Let's make it concrete

Let me take a break from blowing vapor about the bio-psycho-social conception of health and make it real for a bit. We're collaborating with a researcher who I won't name just yet because I didn't ask permission on a project which is really terrific. It's a randomized controlled trial of a program to teach therapeutic massage to caregivers -- spouses, siblings, children, friends, whatever -- of people with cancer. There is an orientation, and a DVD, and a manual, which don't just teach techniques but put massage into the context of loving relationships and the emotional and spiritual (deity free) consequences of serious illness.

Massage has been shown to have powerful palliative effects for people with cancer, reducing pain, nausea and other symptoms as much or more than drugs. This project goes one better, by replacing the professional massage therapist with a loved one who also benefits from knowing that she or he can do something effective to help the cancer sufferer. That feeling of helplessness is one of the hardest things about facing a serious illness in a loved one, of course. And the relationship between the two also benefits. We hope to demonstrate these benefits using the gold standard methods of biomedical research. (I take no credit for developing the program, we're just helping our colleague with the trial.)

Here's the bad news: no matter how powerful the effects turn out to be, and no matter how much the participants love the program and feel they benefited from it, it will be very difficult to see this program widely adopted and available. The reason, of course, is that no insurance company in the world, nor Medicare nor Medicaid, will pay for it. That's just not what they do.

For my commenters who who ask whether physicians should get involved in the psychological, social and spiritual dimensions of their patients' lives, I would say, not very deeply. That's not their job. They are trained in the biological dimension of health and it would, in my view, be positively destructive to start medicalizing social well being. We've already medicalized psychological well being, and as my readers know, a big part of what I do here is criticize and complain about that. But that doesn't mean that we can't integrate biomedicine with a broader understanding and approach to health and well being. In part, that has to mean a shift in resources away from biomedicine -- in other words, for the United States to become more like the civilized countries of the world.

The Height of Irresponsibility

You may have heard that ABC is debuting a new drama show on Thursday about a crusading trial lawyer who successfully sues a vaccine manufacturer for causing a child's autism. The American Academy of Pediatrics has written to ABC calling on them to cancel the show, arguing that "If parents watch this program and choose to deny their children immunizations, ABC will share in the responsibility for the suffering and deaths that occur as a result. The consequences of a decline in immunization rates could be devastating to the health of our nation's children." True enough. ABC says they'd feel just awful if any parents opted not to have their kids vaccinated as a result of seeing the show, but what do they expect? Evidently they're planning to feel just awful.

According to the CNN story, "Greg Berlanti, a co-creator of the show, said the episode is fictional but designed 'to participate in what is a national conversation' about a controversial subject." First of all, the subject is no more controversial than whether the earth is 6,000 years old. Second, the show does not "participate in a . . . conversation," it perpetuates a falsehood. Airing this show would constitute reckless endangerment and a fraud upon the public.

The world needs to get this straight: childhood vaccines do not, and never have, caused autism. Period. Not probably. Not by the consensus of informed opinion. We know this as surely as we can know anything. This is a fraud which has become viral largely because of the dishonest and self-serving activities of Robert Kennedy Jr., an upper class twit who has traded on his famous name to cause immeasurable damage to the public, and brought dishonor and shame to his family and his employers.

The State of the Union

I'm sure you don't need me to tell you that it is extremely crappy. Unfortunately, if you depend on resources such as the Washington Post, you do need me to tell you that.

For years, President Bush and his advisers expressed frustration that the White House received little credit for the nation's strong economic performance because of public discontent about the Iraq war. Today, the president is getting little credit for improved security in Iraq, as the public increasingly focuses on a struggling U.S. economy.

The New York Times had an eerily similar comment. See below, and compare. Could it be that they are both only pretending to be reporters, and actually transcribing the copy fed to them by the White House political office? Naaaah. Dean Baker has news for the independent media who guard our liberties:

The NYT had a piece today on President Bush's economic legacy. In the second sentence it tells readers that:

"Mr. Bush has spent years presiding over an economic climate of growth that would be the envy of most presidents." adding that "Yet much to the consternation of his political advisers, he has had trouble getting credit for it, in large part because Americans were consumed by the war in Iraq." Is that right? Let's check the numbers. Here the ranking of the presidential terms since 1960 by average annual GDP growth:

Kennedy-Johnson -- 5.2%
Clinton -- 3.6%
Reagan -- 3.4%
Carter -- 3.4%
Nixon-Ford -- 2.7%
Bush II --2.6%
Bush I --1.9%

In addition to having the second worst average growth rate in the past 50 years -- losing the booby prize only to his father -- the Chimpoleon emperorship failed to deliver one penny of that feeble growth to U.S. workers - 100% of it went to his obscenely wealthy friends. And yes, he did get credit for that.

Then there's that improved security situation in Iraq, which the corporate media have been relentlessly touting for the past few months. As I do every Sunday, I did the Iraq Today post yesterday, so I've been paying close attention all this time. In the first place, the Post, and the Times, and the TV networks only bother to report a small fraction of the political violence that occurs in Iraq every day. Based on what I've been reading in Aswat al Iraq (the Iraqi news service), DPA, AFP, Reuters, and McClatchy, the amount of violence that goes down every day seems pretty much the same as it has been for years now.

More of it is directed against Iraqi police and military, which doesn't get counted here in the U.S.; and the daily tally of tortured corpses dumped in Baghdad is down from a couple of dozen to four or so, simply because the sectarian cleansing process is complete. The really big car bombings in marketplaces have also become infrequent, but instead we have a continual plague of smaller attacks on police checkpoints, universities and schools, government offices, and so forth. In the Shiite south, civil and political order have been continually deteriorating, and the region is now a patchwork of fiefdoms ruled by party militias and local warlords. North of Baghdad, where "al Qaeda" has supposedly retreated after ostensibly being chased out of the capital, the U.S. has bought comparative safety for its forces by bribing elements of the insurgency with weapons and money. Now that isn't working so well after all. My post yesterday included two U.S. KIAs, and there have been five more announced already today, along with one who died stateside of wounds suffered earlier. After a dip in December, we're back up to the rate of October 2007 now, and trending higher.

Of course, there has been no political progress whatsoever, even though the Times and Post transcribe administration propaganda claiming that there has been. Meanwhile, the situtation in Afghanistan is deteriorating radically. For all this we're continuing to throw billions of dollars down the rathole every week. But Bush is frustrated that he isn't getting credit.

