[I don’t seem to be able to display that image anymore, but here’s a link to what I’m talking about.]
This superb graphic was created to dramatize what’s happening these days in the UK, where the National Health Service is being ruthlessly privatized. Here in the US, for-profit medicine is so taken-for-granted that we barely notice it. It’s true, we hear a good deal about conflicts of interest involving pharmaceuticals. Doctors get paid — in one way or another — to increase the profits of Big Pharma, a practice that is detrimental to the financial and/or medical interests of their patients. We hear less about scaring healthy patients into using doctors and services that increase hospital profits (also known as fear mongering). So it was nice to see a recent opinion piece in JAMA that discussed precisely this. Read more
A year ago, when I decided to call my declining rate of blogging a ‘sabbatical,’ I wrote down some questions to explore while I took time off to read.
How did we find our way into the dissatisfactions of the present – the commercialization of medicine, the corporatization of health care, the commodification of health? Does understanding the path we followed offer any insight into finding a better direction? Was the increasingly impersonal nature of the doctor-patient relationship inevitable once medicine became a science? Or was it only inevitable once health care emphasized profits over patients and the common good?
At the time I thought I would read primarily in the history of medicine, and that was how I started. Appreciating the historical context of medicine is important for understanding both how medicine ended up where it is today and what medicine could become. “The texture and context of the medical past provide perspective, allowing us to formulate questions about what we can realistically and ideally expect from medicine in our own time,” I wrote.
Now that I’ve become more familiar with the social determinants of health, I’m less optimistic about the future. The problem is not simply that the corporatization of health care has increased dissatisfaction among both doctors and patients. The problem is that our focus is so narrowly limited to health care systems that we fail to see the larger issue. As one metaphor puts it, doctors are so busy pulling diseased patients out of the river, there’s no time to look upstream and ask who’s throwing the bodies into the water. Read more
Continued from parts one and two, where I defined the terms used in the following diagram of my blogging interests. Click on the graphic for a larger image.
If I had written the previous two posts a year ago, I would have realized how much my interests were intertwined. I guess I wasn’t ready to do that. Anyway, in this post I catalog some of the connections.
~ Healthism and psychological and physical conformity: Healthy lifestyle campaigns promote an ideal way of life that encourages individuals to alter their behavior and appearance. Although it’s true that we would all be better off if we didn’t smoke, that doesn’t make anti-smoking laws any less authoritarian, i.e., requiring conformity (see the section on anti-authority healthism in this post). The fitness aspect of healthy lifestyles promotes the desirability for both men and women of acquiring (i.e., conforming to) specific body images.
“Self-help is the psychiatric equivalent of healthism.” That’s a slogan I made up. I’m not sure yet if it will stand up to scrutiny. Certainly the self-help industry encourages self-criticism, which leads to a preoccupation with those aspects of personality currently considered undesirable. Read more
Continued from part one, where I discussed the first three of my six interests: healthism, medicalization, and psychological and physical conformity. Click on the graphic below to see a larger image.
The social determinants of health
Social determinants of health (often abbreviated SDOH) refers to unequally distributed social and economic conditions that correlate with unequal and inequitable distributions of health and disease. Presumably there is a causal relationship between the two, not merely a correlation. Definitively identifying the causal mechanisms, however, is difficult. A great many things influence our health (including things we’re not even aware of yet), and it can be difficult to isolate and scientifically study some of the ones we strongly suspect, like poverty, isolation, or a sense of being socially inferior.
The medical model is the preferred framework in modern westernized societies for explaining the distribution of health and disease. It emphasizes risk behavior (smoking, diet), clinical risk factors (blood pressure, blood sugar, cholesterol levels), genetics, health care access and quality, behavioral change, and patient education. One common characteristic of the medical model’s explanation of health and disease is that causes are located in the individual (behavior, genes), not in the individual’s economic and social environment. Read more
It’s always hard to be sure about these things, but I think the reason I decided to take a ‘sabbatical’ from blogging last July was that I was interested in too many seemingly unrelated topics. Writing about all of them left me feeling like I never got to the ‘meat’ of any one of them. And I couldn’t convince myself to focus on just one or two things, since that would mean abandoning the others, which I was unwilling to do.
Now that I’ve taken the past year to read and reflect, I find – duh! – that my interests are not as unrelated as I’d assumed. In hindsight, I should have realized this long ago, but, alas, I did not. I’m writing this post to clarify to myself what I now see as the common threads that connect my interests.
Here is a diagram that groups my interests into six categories. (Click on the graphic to see a larger image.)
Four of the six categories relate to all five of the others. The two outliers (neoliberalism and medicalization) are not as directly related as I feel the others are. Read more
In a perfect world, doctors would not prescribe – and patients would not take – drugs that do more harm than good. But it’s complicated. The benefits and harms of drugs are determined in randomized, controlled clinical trials. For many reasons, the outcomes of such trials may not provide doctors with the information they need to decide who should take what.
