differences in wealth and social class during childhood have lifelong effects on behavior and health.

As sociologist Marc Renaud writes:

One’s capacity to modify potentially pathogenic behaviours and to “stick with it” is directly related to one’s wealth, power, and education — in short to the degree of control one has over one’s future. The higher up in the social hierarchy, the more control one feels capable of exerting over life, the easier it is to change unhealthy habits. In other words, one’s “will to change” is largely predetermined by one’s social environment. To be told, by an education program or otherwise, that one’s life-style should change is neither helpful nor effective.

If a boy grows up surrounded by drug abuse, gang violence, and an abbreviated lifespan for the adult men in his life, it’s unlikely he’ll worry about the possibility of lung cancer 20 years from now.

In an attempt to slow escalating health care costs in the 1970s and ’80s, moral healthism was a convenient way for politicians — at least symbolically — to shift the burden of responsibility for health onto individual citizens. It remains a popular position among politicians who would like to blame high health care costs on those who allegedly eat too much. In addition to serving political interests, moral healthism is used by vendors of health-related goods and services to motivate consumers to make purchases (gym memberships, organic food, diagnostic screening).

When healthism refers to a superior moral attitude, it’s meant to be pejorative and disparaging. People who take pride in the nutritional correctness of what they eat, the size of their muscles, or the absence of any flesh that’s not firm may be examples of healthism in action, but those individuals would not use that term to describe their behavior. At most they might admit to being health and/or body conscious.

Anxiety healthism

Another quality of healthism is anxious preoccupation with health. If we believe we’re personally responsible for our health, it follows that we should worry about whether our behavior is sufficiently health promoting. This attitude is a favorite of pharmaceutical companies (“ask your doctor”) and the food industry (“heart healthy”). It’s also a natural by-product of medicine’s increasing emphasis, since the 1950s, on risk factors for disease.

Moral and anxiety healthism often overlap. When healthism is used by pharma, the food industry, the fitness industry, and the purveyors of medical products and services, there’s usually an element of both anxiety (you should be worried about your health) and morality (you can feel good about yourself if you do (or bad if you don’t)).

Anxiety about health is fueled by all forms of media, both through advertising and by the barrage of information on the latest (often contradictory) health findings. When media companies benefit financially from the public’s interest in and vulnerability to health information, they’re practicing anxiety healthism.

Historically, there may be a connection between the origins of healthism in the 1970s and anxiety. Robert Crawford suggests that the economic insecurities and uncertainties of the 1970s may have prompted efforts to control our health as a way to reduce anxiety. When we can’t control the world around us, we can attempt to keep anxiety at bay by increasing control over ourselves.

It’s only natural that we want to exert some control over our health, our susceptibility to illness, and the length of our lives, no matter which anxious decade we live in. Increased anxiety about health, however, makes us vulnerable to the promotion of lifestyle changes (and their associated consumer products) that will ‘guarantee’ good health. The obsessive pursuit of health, accompanied by anxiety, is in fact unhealthy.

Healthy healthism: Profiting from moral and anxiety healthism

Although it’s exceptional, some people use the term healthism to refer to the desire to be healthy (“Healthism – A Way to Become Healthy“). I’ve come across only two examples of this usage, one in India and the other in Canada. It’s a very ironic sense of the term, since it uses the moral, guilt-tripped compunction to be healthy to promote and profit from anxious, health-seeking behavior.

The president of the Healthism.com site in Canada (in an email exchange) agreed with me that healthism is about personal responsibility for health, but not that the term is pejorative. He believes those who are “marginalized” in society should be held to the same standards as the affluent when it comes to personal responsibility for health. To believe otherwise is “typical academic elitism.”

Healthism.com promotes diagnostic testing and promises to sell “doctor-reviewed products for your health and vitality.” While the site may choose to define healthism as the desire to be healthy, it’s an excellent example of practicing moral and anxiety healthism to profit from our vulnerability to health concerns.

What can I say? In a post-1984 world, people redefine words to mean their opposite all the time.

Disclaimer

Obviously, in just two posts, I haven’t exhaustively captured all possible meanings and nuances of the term healthism. People disagree, for example, about what it means to be personally responsible for one’s health. When Irving Zola first used the word healthism in 1977, his meaning was virtually identical to an early use of the term medicalization.

I will leave for later a response to the accusation that, because I find moral and anxiety healthism objectionable (I hope that’s obvious), this must mean I believe everyone should smoke, be overweight, and never be tested for cancer. (When discussing healthy lifestyles, I really do get this reaction from otherwise highly intelligent people.) That’s not what I think, but it would take more than a few posts to explain what I find so objectionable about personal responsibility for healthy lifestyles. It’s a sign of the effectiveness of the personal responsibility message that many people fail to examine the interests it serves. I myself was once in that category, which is one reason I feel so strongly about the subject today.

A preoccupation with healthy lifestyles to the point of healthism is a coping mechanism in an unhealthy world, just as smoking and substance abuse are mechanisms for coping with the stressors of modern life. It is not the practitioners of healthy lifestyles I find objectionable, but those who exacerbate and profit from our anxiety about health.

I write about the history of healthism because I’m interested in medical, political, economic, cultural, social, and historical factors that influence the way we think about health and health policy today. Changes in health policy cannot happen unless the public understands what ultimately determines health and illness. Healthism — personal responsibility for health by practicing healthy lifestyles — has had an enormous influence on the public’s perception of health. By turning our attention away from the larger social environment in which we live, healthism has reinforced biomedicine’s assumption that our understanding of health must be limited to the narrow confines of the laboratory and the doctor’s office.

Our financially and professionally entrenched system of medical care has a vested interest in maintaining an understanding of health that preserves the status quo. Part of the power of our biomedical culture, however, is that its contingency – the very real possibility that it could be different — is ordinarily invisible to us. What would it take to imagine a widely shared understanding of health that valued not only the quality and availability of health care, but daily living conditions that are conducive to everyone’s health? This is the question I hope an examination of healthism will provoke.

What is healthism? (part one)

Jan — Mon, 20 Feb 2012 22:20:15 +0000

Throughout history there’s been an understandable desire to find connections between our behavior and our health. Human beings have practiced health regimens involving diet, exercise and hygiene since antiquity. When medicine was based on the humoral theory of disease, for example, individuals were advised to purge the body in the spring and, in the summer, avoid foods or activities that caused heat. Bathing in ice water was recommended in the 19th century. Mark Twain quoted the advice: “the only way to keep your health is to eat what you don’t want, drink what you don’t like, and do what you’d druther not.”

In the second half of the 20th century many Americans adopted the idea that a ‘healthy lifestyle’ (diet, exercise, not smoking, etc.) was a good way to prevent disease and live longer. This particular attitude was a product of popular perceptions about health (a surge of interest in holistic/alternative practices, self-care movements such as Our Bodies, Ourselves) and prevailing social attitudes (such as desirable body images). Perhaps more so than in previous centuries, the growth of media consumption and the effectiveness of modern advertising allowed commercial interests (books, magazines, fitness merchandise, vitamins and supplements, weight loss pills, diet and energy foods, …) to exert considerable influence on health behavior.

Also at work was extensive media coverage of a presumed link between preventive lifestyles and risk factors for disease (conflicting opinions about salt and which type of fats to eat are good examples). Unlike the vague aphorisms of previous generations, this more modern source of health advice had the scientific backing of epidemiology, if not the proof that comes from randomly controlled trials.

One of the terms used to describe the enormous increase in health consciousness is ‘healthism.’ Judging from how I’ve seen the word used, it means different things in different contexts to different people. I’m going to describe a few of those meanings.

This post grew rather long, so I’ve divided it into two parts. In part one I discuss an anti-authority sense of healthism as well as healthism’s most common meaning: a sense of personal responsibility for health accompanied by an excessive preoccupation with fitness, appearance, and the fear of disease. Part two discusses the moralistic and anxiety-inducing qualities of the term, plus an odd use where healthism becomes another word for health itself.

Anti-authority healthism

Some people use the term ‘healthism’ to emphasize the imposition of health directives in an authoritarian manner. A prime example is the vigorous anti-smoking campaign waged by Nazi Germany in the 1930s. Supporters of smokers’ rights use ‘healthism’ in this anti-authoritarian sense when they object to limitations on the freedom to smoke whenever and wherever they please. When Frank Davis, a highly articulate smokers’ rights blogger in the UK, refers to ‘healthism,’ he is objecting to the infringement of his rights.

This anti-authority sense of healthism also gets used when referring to the advice that we should exercise more or give up our favorite foods simply because they contain excessive amounts of sugar, fat, and salt. I don’t know of any statistics, but I wouldn’t be surprised if this use of the term is especially popular in the US, a nation proud of its ‘don’t-tread-on-me’ tradition of rugged individualism.

Here’s an example of a patient resisting the health advice of an authority, described by a doctor writing in The New England Journal of Medicine:

After I had berated the patient for his obvious failure to comply with my recommendations to correct his “misbehavior,” he said, “You know, doctor, there is more to life than good health.” These words have helped me rein in my sometimes overzealous attempts to force patients into that glorious state of wellness and maintain a more realistic approach to the best possible state of health.

What distinguishes anti-authority healthism is the open acknowledgement that the injunction to be healthy is externally imposed. This differs from other versions of healthism where the pursuit of health is internally motivated and individuals have little or no awareness of the external origins of their motivation.

Healthism as excessive preoccupation with health

In 1980 Robert Crawford defined healthism as “the preoccupation with personal health as a primary – often the primary – focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of life styles” (emphasis in original). He noted some of the signs of this emerging trend in the 1970s: A remarkable increase in the number of people exercising, jogging, and running. An aggressive anti-smoking campaign. The proliferation of popular health magazines. The increasing frequency of health-related subject matter in newspapers and magazines. Advertisements that appealed to the desire to be healthy, even when the product’s connection to health was entirely superficial.