Listen folks, president Obama isn't going to be able to dig us out of this shithole. Let's hope he at least makes a start and things don't get a whole lot worse next year, but you know what, it may be too late. There is far too little sense of urgency in this country right now. I haven't even mentioned the rest of our crises and ongoing disasters. Sure, politicians feel that they can't afford to sound too pessimistic or critical of the current condition of the U.S., because it doesn't play well with voters or the corporate media. But somebody has to stand up and say it. The current climate of complacency is killing us.

Why is this hard?

Now I get to the stuff I'm supposedly an expert at, and I find it difficult to do a post. The reason is that I'm accustomed to writing about these issues with footnotes and exact numbers and scholarly reserve and all that, and I don't have time for it in a blog post and it would be boring anyway. So I'm just going to lay out some qualitative ideas and if you want the bibliography, send me an e-mail.

Humans are fundamentally social beings. We're the most altricial of all the earth's creatures, to begin with (double meaning intended). Put a human being in isolation, even in the most benign and resource rich natural environment imaginable, anywhere up to, oh I don't know, at least age eight or so, probably older, and it will quickly die. Eventually we develop enough resources to exist independently if we absolutely need to, but even the most resourceful of adults, placed in total isolation from other humans, will go completely insane in a few years and probably destroy itself.

So, our biological existence depends on our social existence. Of course, it isn't just a dichotomous proposition. Our biological state and life expectancy are strongly determined by our social interactions. While it's all the rage these days to claim that our genes have the most powerful influence on our health, that's highly misleading. A genetic inheritance that make us healthy in one environment makes us unhealthy in another, and our environment is largely socially determined. To a considerable degree, it simply is social. The personality traits, and biological traits, to which our genes predispose us interact with our social environment, and they shape it and are shaped by it in turn. Fussy babies have different interactions with parents, and siblings, and grandparents, than do calm babies, which in turn influences the children's behavior, which in turn . . . You get the idea.

There are strong gradients in health status associated with measures of socio-economic status -- level of formal education, job status, income, wealth -- and there are effects of ethnicity which remain even after controlling for these. Inequality within society is actually more important than overall material wealth. Poor people in the U.S. are less healthy than the average Cuban, although the average Cuban has considerably less income. The more egalitarian European societies, though not quite as affluent on the whole as the U.S., have considerably healthier and longer-lived citizens. And so on.

Looking at it from a different point of view, society determines the very meaning of health, in innumerable ways. Disability is a function not only of biological capacity, but of social expectations and barriers. Using a wheelchair is more or less of a disability depending on architecture, and on the attitudes of people around you. Societal expectations about body shape, height, physical capacities, hair, odor, cognitive abilities, behavior, and so on create actual diseases or make them disappear. Think of homosexuality, which was a disease until 1973. Shyness has become a disease, labeled "social anxiety disorder," now that somebody is trying to sell a drug to treat it. We speak of "healthy" relationships and "healthy" attitudes.

I could go on, there are many more dimensions of interaction between the human organism and society, both physical and conceptual. But the summary is that we aren't bounded by our skin. Who and what we are, how we define health, and how much of whatever that turns out to be we turn out to have, is a function of the interaction among mind, body and society. Why then, do we relegate it to a domain of experts whose training is exclusively biological?

A relevant digression

I've tried in recent posts to make the argument that the idea that the mind and body are separate -- that the self is somehow apart from its physical embodiment -- is mistaken. That's important for the philosophy of public health in many ways, which I intend to try to unpack as I go along. Once we unify the psychological and the biological - which I think for most people's sense of self would represent a movement from what seems the innermost core to a larger sphere -- the next step is the social, and that's where I want to go, to think of human health in a terms of a comprehensive bio-psycho-social model.

But I wanted to stop and take note of someone who thought about these issues a long time ago, in a really strikingly modern way. That's Siddhartha Gautama, who lived in what is now Nepal and died somewhere around 2,400 years ago. He is usually called the Buddha but that seems inappropriate to me because according to the earliest records we have of his teaching, he said that he was an ordinary person and that anyone can become a Buddha, which simply means one who is enlightened, i.e. somebody who can see the truth. So he was just a Buddha, not the Buddha, and we should just call him by his name. Many people, for essentially that reason, call him Sakymuni, which means the monk or sage of the Sakyas, the clan to which he belonged.

Of course in order to view his ideas as modern we have to rip him out of his context. In Gautama's time and place everybody believed in reincarnation, that when we die we are reborn as some other being, human, animal, or supernatural. This belief was so completely integral to the culture that his philosophy had to take account of it, but in my view Buddhism fits with the idea of reincarnation very awkwardly. One can dispense with reincarnation and most of the core Buddhist ideas still make sense.

I must also say that, unfortunately in my view, the school of philosophy and community of seekers that he founded wound up evolving, over time, in numerous sects and cultural phenomena most of which are distinctly religious in nature, which often elevate him into a kind of God, and are concerned with supernatural ideas. Although we don't have any direct record of his teachings, the earliest documents, created some time after his death from oral tradition, clearly indicate that he would have been appalled by all that.

He was, in fact, agnostic when it came to God or Gods, and he did not concern himself with religious belief. He said that it was futile to inquire into first causes, that we should devote ourselves to questions which can be answered by observation. He said that nobody should believe anything he said without testing it empirically.

He also said, and this is what is most relevant here, that the self is an illusion. We are just the temporary confluence of various parts that happen to come together during our lifetime, and when we die, it all falls apart, and we are gone. Even within the limitation of a lifetime, the self is an illusion because, first of all, nothing is permanent or even stable, but everything change. The self we perceive now is not the self we perceived a year ago, or ten seconds ago. Finally, the boundary between self and body and self and world can only be drawn arbitrarily, they all interpenetrate and interact so that no real separation exists among them. (That's why the whole reincarnation thing doesn't work very well. If there is no self, what exactly is being reincarnated? A lot of Buddhist scholasticism is about wrestling with this problem.)

This philosophy may seem depressing or nihilistic at first glance, but it is the opposite. It's the key to freedom from suffering, which is the usual fate of humans but for which he had the diagnosis and the cure. Suffering is caused by what is variously translated as desire or attachment, but if we recognize the illusory nature of the self, egoism melts away and with it the frustration of desire and hence suffering. Furthermore, when we are no longer concerned with the needs of the ego, we are freed to experience compassion for all sentient beings. Far from being nihilistic or apathetic, the Buddha is filled with purpose, but that purpose, universal enlightenment, is entirely unselfish.

He taught various methods for achieving enlightenment, but one I particularly want to mention here is mindfulness. As I said earlier, we generally act without awareness of why we act, in fact we generally act without even being aware that we have made a decision. That's how we end up saying cruel things that we regret or taking unreasonable risks or screwing up a task. One extremely important practice is called mindfulness -- to try, throughout our daily lives, to be self aware, to notice what we are doing and to reflect on what might be our motivations and the wisdom of our actions. This has many potential benefits, but one of them, ultimately, is to reveal that the self we thought we knew never existed.

