More health = less disease

Which of those two statements do you agree with?

Of course, neither equation is that simple. Sometimes bringing a disease under control, or removing a pathological lesion, results in a person’s health increasing. It’s true in most acute diseases. But it’s a bit more complex in chronic illness. Better managed diabetes allows the patient a better health experience, and controlled asthma does too, but those chronic diseases don’t go away and a person with any chronic disease isn’t likely to experience health as fully as someone who doesn’t have any such disease. Sometimes increasing health, resilience and wellbeing not only reduces limiting symptoms, but allows the innate self-healing capacity of human beings to work so well that the disease is removed completely. Other times, again in chronic situations, it results in greater wellbeing but not erradication of the disease.

The lack of simplicity reflects the fact we can’t put parts of life into unconnected boxes. There aren’t two, separate, complete states – disease and health. But they influence each other. They influence each other in unpredictable ways because human beings are complex adaptive systems, and such systems have distinct types of relationships between their parts – non-linear links. Non-linear links are typical of human feedback loops. And that’s a good description of the relationship between health and disease – they are bound together in non-linear negative feedback loops.

Most health care focuses on the first statement. We have a disease-focused, disease-management service, not a health service. Health, if it increases, does so as a kind of side-effect of the treatment. Yet, health is still the goal. Taking a health-making focus creates or enhances the conditions for reduction, or control, of disease. But that too may not be enough. The human ability to self-heal is not perfect, and not omnipotent. Management of a disease really can contribute to better health.

Why don’t we do that more?

Are we doing our best to help people to experience as much health as possible?

Not if we only focus on disease. Not if we only focus on health.

We need an integrated health service – where disease management AND health making are available to all patients.

“The vast majority of drugs – more than 90 per cent – only work in 30 or 50 per cent of the people,” Dr Roses said. “I wouldn’t say that most drugs don’t work. I would say that most drugs work in 30 to 50 per cent of people. Drugs out there on the market work, but they don’t work in everybody.”

Whilst that observation caused a stir at the time, and is causing a stir again, now it’s been repeated, at the time it didn’t really surprise me. You don’t have to work as a GP for long to discover that there are no drugs which do what the manufacturers and researchers say they do for every single patient who you prescribe for. How many different BP pills does the doctor have to try sometimes to get hypertension under control? How many different painkillers? Different antidepressants, anticonvulsants, treatments for constipation, diarrhoea…..you name it. I really don’t know of any drug on the market which does what it claims to do for EVERY single patient who takes it. What did surprise me were the figures quoted – 90% of the drugs only work in 30 – 50% of the people!

And yet, there are still those who claim there are only two kinds of treatments available – those which work, and those which don’t.

Life just isn’t like that.

But here’s another comment in that BMJ article which really grabbed me, and I don’t know why I didn’t see this so clearly before!

Pain relief is not normally distributed but usually bimodal,being either very good (above 50%) or poor (below 15%). Using averages is unhelpful and misleading, because “average” pain relief is actually experienced by few(if any)patients, and it tells us nothing about how many patients will experience clinically useful pain relief [BMJ 2013;346:f2690 doi: 10.1136/bmj.f2690]

What does this mean? “Bimodal”? Well, here’s another article, referred to in this BMJ article, pointing out the same problem -

Systematic reviews of regulatory trials often pool average data. In acute and chronic pain, however, underlying distributions are commonly not normal, tending to be U-shaped rather than bell-shaped, where the average describes few individuals [PAIN 149 (2010) 173–176]

When you look at the effect of a drug on a research population you don’t get drugs which work, and those which don’t. What you get is two distinct groups of patients – those who get a “good” result, and those who don’t.

By averaging out the results of the entire group, this reality is obscured.

Whilst these articles refer to painkillers, I believe this finding is likely to be found with pretty much any therapy you can think of. There will be a group who really get no benefit, AND a group which get significant benefit.

This is a common problem in health care – there are no average people. Every single person needs to be considered and treated as an individual. After all even the results from the group trials have been obscured by this averaging out.

This tree is just bursting with potential. Every little seed could grow to become a whole tree. Could you tell what the tree will look like, just by looking at one of these seeds? Only if you have seen one of these seeds before and you recognise it, or if you see it in the context of the parent tree (as you can see in this photo). But even then, you can’t predict which seed will become a full tree, and which won’t. Nor can you tell EXACTLY what the particular grown tree will look like.

But what we do know, is that here is potential and possibility.

Life is like that. YOU are like that.

Bursting full of potential.

What are you becoming…..?

Firstly, he says that having a poor memory has saved him from being an ambitious person – “the defect being intolerable in those who take upon them public affairs”.