In 1980, when preoccupation with health and fitness was new, it was remarkable. Today it is so prevalent that it’s almost invisible — we simply take it for granted. All around us are people who aspire to healthy lifestyles and hold themselves responsible for their health, and we don’t give them a second thought. (Healthism is all around us, yes, in the media, in advertisements, and on supermarket shelves. As far as individuals go, however, healthism is predominantly a white, middle-class phenomenon.)

Some changes in our behavior – exercise routines, for example – are no longer even associated with the pursuit of health. Other explanations have come to suffice: Self-discipline and control are virtues in themselves. Asceticism has an aesthetic appeal. Being fitter-than-thou provides moral superiority. We live, after all, in a consumer culture based on the promotion of self-image and the value of physical appearance. The change in our fitness behavior in the 1970s, however, was linked to the advent of healthism.

Why the time was ripe for healthism

How this transformation happened is a complex story that includes the history of medicine in the late 20th century. The status of the medical profession was in transition in the 1970s. Once the Western world had won the battle against infectious diseases, medicine was confronted with the prevalence of chronic disease. When immediate success on this front was not forthcoming, public confidence in medicine declined.

Highly vocal critics were ruthless in their eagerness to find fault with medicine: Ivan Illich (Medical Nemesis), Irving Zola (Disabling Professions), Eliot Freidson (Profession of Medicine), Thomas Szasz (The Myth of Mental Illness). There were many others who wrote in the popular press, influencing public opinion, whose names are less familiar today.

The decline in confidence in medicine was due in part to a general disillusionment that followed idealistic and unrealized hopes of the 1960s — the world did not turn out to be better place in the 1970s. All professions were subjected to harsh criticism, and medicine was no exception. There were also more specific forces at work, however, at least in the US. The implementation of Medicaid and Medicare, followed by managed care, had a major impact on the stature of the medical profession and on the dissatisfaction with health care among both doctors and patients. It seems reasonable to suggest that if there was a decline in both confidence in and satisfaction with medicine, the public may have been especially receptive to the idea that they should take responsibility for their own health by adopting healthy lifestyles.

The emerging economic and political climate at the time also contributed to the rise of healthism. After the exceptionally stable and prosperous post-WWII decades, the 1970s brought the oil crisis, the combination of double-digit inflation and high unemployment (stagflation), and a turn to the conservative, neoliberal right. In 1980, Ronald Reagan was about to begin his first presidential term. It was expedient to redefine health, access to health care, and unemployment as matters determined by the worthiness of an individual’s character. Self-help — the kind advocated by the promotion of healthy lifestyles — was preferable to government assistance.

Healthism’s legacy for social determinants of health

The political climate favored appealing to the individual even at the expense of society. Looking at the situation in 1980, Crawford believed that healthism’s emphasis on individual responsibility would turn out to be its most significant and unfortunate legacy. The message was: “I have only myself to blame if I fail to modify my behavior and subsequently suffer the health consequences.” Crawford foresaw that the elevation of the individual would work against the search for collective solutions to environmental and occupational threats to health.

Our understanding of the determinants of health has advanced considerably since 1970s concerns about the dangers of air pollution and the inhalation of asbestos on the job. There is now extensive evidence, for example, that health disparities are due to social class itself and not just lack of income or access to health care. The fundamental problem, however, is the one Crawford identified: By focusing on the individual and not the society in which the individual lives, medicine, the health care industry, and governments have failed to address the ultimate causes of disease.

Healthism contributed to this failure. Ironically, the explosive preoccupation with health in the late 20th century has been a formidable hindrance to achieving the improvements in health we claim to seek by practicing healthy lifestyles.

In part two of this post I discuss aspects of healthism that increase our anxiety about health and that appeal to a sense of moral superiority.

Guest post: Is the prevalence of depression related to the modern empowerment of the individual?

Jan — Sun, 19 Feb 2012 22:13:57 +0000

Pierre Fraser is an author, essayist, and (currently) a PhD candidate in sociology at Université Laval. Just as his most recent book (Tous Malades !: Quand l’obsession pour la santé nous rend fous) was being published, I met Pierre on Twitter, where we discovered our mutual interest in the subject of healthism. Pierre blogs at Pierre Fraser and tweets as @pierre_fraser.

This translation would have been impossible without the invaluable assistance of Jan Henderson (PhD in the history of science and medicine from Yale). Her work allowed me to revisit the original French text and enhance it, and in this sense, we followed the injunction of Karl Popper : the duty of clarity. I hope our collaboration will continue, because Jan and I are particularly concerned about the healthization of society, and we try to understand how health has become a social value. Feel free to send us your comments (Jan Henderson, Pierre Fraser).

Pierre Fraser, 2012

When a medical clinician examines a patient, she first determines the presenting symptoms, considers which bodily functions might account for those symptoms, arrives at a diagnosis, and provides the most appropriate treatment. But what if the presenting symptom is depression? As Alain Ehrenberg points out, “depression, like any mental illness, is not a disease that can be assigned to a part of the body.” [1] In fact, as Ehrenberg goes on to say: “when psychiatry can discover the cause of a mental illness, as happened with epilepsy, it is no longer a mental illness.” [2] Such has been the dilemma of the history of psychiatry.

Consider, though, what has happened in the history of depression. Seventy years ago an individual who suffered from depression was considered sick, but curable. Today our assessment is that such an individual has a chronic disease. [3] How can we explain this historical progression?

When we look closely at the history of psychiatry it teaches us one thing very well: “disagreements about the causes, definitions and treatment of diseases, as well as the uncertainties that have accompanied the history of psychiatric reasoning, are particularly revealing about the transformation of the individual.” [4] Since the beginning of the Industrial Revolution, our concept of the individual has undergone fundamental transformations. Given that we now hold “the gospel of personal development in one hand and the cult of performance in the other” [5], we can see that “the history of depression reveals how the type of person we have become has followed in the wake of demands for psychic emancipation and individual initiative. What insanity is to reason and neurosis is to conflict, depression is to insufficiency.” [6] Emancipation and empowerment bring the expectation that the individual will perform. But will that performance be adequate? Depression is the result of feeling that our life’s performance is not sufficient.

A social bond in crisis

The Age of Wild Capitalism (1860-1929) was dominated by the captains of industry. Private enterprise reigned supreme and regard for the individual was at the same level as regard for commercial merchandise. This was followed by the Age of Democratic Capitalism (1930-1973), when the state, in response to the Great Depression, began to intervene in markets by imposing regulations. The Age of Supercapitalism (1973-2005) began with the first oil crisis. The economic difficulties of the era created an opportunity for President Ronald Reagan and Prime Minister Margaret Thatcher to deregulate a variety of economic sectors. The period culminated with globalization. Finally, I would like to propose that we are now in an Age of Distributed Capitalism [9] where the dominant influence will be high-tech industries. This stage will enable the complete empowerment of individuals: they will be fully in charge of their lives through the use of inexpensive and widely available technologies.

In this table what stands out first and foremost is a correlation between the dominant ideology of each era and the relative hierarchy of the players. In the Age of Democratic Capitalism, the state is the most prominent social actor. Entrepreneurs and financiers are relegated to the bottom of the scale. This is a complete reversal of the positions they held in the previous age. The reversal is apparent not only in the rise of unions, but in the implementation of major social protection programs that are characteristic of this age. Though these programs took on different forms in different countries, the intention was the same. We see here an example of what Durkheim called ‘organic solidarity’: a social cohesiveness and interdependence that arises from the division of labor. This state of affairs allows individuals to benefit from the basic protections of society while feeling their contributions are valued as useful. [10]

On the grammar of depression

The Age of Democratic Capitalism appears, at first glance, to be highly favorable for the individual. Thanks to various social measures, it was a time when the state offered increased protections against life’s misfortunes. Living conditions improved for all economic classes. Purchasing power increased annually, and “those born after 1945 not only have the best physical health in modern history, but have also been raised in a period of unprecedented prosperity.” [11]

It might seem paradoxical that the prevalence of depression would increase in this era, but this was definitely the case. In 1989, the American Medical Association published a summary of epidemiological studies of depression and concluded: “the increased risk of depression for those born after the Second World War is indisputable.” [12] There had been an astonishing amount of material progress, yes, but this was accompanied by “urbanization, geographic mobility, emotional breakdowns, the growth of social anomie, changes in family structures, and the embrittlement of gender roles.” What is especially interesting about the epidemiological studies is that they all converge on the same explanation for the rise of depression: social change.

We must admit that social change alone cannot explain everything about depression. There must also be a ‘grammar of depression’ through which individuals may conduct their own diagnoses, and this grammar can only exist if depression is institutionalized. Around 1960 “anxiety, insomnia and overwork as the themes of depression appear publically in major magazines.” [13] They provide “an interpretive tool to solve or overcome intimate problems.” [14] In other words, depression involves actors who supply the hows and whys of their problems, while mass media tell people how to deal with those problems. Depression is thus “produced in a collective construction that provides it with a social framework in which it exists.” [15] Depression becomes a social reality and a “grammar of the inner life for everyone.” [16] Once individuals understand that they are subject to depression, however, there is a social crisis. If individuals regard themselves as depressed, will they be able to perform the roles expected of them by society? A society functions best when its members feel that what they are doing is useful. Depression, with its sense of the insufficiency of the individual, calls this into question. A society needs motivated, mentally healthy citizens, but will it be able to alleviate the widespread incidence of depression?