Of course, enlightenment is an ideal, a goal which none of us really expects to achieve. But think of it as a path, a way of living. Because Gautama's philosophy was essentially pragmatic, and concerned with methods more than metaphysics, it is a good model for contemporary forms of psychotherapy, particularly cognitive behavioral therapy, and indeed I have met psychiatrists who base a lot of what they do on essentially Buddhist ideas. So I offer this as another way into some of the problems I've been writing about lately, for what it's worth.

Democracy

National Pubic Radio does a lot of those person on the street interviews with prospective primary voters, and while they are not good for my blood pressure, they force me to confront an inconvenient truth. Here are the Republican voters I've heard recently:

• A guy whose number one priority is getting the U.S. out of Iraq. He has decided to vote for John McCain because McCain's a military veteran, and that means he's the guy who knows how to end the war and bring the troops home. One major problem with that theory is that McCain has absolutely no intention of bringing the troops home. On the contrary, he says that he doesn't mind if they stay there for 100 years.
  
  
• A woman who says that she's going to vote for Mitt Romney because "he's a committed Christian, and he isn't ashamed of it." Uh, lady -- I've got news for you.
  
  
• A guy who is also going to vote for Mitt because "he looks presidential, he sounds presidential, and he did things in Massachusetts that have never been done before." In fact, the only thing Romney ever did in Massachusetts that he hasn't completely and utterly repudiated was to try and fail to repeal same sex marriage. True, that hadn't been done before.

The fact is that election campaigns are largely contests for the votes of people who know almost nothing about public policy and have no concept of what is at stake. People who are well informed and who vote based on policy just aren't all that persuadable by the methods available to candidates -- 30 and 60 second advertisements and debate sound bites. They already know what they want and they know who is in favor of what. There isn't enough time or space to make reasoned arguments that might actually persuade a thoughtful voter, and the completely idiotic corporate media just exacerbate the problem. So it's the votes of the ignorant and the barely interested that are at stake.

My youthful idealism has had to give way, in part, to a recognition that our republic is unlikely ever to be a mechanism for translating people's real interests into government action. It may -- and right now I can only say "may" because we are certainly tottering on the brink -- provide a firewall against the worst excesses of tyranny. But that's about the best we can hope for.

Nevertheless, for me, la lucha continua.

Juxtapositions

Yesterday a few thousand demonstrators marched in DC on the anniversary of the Roe v. Wade decision, proclaiming the "right to life," which in their view applies to blastocysts and fetuses.

It does not, however, apply to children. On the same day, UNICEF released its annual report on the state of the world's children. It seems that almost ten million children under the age of five died last year from readily preventable causes - malaria, malnutrition, diarrhea. For the cost of a bus ticket to DC, each of the demonstrators could have saved a dozen of them.

And, another open door crashed through: as you have no doubt already heard, the Center for Public Integrity put together a handy dandy database of Chimpoleon administration lies in its campaign to go to war in Iraq. No news here, of course, but anyway, none of the lies was about a blowjob so it really isn't important.

I am very proud that unlike Christians, I don't have moral values.

Freud was sorta kinda right, in a way

Okay, while the global economy collapses and the veep tries to get a war with Iran started while he's still got the chance, I'm going to plow ahead with the current program. Freud made a lot of mistakes, in substituting intuition for research and the specific culture of upper middle class turn of the century Vienna for all of human existence. No, it probably isn't your toilet training or your suppressed desire for your cousin that's responsible for your unhappiness, and all those profound symbols in your dreams are probably just meaningless brain spasms. He also seriously lost his when he decided that those tales her heard of childhood sexual abuse were actually fantasies.

However . . .

It is true that our consciousness offers only a tiny slit of a window into our mental processes. We are largely unaware of why we do what we do, and our free will is mostly, if not entirely, an illusion. Processes go on in the brain that result in decisions to act, that we become aware of only after they have been made. It appears to us that this conscious entity, this self-aware ego, exists somehow apart from the body, and controls its actions, but that is not how it works at all. Freud gave us an animal id and a socially created superego. Squeezed between the two, the ocean and the air, the soul drifted with wind and tide. The parsing of the psyche into those three parts was arbitrary. I would say that it reflected common assumptions about human nature as inherently amoral and requiring external force to control depravity, but the basic idea that the vast bulk of mental processes are not perceptible to consciousness was correct.

Nevertheless, when it comes to what we, as humans, value, it's what's in our consciousness that matters. Whatever it is that's making us want something, we experience desire. If we behave in a way we regret, it's the opposite of consolation, at least to me, that the behavior was generated by a process of which I was not conscious. I still want to do something about it, to behave less counterproductively in the future. The recognition that free will is illusory only means that change is is more difficult than I would like, it is not helpful as an excuse.

I apologize for the recent eruption of bullshit, but I'm still going someplace. More to follow.

Thoughts for the Day

When I was young, Martin Luther King meant a lot to me. I understood that the world was changing, because oppressed people had risen up and refused to accept oppression any longer, and he embodied the movement. But he did more than that. He accepted the responsibilities and burdens of leadership, and of the symbolism that surrounded his identity. He knew that he would pay with his life for his choice to take up those burdens, but such was his courage that he scarcely acknowledged his doom until the night before he was murdered. He became great in a cause which threatened only a decadent and fading order in the most backward part of the country, but he carried his hard-won moral capital into a direct confrontation with the world's most powerful elites, as an opponent of imperialism and militarism, and a champion not only of an oppressed caste, but of all poor people.

It so happens that this most valiant and benevolent of people had private flaws. The Director of the FBI, a vicious bigot who hated him, tried to blackmail him into committing suicide by threatening to reveal his adultery.* How would today's "Christian" political movement view a new MLK? You know the answer -- they are the same people who hated him when he was alive, the same people who found justification for slavery and racism in the Bible, and today find justification for other hatreds, for imperial conquest, and the privileges of wealth. King's sexual transgressions would be just one more weapon with which to discredit his passion for justice.

There is a great deal that I have found deeply disturbing about the past decade or so in this country, but one item at the top of my list is the craven silence of Christian leaders who still claim to believe in a Jesus who championed justice, peace and compassion in the face of the hijacking of their faith by hate filled, greedy and violently reactionary extremists. Who has stood up publicly, in the name of Christianity, to condemn these hypocrites, these deniers of Jesus, these howling demagogues who champion oppression, ignorance, vengeance and sanctimonious self-righteousness in the name of God and Jesus? No-one of any consequence. There is no-one with the courage to restore the good name of Christianity.