For example, harmful effects (like death) may not show up during the limited time span of a trial. Data from trials may be selected – and other data ignored — to produce positive results. This is apt to happen when clinical trials are conducted by the pharmaceutical industry, rather than by economically disinterested parties, such as the NIH or independent academic institutions. Also, the participants in the trial may differ significantly (in age, gender, and health, e.g.) from patients who end up taking the drugs. As a recent article in JAMA put it, “most clinical trials fail to provide the evidence needed to inform medical decision making.”
The Inverse Benefit Law
If you follow pharma news, you will have noticed that many high profile, aggressively marketed drugs turn out to be either ineffective or positively dangerous (think Vioxx, widely prescribed for arthritis, which turned out to cause heart attacks and stroke). Howard Brody, MD, and Donald Light, PhD, have proposed an explanation for this phenomenon. They call it the Inverse Benefit Law: “The ratio of benefits to harms among patients taking new drugs tends to vary inversely with how extensively the drugs are marketed.” Or (for those who feel fuzzy about inversion): The more aggressively a drug is marketed, the more likely the drug will cause harm, be ineffective, or deliver little by way of benefit. Read more
First, the reviewer, British sociologist Linsey McGoey, criticizes the book for continuing its attack on the medicalization of life.
A few pages in, it’s hard not to feel déjà vu. Moynihan came out a few years ago with Selling Sickness, a book tackling the problem of medicalization, the tendency for typical life phases or human behaviour such as shyness to be medicalized – treated as disorders and diseases requiring medical treatment.
IMHO, there can never be enough books educating the public about medicalization.
Next she defends the pharmaceutical industry:
They [the authors] want to condemn [the pharmaceutical] industry for preying on human insecurity and profiting from the oldest adage in the book: Sex sells. The problem is, just as Viagra has been embraced by millions, its pink equivalent would be a sure seller – and not because consumers are dupes, or because industry is inherently malevolent, or because doctors are in the pockets of companies. Sure, some are, but such a thesis always oversimplifies the links between human disease and human desire. Most of them [sic] time, people want to be told that a problem is medical in orientation. It helps to exonerate a sense of personal blame.
Eliminating a sense of blame or shame is exactly the tactic pharmaceutical marketing employs. (See How the pharmas make us sick.) Viagra has been embraced by millions because ED has been medicalized! I was just reading about a “renegade” Canadian doctor who’s quoted on the subject: Read more
Following up on Dr. H. Gilbert Welch’s comments on the new blood test for cancer – that overdiagnosis may lead to an epidemic of individuals who mistakenly believe they have cancer – here’s a description of the climate that’s created when we try to scare people into believing they have cancer. It’s from a review of The Emperor of All Maladies, a new book on the history of cancer by Siddhartha Mukherjee.
Writing in The New Yorker, the author of the article, Steve Shapin, explains optimism surrounding the drug Gleevec, a new type of cancer drug that targets a known cancer gene. Gleevec has been quite successful in the treatment of leukemia. (emphasis added) Read more
Earlier this month scientists announced a test that can detect a single cancer cell in a blood sample. Although some news reports were realistic – BusinessWeekcommented that “researchers still aren’t sure what these circulating tumor cells (CTCs) actually mean” – most greeted the news as a revolution in the fight against cancer, promising early, non-invasive detection.
Dr. H Gilbert Welch offered a more sober opinion. Welch is the author of Should I Be Tested for Cancer?: Maybe Not and Here’s Why. While it’s commonly assumed that screening saves lives and that more screening is always better, Welch’s book helps patients (and the medical profession) understand that the implications of cancer screening are more complex.
More medical care leads to more screening
As Welch points out, medical care is a much more prominent part of our lives today than it was in the past. There are a number of reasons for this. Read more
Here’s an editorial from an issue of The Journal of the American Medical Association published 100 years ago (emphasis added):
One of the cruellest and most despicable phases of the “patent medicine” business is the studied effort made by nostrum exploiters to frighten their victims into the belief that they are suffering from some more or less serious disease. Not content with the sale of their preparations to those who have—or who believe they have—one of the many diseases for which the products are recommended, the “patent medicine” vendors strive to create an artificial demand for their stuff by working on the imagination of the healthy and persuading them that they are sick. The scheme is an old one but none the less disreputable. One of the more recent modifications of this trick is the “gall-stone remedy” fake …
Compare this with a discussion of medicalization by Carl Elliott in his new book, White Coat, Black Hat . After describing how the condition formerly known as “urge incontinence” was repositioned as “overactive bladder” (to remove the stigma), he continues (emphasis added): Read more
Are celebrities crossing the line on medical advice? (USA Today)
“Many doctors say they’re troubled by stars who cross the line from sharing their stories to championing questionable or even dangerous medical advice. … Actress Suzanne Somers– already well-known for her diet books and ThighMaster products — in October released her 18th book, Knockout, which experts describe as a catalogue of unproven or long-debunked alternative cancer ‘cures.’ … [Celebrities] ‘can spread misinformation much faster than the average person with a wacky theory. … Correcting that misinformation — even with a mountain of evidence — can be a challenge. … ‘It’s much easier to scare people than to unscare them.’ ”
As you may have noticed by now, I’m a fan of Robert Reich. He has an opinion column in the Wall Street Journal that pulls together much of what he’s been saying in his blog posts on health care, such as his insistence on the importance of a public health insurance option.
