Heroes Not Zombies

We all love simple solutions. Human beings have such strong urges to understand. We are driven to try and make sense of our experiences and our lives. It could be argued that this drive is a significant factor in human survival and development. It’s a good thing to try to understand. What’s not appreciated so much is the value of doubt. Whilst it’s good to understand, it’s the belief that we never completely understand anything that drives our continual growth. Without doubt, thought stops, reflection ceases and learning hits the buffers.

I’m not arguing for obfuscation. I do like clarity. But the reality is that we are complex creatures living complex lives. Health and illness cannot be reduced to simple formulae or single causal factors. It’s for these reasons that I find myself so impressed with the recent work from the Glasgow Centre for Population Health which has just published an interesting piece of research.

They have studied 20 European regions to make comparisons with the experience of the West of Scotland. The regions they studied were similar to the West of Scotland in terms of de-industrialisation, deprivation and poverty. What’s happened over the course of the second half of the twentieth century is that the West of Scotland has fallen behind all the other regions. Life expectancy figures and a whole bank of illness and health measures have shown all the other regions are improving faster than the West of Scotland.

There’s a common and fairly simplistic view that deprivation is the main cause of ill health, but deprivation cannot explain the differences between the West of Scotland and other similar regions. That’s the somewhat startling conclusion of this study. If deprivation cannot explain it, then what is the explanation? I’m impressed that the Centre for Population Studies has explored a number of possible explanations but hasn’t found any of them to be satisfactory. However, complex causes such as income inequality (it’s been repeatedly shown that the greater the income inequality within a community, the poorer the health experience at any discrete level of wealth), migration and the speed of change (de-industrialisation), are probably all significant, whilst, simple explanations such as absolute deprivation scores, cigarette and alcohol consumption, and so on, cannot explain the differences.

Health is a complex phenomenon and this kind of adult, intelligent research is just what we need.

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I recently posted about the claimed health benefits of tomatoes, and continuing in that vein………something else I really enjoy is my daily coffee.

Apart from enjoying it, can I add a little health-benefit smugness to my mug? Turns out I can! Recent research has shown that caffeine protects the “blood brain barrier” from the damaging effects of cholesterol. One of the many ill-effects of cholesterol is damage to the tissues which protect the brain from toxic substances circulating in the blood. The researchers believe this may explain the potential for a coffee a day to reduce the chances of getting Alzheimer’s Disease.

Like with the tomatoes, I don’t really need other reasons to enjoy coffee, but it’s good to know I can consider it part of my healthy lifestyle!

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We do live in a “pill for every ill” society. Arthur Frank, in his “Wounded Storyteller” describes the commonest type of story told by patients in contemporary society as being the “Restitution Story”. By this he means “I’m broke, Doc, please fix me”. He says it’s the fast food approach to health, the quick oil change while-you-wait approach. It’s technological and it’s based on a conception of illness as being about a bit of the body that’s not working and on a conception of Medicine as being about applying the right technology for the quick fix.

Whilst this approach has delivered dramatic results in acute situations, it’s done really nothing in the long term for chronic ones. Even in societies where the burden of death and disability from infectious disease has been reduced we are seeing steadily growing rates of chronic illness. The quick fix approach doesn’t deliver long term health and it doesn’t deliver a very effective fix!

Here’s a paper from the “Harvard Health Letter“, headed “Managing Seven Common Conditions without Medication”.

In summary, they say Arthritis – lose weight, gain mobility and less pain; Cholesterol – drop your LDLs (bad blood fats) 5% by keeping saturated fats off your diet; Cognitive decline – brain exercise and physical exercise slows this up; Depression – regular physical activity lifts mood; Diabetes – regular physical activity drops sugar levels; High Blood Pressure – lose weight, regular exercise; reduce salt and drop your BP; Osteoporosis – lose weight and eat more vit D and calcium for stronger bones.