*Quite likely, in my view, Hoover arranged King's murder, but I don't want to dilute the main point of this post with speculation. The attempted murder by blackmail, however, is undisputed historical fact.

Truly, profoundly disturbing

I'm talking about Mike Huckabee, who just might be the Republican nominee for president -- and no, it is not farfetched at all. CNN and the New York Times can't be bothered to tell you who this guy really is, but Alex Koppelman and Vincent Rossmeier will. It's not a secret either. But the corporate media, the politicians, and religious leaders who are somewhere this side of sane are all afraid to say anything about it.

The candidate's religion is supposed to be off limits. We can't talk about Mormon doctrine and how that might influence a Romney presidency. In fact, it isn't polite even to inquire what it is. The same goes for Huckabee.

Why the hell not? Huckabee has already said, publicly and right out loud, that he wants to amend the constitution of the United States to conform to his religious beliefs. He has said more generally that he will be guided in his conduct in office by his religion. So it seems to me a matter of the highest urgency that we all know exactly what his beliefs are. It is perfectly appropriate to demand that he spell them out, completely and in detail. He's the one who says it matters.

Governor:

• What do you believe is the age of the earth? Of the universe?
  
• Do you believe that the diversity of biological species on earth today is the result of Darwinian evolution?
  
• Do you believe that at some time in the near future the world as we know it will end? If so, what specific events will occur at that time? What are the implications of this prophecy for public policy right now?
  
• Do you believe that the United States should be governed as a Christian theocracy?
  
• Do you believe that the Bible is the ultimate test for all claims as to what is true?
  
• If so, do you want the United States to be governed by Old Testament law? What should be the punishment, in a Christian United States, for blasphemy, for homosexual acts, or for profaning the Sabbath?
  
• What should happen to citizens who are not Christian, who deny the divinity of Jesus, and who refuse to be governed by biblical law?

Will anyone stand up in a public place and ask him any of these questions? What if he refuses to answer?

Stuff

Item One: It is my duty to comment on the study published last week in NEJM that came up with a new estimate of civilian deaths in Iraq following the 2003 invasion. The consensus spin on this was "See, those peaceniks got all hysterical over the earlier estimate of 600,000, it was only 150,000." So I guess the war was a good idea after all. Actually neither study is conclusive. The new one was based on a larger sample, which all things being equal is better, but it was conducted later, which is worse. The basic problem is that households in which people have died are less likely to be around to be sampled, and the problem gets worse as time goes on. This happens for a few reasons -- some households get wiped out entirely, and then there is no-one left to sample. Households that have lost the breadwinner are likely to dissolve, to move in with relatives, to leave the country entirely -- as 2 million Iraqis have done. The researchers tried to correct for this using various assumptions, but these were largely guesswork. Probably the worst thing about this study is that they used the Iraq Body Count database for geographic weighting. I could go on, but the bottom line is, this study might make you lean toward the lower bounds of the Johns Hopkins confidence limit, but it doesn't make me reject the earlier study. The truth might lie somewhere in between the two, but who cares? 200,000, 400,000, 600,000 -- it's still horrific.

Item 2: The Vytorin debacle -- which I linked to a couple of days ago -- is worse than you think, on many levels. To recap, if you watched even one hour of TV in the past months, you saw that weird ad in which people are presented who are dressed up to look like various items of food. It was telling you that a combination of a (patented, expensive) statin and a drug called ezetimibe is the best thing for preventing heart disease. The fact is, the manufacturers had absolutely no basis for believing that, ever. It lowers LDL cholesterol more than a statin alone, but that doesn't prove it is more effective at the ostensible purpose, which is to prevent heart attacks. The FDA nevertheless approves drugs based on these so-called "surrogate endpoints," even though it has turned out, repeatedly, that they do not predict health outcomes after all. Even worse, the main point of the two-drug combination was to force doctors to prescribe the more expensive statin, instead of a cheaper generic, if they wanted to give people ezetimibe. Now it turns out that the companies knew for months the results of studies showing that people taking Vytorin had worse arterial plaque than people taking a statin only, and they delayed releasing those findings while they continued the massive advertising campaign, obviously trying to milk every last dollar out of the situation they could. Last but not least, ezetimibe has side effects, sometimes quite severe -- which they were inflicting on people for no benefit, at the same time they were robbing them. But that's just typical drug company behavior. The jails are full of crack dealers and smack dealers, let's put some Vytorin dealers in jail for a change.

Item 3: Suppose one of the leading Democratic presidential candidates was a radical extremist who wanted to amend the constitution to accord with Marxist doctrine. How do you think that candidate would be treated by the corporate media? Then we have Mike Huckabee.

Item 4: This just makes my blood boil. (Abstract only available to you uncredentialed scum.) The incremental reforms at the FDA now include the requirement that drug companies register all the trials they have done on their dope, including the ones that aren't published. So these sleuths managed to wangle all the data on antidepressants. Of the trials done testing anti-depressants, almost exactly half found a beneficial effect, and half did not? Guess which half got published. Actually, it's worse than that -- some of the ones with negative findings were published, but claimed positive findings. They get away with that by fishing around for a comparison somewhere in the data that makes the drug look good, even though that wasn't what the trial was intended to test, and then pretending that was the point of the trial all along. They would often omit to mention the negative finding at all. (The reason that is totally not legit is because some apparently significant findings will appear by chance, even though there isn't any real effect. If you comb through your data looking for significant p values, and just report those, you're committing a kind of statistical fraud.)

I mean it. The wrong people are in jail.

Head trip

In my last post, I asked people to think through the implications of accepting the idea that fibromyalgia (for example -- the analysis extends much further) is, yes, a real phenomenon and a physical phenomenon, and also is located in the brain, not the body parts that hurt. C. Corax notes, correctly, that making the diagnosis psychiatric or psychological both stigmatizes sufferers, and may limit their insurance benefits for the condition. But why is this?

My main purpose here is to think harder than we usually do about the mind/body problem in the context of health and illness. What, in general, makes a disease psychiatric in the first place? In a nutshell, as I have argued before at greater length, just two criteria: the manifestations are principally behavioral, and the etiology -- the causal process -- is unknown. Complaining of pain and fatigue is a behavior, by the way. FM sufferers may also show other behaviors such as not working or not exercising very much (they tend to gain weight as a result), but they can be diagnosed simply because they report symptoms, even if they work through them.

Complaints of pain that can be linked to a known etiology, that is to say some physical finding or even a coherent physical explanation which cannot be physically detected or demonstrated, receive diagnoses which are not psychiatric. For example, chronic pain syndrome resulting from a long-healed injury is attributed to priming of pain circuits which then become permanently overactive. This diagnosis is considered neurological. (The phenomenon, by the way, was first noticed during the Civil War and has had various names, but nowadays it is usually just called chronic pain syndrome.)