As Alain Ehrenberg has emphasized, “democratic modernity — this is its power — has gradually turned us into men who have nothing other than our own selves to guide us. We are gradually put into a position where we have to make our own judgments and create our own standards.” [17] The possibility of living our lives as sovereign, autonomous individuals has not only become a reality for some of us, as anticipated by Nietzsche, but is now the common reality for everyone. In times past, an individual who did not respect the rules (what is permitted/prohibited) was seen as guilty of a ‘sin.’ Today, however, he is blamed for a ‘failure of responsibility’ (what is ‘possible/impossible’). The individual can no longer agree to accept the label ‘guilty’ without giving it much thought. The sovereign individual must feel the weight of responsibility for his actions. This reconfiguration of the individual self brings us back to the contemporary prevalence of depression. As Ehrenberg points out, depression is now something intrinsic to the individual: “it is the failure of internal resources.” [18]

About depression

It is quite possible that depression is an anomic condition (Durkheim). That is, it occurs in contexts where the individual, confronted with the duality “possible/impossible,” feels he must “be himself,” but he lacks the “instructions” for how to accomplish this. We are no longer expected to conform to an obvious discipline. We are required to “be ourselves.” Depression, as Durkheim suggests in connection with suicide, arises from the “malady of infinite aspiration,” where everything seems possible, but in fact, nothing is possible.

To answer the basic question with which I began — whether there is a causal link between depression and the increasing empowerment of the individual — it seems plausible to say yes, given that “projects, motivation, and communication are now norms that dominate our culture.” [19] “Depression becomes, so to speak, how the individual safeguards himself. It acts as a kind of counterpart to all the energy that must be exerted simply to maintain the self as sovereign.” [20]

© Pierre Fraser & Jan Henderson, 2012

[1] Ehrenberg Alain, La fatigue d’être soi, dépression et société, Odile Jacob (poches), Paris, 2000, p. 21.

[2] Idem, p. 22.

[3] Idem, p. 251.

[4] Idem, p. 22.

[5] Idem, p. 255.

[6] Ibidem.

[7] I designed this table in 2009 — to gain an overview of the historical eras — when I co-authored the book “Les imbéciles ont pris le pouvoir, ils iront jusqu’au bout !” Published by “Near Future.”

[8] Krugman Paul, L’Amérique que nous voulons, Flammarion, Paris, 2008, p. 352.

[9] This is currently a speculative proposition that must be supported by empirical evidence from current trends.

[10] Durkheim Émile, De la division du travail social, eBooksLib on iBookStore, iPad version, p. 377.

[11] Ehrenberg, 2000, p. 142.

[12] Ibidem.

[13] Idem, p.143.

[14] Ibidem.

[15] Ibidem.

[16] Idem, p. 145.

[17] Idem, p. 15.

[18] Idem, p. 177.

[19] Ibidem.

[20] Hadler Nortin M., Malades d’inquiétude ?, translated from English by Fernand Turcotte, MD, Québec, PUL, 2010, p. 1.

Why medicine is not a science and health care is not health

Jan — Mon, 31 Oct 2011 04:00:01 +0000

Here’s something I read recently in a blog post (The Limits of (Neuro)science at Neuroskeptic) that started me thinking:

Will science ever understand the brain? …

The notion that humans are complex and hard, while nature is easy, is an illusion created (ironically) by the successes of reductionist science. Some of the biggest questions facing mankind for eons have [been] answered so well, that we don’t even see them as questions. Why do people get sick? Bacteria and viruses. Why does the sun shine? Nuclear fusion. Easy.

I started to write a simple reply, but it grew into the following.

Medicine is an applied science, not a pure science

It may be true that understanding the human brain is only an order of magnitude more difficult than understanding any other aspect of human biology. I’m uneasy, however, about putting ‘why people get sick’ in the same category as ‘nuclear fusion.’ Particle physics is a science. Questions can be asked and (usually) answered under the controlled conditions required by the objectivity that characterizes science.

Medicine is the application of certain sciences (molecular biology, biochemistry, medical physics, histology, cytology, genetics, pharmacology, neuroscience) to – ultimately — individuals. Each individual is the product of a unique, lifelong sequence of social, cultural, economic, and psychological (as well as physical, chemical, biological, and genetic) influences. To this day, we don’t really know why some people get sick and others do not. To my mind, that makes medicine an application of science – like engineering – not a science in itself.

Take bacteria and viruses. It’s true that pathogenic bacteria can make people sick, but what’s interesting is that they don’t always. Inspired by the germ theory of disease, medicine in the late 19th century held that a specific disease must have a single cause. The cause of tuberculosis was the tubercle bacillus: if you had the ‘germ’ you must have the disease. By the 1930s, medicine began to acknowledge that diseases could have multiple causes. And by the mid-20th century, medical textbooks explained that the presence of the tubercle bacillus did not always lead to TB. The bacillus was a necessary ‘seed,’ but the patient was the ‘soil’ in which the seed might or might not grow.

Does the scientific nature of medicine limit its potential?

I admit there may be large, indefensible holes in the assertion that medicine is not a science. How different is it from geophysics, which studies the earth and its environment (including the earth’s climate)? Isn’t that a science? Yes, because it adheres to the scientific process of measuring observable data, publishing the results for peers to review, and not giving credence to mere opinion. Surely the same could be said of medicine.

My real objection to medicine as a science is that by focusing on what can readily be quantified, it ignores what cannot, such as the social determinants of health and disease. Medicine’s historical desire for the respectability that comes with being a science gets in the way of discovering what could actually make us healthier.

Health care does not create health

Although we don’t know why some people get sick and others do not, we have some ideas. It could be what we eat, the quality of the air we breathe, our occupation, how much we earn, whether we feel our situation in life is fair, how we were treated as a child, numerous sources of stress in our lives.

Science prefers to isolate and understand one thing at a time, but the ideas I just mentioned are difficult to separate from their social context and cannot readily be studied in a controlled environment. The topics for medical research that seek and receive funding are those that investigate ‘reductionist’ theories of disease: things that fit neatly into categories sanctioned by the medical establishment and that can be readily measured, compared, and replicated. The cause and effect relationship between stressful living conditions and the health of individuals does not fit neatly into any simple mechanical model with the potential to make successful predictions.

For political reasons, it’s safer for medical research to stick to the limited agenda of what’s easily measured. If researchers investigated the social determinants of health, the answers could prove disruptive or inconvenient for prevailing economic (and thus political) interests. I’m thinking here of things like reducing air and water pollution, keeping carcinogens out of the food supply, and making sure drugs are safe before they’re prescribed for a large segment of the population. (The negative externalities of corporate culture, in other words.) It’s quite likely that social determinants of disease are extremely important for health. We don’t know for sure, not only because they’re hard to measure reliably, but because pursuing them tends to be politically unpopular.

Health care systems, informed by the scientific categories of medicine, are not designed to deal with things that cannot be easily quantified. Health care policy is set by politicians whose financial interests have been known to trump the common good. What preventive health care is good at these days (as opposed to the days when there was time for the doctor-patient relationship to offer comfort and relief) is creating guidelines for unacceptable levels of blood pressure, cholesterol, or blood sugar and prescribing drugs when tests indicate a patient has crossed an arbitrary but measurable threshold. That, and shift the blame for poor health onto the lifestyles of individuals, and be very expensive.

This is short-sighted.

A society that spends so much on health care that it cannot or will not spend adequately on other health-enhancing activities may actually be reducing the health of its population.

We need to figure out a way to liberate health from the financial interests that drive health care. Until then we’re stuck with a system that cares more about profiting from the narrow agenda of scientific medicine than it cares about improving health.

Recommended (online) reading

Jan — Sat, 01 Oct 2011 05:04:50 +0000

I’m still on “sabbatical.” Mostly reading. Thinking about what I most want to write about. I know what my interests are — the problem is, I have too many. Meanwhile, here are some blogs I enjoy reading.

Thought Broadcast by Dr. Steve Balt

Psychiatry is a controversial topic these days. We (speaking for myself, anyway) love to criticize the overprescription of psychopharmaceuticals, the medicalization of the slightest deviation from “normal,” and those psychiatrists who are eager to take “gifts” from the drug companies whose products they subsequently prescribe and promote.

I suspect people relate to psychiatry more readily than to the science of medicine. We’ve all known moments of slippage along the spectrum of mental health. We’d all like to understand ourselves better, something psychiatry used to promise before it tried to reduce us to the chemical interactions inside our brains.

Dr. Balt writes about all of this. What I especially like about his blog is his compassion for patients and his honest assessment of the psychiatric profession. His writing has a quality like Gawande’s: He maintains a strong personal presence without straying too far into the overtly personal.

To get a sense of Thought Broadcast, read Dr. Balt’s My Philosophy page. A recent post I’d recommend: How to Retire at Age 27. It’s on psychiatric qualification for disability. His point is that labeling (and medicating) someone as disabled does nothing to solve underlying social problems. It concludes:

Psychiatry should not be a tool for social justice. … Using psychiatric labels to help patients obtain taxpayers’ money, unless absolutely necessary and legitimate, is wasteful and dishonest. More importantly, it harms the very souls we have pledged an oath to protect.

Abetternhs’s Blog by Dr. Jonathon Tomlinson

The name “Abetternhs’s” always strikes me as an obscure word in Welsh, but it actually parses to “A Better NHS.” Dr. Tomlinson is a GP in the UK. What I first noticed about him was his appreciation for the impact of neoliberal politics/economics on health and medicine. For example,

At the heart of the NHS reforms is the intention to convert patients into consumers and to shift the responsibility for health as far downstream as possible. The neoliberal project is to explain illness in terms of moral failure and the consequences of this are self loathing and social prejudice, directed overwhelmingly at the poor and vulnerable.

