Map of life expectancy at birth from Global Education Project.

Friday, November 01, 2013

A righteous rant

This one from British doc Iona Heath. (I'm not 100% sure you can read this, I can't test the site without my magic cookie.) Anyway, she reminds me of Ivan Illich's famous book Medical Nemesis. Illich, writing back in 1982, argued that medicine, on balance, did more harm than good. Heath doesn't go that far, and neither do I, although in 1982 Illich had a defensible case. Medical intervention has become more effective since then, as the longer survival of people with heart disease, which I discussed a couple of days ago, demonstrates. However . . .

In addition to the downside that those longer lives are often spent in a condition of sickness and disability, medicine inflicts harms directly. First of all, money wasted on ineffective, futile or harmful medical intervention is money taken from some better use. And that includes improving the social and physical conditions of people's lives in ways that will keep us all healthier in the first place. It also includes putting disease labels on people who have no symptoms and whose only "disease" is some lab test that is outside of an arbitrarily defined range of normality.

Those people then have to live with anxiety and the sense that they aren't really healthy after all. They may take pills that cost them money and have adverse effects. They may undergo biopsies, or surgery, go back for repeated physician visits just to be told the results of yet more and more lab tests. As Heath writes:

[W]e have, for the first time in history, separated our notions of disease from the human experience of suffering and have created an epidemic of disease without symptoms, defined only by aberrant biometrics. An ever greater proportion of healthcare resources are directed towards reducing these numbers to some fictitious state of normality. In the process, those who are perfectly well are not only assigned labels that in themselves can be shown to compromise health but are also exposed to treatments with significant adverse effects. . . . . If nothing else, this serves to distract attention from the government’s failure to meet its own responsibilities for health protection through fiscal and legislative measures, such as promoting greater socioeconomic equity, nurturing vulnerable families, and such policies as minimum pricing for alcohol, and plain packaging for cigarettes.

Extending the range of what is considered abnormal clearly expands markets for pharmaceutical and other interventions, and thereby the possibilities of maximising commercial profit. . . . As more and more people previously considered normal are included within the definition of, for example, hypertension, diabetes, or breast cancer, outcomes improve: rates of hypertensive stroke or diabetic foot amputation or breast cancer mortality seem to fall. In this way, extending the definitions of disease and lowering the thresholds for preventive interventions create the illusion of improved population outcomes, while there is no difference at all in the outcomes for affected individuals. Clinicians, health policy makers, and politicians have found it difficult to resist these seductive illusions of progress.
 We are chasing a mirage. Health is not a biological state read off of an elaborate construct of structured biological measurements. It is a condition to which medicine can contribute sometimes, in some circumstances, but too much medicine is bad medicine. Somehow our culture cannot encompass that.

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