In my previous post, I suggested that FM is, at least in some cases, essentially a more generalized version of this phenomenon. The only reason that it would be construed as a psychiatric, rather than a neurological diagnosis is because there isn't any specific injury or insult that can be identified which might have triggered it, in other words, there isn't a good etiological story. So why should that matter?

Here's why, in my view. Most people, including most people with FM and most of their doctors, whether they will say so or not, believe in a ghost in the machine. (That is philosopher Gilbert Ryle's derisory summary of Cartesian dualism.) Once we locate an explanation in the brain, but we can't point to a specific physical anomaly, we blame the ghost, and that is tantamount to blaming the individual sufferer. The ghost is you, the machine merely your body. If we can find the problem in the machine, you are the victim, but if the problem lies in the ghost, you are the perpetrator. Hence the stigma, the lack of insurance coverage, and the disparagement of the condition.

What I am saying is, that is entirely false. All pain is located in the brain. If you are in pain because your hand has been crushed by a falling safe, it isn't your hand that hurts after all. Nerves in the hand are sending signals to the brain, but it is the brain that is producing the sensation of pain which you feel consciously when the right signals are delivered to your frontal cortex. People with FM feel pain for the same reason, because their frontal cortex generates it somehow. We don't know quite why, in this case, but the ghost is not responsible.

Is the ghost an illusion? That might seem contradictory, because in order for there to be an illusion there must be experience, and experience, ultimately, is not the same as the physical substrate which generates it. Here we come to the mystery of consciousness, which I will be the first to concede is the single great difficulty and embarrassment for realism. Positivism in its original form also has great difficulty with probability and statistics, but a version of realist philosophy can survive that challenge.

The remnant of the ghost survives the assault of reason in the form of conscious experience, but the illusion is that consciousness can be a cause of anything. This finding creates difficulties for morality -- if the ghost is only an effect, how can we be responsible for our actions? -- but the solution to that problem is pragmatic rather than metaphysical. We retain moral principles because they are useful, because they make human society and human happiness possible, and in some cases it is necessary to promote or enforce moral principles through the mechanism of blame. But if we recognize that free will is an illusion, blame must be coupled with compassion.

Don't worry, all this blowing of smoke matters. It's going to lead us back to that question of the fundamental concept of health and what a health promoting society is all about.

Update: Upon re-reading I see that I raced through some complicated ideas very quickly toward the end there. If you aren't following me, let us know and I'll try to explain myself better.

It's all in your head

As I was intending to get back to the mind/body thing, along comes a fortuitous hook: Pfizer, the same people who give you the whorish Dr. Jarvik hawking an expensive statin that is no better than its far cheaper generic competitors (even though he has no relevant expertise and has never practiced medicine), is now marketing a new drug for fibromyalgia.

To us medical sociologists, fibromyalgia is an endless source of fascination. Like the psychiatric "diseases," it is diagnosed based on a checklist of self-reported, qualitative and subjective symptoms. There is no known etiology and there are no physical findings whatsoever. So there is raging controversy over whether there is any such "disease" as fibromyalgia.

People who suffer from the symptoms are generally highly offended by this controversy, and they are particularly offended by suggestions that the cause of the disorder is located in the brain. They think that saying its causes are psychological is to devalue or even deny their suffering, or to blame them for their own condition. Alex Berenson tells you in the above-linked article, they feel vindicated by FDA approval for marketing the drug called Lyrica to treat fibromyalgia. Berenson correctly draws an analogy with depression, which also has had its status as a specific disease enhanced by marketing of drug treatments. (He's maybe a bit sloppy on the exact history there, as antidepressant drugs and corresponding etiological theories go back to way before Prozac.)

But here's where us sociologists pick up the BFH* of deconstruction. Suppose the complaint does indeed stem from processes in the brain? What if one proposed explanation is correct -- that sufferers are hypersensitive to the pain signals that our nerves are always sending under ordinary circumstances? Sitting here at my desk, I have an ache in my lower back, my left hand, and my right foot, my eyes itch, and my neck is a bit stiff. I'll notice little tweaks and shoots of pain here and there now and then, but only if I'm not concentrating on something else. All of these sensations are minor and I completely ignore them most of the time. If you do a careful inventory and really pay attention, I'm pretty sure that you will make the same discovery.

Now, if someone could not ignore a level of discomfort that everybody feels all the time, for whatever reason, would that make their suffering unreal? Would that make them somehow responsible for it? The cause would be in the brain, of course, but does that mean the problem doesn't exist, or doesn't deserve respect? Why would that constitute denial or disparagement? Would that make their problem not a "disease"? And why would it matter?

Would it make the problem somehow other than physical? After all, the brain is a physical organ, it's part of the body, and something physical is happening in the brain -- whether it be in the neural wiring, or firing patterns, or chemical environment, or all of the above -- that we don't currently have any way of directly observing but which is nonetheless certainly real.

Why is that fundamentally different from a strep throat, or cancer, or a torn ACL? And why, if you had that problem, would you fiercely resist that particular explanation? Think about it, and then think about further implications.

*That's a carpenter's term for a really big hammer. You can figure out what the F stands for.

Murder Most Foul

mur·der /ˈmɜrdər/ –noun
1. Law. the killing of another human being under conditions specifically covered in law. In the U.S., special statutory definitions include murder committed with malice aforethought, characterized by deliberation or premeditation or occurring during the commission of another serious crime, as robbery or arson (first-degree murder) . . .

Please forgive my absence . . .

I'm sure my 4 1/2 readers have already figured out that I've been a bit scarce around Blogostan lately, and it's probably not a mystery why. This is my 1,211th post on Stayin' Alive -- and I've posted a fair bit elsewhere as well. On the one hand, it doesn't feel right to recycle, although truth be told there probably are quite a few posts I made earlier that I'd like folks to read again. On the other hand, I'm finding current events dispiriting rather than inspiring lately. The whole presidential primary campaign, which is the obsession of not only the corporate media but the liberal blogosphere as well, is repulsive and ridiculous as far as I'm concerned. I just want it to be over. It certainly is not an exercise in meangingful civic engagement and it makes a mockery of democracy -- that includes both parties by the way.

So, I've been blowing smoke about matters that tend to concern professors. They interest me as well but haven't gotten much of a rise out of the masses. So let me take a break from that project and think about some odds and ends.