Quite understandably, the focus of Dr. Tomlinsons’ blog these days is the British government’s proposed NHS reforms. It’s an excellent source of information if you want to stay up-to-date on issues and developments.

Like Dr. Balt, Dr. Tomlinson provides an inspiring example of how we would like all doctors to regard their patients. See, for example, the post Doctors, patients and obesity. Over and over, he returns to the importance of listening to his patients, regarding each in their uniqueness, understanding what makes their lives difficult.

Also like Dr. Balt, Dr. Tomlinson is an excellent writer. An essay of his appeared in the London Review of Books this past summer. It was called Diary: In the Surgery. With restrained anger, it describes a typical day in the life of a GP who must cope with a dysfunctional health system while caring deeply about patients. (Unfortunately, the complete article is behind a paywall.)

Laurie Essig

I’ve been a big fan of Laurie Essig ever since I read her book American Plastic: Boob Jobs, Credit Cards, and the Quest for Perfection (which I’ve written about here, here, and here). Essig is a professor of sociology who applies her academic discipline to contemporary phenomena: Lady Gaga, Michelle Bachmann, the royal wedding, Chaz Bono on Dancing with the Stars, Harry Potter, Anthony Weiner (forgot him already?). Many of her essays concern sexuality, alleged deviance, heteronormativity, and political hypocrisy.

Essig’s work appears regularly in the Chronicle of Higher Education. She also has a blog at Psychology Today called Love, Inc. Here’s a description:

Love, Inc. is about the intersection of emotions and capitalism. Human emotions may be more or less universal, but how they are acted upon is firmly rooted in particular histories, cultures, and economies. In the US, how we feel is always a potential source of profit- from big white weddings to porn to romantic comedies. This blog is about emotions and the industries that profit from them.

Essig’s writing is funny, incisive, sarcastic, incensed, biting, and outraged. You probably won’t find her appealing unless you’re already sympathetic to her socio-political stance. For example, she understands – and can be extremely articulate about – why neoliberalism is so objectionable. I think every piece she writes is a near gem, but as a recent sample, try The Revolution Will Be Livestreamed, about the Occupy Wall Street events.

Carl Elliott

I’m also a big fan of Carl Elliott. I enjoyed his most recent book, White Coat, Black Hat: Adventures on the Dark Side of Medicine. I was even more impressed, however, with his earlier book, Better than Well: American Medicine Meets the American Dream. White Coat offers a fresh take on corruption, greed, and collusion in the medical/psychiatric/pharmaceutical complex. It’s a topic many authors and bloggers discuss, and it’s of interest to a wide audience, especially those who enjoy feeling incensed. Better than Well, however, strikes deep into your psyche. You come away, not with your sense of moral outrage stoked and thus partially appeased, but disturbed by what it means to be a human being living in a commercial, consumer culture. Elliott manages to accomplish something I’ve long admired: He reveals those operating assumptions of our lives that only rarely make it into consciousness.

There’s a passage from Better than Well that I’ve quoted more than once in previous blog posts. It concerns the illusion of choice about personal appearance. What I like about it is the impact of the insight it captures.

You can still refuse to use enhancement technologies, of course – you might be the last woman in America who does not dye her gray hair, the last man who refuses to work out at the gym – but even that publicly announces something to other Americans about who you are and what you value. This is all part of the logic of consumer culture. You cannot simply opt out of the system and expect nobody to notice how much you weigh.

There’s a list of some of Elliott’s online articles on the Better than Well website. It appears it was last updated in the middle of 2008. There is another, more current list, but be forewarned: This is on a strange website, purportedly by one of Elliot’s brothers. It’s either an outlet for Elliott’s dark sense of humor or it’s somewhat embarrassing. It keeps me guessing, which may or may not be the intention.

Included in that more recent list is a superb, classic essay, Medicate Your Dissent. Not included are the more recent The Deadly Corruption of Clinical Trials (Mother Jones) and Meddle Management (Wall Street Journal), a review of the book “The Fall of the Faculty.” Maybe I should create a bibliography page here on my site and keep it updated.

Elliott sometimes links to his writings from the blog Fear and Loathing in Bioethics — a site related to a seminar on investigative journalism and bioethics — but he’s not a reliable self-promoter.

Bottom line: Anything by Carl Elliott is worth reading.

I’m Not Tired Yet: Larkin Callaghan

One more blog. Larkin Callaghan is currently writing her dissertation at Columbia in Health and Behavior Studies. Her specialties are reproductive health and body dysmorphia, with a focus on “the relationship between weight perception and high risk substance use and sex behavior in adolescent girls.” Since finishing her thesis keeps her busy, she only has time to blog when she comes across something that really annoys her.

That seems to happen with some regularity. Sample posts: The sexualization of young girls in advertising, Yoplait commercials that question whether a woman is “good enough” to eat cake, the ’humorous’ portrayal of women as “unpredictable shrill harpies who have no control over their emotions,” JC Penney’s “I’m too pretty to do homework so my brother has to do it for me” shirts for girls ages 7-16, how feminism is not about hating men.

What I like about this blog is its worthy subject matter and the passion of a young, idealistic blogger who wants nothing more than to make the world a better place. May we all be fortunate enough to retain that sentiment ‘til our dying day.

When the poor were contagious

Jan — Thu, 11 Aug 2011 05:28:05 +0000

The Western world first industrialized in Great Britain, prompting vast numbers of inhabitants to move from the agricultural countryside to urban centers. Living and working conditions were deplorable. Andrew Mearn wrote in 1883 of the “pestilential human rookeries … where tens of thousands are crowded.” He continues:

To get to them you have to penetrate courts reeking with poisonous and malodorous gases arising from accumulations of sewage and refuse scattered in all directions and often flowing beneath your feet; courts, many of them which the sun never penetrates, which are never visited by a breath of fresh air, and which rarely know the virtues of a drop of cleansing water…. You have to grope your way along dark and filthy passages swarming with vermin. Then, if you are not driven back by the intolerable stench, you may gain admittance to the dens in which these thousands of beings who belong, as much as you, to the race for whom Christ died, herd together.

Pretty graphic. Roy Porter’s comment on this passage: “Historians still dispute whether industrialization raised or depressed wages and living standards – something, perhaps, impossible to measure.”

London then and now

I’ve been reading about the London riots and thinking about what’s different today, both for the socially disadvantaged – the poor, the unemployed, the uneducated and undereducated, immigrants, ethnic minorities, the children of all of the above – and for the governments responsible for maintaining social order. One difference is that we have, to a large extent, eliminated the enormous threat of infectious diseases that thrived in unsanitary living conditions. What hasn’t changed is the reluctance of those in power to take responsibility for the living conditions – both physical and mental – of the socially disadvantaged.

Here’s Roy Porter again, discussing the government’s attitude towards the health of the working class poor in the 19th century (emphasis added):

Awash with people and haunted by premature death, the nineteenth-century shock towns had their evils unceasingly spotlighted. But it would be naive to assume that once the evils of industrial society were exposed they were automatically righted. Together with the question of medical efficacy, imponderable issues were raised of culpability, individual rights, the duties of government and the sanctity of private property. Could such evils be rectified? Or were they nobody’s fault, nobody’s business, all a muddle, best left to individual action or the hidden hand? And if they could be remedied, how and by whom? And who would foot the bill? These issues were real, even if they often served as sanctimonious excuses for inertia by those who worshipped Mammon. …

Especially in the Anglo-American world, political economy ordained freedom of trade; it was not for Parliament or Congress lightly to meddle with people’s livelihoods. Government would uphold the law, and it was up to individuals to be healthy and to charity [or today’s volunteers?] to rectify hardships. Whether to work in a deadly trade was a free and individual decision. When operatives fell sick, blame was often laid upon their faulty constitutions, regarded as the root cause of work-triggered consumption or blindness.

Nevertheless, despite the ideological attractiveness of self-help doctrines, no state could idly stand by and watch the crippling impact of mass diseases — anyone might die, Prince Consorts and all, and the social fabric was under strain with revolution in the air. Surrounded by the great unwashed and threatened by cholera, jittery members of society feared that disease might spark insurrection — or might spread to them. They began to look to urban cleansing and health reform as medicine for society, even as an opium of the people. Cleanliness was next to godliness. With disease spelling disorder and danger, public responses followed.

In the 19th century, the working classes were much needed to maintain the engine of industrial production. It was the first century in which the population was able to replace itself through reproduction. But just barely. Not only did children die of infectious diseases. So did many of their mothers shortly after they gave birth.

In today’s global economy, the socially disadvantaged are no longer needed to supply the labor market. Nor are they needed in the militia, which was once a concern that motivated governments to care about the physical health of the poor. Without infectious diseases, without the need for workers or soldiers, the financial interests that determine what happens in the world no longer have to care about the consequences of wealth inequality. We see this playing out between the Greeks and their prosperous neighbors in the current European economic crisis.

Will the London riots raise questions about a social and economic system that doesn’t care about the socially disadvantaged? Questions, certainly. Will that be enough to change public attitudes and government policies? Probably not. Unfortunately, the situation will need to get much worse. And even when that happens, current financial interests are likely to prevail.

Is this discouraging? Yes, but …. This struggle has a long history of gradual progress. When the British Public Health Act of 1848 proposed improving sanitation for the poor, editorials argued “Cholera is the best of all sanitary reformers.” Surely we have more sense — and compassion — than that now. Plus, in common with many who came before us, we have a firm conviction that this is a struggle worth waging and worth winning.

The Dreams of the Founders of Family Medicine

Jan — Thu, 23 Jun 2011 23:07:20 +0000

Laurence Bauer has been an ardent, longtime advocate of family medicine. Among other things, he is Chief Executive Officer of the Family Medicine Education Consortium, a not-for-profit corporation that encourages and supports collaboration among Family Medicine Residency Programs and Departments of Family Medicine.

