Heroes Not Zombies

There are a depressingly large number of stories around about the inappropriate levels of influence drug companies have over government authorities who are responsible for developing, delivering and regulating health care. Most of the ones we read relate to the US and UK, but here’s one from France.
This is the story of a drug called Mediator which is supposed to be prescribed for diabetics to help them lose weight, but seems to have been prescribed to a lot of French people over the years whether they’re diabetic or not. As far back as the 1990s reports of deaths occurring in patients taking this drug began to emerge and the problem seemed so serious that the US, Switzerland and Spain all banned it. More recent studies have suggested between 500 and 2,000 French people may have died taking this drug. The question being asked is why did it take until November 2009 for the French authorities to act on the evidence?
The company which makes Mediator is Servier which is an old French family business with longstanding connections in the French establishment.

“Servier has shown an extraordinary capacity for escaping criticism,” said Socialist deputy Gerard Bapt, a cardiologist who has taken a close interest in the scandal. “The main reason is because it has been able to infiltrate all the relevant scientific committees working on this drug.” For Irene Frachon, “the conflicts of interest are palpable… Among the medical establishment, in the pharmaceutical and cardiological communities, there are people close [to the Servier laboratories].”

Larry Dossey has written an article about harmony and chaos. As he rightly points out the concepts of harmony, order and “coherence” are so universally accepted as characteristics of a healthy system or organism that nobody really ever considers that this way of thinking might not completely capture the reality of health.
I suppose one area where I began to realise that health isn’t all about order and coherence was when I discovered that epileptic fits arise, not when the brain dissolves into the chaos of an “electrical storm” as was previously thought, but, rather when consistent waves of co-ordinated electrical activity wipe out the normal brain function. In other words, a seizure emerges out of rigidity, not chaos.
Healthy brain activity is probably more accurately represented as edge of chaos which can tip, on the one hand, into total chaos, or, on the other, into rigidity – neither of which is healthy.
It seems that studies on aging are beginning to highlight a similar issue. Both at the level of individual organs, like the heart, and at the level of the whole organism, it seems that as we age we lose a capacity to exist in some healthy zone of near chaos. In fact as we age we stiffen, we lose flexibility and, hence both resilience and adaptability.

“Chaos in bodily functioning signals health. Periodic [regular, rhythmic, coherent] behavior can foreshadow disease. Transitions to strongly periodic dynamics are observed in many pathologies, including Parkinson’s disease (tremor), obstructive sleep apnea, sudden cardiac death, epilepsy, and fetal distress syndromes, to name but a few.”

This makes a lot of sense when you consider the characteristics of complex systems. It’s true that you need a healthy level of “integration” ie of harmonious linkage between differentiated parts. However, for a system to be adaptable it must be flexible and for it to grow it needs to develop new patterns (a biological phenomenon known as “emergence”). Emergence only occurs when a system moves towards a “far from equilibrium” point, or some kind of tipping point. There are characteristics of complex systems known as “bifurcation points” where a system may go one way or another, and of “phase transitions”, where the whole behaviour of a system might suddenly change (for example, where liquid water turns to gaseous steam).
We are complex adaptive systems. We do need an incredibly intricate complex set of checks and balances, of feedback loops, of harmony and coherence. But we also need a bit of chaos, too much regularity can mean insufficient flexibility.

Jonah Lehrer’s written a good piece in Wired about the importance of therapy
By therapy, he’s specifically referring to talking therapy as opposed to drug therapy. We’ve got a very drug-centric approach to health care, but the research evidence into anti-depressants clearly shows they are no more effective than placebo for all but the most severe depressions. So why do we persist in using drugs as first line treatments for depression? In fact, we often dismiss the value of the “talking therapies” (psychoanalysis has found it very hard to present an “evidence based” case, the way Cognitive Behavioural Therapy has done, and, as a result, often loses out in decisions about resource allocation)
Lehrer refers to some work comparing a mindfulness approach to depression to drug treatment and the conclusion on long term effectiveness was –

The results were stark. Not surprisingly, patients who escaped depression with the help of anti-depressants, and then stopped taking the drugs, relapsed about 70 percent of the time. The chemical boost was temporary. However, during the 18 month follow-up period, only 28 percent of patients in mindfulness therapy slipped back into the mental illness.

As he helpfully concludes –

What we often forget is that therapy alters the chemical brain, just like a pill. It’s easy to dismiss words as airy nothings and talk therapy as mere talk. Sitting on a couch can seem like such an antiquated form of treatment. But the right kind of talk can fix our broken mind, helping us escape from the recursive loop of stress and negative emotion that’s making us depressed. Changing our thoughts is never easy and, in severe cases, might seem virtually impossible. We live busy lives and therapy requires hours of work and constant practice; our cortex can be so damn stubborn. But the data is clear: If we are seeking a long-lasting cure for depression, then it’s typically our most effective treatment.

And this is the nub of the issue, isn’t it? Life is complex and resolving difficulties takes time, effort and practice. It’s foolish to consider human beings as chemical/mechanical beings which can be “fixed” with chemical and mechanical “solutions”. Human interaction, awareness, consciousness, communication, all bring about changes in the internal “chemical” environment. My preference would be that we address people as people not as examples of some “chemical imbalance”.

In another piece of research looking at the psychoneurological mechanisms involved in placebo responses, we can clearly see that the placebo response is neither “nothing”, nor something artificial. In fact, it seems to be an integral part of every single therapeutic intervention.

By falsely dividing drugs into “verum” and “placebo”, or “proven” and “ineffective” we fail to understand these intrinsic biological healing capacities.

This is an interesting paper because it explores this phenomenon in detail, but the part which really struck me was the reference to the work of Benedetti et al on patients with Alzheimers. They show that damage to the prefrontal cortex specifically reduces the placebo response in these patients. Not only does it reduce the response to a prescribed placebo, but it results in the reduction of effectiveness of drugs such as analgesics, presumably because part of EVERY drug action is a placebo action and as this component is inhibited, the drug dose needs to be increased to continue the desired effect.

I’m sure a lot more work needs to be done to understand these mechanisms but it is encouraging to find research which at least begins with the hypothesis that the placebo effect is neither a trick nor is it equivalent to doing nothing.