Heroes Not Zombies

There are a couple of common views about new drugs amongst doctors. Both are based on the same phenomenon.

The first is “use new drugs quickly……..before their benefits wear off”

The second is “don’t use new drugs quickly……wait till you find out what there real effects are”

The phenomenon these views are based on is that when a drug first becomes available as a new “proven” or “evidence based” drug, it often seems spectacularly wonderful. Remember barbiturates? Benzodiazepines? Steroids? Betablockers? SSRIs? and so on and so on. When they first come to market they are described as breakthroughs (I don’t mean all the me-too drugs which just copycat the new ones). The early studies show wonderful outcomes and precious few side effects. However, it seems that frequently not only do the side effects become more predominant and problematic but the early promises turn out to be not quite so spectacular as originally believed.

It’s interesting to see this phenomenon now being more formally described.

But now all sorts of well-established, multiply confirmed findings have started to look increasingly uncertain. It’s as if our facts were losing their truth: claims that have been enshrined in textbooks are suddenly unprovable. This phenomenon doesn’t yet have an official name, but it’s occurring across a wide range of fields, from psychology to ecology. In the field of medicine, the phenomenon seems extremely widespread, affecting not only antipsychotics but also therapies ranging from cardiac stents to Vitamin E and antidepressants: Davis has a forthcoming analysis demonstrating that the efficacy of antidepressants has gone down as much as threefold in recent decades. For many scientists, the effect is especially troubling because of what it exposes about the scientific process. If replication is what separates the rigor of science from the squishiness of pseudoscience, where do we put all these rigorously validated findings that can no longer be proved? Which results should we believe?

I’ve said it before……this binary thought process of dividing treatments into “those which work” and “those which don’t” is nonsense. The world is not so simple. And “facts” are a lot more slippery and context bound (in time as well as circumstances) than a lot of “scientists”, and certainly drug companies,  would like us to believe.

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Doctors are taught to use two basic concepts – health and disease. Disease figures very predominantly on the medical curriculum. In fact, Davidson’s Textbook of Medicine is all about disease. There isn’t even an entry in the index for “health”. We create our “health services” around disease, with specialists who specialise in understanding and managing diseases of certain parts of the body. That’s why we have oncology departments, gynaecology departments, dermatology, cardiology, otolaryngology (ENT) departments and so on. Out in the world of Primary Care in the UK there’s an attempt to do it differently. Most Primary Care doctors work in “health centres”. However, especially since the introduction of the “Quality Outcomes Framework”, there’s been a further push towards concentrating on diseases rather than health.

This enormous emphasis on disease has led many doctors to act as if disease isn’t a concept at all. They treat it as if each disease is an independent entity. This is a misunderstanding. It’s also led to the development of so-called “evidence based” protocols for managing disease.

Where’s the attention paid to health (without reference to disease at all)? Where are the health experts as opposed to the disease experts? Have you ever wondered what a true “health” service would be like? One which addressed “health” either in addition to “disease” or as a first point of engagement with patients instead of the first point of engagement being once pathology has emerged? (and I do mean health as a whole organism state of being, not drugged psuedo-health!)

As I see it, it all depends on the timescale you consider. In acute illness, disease-focus strikes me as highly appropriate. It’s where we show the greatest effectiveness of pharmaceutical and surgical interventions. But in chronic illness, the disease-focus gets less and less useful. Here the emphasis needs to shift to a health-focus – and as health is a lived experience, that requires understanding and engaging with the human at an individual and whole-person level.

Disease is a biological dysfunction.

Health is a life state.

Disease impacts on health, and health impacts on disease. Don’t we need to address the issue of illness from both angles, emphasising what’s most important according to the time scale we’re considering?

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