Larry and I met thanks to our mutual interest in Marcus Welby, MD. The practice of medicine has changed dramatically since Dr. Welby inspired doctors to become practitioners of family medicine. Yet each time I talk to Larry, I’m reminded of today’s dedicated students and physicians who want to practice comprehensive care with the same concern for the whole person that Welby expressed for his patients. This remains a timeless value of the medical profession, and for Larry, it’s important to keep that value alive in an age of narrow subspecialties and corporate medicine.

Family Medicine as a specialty (a three-year residency after medical school that includes the study of internal medicine, pediatrics, obstetrics-gynecology, psychiatry, and geriatrics) emerged in the late 1960s. Those who initially endorsed family medicine wanted to change the direction of medical culture and influence its future. In the words that follow, Larry addresses those early visionaries. I’d like to thank him for allowing me to share his thoughts.

The Dreams of the Founders of Family Medicine

When poetry strays too far from music, it atrophies. When music strays too far from dance, it atrophies – Ezra Pound

As Family Practice emerged from the field of General Practice, it is important to realize that many in and out of medicine told the founders they would not succeed. The cynics believed that the dominant forces in medicine were too entrenched and there were too many societal forces working against the idea of a generalist renaissance in medicine. “Real” medicine of the future aspired to something more worthy. Real medicine involved care of hospitalized patients and was informed by the scientific and technological advances associated with sub-specialty medicine. Anyone could care for the people “out there”. But the founders dreamed big, bold dreams; they were a determined and visionary group.

They dreamed of a cadre of talented and competent Family Physicians that would serve the people in all the communities of our nation. The rich, the poor and all in between in rural, urban and suburban communities; all needed access to a well trained Family Physician. They believed that the practitioners in this specialty would focus on the needs of their patients and communities and would protect people from the medical industrial complex as much as possible

They dreamed that a new academic specialty would emerge whose core would focus on issues surrounding patient management and the care of the whole person in their community. They believed that medical education was moribund and harmful and in need of a compassionate and thoughtful revitalization.

For the founders, the biomedical model was inadequate. They believed that it is not possible to be effective as a physician without understanding the contextual issues that influence a person’s life. The biopsychosocial model, the power inherent in relationships and the abilities and skills involved in creating facilitative relationships needed to be integrated into medical education, practice and scholarship.

While they were mindful of and grateful for the powerful advances in medicine, they believed that social and economic conditions which influenced the life of a person and a community had a greater impact on a person’s life and health than did the power and might of all of medicine.

They believed that medicine was a profession that involved more than a technical set of skills and a high income. They accepted the responsibility of caring for the whole person; mind, body and soul.

They believed that the practice of medicine required team work among the medical and helping professionals and that the patient was to be an active partner in the care process. In fact, it is the patient’s goals and agendas that drive the healing process.

They believed that life-long learning and the need to continuously upgrade one’s knowledge and skills was critical to the practice of medicine.

They dreamed of generations of leaders who would rise to take their places and extend their efforts.

They believed that Family Medicine was more than another group of medical practitioners. Family Medicine should serve a transformative agenda that changed the academic medical centers and health systems so they would better serve the people and communities.

They were willing to bring other generalist colleagues to their ranks. They respected the pediatricians, especially, who wanted to contribute to Family Medicine’s early development. They sought a relationship with psychiatry and mental health professionals. They had a comfortable relationship with the general surgeons, general internists and all their colleagues who respected the value of a generalist practitioner.

In the days of Marcus Welby, MD, primary care was family medicine. Although much has changed since then, the founders’ vision of how medicine could be practiced remains an ideal for both doctors and patients. It’s easy to feel discouraged and cynical these days and to believe that the medical-industrial complex has overwhelmed the hearts and minds of the medical profession. Yet when I listen to those like Larry Bauer, who still believe in the power of dreams, my hope is always restored.

Guest post: Guilt-edged

Jan — Sun, 12 Jun 2011 09:33:14 +0000

Today was in need of humor. Here is another guest post from Kate Gilderdale (the original can be found here), who blogs at The Jaundiced View.

I found a website that lists (in a most unfortunate typeface) 29 types of humor. I’d say Kate’s writing combines – not always in the same post — wit, irony, understatement, repartee, satire, and that je ne sais quoi that can only be acquired by growing up in the British Isles. The word urbane also comes to mind. At any rate, I find that Kate’s posts brighten my days.

Guilt-edged

I know you can have Catholic guilt and Jewish guilt but you really don’t need religion to make you feel that whatever goes wrong is somehow your fault.

I feel guilty when I go through customs even though I am scrupulous about not bringing in anything illegal. I feel guilty when I go the dentist in case I haven’t flossed in the approved manner. I feel guilty when I try to defend my decision not to be tested for a disease I haven’t got, or don’t know I’ve got, or might have because at some point I’ll have to die of something – simply because I’d rather not know.

Now The Globe and Mail Life section reveals I could be guilty of hastening my demise by eating fruit. See The New Enemy in today’s paper, which warns that bananas are the arch enemy of the serious dieter and “that the high fructose content makes grapes and cherries as unhealthy as a plate of cookies.” Or not. Depending on which ‘experts’ you believe.

My chances of survival look gloomier by the day. I’m not training for a marathon, or even a half-marathon, my pecs and abs are frankly flabby and the only exercise I get is walking, gardening (on the odd occasion the spring monsoon lets up) and fidgeting. I don’t own a pedometer, or catalogue the kilometres I cover, or even measure my daily consumption of alcohol units.

I am a (non-power) walking time bomb. A poster person for decadent self-neglect. My name is Kate and I eat bananas.

Are we not one world?

Having yet again won the battle with Microsoft Word to retain the spelling I intended, I add this note to Americans: In the UK, Canada, Australia, and many other parts of the English-speaking world, “kilometer” is spelled “kilometre.”

There are two pronunciations: KIL-o-mee-tər and ki-LOM-i-tər. The first pronunciation follows the general rule for pronouncing metric units (CENT-i-mee-tər) and is preferred by the BBC. The second is preferred by scientists, as it follows the stress pattern for the names of measuring instruments (ther-MOM-i-tər).

For an obscure discussion of whether Australian Prime Minister Gough Whitlam objected to the first pronunciation, arguing that “kilo” and “metre” come from the Greek, a language that stresses the antepenultimate syllable, see E-mail Discussions on “Peeves” Topics. Nostalgically, this modest page contains entries dating back to 1998, when the Internet was so much younger than it is now.

Is a liberal arts education good preparation for being a doctor?

Jan — Thu, 09 Jun 2011 09:58:13 +0000

I’ve written before about doctors and the arts. In 1980 the cultural historian G. S. Rousseau, citing the techo-scientific nature of modern medicine, claimed that doctors no longer maintained the rich tradition of physicians as humanists. “Until recently, physicians in Western European countries received broad, liberal educations, read languages and literature, studied the arts, were good musicians and amateur painters; by virtue of their financial privilege and class prominence they interacted with statesmen and high-ranking professionals, and continued in these activities through their careers.”

Contemporary evidence contradicts Rousseau’s claim that physicians are no longer practitioners and connoisseurs of the arts. We may not personally encounter a doctor with her cello or recognize one painting en plein air in the little free time doctors have these days, but doctors write books that ascend the best-seller list, and many more write thoughtful, provocative blog posts. The poetry of doctors is published in medical journals and is available online in modest chapbooks. Nearly every major city throughout the world has an orchestra staffed by the medical profession. And the American Physicians Art Association encourages and assists physicians with art organizations and exhibits.

Is a liberal arts education valuable to physicians?

I have many unanswered questions about doctors as practitioners of the arts. I’d particularly like to know if the long-standing tradition of physicians as humanists has changed over the past half century. Higher education has definitely changed since the mid-20th century. In particular, there’s less emphasis on the value of a liberal arts education. (On this, see the excellent book, Not For Profit: Why Democracy Needs the Humanities, by Martha Nussbaum.) Has this affected physicians, either in their satisfaction with their careers or in their understanding of patients?

Although there are certainly many exceptions, it’s generally assumed that those who appreciate and/or practice the arts have a liberal education, an upper-middle class background, or both. Were pre-med students in the past more likely to study liberal arts because this was required as part of the civilizing process of higher education? Are undergraduate students today encouraged to focus prematurely on the professional subject matter of their choice? Have the prerequisites for medical school changed so as to encourage an early focus on scientific depth at the expense of a broader understanding of the humanities? How has the socio-economic class of medical students changed over the past half century and what difference has this made?

Then there is the larger question: How valuable is a liberal arts education to a doctor, anyway – an education that includes the study of literature, history, philosophy, political science, languages? I don’t have answers to any of these questions at the moment. I’m in the process of collecting data, bibliographic references, and subjective impressions.

Observing patients in the context of their lives

Consider, for example, the value for a physician of contemplating a work of art. Here is a portrait of Vsevolod Mikhailovich Garshin by the Ukranian painter, Ilya Efimovich Repin. If you enlarge the image and imagine a doctor taking in this human being as a patient, what is there to see? A commentary on the painting points out the rounded shoulders and upper spine, characteristic of a novelist and playwright who spends his time among books and papers. A man who seems not to care about what he wears or about the material concerns of life. Also a man who suffers from depression; whose father and brother committed suicide. Four years after this portrait was painted, Garshin fell down a flight of stairs. On purpose.

Or consider John Singer Sargeant’s “Portrait of Dorothy,” painted in 1900. The painting reminds us that our attitude towards childhood itself can change. We no longer dress children in oversized, ostentatious clothing to make them look cute and vulnerable for their portrait, for example.