Secondly, he says it has saved him from deafening all his friends with his “babble”

I have observed in several of my intimate friends, who as their memories supply them with an entire and full view of things, begin their narrative so far back, and crowd it with so many impertinent circumstances, that though the story be good in itself, they make a shift to spoil it…for whilst they are seeking out a handsome period to conclude with, they go on at random, struggling about upon impertinent trivialities, as men staggering on weak legs.

…..old men who retain the memory of things past, and forget how often they have told them, are dangerous company; and I have known stories from the mouth of a man of very great quality, otherwise very pleasant in themselves, become very wearisome by being repeated a hundred times over and over again to the same people.

Thirdly, he says he is less likely to remember the injuries he has received (and therefore doesn’t hold grudges)

Fourthly….

the places which I revisit, and the books I read over again, still smile upon me with fresh novelty.

And, finally, (getting to the title of the essay) he says that it has saved him from being a liar, because liars always forget the details of their lies and trip themselves up. Knowing he has a bad memory means he doesn’t trust himself to lie!

What a beautiful shape! Here is one stem of a fern unfurling, unfolding, becoming. If I came back next week and photographed this exact fern, it would look very different. If I could take a photo every few minutes and view it as stop motion video it wouldn’t look so still. We would see it was constantly moving, restless, stretching, curling and uncurling, spreading its leaves in the sun.

This single fern is a wonderful example of how, if we want to really know an individual, we have to follow them through their unfolding. Single moments, isolated snapshots of existence only hint at the complexity, the movement, the development which is at the heart of all Life.

Becoming, not being…….

A little white feather, caught in grass which has pushed up through the Tarmac.

i’m sure you’ve seen LOTS like this before, but, wait a minute. Don’t rush. Take a look at it. It’s  beautiful. It’s delicate. It’s strong. And it’s complex. What an amazing structure.

The way my mind works I look at this and I think about becoming……..how does a bird make this structure? How can one cell, fertilised by one other cell, double and double in numbers, then differentiate so that some cells become eyes, some become brain cells, some become legs and some produce feathers. And all in just the right places. I was entranced by my embryology lessons at university and this incredible process still fills me with wonder and awe.

And I think about how the first feathers appeared on the Earth. Were there many stages of almost-feather which eventually become feathers? Did they appear suddenly? One day there were no feathers on Earth, then the next day, there they were?

And then I come back to this particular feather. Where is the bird which grew this feather? Is it a swan? A seagull? Does it live around here?

And. Then I remember that Paulo Coelho, the author, says he starts to write a new book only after he finds a white feather, and I wonder which bird, therefore, created The Alchemist!?

A few years ago they started to develop Leith harbour. They built blocks of flats, terraces of houses, laid roads……then, CRASH, it all stopped. I can understand how these projects hit the buffers, but this little false start of a road with its pointless, well-painted junction leaves me wondering.

Why would you tarmac the roads before laying the foundations for the buildings? But, really, why would you PAINT THE WHITE LINES on a road which, after three paces, ends in shrub and grass? Complete with the double dashed “give way” rule? Give way when you’re coming from where?

What do you think of this road less travelled? This road to nowhere? This abandoned little bit of hope and planning?

What do you think of bothering to mark the rules of the road so long before anyone can ever be subject to those rules?

I’m not sure what I think about all this, but I do know this image is disturbing to me. It keeps popping back into my head and asking me questions. It’s an image without answers.

Start living differently, if we reckon we’re not living the way we want to live? Eat differently, if we reckon we want to change our diet?

Start a project? Pursue a dream? Make a different choice?

I’m sure most advice is to start today. But then today passes and becomes yesterday and we haven’t started yet, so now what? The advice remains the same – start today.

I understand the wisdom of that advice…..I just have difficulties following it! If you do too, maybe this little excerpt will bring a smile to your face, the way it did to mine yesterday -

…Luigi Cornaro (1467-1566), a Venetian nobleman, published four editions of a work on “The Temperate Life.” He had been subject to digestive disturbances and gout for fifteen years, when at forty he took to dieting and hygienic living. Until within a few years of his death at ninety-eight he was able to write for seven or eight hours a day, conversed with his friends, attended concerts, etc. His first book was written when he was eighty-three, the others when he was eighty-six, ninety-one and ninety-five. The later ones contain apologies for the juvenile crudities of the earlier compositions!

A couple of interesting things about that story, huh? He had his illnesses for 15 years before he decided to live a healthier life. Having decided, aged 40, he went on to live another 58 years. We aren’t told whether or not his diseases went away, but we are told that for most of that time he was able to be creative, to be socially active and to enjoy music and attend events. That’s the important part isn’t it? What kind of life did he live? A fully engaged, creative life.