Drugs are expensive and drive up the cost of health care. The problem with drug companies, however, is not simply that individual drugs are expensive. There’s a story in the news today about how the Obama victory and a Democratic congress may put downward pressure on drug prices. One industry analyst thinks this won’t be a serious problem since drugs have a very high markup: the number of products sold, not their price, drives industry growth. If health coverage expands, drug sales will increase, which is good news for drug companies.
In 1976, the chief executive of Merck told Fortune magazine that he dreamed of marketing drugs the way Wrigley’s markets chewing gum: to as large a market as possible. The real problem with drug companies is their attempt to convince as many people as possible that they need drugs. This is disease mongering: expanding markets by convincing healthy people that they’re sick. Health has come to mean that feeling fine is an illusion easily shattered by the next news cycle or by the next prescription drug you’re encouraged to “ask your doctor about.”
When a patient has a disease and a doctor prescribes treatment, the doctor can observe whether or not the patient responds to the treatment. If the treatment doesn’t work, it’s discontinued. When a healthy patient is at risk for disease and a doctor prescribes treatment, there’s no way to be certain the treatment is working. The patient might never have gotten sick. So the treatment continues indefinitely. This wouldn’t be a problem if pharmaceuticals were harmless, but all drugs have side effects. The more people you treat with preventive pharmaceuticals, the more people there will be who suffer the adverse effects of treatment.
From Iona Heath: “[D]isease mongering exploits the deepest atavistic fears of suffering and death. … Human societies are riven by the effects of greed and fear. The rise of preventive health technologies has opened up a new arena of human greed, which responds to an enduring fear. The greed is for ever-greater longevity; the fear is that of dying. The irony and the tragedy is that the greed inflates the fear and poisons the present in the name of a better, or at least a longer, future. Ultimately, the only way of combating disease mongering is to value the manner of our living above the timing of our dying.”
(Hover over book titles for more info. Links will open in a separate window or tab.)
I don’t have a lot of personal complaints about medicalization. As a woman, I don’t worry about erectile dysfunction or male pattern baldness. I haven’t had to decide to use Ritalin for a hyperactive child or growth hormones for a son who is shorter than his classmates. In my heart of hearts, I consider myself a social deviant (and am proud of it), but I don’t exhibit behavior that brings me to the attention of physicians, psychiatrists, or the law.
Many things that used to be considered a normal part of life – childbirth, menopause, insomnia, sadness, excess weight, aging, death – have been redefined as medical conditions and subjected to diagnosis and treatment. This process is called medicalization: Redefining a non-medical condition as a medical one. Medicalization is a major contributor to the health culture. It broadens the definition of health and encourages us to think of ourselves as in need of medical attention.
The active process of converting a benign condition into a medical disease is called disease mongering. Lynn Payer wrote a whole book on the subject: “[D]isease mongering – trying to convince essentially well people that they are sick, or slightly sick people that they are very ill – is big business. For people to use a diagnostic product or service, they must be convinced that they MAY BE sick. And to market drugs to the widest possible audience, pharmaceutical companies must convince people – or their physicians – that they ARE sick.” Read more
There was a follow-up letter to “The Last Well Person” (see previous post) from a doctor in Spain. He pointed out that the “extinction of well people” was anticipated in the 1920s by the French comedy, Knock, by Jules Romains. Dr. Knock purchased the unprofitable practice of a country physician and proceeded to diagnose everyone in the village with an illness. He prescribed cures commensurate with the patient’s income. (This is really quite considerate compared to the reality of bankruptcy caused by medical costs in the US.)
Just as Dr. Meador used the quotation “A well person is a patient who has not been completely worked up,” Dr. Knock was known to say “The healthy are ill people who are unaware they are ill.” Meador’s response to the letter mentions further explanations for the “The Last Well Person” phenomenon: insurance coverage that requires a specific diagnosis even when there is none, disability insurance, worker’s compensation, Medicare, and television advertisements. Read more