Prior to the turn of the 20th century, children had been thought of as little more than miniature adults. In the new attitude that emerged, children were regarded as individuals with a right to be healthy and happy as children. They acquired a new status in society. Pediatrics was not recognized as a certified specialty until the 1930s (in the US), but general practitioners at the turn of the century took a greater interest in the health concerns specific to children. Believe it or not, the marketing of goods to children also increased at this time. (I guess we shouldn’t be too surprised.)

Medicine is the practice of healing the whole human being

The relevance of fine art to medicine is not limited to portraits. Some of the parallels between art and medicine have been described by M. Therese Southgate, who points out that both art and medicine are about seeing – not only the superficial observation of what the eye can capture, but the deeper seeing that happens when a physician “attends” to a patient. A good physician uses her experience and intuition to see more than just another patient with high blood pressure or diabetes. “The good physician treats the disease; the great physician treats the patient who has the disease.” (William Osler)

Literature, fine art, poetry, music – they all serve to remind overworked clinicians that they are part of a timeless tradition of healing whole human beings – individuals who present themselves in all their magnificence and complexity. Also, that physicians themselves participate in the tradition of physicians as humanists. Perhaps that’s why a liberal arts education – in my opinion – makes an important contribution to the practice of medicine today.

The misuse of health statistics by politicians

Jan — Sun, 29 May 2011 08:35:53 +0000

[This post contains links to the New York Times. If you position your mouse over a link, you can view the destination URL at the bottom of your browser.]

When former New York City mayor Rudy Giuliani was seeking the Republican presidential nomination in 2007, he used to give a campaign speech that referred to prostate cancer and health care. His sound bites were turned into a radio commercial and included the following:

I had prostate cancer five, six years ago. My chance of surviving prostate cancer — and, thank God, I was cured of it — in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine.

What’s wrong with this picture? Several things.

The numbers themselves – the 82 and 44 percent — were incorrect. Chances of survival are typically stated as the prospect of living another five years. According to the National Cancer Institute, the five-year survival rate for prostate cancer in the US is 98.4%. For England (according to the United Kingdom’s Office of National Statistics), the number is 74.4%.

Where did the lowly 44% for England come from? Giuliani’s health care adviser started with the number of people who have prostate cancer and the number who die (called incidence and mortality rates): how many people have the disease in a given year and how many die from the disease in that year. From those numbers he came up with a five-year survival rate. This is not possible. “Five-year survival rates cannot be calculated from incidence and mortality rates, as any good epidemiologist knows,” according to the Commonwealth Fund.

Comparing apples to oranges

More importantly, comparing five-year survival rates for the US and England is fundamentally misleading. Prostate cancer is overdiagnosed in the US. Many men who receive the diagnosis do not have cancer or will never develop symptoms, let alone die from the disease. The estimate for the US is that 48% of men diagnosed with prostate cancer do not have a progressive form of the disease. In England, on the other hand, testing is performed after symptoms appear, so a diagnosis is much more significant and meaningful.

Another way to understand this is to consider a group of men who die of prostate cancer at age 70. If their symptoms do not develop until they are age 67+, and if they are not tested until they have symptoms, their five-year survival rate will be zero percent. That corresponds, hypothetically, to England and seems pretty dire. But suppose, through aggressive screening, those same men had been diagnosed at age 64. Their five-year survival rate would be 100%. That corresponds to the US and makes Americans seem so much healthier. But in both cases, all of these hypothetical men live to the same age of 70.

To say that survival rates are better in the US than in England means nothing if screening policies are significantly different in the two countries. A higher five-year survival rate does not mean Americans are better off. What counts is the annual mortality rate: how many men per 100,000 die from prostate cancer in a given year. It turns out, according to New Scientist, that England and the US are statistically in a dead heat for this number.

Unfortunately, both politicians and journalists prefer shocking sound bites to more complex facts. As I quoted from the New England Journal of Medicine in the previous post, “Misleading headlines, designed to attract larger audiences, can make life difficult for physicians who want to practice cost-effective medicine [or, I would add, act in their patients' best interest] but are beset by patients’ requests or demands for costly new therapies: the public reflexively mistrusts any apparent withholding of widely touted diagnostic or therapeutic interventions, even when they might do more harm than good.” The “more harm than good” that can result from a false diagnosis and unnecessary treatment of prostate cancer is impotence and incontinence.

Politics as usual

Also misleading about the Giuliani commercial was the “socialized” medicine slur. It’s true that Dennis Kucinich advocated a government-run health care plan that would include all adults and children. The other leading presidential candidates, however, made a point of saying Americans could keep the insurance they currently had. What goes unsaid by opponents of “socialized” medicine is the well-documented fact that survival rates for cancer patients are significantly lower for the uninsured.

The misleading nature of Giuliani’s numbers were immediately pointed out by FactCheck.org and the New York Times. The numbers ultimately came from a publication (City Journal) of the conservative think tank, the Manhattan Institute. When questioned about this, a spokeswoman for Giuliani told the Times: “The citation is an article in a highly respected intellectual journal written by an expert at a highly respected think tank which the mayor read because he is an intellectually engaged human being.” (So there!) When the Times asked if Giuliani planned to continue running the radio ad and to claim, on the campaign trail, that these incorrect numbers were true facts, the spokeswoman replied (defiantly): “Yes. We will.”

Such is the state of truth and politics these days. (A more recent example, on Planned Parenthood funding: “his remark was not intended to be a factual statement.”) No wonder we make so little progress in slowing the growth of health care costs.

Resources:

Image: Daily News

A Bogus Cancer Statistic, FactCheck.org, October 30, 2007

Julie Bosman, Giuliani’s Prostate Cancer Figure Is Disputed, The New York Times, October 31, 2007

Marianne Freiberger and Rachel Thomas, Spin doctors: Die another day, New Scientist, February 12, 2011 (subscription required)

H. Gilbert Welch, Overdiagnosed: Making People Sick in the Pursuit of Health

Why is it so hard to reduce US health care costs?

Jan — Thu, 26 May 2011 10:23:05 +0000

Professor Victor Fuchs and Dr. Arnold Milstein, both of Stanford University, have an article in a recent issue of The New England Journal of Medicine that asks: Why is it so difficult to reduce health care costs in the US? The article is available in its entirety online, but for those short of time, here’s a concise (and depressing) summary.

The graphic accompanying the article is dramatic in its simplicity. Health care spending in the US is 17% of GDP. In other developed countries (Western Europe, Canada, Australia), the number fluctuates around 10%. And yet life expectancy in the US is the lowest of these countries – almost four years below that of the number one country.

We know that some physicians and health care providers manage to operate at less than 20% of the average cost of care, without sacrificing quality. If everyone followed their example, the US could save $640 billion a year (US health care costs for 2008 were $2.3 trillion). Why doesn’t that happen, or as Fuchs and Milstein put it: “Why don’t cost-effective models diffuse rapidly in health care, as they do in other industries?” The answer comes down to perceptions and behaviors.

Insurance companies resist the standardization needed to reduce costs because they would lose their competitive advantage over other companies and their profits would go down.
Large employers are afraid of alienating employees; plus they’re determined to resist any efforts that would increase the government’s role in health care.
The public opposes change because they do not understand who really pays for their health care. “The media, with rare exceptions, is the principal source of this misunderstanding.” Workers see employment-based insurance as a “generous” gift, rather than the reduction in wages that it actually is. The media emphasize misleading statistics: the relative benefit of clinical interventions, rather than absolute benefit. Plus: “Misleading headlines, designed to attract larger audiences, can make life difficult for physicians who want to practice cost-effective medicine but are beset by patients’ requests or demands for costly new therapies: the public reflexively mistrusts any apparent withholding of widely touted diagnostic or therapeutic interventions, even when they might do more harm than good.” Overuse leads to the dangers that come with overdiagnosis, but the public does not understand this. (Iatrogenesis is the third-leading cause of death in the US.)
Legislators, otherwise known as politicians, oppose cost-effective health care because their re-election depends on contributions from “health industry stakeholders who benefit from the current inefficient arrangements.”
Hospital administrators are afraid their revenues will decline; plus, they are afraid of any attempt to change the behavior of physicians, who might decide to use another hospital.
Physicians are resistant to change out of a fear of loss of autonomy and a concern that incomes would decline. “[I]ndeed, physicians in highly paid specialties would probably lose income in a more cost-effective system, though primary care physicians would probably come out ahead.”
Academic health centers fear cost-reduction because they’re concerned about possible conflicts of interest with their research and education objectives.
Manufacturers of drugs, medical devices, and equipment have the most to lose if accountable care or managed care organizations were free to negotiate for the best prices. “To preserve the present system, manufacturers of health care products spend heavily on federal lobbying.” See “legislators” above.

Physician, manage limited resources wisely and cost-effectively

Altogether, not a pretty picture. Is there any hope? Fuchs and Milstein propose that the problem could be solved with tax-supported universal coverage and/or “disciplined managed competition among health insurers.” They immediately add: “Neither solution is politically feasible.” But they have this caveat: not politically feasible “without robust physician support.”

[T]he public’s visceral distrust of policies aimed at improving the cost-effectiveness of health care can be neutralized only by their confidence in what their physicians support. … [P]hysicians are the most influential element in health care. The public’s trust in them makes physicians the only plausible catalyst of policies to accelerate diffusion of cost-effective care. Are U.S. physicians sufficiently visionary, public-minded, and well led to respond to this national fiscal and ethical imperative? It’s a $640 billion question.

A modern version of the Hippocratic Oath, the Physician Charter, commits physicians to work toward “the wise and cost-effective management of limited clinical resources.” But there’s little physicians – or anyone else – can do to change the behavior of politicians, insurance companies, pharmaceutical companies, or other entrenched stakeholders.