I've always been a science fiction fan, particularly as a youth but I still read the best of the genre from time to time. Those galactic civilizations depend on faster than light space ships or farcaster portals or some such device, but a far as we know right now all of that is impossible. And yes, it is possible for things to be impossible. The universe has structure and that imposes limitations.

Interstellar travel is absolutely possible, in fact it isn't even difficult. We could mount a robotic expedition to a nearby star using current technology, that could send back information about whatever it finds there. It is even quite plausible that if civilization doesn't collapse and current trends in scientific and technological development continue, we could even send some frozen embryos, artificial wombs and robot nannies and establish a colony -- if there was a habitable place for it.

Alas, there is a very good reason why nobody is proposing such an endeavor right now, and that is the dimension of time. We are talking about sending a probe into the far future -- and I mean thousands of years. Lots of thousands. To give you an idea, the Voyager 1 spacecraft, which has already left the solar system, is traveling at about 540 million km/year. One light year is about 9.5 trillion kilometers. So, according to my crude calculations, if we concentrated on acclerating a probe to the maximum possible velocity, we ought to be able to get to above a billion km/year, which means we could cover a light year in less than 10,000 years, and get to the nearest star system in about 40,000 years or so.

With methods far superior to the pathetic chemical rockets we use today, we could probably cut that down quite a bit, but of course you would then have the problem of decelerating on the other end. Let's take an optimistic view and say you could travel between stars in 5,000 years. To an extremely long-lived species, or a species capable of taking a very long view, this would not be a problem. Five thousand years is an eyeblink in geological time, and little more than an instant in cosmic time. If a civilization had millions of years to develop, it could spread throughout a large region of the galaxy.

But, as far as we can tell, this hasn't happened. If they are out there, where are they? The most likely conclusion, to my mind, is that there just aren't any intelligent species with such immense life spans that investing in interestellar travel makes any sense. And the reason for that is a very basic fact about life.

Life cannot exist without death. Without death, there can be no evolution. A species that lives too long is going to lose the game of life, because it won't get out of the way of its offspring and more rapidly evolving species will soon eat it for lunch. That doesn't necessarily mean the shorter the better. Bacteria can evolve much faster than we can but they sacrifice the chance for complexity, and definitely for intelligence. So there is a balance.

As an intelligent social species, we need fairly long lives in order to realize the advantages evolution has given us. We need to be able to learn, to acquire knowledge and develop skills, and put those acquired assets to use in making discoveries and solving problems. The amount that we can stuff into our heads gets to the critical mass that can support maximum creativity in a little more than 20 years, for most of us, and most people can sustain a creative life for 50 years or so, and then we're done and we need to get out of the way. So our life span is about right for our ecological niche.

I suspect that is more or less true for the Zorg of Planet Bleflspk and the Vortans of Planet Frbmlr as well. Hence, no intelligent species that lives for 5,000 years, and hence no galactic civilization. It just doesn't make sense to be investing in a project that's going to come to fruition only after hundreds of generations. Very disappointing, to be sure, but why do I go through this exercise anyway? It's to point out that scientific understanding of the big questions of cosmology and biology has fundamental importance for the big questions of meaning as well. Religion tries to explain death by reference to God, but we don't need God to explain death, or for that matter to make sense and meaning out of our mortal lives, even if we don't necessarily like the answers.

Current Events

Okay, since the NYT decided to hire Bill Kristol over me, I'll have to restrict my punditication to this space.

You may have noticed that I've had basically squat to say about the presidential campaign. I did point out that of the three Dem contenders, Edwards has the best health care plan, and Obama has the worst, but who cares, really? It's not as if an Edwards presidency -- which seems unlikely at this point anyway -- will result in the legislation he has posted on his web site becoming reality. In the best case, a Democratic president and a somewhat more Democratic congress in 2009 will result in some marginal changes around the edges. Big Pharma and Big Insurance aren't going to get rolled no matter who is elected.

In fact, the obssessive coverage of the presidential campaign has taken everybody's focus off of a lot that is going on, that really matters. To the extent it has served to create some focus, it's mostly in the form of false consciousness. For example, McCain is making his comeback largely by tying himself ever more tightly to the so-called "surge" and the prospect of "victory" in the Iraq war; and the corporate media are all busy convincing us that it's really working and the situation in Iraq is getting better. No and no. Three U.S. soldiers were killed today, but that isn't even being reported. The reason U.S. deaths are less frequent than before is not because "we are winning," it is because "we" have already surrendered. We stopped fighting the Sunni Arab insurgency, let it take over vast swaths of territory where U.S. troops and the Iraqi army no longer tread, and started bribing it to fight Islamist elements. In other words, the new policy is to accept the de facto breakup of Iraq. Where that will lead in the long run is hard to say, but it's probably nowhere good. Meanwhile, WTF are we still doing there? The people hate us and want us gone, and there doesn't appear to be any objective left.

What is most extraordinary is that the U.S is headed for a brutal economic crack up, and it's largely being ignored -- by the candidates, by your member of congress, and by the corporate media. Emperor Chimpoleon, running his programming, has come forth to insist that it's a reason to make the tax cuts for the wealthy permanent -- and economic boom times would an equally good argument for that position, of course -- but nobody else seems to have a plan, or even to be noticing. With the huge public and private debt, unfunded pension liabilities (no, not Social Security, but state and local government and private corporations), Medicare and Medicaid deficits, and deteriorating infrastructure hanging over us like the sword of Damocles, a recession will cut the thread. Hello!

Climate? If an outbreak of tornadoes in January doesn't get your attention, nothing will.

But coverage of the presidential campaign is about none of this. It's about who is for "change," and who is crying, and who is "for real" and who is "phony." Hell, I don't care how phony the candidate is, so what? Mitt Romney's gay bashing may be insincere, but that is not the basis on which I evaluate it. I'm sure Mike Huckabee really is a Christian dominionist to the very depths of his being, but the genuineness of his beliefs does not endear me to him. Maybe Hillary Clinton does restrict herself to saying stuff in public that has been tested with focus groups, but who gives a shit? Update: I also don't give a shit whether she cried on purpose or not. If she's that good an actor, good for her.

In November I assume I'll vote for the Democrat. Meanwhile we have bigger fish to fry.

A Healthy Discussion

So okay, I could wallow around in wishy-washy sophomoric philosophy for a few more days, but let's put the key issue on the table. What do we mean by good health? Sure, that's technically just a semantic question, but it's actually substantive because the word "health" tends to stand in for whatever the ultimate goal is supposed to be of the blob that ate the economy -- or at least one of the blobs, the Department of Imperial Hegemony Defense being the other.