He published four books between the ages of 83 and 99, and his FIRST book was when he was 83, but how long had he been writing for 7 or 8 hours a day? Since he was 40?

Finally, don’t you love the humility of this man, and his understanding of the developmental nature of knowledge? In his final books, he apologies for the “juvenile crudities” of his earlier writing (the book he wrote when he was a mere 83!)

I guess one of the main lessons I take from this is that there is no “right time” to start, but the important thing is to start!

Oh I wish there was a tag to insert scent into a post!

Which scent stopped you in your tracks recently?

OK, let me reflect on the current benefits outweighing the harms argument. Let’s deal with harms first of all, because in some ways they are more straightforward. Here’s a couple of interesting facts. Medical interventions are the third most common cause of death in the US. Numbers of deaths decreased when Israeli doctors went on strike. So, there is still plenty of potential for doctors to harm you.

What about benefits? Many infections which previously could overwhelm and even kill patients can now be successfully treated with antibiotics (although we are never far away from predictions that our fifty or so years of success in that area are coming to an end as bacteria adapt, develop resistance to the drugs, and spread that newly acquired ability far and wide). In Surgery there have been enormous improvements. I’ve talked to two patients this week who recently underwent cholecystectomy (removal of the gall bladder) using four small cuts in their abdomens, an extremely short hospital stay and very rapid, complete recovery. Cholecystectomies weren’t like that when I was a young doctor. People having a heart attack who have a clot in a major artery can have it quickly dissolved, or a stent inserted to break through the blockage within hours now. Montaigne’s last two years of life were spent bed ridden, in pain, from kidney stones. You wouldn’t believe how easily that can be dealt with nowadays. I could go on. I’m sure you can add your own examples from your own experience.

But.

There’s a problem. And I don’t mean the harms problem. The problem is that interventions, especially drugs, but surgical ones too, don’t result in the same benefits for everyone who receives them. Roses, of GlaxoSmithKleine, famously gave the game away when pushing the case for pharmacogenomics. He said – We all know that most drugs (90%) don’t work for most patients most of the time (less than 30 – 50%). Why did that statement seem so shocking? Don’t we all know that? Why have all pharmacies got shelves full of drugs which all claim to do the same thing? Whether they are pain relievers, treatments for cold symptoms, allergies, or tummy upsets? Every prescribing doctor will tell you they are glad they have a number of drugs to choose from because no single drug gets the results every time it is prescribed (this is true of EVERY drug, from painkillers, to blood pressure pills, to treatments for asthma, heart failure, epilepsy…..you name it). And here’s where the next aspect of the problem arises. It’s a version of if you give a man a hammer everything will look like a nail. There are drugs and surgical procedures which effectively alter diseases, directly changing the characteristics or behaviours of dysfunctional tissues or organs. (These interventions are often claimed as cures, but I think doctors should retain a little humility here – there are no cures other than through the human being’s capacity to self-heal and self-repair. Treating diseases can increase the chances that self-healing will work, but no drugs or operations directly stimulate or support self-healing.) But what happens when all the drugs tried don’t work? Often one or a number of them are continued, in reality because the doctor doesn’t have anything else to offer. But continuing a drug which is not working tips the balance between benefits and harms enormously. The longer most drugs are taken, the greater the risk of harm. Almost worse than this is that this form of Medicine is used completely inappropriately. Many, many drugs are not prescribed to cure, to heal, or even to control a disease. Instead they are prescribed to reduce symptoms. Reducing symptoms can reduce suffering and whilst we can be supportive of that, it can inhibit dealing with the causes of the symptoms.  However, Palliative care in terminal illness can seriously reduce suffering completely appropriately. But when the cause of the suffering is not addressed, and is ongoing, then a symptom reduction strategy leads to the same problem as the ineffective drug one – the balance tips from benefit to harm.

So Montaigne’s experience and views are still relevant over four hundred years on. Dealing with doctors can be a dangerous experience, and giving them power over you is still not a great idea. I’m of the opinion that the less you have to deal with doctors, the better your life!

When I read some of Montaigne’s comments about doctors, one thing he said which particularly struck me was why don’t doctors have much better health than other people, given they claim specialised knowledge and skills in health?

So, I did some research to see if it was still true that doctors’ health and illness knowledge brings no advantages over others. It’s not entirely true. The famous phenomenon of doctors as an occupational group giving up smoking on reading of Richard Doll’s epidemiological work has resulted in doctors having less smoking-induced illnesses than others. However I can find no evidence that doctors live significantly longer than other people (of similar wealth, race and sex). Nor can I find any evidence that doctors are less likely to suffer from diseases over all.

Looks like Montaigne is right again – if doctors are the experts in health, how come they don’t have healthier, longer lives?