It would be heartening to see visionary, public-minded physicians emerge as leaders of the medical profession in the fight to solve this important and extremely difficult dilemma. Perhaps they could inspire individual physicians to influence their patients, the public. And then …. Who knows? This is still a democracy, isn’t it?

Resources:

Image: The Independent Report

Victor R. Fuchs, Ph.D., and Arnold Milstein, M.D., M.P.H., The $640 Billion Question — Why Does Cost-Effective Care Diffuse So Slowly?, The New England Journal of Medicine, May 26, 2011, Vol. 2011 (364), pp 1985-1987

Bruckner on the good life, money, and the unequal world of work

Jan — Sun, 22 May 2011 07:55:47 +0000

Once more, from Perpetual Euphoria: On the Duty to Be Happy. This time on our relation to wealth.

Why is it American conservatives deplore European social democracy? Could it be that it doesn’t stimulate consumerism enough to satisfy a free market economy? (emphasis added in the following quotations)

[T]he power of the great upheavals of the preceding century in France, including those of 1936 and 1945, consisted not only in redistributing the social pie, but also in creating new kinds of opulence for the majority of the people: free time, poetry, love, the liberation of desire, the sense of everyday transfiguration. Not being content to manage penury, but discovering everywhere new goods that are unquantifiable and escape the rule of profit, prolonging the old revolutionary dream of luxury for everyone, of beauty made available to the most humble. Today, luxury resides in everything that is becoming rare: communion with nature, silence, meditation, slowness rediscovered, the pleasure of living out of step with others, studious idleness, the enjoyment of the major works of the mind – these are all privileges that cannot be bought because they are literally priceless. Then we can oppose to an involuntary poverty a voluntary poverty (or rather a voluntary self-restriction) that is in no way a choice to be indigent but rather a redefinition of our personal priorities. This may involve giving up things, preferring freedom to comfort, to an arbitrary social status, but for a larger life, for a return to the essential instead of accumulating money and objects like a ludicrous barrier set up against fear and death. In the end, true luxury is the invention of one’s own life, master over one’s destiny; “but everything that is precious is as difficult as it is rare” (Spinoza).

This is not to say that Bruckner fails to appreciate the situation of the poor. Written in 2000, way before the financial crisis, this comment is even more relevant today:

[P]overty in developed countries may never be overcome, simply because the rich no longer … need the poor to get rich. … The misfortune of being exploited has been succeeded by the still worse misfortune of no longer being exploitable.

Reminds me of a recent headline: “McJobs becoming the norm?”

On the working class and the working elite:

Obsessed by full employment, our societies want to keep people busy at all costs, and they celebrate wage slavery without looking into the quality of this employment. To the point that working too much has become an outward sign of power, and whereas the working classes aspire to idleness, the so-called idle classes are increasingly busy, boasting that they work sixty to eighty hours a week, and brandishing overwork as a sign of their superiority.

On money as an idol and an end in itself:

If making a living is a drag, getting rich quick is a game that approaches erotic frenzy. … When it [money] is raised to the rank of an idol, an absolute goal, it becomes so desirable that it makes everything else undesirable. …

[A] very fine, imperceptible line separates money as an end from money as a means, and consumerism and advertising constantly seek to blur this line.

Resources:

Image: flickr

Pascal Bruckner, Perpetual Euphoria: On the Duty to Be Happy

Why are we so willing to undergo cosmetic surgery?

Jan — Fri, 13 May 2011 23:15:39 +0000

Miss Plastic Surgery pageant, Beijing

A recent article on cosmetic surgery in China observes that, despite the highly publicized death of aspiring pop star Wang Bei (see The death of Wang Bei: Cosmetic surgery as a moral choice), “the ugly side of Chinese obsession with beauty … is a gamble that millions of people are willing to take.” Why is that?

The high rate of cosmetic surgery in Asia has been widely discussed, including an article in The New York Times. What caught my attention in this more recent piece was the postmodern/feminist spin.

Susan Feiner, a feminist economist, offers these comments: (emphasis added)

Parents are caught between a traditional world view and a postmodernist world view. On the traditional side especially, your daughter is your property and potential to social advancement. … On the postmodern side you have this idea that western beauty, this imported beauty ideal, is really a sign of your family’s openness to the future. So those two impulses – a very traditional impulse and the more modern neo-liberalism impulse come together at the moment of submitting your own daughter to the knife. …

On one hand we have all of this acceptance and even approval for women to become doctors and lawyers and political leaders and at the same time what’s been held up to women is this Walt Disney notion of our lives. That really even if you are a doctor or a lawyer or a political leader the best you can really do is to be beautiful and get some wealthy rich man to take care of you, so the best possible outcome for any women is to be both hugely successful professionally and be knock-down beautiful.

Why so much willingness to reshape the body?

What drives the popularity of cosmetic surgery? As bioethicist Carl Elliott notes in one of my favorite books, Better Than Well, medical enhancements, along with body size, are part of the logic of consumer culture: “You cannot simply opt out of the system and expect nobody to notice how much you weigh.”

Sociologist Arthur W. Frank would agree with Elliott about the logic of consumer culture: the body is a bankable commodity. He offers an explanation of how cosmetic surgery functions in contemporary society, drawing on Pierre Bourdieu’s concepts of field and capital.

In our daily lives, we move among various “fields” — settings or arenas of life such as job, family, romantic relationships, politics. Our success in a particular field depends on how much “capital” we have. Capital can be economic, social, cultural, symbolic, or physical (the body). Capital is our “clout” in a given arena, so to speak.

Different fields give varying weight or value to each type of capital. The entertainment field places a high value on physical appearance, for example. Capital determines power relationships within a field and location in a social hierarchy. An athlete’s physical ability brings the power to demand more money and creates celebrity status in the social hierarchy.

Consider a woman who wishes to surgically alter the shape of her feet (creating “designer” feet). Frank writes: (emphasis in original)

This woman’s capital, in at least one of the multiple fields of her life, includes being able to go barefoot or wear sandals and have her feet look a certain way. … This woman, in her field, is doing with her feet what all members of any society … do with our bodies and with our talents: we shape and allocate them in order to make them count as capital. Feet can be a form of capital not only in dating and marriage markets, but in job markets as well.

What counts as capital goes well beyond the feet themselves. Reshaped feet display the willingness to reshape one’s body to conform to the demands of the field. The woman’s feet mark her ability to read properly what counts as capital and to endure what has to be endured to accrue that capital. This interpretive skill and the complementary endurance are the woman’s real capital. Any self-reshaping … is properly brought off when and because it demonstrates the person’s attunement to the demands of a specific field. … Members of traditional societies accepted being told when and how to reshape their bodies. Their decision was binary: either participate or leave the group. In contemporary society, each individual is responsible for choosing and effecting her own reshaping, thus demonstrating her fitness for membership within a given field. Hierarchical position depends on displaying attunement to the field …. including what kind of body counts as right. The right body demonstrates having made the right assessment of capital, and thus becomes a potent display of rights to participation and position.

If you think this is merely abstract postmodernist theory, I recommend you read any number of recent news stories, including Beautiful people cash in on their looks (USA Today), When cosmetic surgery is a marker of ambition (The Guardian), Cosmetic surgery helps people to get ahead at work (Private Healthcare UK), Older workers nip and tuck to stay competitive in job market (Chicago Tribune), and – one of my favorites — Firm to Female Lawyers: Wear High Heels, Embrace Your Femininity (The Wall Street Journal). The message to maximize your physical capital could not be more clear.

Neoliberal medicine

The feminist economist quoted above describes the acceptance of neoliberal ideas by Chinese parents as an openness to the future. This may be a realistic assessment of the future, but — as she points out — not an entirely satisfying one for women. In his discussion of surgically shaped feet, Frank goes on to point out that Bourdieu – who opposes neoliberalism — is by no means offering a neoliberal defense: What else can a woman do?

Neoliberal medicine asserts that medicine should be a for-profit business, ideally controlled by corporations. Corporate dynamics turn medical services into consumer products. When a woman seeks designer feet worthy of her designer shoes, she may be operating under the neoliberal assumption that personal choice should prevail over all other considerations. But that does not mean we should applaud the underlying assumption.

What Bourdieu’s concepts offer is an understanding of this woman’s motivation. Given the world we live in, it allows for a more “generous” view of her dilemma. Frank: “Unless this woman leads a charmed life, she will have other experiences that will shift her scale of what counts as humiliation. But for now she is doing what we all do: she is trying to hold her own. And so is her podiatrist.”

As I’ve written before, when we choose to have cosmetic surgery – on our faces, our feet, our thighs – we tell ourselves this is entirely a personal and private decision that affects only the individual. But in fact, our decision changes the standards of acceptable appearance in which everyone else must live. “The personal is communal.” Ultimately the decision is a moral one.

To quote Frank, paraphrasing Foucault, the woman seeking designer feet “knows what she is doing, but she seems to have little awareness or interest in what her doing does.” She has demonstrated her “fitness for membership” in modern, neoliberal society. But is that the society the rest of us want to live in?