For quite some time, the approach to this question seemed to be that death was like checkmate, the only thing that matters, and we rated the badness in the world by years of life lost. But then researchers -- economists, mostly -- started to survey people and ask them how much life expectancy they would give up in exchange for, say, not going blind or not losing their legs, and so on. It turns out that the numbers were consistently more than zero, and this led to the concept of Disability Adjusted Life Years (DALYs) or Quality Adjusted Life Years (QUALYs). That became an alternative way of judging the burden caused by various diseases and the value of various treatments.

Sure, it's an advance, but it's still narrowly biological. We're paying money for those QUALYs, for one thing, and that money might buy us something else entirely, but we still don't have a good way of making comparisons between the value of QUALYs and true love, or a new Gameboy. You can't really do it through a survey because QUALYs are just too complex and abstract for people to grasp in making such a comparison.

Amartya Sen has proposed some good stuff, much of which is hard to value in money or QUALYs. There are basic needs, such as adequate nutrition, shelter. And then there are internal psychological states, such as self respect, happiness. And there are social goods, such as the ability to appear in public without shame, ability to entertain friends, a part in the life of the community. (Sen is a genius, by the way, but you probably could have thought of those if you tried hard enough.) So look - that's the bio-psycho-social concept of health that I mentioned earlier. And they all affect each other. Each one of those states enhances the prospects for the others, but they also have independent determinants.

Now here's the nut. If the definition of health is something like Sen's encompassing definition of human welfare, then public health really is everything. But is medicine? Is it up to physicians to get involved in who ought to be ashamed or whether we have adequate housing? (The argument for the latter might be stronger than the argument for the former, or it might all depend.) If not, can public health claim those concerns, or is public health supposed to be about maximizing the stuff that health care is also concerned with, only by more general means? This is also a semantic question but it deeply affects questions such as who gets money to do what, and what you are allowed to write about and still get tenure. It also affects the framing of important public policy questions and how we argue about ethics and social change.

(You may have noticed that I am avoiding current events recently. That won't last forever but blogging can easily become largely reactive. I'm trying to beat that tendency for a few days.)

Bit of a thumbsucker

I'm not going to give much in the way of references or concrete history in this post -- it's basically for conceptual background. But, just pulling it out of an orifice, the story goes something like this.

Until around about the 1960s -- by which I really mean the early 1970s, since the 60s lasted from about 1965 through 1974 -- there was very little questioning of the medical enterprise from within -- or from without, for that matter. Or at least there hadn't been for a long time, since the critical ferment surrounding the Flexner Report in 1910. Back then, the criticism was essentially that medicine was largely unscientific, but in the 1960s, the problem turned out to be just the converse -- that medicine had become too narrowly biological, in the process becoming patriarchal, inhumane, and even contrary to the interests of patients.

There were many critical approaches, complexly interrelated, some mutually reinforcing, others arguably contradictory. The generally accepted relationship between physicians and patients in the West was of a nature now characterized as "benevolent paternalism." The expertise and wisdom to choose the appropriate treatment of disease resided entirely with the physician. The patient's role was to trust the physician and to follow "doctor's orders" --a condition analogous to childish dependency.

Patients ordinarily could be said to have consented to treatment, if only because, as a practical matter, they had to physically submit to the surgeon's knife or swallow the doctor's potions. However, there was no expectation that the patient would be specifically informed about the physician's theory of the patient's disease state, the theoretical basis of the proposed remedy, possible adverse effects, or alternative treatments.

The U.S. Congress, in 1981, mandated a study of "the ethical and legal implications of the requirements of informed consent" in medical practice. The Commission proposed an ideal model of medical decision making in which physicians and patients are partners. While physicians possess expertise about diseases and treatments, the patient is the expert on his or her own tolerance for pain and inconvenience, fear of disability or death, and other subjective factors essential to determining the consequences of a treatment choice for the patient's well-being. The report also puts forth self-determination as having intrinsic value.

At the same time, the very definition of health was subject to reconsideration. Doctors were trained in biological science, but people do not only value their biological state. Most basically, obviously, we also care about our psychological, social and spiritual conditions. Furthermore, our biological state matters to us largely as it affects the latter three. Yes, we need to be alive and conscious even to care, but beyond that, physical abilities and limitations are meaningful only in context. I can't dunk a basketball but I can live with that, whereas Kevin Garnett cannot. Sociologists such as Elliot Mishler -- who found doctors thwarting patients' efforts to tell their stories in their own terms, in which their physical condition was interwoven with their lives as social beings -- and Irving Kenneth Zola -- who found that disability emerged largely in the setting of social demands and physical environments -- recast the very foundation of the medical enterprise. Howard Waitzkin linked it to economic oppression, and Alexendra Dundas Todd to gender oppression. Epidemiologists discovered that low social status was a powerful predictor of disease and death, and found medical intervention to be of little importance to people's health in comparison with the basic conditions of their lives. Holistic views of the human person found medicine to be absurdly reductionist -- doctors didn't treat people, they treated body parts -- livers, kidneys, hearts, colons. But we aren't just the sum of our organs.

But then many of the same critics, such as Irv Zola, who had discovered the inadequacy of the underlying philosophy of medicine, became alarmed by the response, which seemed to be to convert every problem into a medical problem. The medicalization of every social problem from excessive drinking to child abuse to sadness to hunger was often seen, not as an effort to make medicine more humane and patient centered, but as a new form of oppression, displacing social criticism with efforts to locate problems in the damaged individual, and replacing the agency of individual and community with the benevolent paternalism of the medical institution.

So, the intent of this post has been to introduce these problems. Next, let's see how we can untangle them.

And this just in . . .

Via The Prescription Project, this link to a U.S. News and World Report article on the upcoming DSM-V: Who's Behind the Bible of Mental Illness. A taste:

By Kent Garber

In what is arguably the most important mental-health development since the early 1990s, the American Psychiatric Association will spend the next five years producing a new edition of the psychiatrist's "bible," the official guidebook for diagnosing mental problems. The Diagnostic and Statistical Manual of Mental Disorders, as it is known, is hugely influential because it determines what is and is not a mental disorder. In turn, it is responsible for much of the sales growth in prescription drugs.

The most recent edition of the DSM, published in 1994, drew controversy because it turned what had once been a thin guidebook into an 886-page tome that significantly expanded the definition of mental illness. Traits once associated with shyness, for example, became symptoms of "social anxiety disorder." And drug companies went on to spend millions promoting medicines for those problems. Eyebrows were further raised in 2006 when a study showed that more than half of the researchers who worked on the manual had at least one financial tie to the drug industry.

This time around, pledging to avoid even the appearance of conflicts, the APA has instituted screening procedures for the 27 members of its DSM task force, asking them for detailed financial information about stocks, honoraria, and consulting fees from drug interests. It calls the effort the "most transparent" in the medical industry. Yet the summaries of the disclosure statements that were recently released to the public are remarkably spare; they show only the existence of corporate connections, not their dollar amount or their duration.

