Map of life expectancy at birth from Global Education Project.

Friday, October 09, 2009

Credit where it's due

I have tossed my share of snark in the direction of National Public Radio, but this time, they get their full complement of "l"s. I thought this story by Alix Spiegel was exemplary journalism. This is what the profession ought to be about, and is so seldom.

It's also a great follow-up on yesterday's post and gives me a chance to make an additional important point. You'll notice the URL for this site - health vs medicine. That represents a basic premise that I probably don't bring to the foreground often enough. Obviously medicine is supposed to be making us healthier, but it's just as much the enemy of good health as it is the champion. This happens in multiple ways. Taxonomies are always a little bit arbitrary -- you can lump or split as you like, and organize groups of phenomena in various ways. I'll just make a crude first effort here.

First, as Spiegel's story makes clear, doctors may simply do things that hurt more than they help. They have enormous power over our bodies, including the power to cut out essential parts. We don't generally know any better than to trust their judgment, but it isn't necessarily very good. This is partly due to the general culture and the specific medical culture that's both embedded in it and highly influential. We have a bias toward action, toward doing something; we're all about being bold and decisive and heroic. And we have a lot of faith in technology and anything that wears the guise of science. But the shocking truth is, much of medical intervention is not based in science at all, is not driven by evidence, but by physician's intuitions and customary ways of doing things. And, let's bite the bullet and make this painful admission: doctors are paid to do stuff, and the more radical their actions, the more they are paid.

Second, by holding out the false promise of perfect health and great longevity, medicine distorts the culture and our individual response to pain and disability. Ivan Illich, who was a Catholic priest and had that Catholic fatalism, was an aggressive proponent of this view. It showed up in Keith Olbermann's special comment, where he seemed to champion the defeat of death and worship at the altar of medical miracles. Life sometimes throws adversity our way. Not that it isn't worth trying to cure disease and relieve pain and give people a good lifespan, but we also just have to suck it up and deal with it sometimes.

Third, our excessive faith in medicine diverts our attention from the very important social determinants of health, to which Bix eloquently alludes in a comment on yesterday's post. Social justice begins long before we even think about universal health care. Sure, if we had it our society would be more just than it is now but we would still have huge inequalities in health and life expectancy because of all the other inequalities that would remain, for which medicine does not have the answer.

And fourth, every dollar we spend on medicine is a dollar we don't spend on something else, whether it's a modicum of justice, or a measure to promote the general welfare such as generating cleaner energy or providing parks or mass transit or clean water.

That's why health care reform is only the beginning. And the wrong kind of reform, that just extends the present medical pathology to everyone, and sucks more money and more social and cultural capital out of us all, will be worse than nothing.


Nosmo said...

You probably saw this in the New Yorker and may have commented on it, but it deals with the same issues in more issues and discusses the culture that causes it.

What a Texas town can teach us about health care
link here:

Nosmo said...

that link looks cut off
this is the same:

robin andrea said...

An excellent NPR piece. Everyone in Congress should listen to that while they are discussing our health care future.

kathy a. said...

that is a very good NPR piece. what it points to is the need for patients to have more information before choosing more invasive and/or potentially harmful options, i think.

the point was more along the lines of pressures on doctors to do more intervention, but ultimately an informed patient is supposed to be the decisionmaker. if one knows that half of back surgeries cause more harm than good, one will be less inclined to try that out, for example.

there was one vignette from a woman who had an early hysterectomy in a small town where that was common. she felt that was because most people were catholics, and women were worn out by having many children. i thought that explanation was unfairly discarded; yes, the doctors may have pushed hysterectomies because of custom or profit, but women may have accepted that option if they were exhausted and felt they had no other options to stop childbearing.

it's not all about the doctors. why people choose certain procedures may be more complicated. that may be especially true with end of life care.

i think my dad chose to continue fruitless chemo treatments that made him horribly sick, even though he knew he was dying, because he thought he'd be considered a loser if he didn't stop fighting the cancer. as far as i can sort it out, one of my sisters promoted this view, relentlessly -- the one who wanted to sue everyone afterwards, but the rest of us wouldn't let her.

hospice would have helped with the family dynamics. dad died a few days after his last chemo -- and it was going to be his last -- so he was considered to be in active treatment, and ineligible for hospice.

Bix said...

Thank you for Spiegel story.

I liked this line:

"so it wasn't the illness that was driving this, this must be coming from the provider side."

Anonymous said...

Good link from the New Yorker, thx, this sentence popped out at me:

quote: In 2006, doctors performed at least sixty million surgical procedures, one for every five Americans.

That is insane! Where does that 60 million come from, and what is with the ‘at least’?

And the one in every five Americans = US citizens, its official population, 304 million, including babies, teens, healthy twenties, dashing thirties, etc.

Of course, some will have had 2 or 3 or more procedures in the one year. Probably in the ‘end of life’ age-slice 70% of ppl undergo at least one procedure...who knows...

A quick goog turns up only a report that examined 32 million 2006 surgical procedures (US)

quote: (75%) ...surgeries were performed in freestanding facilities, physician’s offices, or in hospitals as outpatient procedures. 

So that is Lasik and removing verrucas?? (see paper for some clues.)

and this OK paper on back surgery, country comparison:

Why is it so hard to find general, overview, solid, clear info on health in the US? Not of course that it is so easy / excellent in other countries, though some like GB, FR, Switz, EU / OECD, etc. do a better job imho. Well I suppose I can answer my own question. What a mess.