Resources:

Image: Zimbio

Sharon LaFraniere, For Many Chinese, New Wealth and a Fresh Face, The New York Times, April 23, 2011

Rebecca Valli, Getting Sexy in China, Asia Sentinel, May 11, 2011

Carl Elliott, Better Than Well: American Medicine Meets the American Dream

Arthur W. Frank, Emily’s Scars: Surgical Shapings, Technoluxe, and Bioethics, Hastings Center Report, March-April, 2004

Sharon Jayson, Study: Beautiful people cash in on their looks, USA Today, March 31, 2011

Jacqueline Sanchez Taylor, When cosmetic surgery is a marker of ambition, The Guardian, February 14, 2011

Cosmetic surgery helps people to get ahead at work, Private Healthcare UK, January 2011

Bonnie Miller Rubin, Older workers nip and tuck to stay competitive in job market, Chicago Tribune, December 25, 2010

Dan Slater, Firm to Female Lawyers: Wear High Heels, Embrace Your Femininity, The Wall Street Journal, December 23, 2008

Bruckner on the family, being gay, and AIDS activism

Jan — Thu, 12 May 2011 22:29:35 +0000

I recently read and very much enjoyed Pascal Bruckner’s newly translated book, Perpetual Euphoria: On the Duty to Be Happy (originally published in 2000). Here’s a passage from the chapter “The Fat, Prosperous Elevation of the Average, the Mediocre.” (emphasis added in the following quotations)

[W]hat a contradiction to see in civil unions or in gay marriage with adopted children the forerunners of the disintegration of the family! It is exactly the reverse: it is the familial order that is triumphing over all of us, no matter what group or belief we subscribe to, and it is hard to see any argument, anthropological or other, that we could make against it.

Good point. Lost on conservatives, unfortunately. The new normal in family formation is resisted by those who cling to traditional values, while the traditional value of family prevails.

The paragraph continues with a discussion of conformity and anticonformity, and includes the following footnote:

According to Lucien Sfez, in 1995, 45 percent of literature majors at Stanford said they were gay, a figure that has little to do with reality. The author sees three reasons for this phenomenon: it is cool to say you’re gay and not to have the brutal image of the heterosexual; gays being a minority are protected by labor unions; and finally, gays cannot be accused of sexual harassment. La Santé parfait, p. 65.

The first reason makes sense, the second is irrelevant today, and the third certainly isn’t true in the US.

The footnote appears in connection with a critique of identity politics. “People state their identities only to make others yield, and display them noisily, perhaps out of fear that without them they would not exist.” Later on, however, in a chapter on suffering, Bruckner does not fault those who go public with an identity that features an incurable disease or disability.

The impact of AIDS activism on attitudes towards illness

Our relationship to both health and illness changed profoundly in the late 20th century. Bruckner describes the role of AIDS activism in this transition.

Something tiny but decisive may have changed in our relationship to illness. We fear it and avoid it as much as ever, but we are no longer willing to be dispossessed of it by an outside authority, whether medical or other; henceforth we demand to be associated as much as possible in the process of caring for ourselves. … AIDS not only revived the old association between sex and death …. It brought into confrontation two universes that no longer had anything to do with each other, youth and the tomb, at the end of a century that had promised us all that we would live, if not forever, at least to the age to 120. … [G]enerations of viruses were waiting in the shadows to kill us. … [I]t put an end to the myth of medical omnipotence and restored a terrible meaning to the word “incurable.” …

AIDS acquired a special status, half-political, half-medical. … It is perhaps thanks to AIDS … that patients have become legal and social actors (and no longer simply passive objects in the hands of physicians).

The age of paternalism in the doctor-patient relationship is a thing of the past in the US. In other countries that change is just now happening. For example, this comment from a doctor in Singapore: “The paternalism that largely characterises Asian healthcare today is increasingly unwelcome by patients who want and expect their doctors to be advisors and advocates rather than decision-makers on their behalf.”

What used to be “bad” is now seen as prejudice

AIDS reformulated what it means to be a “victim” of disease or disability, and this new meaning was contagious.

… people who refuse to allow themselves to be reduced to victimhood and who aspire, even in their weakened physical condition, to regain their freedom and responsibility. Rejecting the victimization that argues that a handicap requires special exemptions, they bring their sickness into the public sphere in order to be recognized and to return to normal life: for example, the young French woman aviator who was confined to a wheelchair after an accident and who created a movement to gain acceptance for handicapped pilots. By deciding that a certain abuse is no longer tolerable, and by translating their revolt into legal and political terms, these people modify the norm and shift the threshold of intolerance for everyone.

[B]ecause of the demands made on it by hemophiliacs, cancer patients, AIDS patients, and people with disabilities, a whole society is trying to come to terms with a new problem and to take control over its calamities through a dual effort of pragmatism and sheer determination. … What used to a matter of bad luck is now conceived in terms of prejudices, that is, a “modifiable inevitability” (Ernst Cassirer). … [T]he seriously ill, the traumatized, and accident victims, strong in their common weaknesses, manifest their freedom with regard to what had previously put them in the category of subcitizens, those receiving assistance. They are fighting against the segregation that made them lepers, bearers of bad news. They are fighting to remain members of the human community.

In the Internet age, remaining a member of the human community includes blogging for the duration of a terminal illness. See Blogging Til I Die: A cultural revolution? from Pallimed and Blogger announces own death after battle with cancer from CNN.

Resources:

Image: History of AIDS Activism

Pascal Bruckner, Perpetual Euphoria: On the Duty to Be Happy

Lucien Sfez, La sante parfaite: Critique d’une nouvelle utopie

Blogging Til I Die: A cultural revolution?, Pallimed, April 27, 2010

Katie Silver, Blogger announces own death after battle with cancer. CNN, May 8, 2011

Susan Sontag, Illness as Metaphor and AIDS and Its Metaphors

Pascal Bruckner on doctors and patients

Jan — Sun, 08 May 2011 07:12:39 +0000

A concise summary of the history of the doctor-patient relationship: It began with reverence and respect for the physician, changed dramatically in the 20th century, is in an unhappy state today, but may aspire to something more satisfying in the future. (emphasis added)

There is no figure more ambivalent than the doctor, who is simultaneously a preacher, a magician, and a healer, the master of both life and death. For a long time the image of him oscillated between two extremes: that of an arrogant practitioner intoxicated by his power and endowed with all the attributes of knowledge; and that of the family doctor, the tutelary divinity of French society who knew how to combine sound, precise diagnosis with friendly advice about what to do. …

Everything changed when medicine became specialized and liberalized. In the hands of a specialist, not only is the human body fragmented, but each part of it is subject to competing authorities. The result of this new status is that in dealing with a physician we oscillate between faith and absolute suspicion. Since he is supposed to know everything, a doctor has no right to be mistaken. … The contemporary patient is a skeptic who does not believe in any treatment but tries them all, combining homeopathy, acupuncture, sophrology, and allopathy, a little like new converts who embrace several religions to increase their chances.

The more we expect from medicine in general (and today we ask everything of it, including the impossible, total recovery and victory over death), the more we grow impatient with the limits of doctors in particular. Medical science’s individual servants are crushed under the weight of its promises, becoming commonplace and losing their authority; they are simple service providers who can be sued – often justifiably, moreover – if they commit an error. While the medical researcher, the scientist, and some surgeons whose skill amounts to genuine artistic genius retain immense prestige, in many cases the doctor is now seen only as a repairman who gets the machine running again until the next breakdown.

However, it is not clear that we are doomed to this fragmentary medicine, which often seems more like plumbing. Sometimes, fortunately, a communication is established between patients and physicians that is not merely utilitarian and allows the former to talk about their suffering, to make their symptoms part of a personal history. Then the relationship, instead of being inegalitarian, a relationship between a mandarin who orders and a patient who obeys, becomes an exchange and a contract in which two actors who are conscious of their limits try together, in mutual respect, to achieve the best cure possible. Perhaps the future lies in a union of the specialist’s competence with the human understanding of the general practitioner.

From Pascal Bruckner’s Perpetual Euphoria: On the Duty to Be Happy

Resources:

Image: The Art of Patient Care

Pascal Bruckner, Perpetual Euphoria: On the Duty to Be Happy

Can pharmaceutical drugs benefit society?

Jan — Thu, 05 May 2011 07:29:12 +0000

Here in the US, we’re apt to hear about the British health authority NICE (National Institute for Health and Clinical Excellence) when a stage-four cancer patient makes a desperate appeal for access to an expensive drug not in the approved formulary. The British system has been characterized as rationing, and conservative US politicians like to use such incidents to argue against “socialized” medicine, which will surely do away with Granny before her time is up.

There are big changes currently underway in the British health care system, and NICE will actually be replaced by a different decision-making process in 2014. Although health care reform in the US (the Affordable Care Act) rejects the British model, a recent article in the New England Journal of Medicine suggests there’s much we can learn from the British experience.

Why not design drugs to have wider societal benefits?

Of particular interest is the concept of the social value of drugs. The idea is that if a drug demonstrates “wider societal benefits,” the British government would be willing to pay more for the drug. Presumably this financial incentive would lead the pharmaceutical industry to invest more heavily in products with a high value to society.

What might these values be? In discussions of how the new system would work, the only example provided is drugs that benefit the care-takers of patients. The article’s authors, however, suggest a few more: “narrowing health inequalities, advancing children’s life prospects, reducing burdens on social services, increasing tax revenues, and decreasing workforce absenteeism.”

There’s more to the value of health care than clinical effectiveness for patients and cost-effectiveness for individuals and governments. As we plan for the future of health care, a welcome addition would be to consider the wider benefits to society.

In the US these days, it’s hard to imagine overcoming the political differences that prevent us from agreeing on what it means to benefit society. But it’s worth invoking the genius, power, and magic in bold thinking. This would be a great opportunity for those Harvard Business School types who advocate “shared value” in corporate thinking to make some concrete suggestions — an opportunity for a major contribution both to health care and to a better future for ourselves and our children.

Resources:

Image: The school for heroes

Ruth R. Faden and Kalipso Chalkidou, Determining the Value of Drugs — The Evolving British Experience, The New England Journal of Medicine, April 7, 2011, 364: 1289-1291

Michael E. Porter and Mark R. Kramer, The Big Idea: Creating Shared Value, Harvard Business Review, January-February 2011 (article is behind a paywall, but the extensive comments are not and are worth reading)