OK, so not exactly rocket science – basically lose weight and exercise more – but at least it’s a start. It’s the mentality behind this report that appeals to me though. When our first concern with an illness is what drug to take or operation to have, we’ve missed the boat. Our first concern should be “what do I need to do differently?” because if you keep doing the same you’ll just get more of the same! But I think we need to push this agenda a lot further and into areas so far pretty unexplored. Sure, things like smoking, alcohol, drugs, diet and exercise are all modifiable factors in our lives which can influence which diseases we get and how those diseases progress, but we need to think of whole people, and not solely in this kind of mechanical or reductionist way. Mental states are significant factors in maintaining health and in determining recovery – positive attitudes, empowerment, hope, loving and being loved aren’t talked about so much by doctors or health care providers but they should be. In fact, if we treat people as only physical bodies we don’t treat them as human beings at all. We are much more than our physical selves.

So let’s all agree that diet, exercise and drugs are important considerations in health and illness, but what other factors would YOU consider? What about writing for example? Or music?

What factors are important in YOUR life to keep you healthy, or that you’ve found were important parts of your recovery from illnesses?

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Every time I see a patient for a first consultation I draw the following diagrams to explain what I’m trying to do and how it might fit with whatever other treatments they are receiving.

First I draw two simple shapes –

I say, “The circle on the left represents health and the disordered looking circle on the right represents ‘not health’. In acute diseases, it’s usually pretty easy to understand what’s caused the problem (represented by the red arrow). For example, along comes the flu virus and gives you flu, or along comes the number 6 bus and knocks you down and breaks your leg”. “The whole purpose of undergraduate training in medicine is to teach doctors how to recognise the disordered circles. It’s called ‘making a diagnosis’. This training focuses on the disease or the lesion. The doctor says ‘I know what this is. It’s the flu.’ or ‘You’ve got a broken leg’ or whatever. Whatever the problem, the body sets about its normal activity of trying to repair damage and restore health. This process is represented by the sweeping purple arrow –

“Interestingly, because doctors are trained to diagnose the problem in terms of the disease, all the treatments you are offered are intended to fight, suppress, or remove the disease. What the treatments are not designed to do is enhance the process represented by the purple arrow. Benjamin Frankin understood this. He said ‘God heals and the doctor takes the fee’. It seems strange to me that at medical school we only learn about pathology, about diseases and how to fight them, when, in reality, nobody, but nobody, gets better from any illness without the healing process working. It’s the body’s own capacity to self-repair, self-heal and self-restore which returns, or attempts to return you to health. Treatments directed against diseases might give the body a better chance to do that. In fact, with many diseases, the problem may be too serious for the body to manage to self-heal without the support of fighting the disease. Fighting the disease isn’t a bad thing. It’s just not enough. We need to see what we can do to support and promote your self-healing.”

I then add the following elements to the diagram –

What this shows is the addition of arrows, representing treatments, on the top right directed against the disease. The horizontal lines represent the kind of wall these treatments attempt to put between the disease and the outside world. Many, many treatments are called “anti-something” – anti-biotics, anti-inflammatories, anti-depressants, anti-hypertensives – that’s because most treatment is intended to act against the disease. I point out that, that may be important to do, but that what is missing are the treatments represented by the arrows added on top of the big purple arrow. These represent any treatments intended to support and stimulate the processes of self-repair and self-recovery. (I might then have a discussion with the patient about what factors influence these processes). The final element of this little diagram is the addition of the arrows around and within the circle which represents health.  What I say about them is “In acute disease, as we already discussed, the cause is often obvious and single. In chronic diseases, however, the factors which have produced the problem are typically multiple. The aetiology, or origin, of chronic disease in a person is multifactorial. Some of these factors may be internal – genetic factors, hormonal and nutritional factors for example. Some of them will be external – impacts from the environment, viruses, bacteriae, physical trauma, emotional and psychological traumas and so on. Really anything which impacts on you as a person can impact on your health, and may be a factor involved in causing the illness.’

I find this introduction opens up a holistic, mind-body approach to any illness, empowers the patient, allows for their to be hope, and takes away any “either/or” thinking about dealing with illness from a biomedical perspective of fighting the disease or a biopsychosocial perspective of helping a person with an illness to recover better health.

What do you think? Tell me if this is clear and whether or not you think it is helpful. It’s easy for me to adjust the conversation with the patient at the time, but in a little post like this it might not be so clear?

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