Read on . . .

Such stuff as dreams are made on . . .

While Freud got psychiatrists out of the lunatic asylum and into cushy offices, nevertheless his work only increased the influence of dualism in psychiatric practice and the relationship between psychiatry and the rest of medicine. While the theory of "functional disorders" did forge a link between mind and body, the etiology of the disorders lay in psychodynamic processes, the still ethereal stuff of mind. A psychiatric diagnosis depends on ruling out "organic illness," and vice versa.

In the 1930s, psychiatrists tried to further advance their prestige within the medical profession by creating the field of psychosomatic medicine. In the functional disorders, patients experience physical symptoms but no organic referent for those symptoms can be found. Psychosomatic illnesses, in contrast, are "real" in that organic symptoms are observable.

In early theories of psychosomatic illness, organic syndromes were linked to psychodynamic processes with a crude narrative logic. For example, ulcers were caused by conflicts over the symbolic meaning of food stemming from the patient's relationship with his or her mother. Based on such theories, psychiatrists claimed they could cure various illnesses through psychoanalysis. Thanks to these treatment approaches, psychiatrists started to get jobs in general hospitals and medical schools. World War II brought further gains for the psychiatric profession as traumatized soldiers required treatment for their supposed psychosomatic illnesses. Alas, in the 1950s, the psychosomatic theories got their comeuppance as attempts to rigorously demonstrate the efficacy of psychoanalysis for physical diseases failed.

As psychodynamic theories began to lose the luster of scientific credibility, psychiatry reorganized its diagnostic schema. The Diagnostic and Statistical Manuals I and II, published in 1952 and 1968, based diagnoses largely on supposed underlying etiologies based on theories about repressed desires and frustrated fantasies and so on. But the DSM-III, first published in 1980 after a developmental process that began in 1974, based diagnoses on checklists of symptoms -- 2 from column A and 3 from column B and aha! You have Major Depression, or Boderline Personality Disorder. Little or no concept of etiology was provided. Since then we've had multiple revisions under the guise of various editions of the DSM-IV. (One of the most notable developments during this period was the elimination of homosexuality as a disease, after much political controversy.)

Since then, etiological theories have largely been driven by the interests of pharmaceutical companies that seek to have DSM disorders explained as chemical imbalances of one sort or another that can be corrected by drugs. For example, while the drug companies claim in their advertising that depression is actually a shortage of the neurotransmitter serotonin, there is no evidence for that whatsoever, in fact the evidence pretty much rules that out. In fact, the evidence rules out that there is such a "disease" as depression at all. People who qualify for a diagnosis of depression under the two from column A and three from column B criteria - or more commonly, in research, based on scores on a questionnaire of 20 or so items -- may or may not respond to antidepressants (usually not, in fact) and may or may not have various chemical signals or functional MRI patterns. One thing they do not have is a shortage of serotonin.

In fact, it is still true today that once an organic disease process is discovered which truly underlies a psychiatric diagnosis, the diagnosis ceases to be psychiatric. The only reason psychiatrists get to prescribe pills is because they don't have a clue what they're doing -- it's a purely empirical art, in other words, let's try this and see if it works. If it doesn't, let's try something else. If it does, great, but we don't know why it worked, or even if it really did -- maybe you just got better.

That is not to say that counseling can't help people. It definitely can, and that's something that psychiatrists still do, some well, some badly. But psychoanalytic or other kinds of psychodynamics based counseling have not been shown to be beneficial in trials. Rather, more pragmatic kinds of counseling -- teaching people to change bad habits, whether of thought or action -- are what works. And so, next time, on to bio-psycho-social concepts of health and the criticisms thereof.

Unsolicited Advice

Today it's colder than Boston in January, so I got home a bit early to stoke the woodstove. In the mailbox is an envelope announcing "You were right, Cervantes, the news media are biased -- just not in the way you think." Uh huh. I open it up and it's an ad for the Christian Science Monitor.

Here's my unsolicited advice: wait to become a Christian Scientist until after you've had your appendix out.

Won't get back to the mind/body thing until tomorrow. As you may have heard, researchers have to spend all their time writing proposals. I'm no exception and I'm in the middle of three of them, all due at the same time. So catch up with me on Friday.

Mind and Body

Continuing with the question "What is health?", let's consider the mind-body problem.

The ancients viewed the mind and body as a single entity. Hippocrates could write with equal authority about diseases we would today differentiate as physical or mental. "Hysteria," for example, was caused by movement of hte uterus, and depression by imbalance of the humors.

Modern positivist philosophy, often traced back to Descartes, has famously split mind and body. From Descartes' time until very recently, if at all, the inner workings of the mind have not been readily susceptible to empirical investigation by the standards of positivist science. (Maybe functional Magnetic Resonance Imaging is changing that -- we'll see.)

During the 18th Century, institutions that cared for the mentally ill in the Western world developed entirely separately from the rest of the medical institution. As Paul Starr wrote, "Although by the 1840s, most superintendents [of mental asylums] were doctors, they kept aloof from other physicians. And, increasingly, as mental hopsitals shifted from therapeutic to custodial functions, psychiatry became primarily an administrative rather than a medical specialty." Back then, the remainder of physicians, who delivered services in patients' homes and their own offices, could do no better than psychiatrists at curing the diseases which came their way. That didn't change until the germ theory of disease and the discovery of hygenic practices which made surgery possible with a reasonable chance of not killing the patient; and ultimately, during WWII, the discovery of antibiotics which for the first time allowed physicians to do more good than harm.

Psychiatry, however, did not benefit fromt he empirical advances of the early 20th Century. When so-called paresis was found to be in fact an infectious disease -- tertiary syphillis -- it left the domain of psychiatry. Even today, when individuals present with other syndromes of brain disease or trauma such as stroke, epilepsy, or tumor, as soon as the organic disease process is identified, psychiatrists lose control of the case and it passes on to neurology or another specialty.

While Sigmund Freud's theories lacked any real empirical support, he did provide psychiatrists with a toolkit for treating the mind. By discovering the so-called "conversion disorders," he forged a link between psychiatry and "physical" medicine which psychiatrists could exploit to enhance their prestige within the medical community. At last psychiatrists had something to offer other physicians in the diagnosis and treatment of "real" diseases. (The conversion disorders were physical symptoms supposedly caused by repressed conflicts or desires.) At last, Freud got psychiatrists out of the lunatic asylum and into private practices where they could treat paying patients.

Next: Cartesian dualism in the 20th Century.