Heroes Not Zombies

Iona Heath writing in the Public Library of Health Medicine journal nails the issue of disease mongering.

There are a number of issues to consider in relation to the problem of disease mongering. She particularly focuses on the use of pharmaceuticals for preventitive medicine reasons.

The first step has to be a genuine disentanglement of the medical profession from the pharmaceutical industry—there really is no such thing as a free lunch

Sadly, there is an enormous, unhealthy, amount of pharmaceutical industry influence on not only individual doctors, but on regulatory bodies, governments and the publication of so-called evidence on which policies and protocols are based. Until we tackle this influence, disease mongering will continue to grow apace.

Beyond this, there is a need for better science that has the integrity to demand more explicit acknowledgment of the limits of medical knowledge, less extrapolation beyond research findings, and much more responsible use of statistics, so that the true extent of the benefits and harms of proposed treatments can be properly understood.

There’s a terrible tendency these days for people to claim knowledge which enables them to make predictions about treatments with certainty. Human life is not certain, and, as human beings can be considered as complex adaptive systems, it is impossible to predict outcomes in detail in any individual case. Research trials and statistics are not the whole truth, and they never will be.

Most variables are distributed across a continuum, but despite this, the medical tradition has been to dichotomise the continuum into normal and abnormal

It is irrational to divide human phenomena into two discreet categories – normal and abnormal. It isn’t scientific to do that, and it certainly isn’t realistic. There is no such thing as some drugs which work and others which don’t. No drug has the same effects on everyone who takes it.

When doctors treat patients with diseases, progress can be assessed and the outcome is measurable. This means that if the patient responds to treatment, it can be continued; if not, the treatment can be stopped. When doctors treat people who are merely at risk of disease, the outcome is probabilistic, so whether disease is prevented or was never going to develop, the treatment continues indefinitely

I’m not sure it’s always so clear that a patient has responded to treatment, or at least, responded sufficiently to treatment. After all, who is to judge the “sufficiently”. However, I do agree with Dr Heath’s point that if you prescribe drugs to reduce risks you can never stop prescribing them. You are condemning those “at risk” to a lifetime of treatment as if they had a disease.

Part of the rationale for expenditure on the treatment of health risks is that it will reduce health costs in the long run, but such arguments do not stand up to close scrutiny. The costs of health care are highest during the year before death, regardless of the age at which death occurs. Everyone must die and be cared for while dying, and no amount of preventive pharmaceuticals can reduce the cost of providing this crucial end-of-life care

You don’t make people healthier by prescribing drugs, and you never achieve immortality. We all die, and the last year of life is the year we receive most health care.

Dr Heath’s final sentence is this –

Ultimately, the only way of combating disease mongering is to value the manner of our living above the timing of our dying.

Couldn’t put it better. We need to focus on health more than disease, and on living, more than dying.

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”.