Tuesday, April 5, 2011

Broadening the context to improve our approach to healthcare and the environment (part 1)

Science provides the dominant narrative in contemporary American culture. What once would have been considered social, psychological, political, historical or moral questions are examined now through scientific lenses, often to the neglect of these other disciplines in public discourse.

Scientism is visible in the debate [sic] over environmental regulation, which is taking place almost entirely in the realm of scientific fact, or, more precisely, over what counts as scientific fact and how to interpret it. This is unfortunate for several reasons. First, other disciplines contribute to our knowledge of human effects on climate, most notably, history: see, for example, Steven Stoll's excellent article, "The cold we caused," in the November 2009 issue of Harper's Magazine. Second, the climate models are so complex and require such specialized knowledge that lay people have little hope of contributing intelligently to the discussion, despite being asked to make policy decisions based on that knowledge [1]. Third, ideology, by definition, is not amenable to factual argument; indeed, it tends to become more entrenched within the echo chambers ideologues inhabit, especially if the sound of cash registers is deafening.

There are interesting parallels in the realm of medicine. Biomedical sciences have been particularly greedy for new territory, with genetics taking pride of place: hardly a week goes by without some enthusiastic report of a new genetic basis for this or that disease, personality trait, or tendency to obesity, ovarian cancer, depression, preferring daffodils to petunias, etc. (In some cases the tendency becomes itself something to be treated as a disease, but more on that in another post.)

There is also a growing movement among medical schools to train their students to be more “scientific.” The NIH and academic medical centers had assumed that all the investment in basic research would bring returns in the form of “rationally designed” treatments for a host of human diseases. In a few cases this has worked; thus the current rage for "translational research." But the majority of drugs currently in use were actually discovered by chance observation rather than designed according to an understanding of the disease’s underlying pathogenesis. Can greater emphasis on science, and less on the more clinical skills of perceptiveness, patience, empathy, and the ability to construct and sift through various possible narratives that accommodate the evidence, bring better health?

I’ve written
here recently about technophilia in healthcare, which is certainly part of this scientism, but here I want to highlight the influence of reductionism which is, in part, a consequence of the success of two revolutions over the past century: the first in microbiology and the second in genetics.  There is no doubt that antibiotics and gene discoveries for Mendelian disorders have been valuable [2], but the notion that most diseases are reducible to a single gene or microorganism is a poor way to think about health and illness in general.

Consider, for example, pneumococcal pneumonia, a relatively straightforward disease that is caused (in these terms) by S. pneumoniae. The trouble is that many people harbor the bacterium without developing pneumonia: more is required to develop the disease than merely serving as a host for the microorganism.  The same can be said for tuberculosis: TB can manifest as a lung disease, as a kind of meningitis (in the nervous system), or as Pott’s disease (in the bone). Clearly, factors beyond the identity of an organism determine what kind of TB, or pneumonia, or typhoid fever, or HIV infection a person develops.

Eric Cassell explores the possibilities in a hypothetical case [3]: 
A 76-year old man is admitted to the hospital with pneumonia. He had been found on the floor of his 5th floor walk-up apartment by police responding to a call from a neighbor who had not seen him for a few days. From a test of the man’s sputum, the ER physician believes that the pneumonia was caused by pneumococcus (a belief later confirmed by the lab), and the man is treated with penicillin. By the next day his fever is down and within a few days he is much improved.
At the time of his admission to the hospital, his doctors noted that one of his knees was very swollen. Initially his doctors thought it was an unusual kind of joint disease, but it turned out to be osteoarthritis. In the ensuing days a more complete story emerges: the man’s wife had died a year earlier, leaving him virtually alone in the city. The knee had become increasingly swollen in the weeks before his collapse, and walking became so painful that he restricted his activities markedly, going out to shop as infrequently as possible. Like many elderly bereaved, he knew few people his age (most of his friends had died or moved away) and he had withdrawn from social contact. Having little interest in food, he lost weight and became malnourished.  It is quite common for pneumonia to occur in this setting.
So what "caused" his pneumonia? Obviously he wouldn’t have had pneumonia if the streptococcus hadn’t colonized his lungs. But if he had not had the lung infection, he might have had a different kind of illness, perhaps a bladder infection.  The severity of his malnutrition practically guaranteed that he would develop some kind of infection: perhaps the malnutrition, then, should be viewed as the cause of his illness.
Would he have been malnourished, however, if he had not been grieving, or if he had been able to walk normally, or if he lived on the first floor instead of the fifth, or if he were wealthy and had people to cook for him? 
The factor considered to be “the” cause of his illness will differ according to the perspective of the person asking the question. The ER physician focuses on the pneumococcus; the man’s children, who live across the country, might focus on his isolation; others might attribute the whole thing to grief; still others would blame a social system that permits old people to be neglected. Each of these differing perspectives has merit but is incomplete.
Most American physicians would be quick to point out that, aside from the pneumococcus, none of those other features of the case are specific to the pneumonia.  But given only the pneumococcus, which might have inhabited the old man’s respiratory tract for years, no such specificity exists: he might well have gotten pneumococcal meningitis instead, or an infection from an altogether different microbe.
Moreover, a change in any one aspect of his circumstances would lead to a different scenario.  Suppose that the man’s knee pain had led him to take large quantities of aspirin. This might have controlled the arthritis sufficiently for him to buy food; he would not have been malnourished and thus might not have developed pneumonia. On the other hand, high doses of aspirin might well have led to a GI hemorrhage that in turn led to progressive anemia, which would also have resulted in his collapse and hospitalization. In that instance the disease would be gastritis (or ulcer) and the cause would be considered aspirin. Or, his grief might have led him to start drinking, also leading to GI bleeding (and often malnutrition) or pancreatitis or liver disease. Or again, if the knee had not been troubling him there might have been no “case” at all. At the very least he would have been able to go out to buy food.
In short, illness is a complex narrative, and it is artificial to pin it on one cause or type of cause, whether that be genes, microbes, race, diet, socioeconomic status, or education. This is a key difference between Western and Eastern or “alternative” (to us, not to them) approaches: the Western viewpoint requires that illness be explicable by clear causes that are amenable to acute treatment. Unfortunately, the spectacular success of Western medicine in dealing with a few such diseases (e.g., smallpox) has blinded us to the fact that the vast majority of illnesses do not fall into this category. We sift through genes and molecules, hoping to find the magic key that will release us from suffering once and for all.

There is, of course, a practical motive for this approach that accounts for its appeal. Scientific research operates by breaking down a problem into its constituent parts, to better examine and understand each component.  It is far easier to study one molecule than to study a hundred interacting with one another. Equally important, it is easier to get funding to study a clearly delineated problem than a vague one. 

But, even if we can gain valuable information from studying basic mechanisms of disease, there is another problem: the ability to reduce everything to simple fundamental laws does not guarantee the ability to start from those laws and reconstruct the universe.  As has been said before, constructionism breaks down before the twin difficulties of scale and complexity. The behavior of large and complex aggregates of elementary particles, for example, is not to be understood in terms of a simple extrapolation from the properties of a few quarks and muons. At each level of complexity entirely new properties appear.  This fact alone should make us very humble about tinkering with large, complex systems.

The body is one such complex system; communities, cities, and ecosystems are even larger, more complex systems.  Because science, of necessity, focuses on large populations of simplified, even atomized, units, whether molecules, neurons, or people, it is ill-equipped to address the needs of an individual. This is the irony of the belief that science will lead to personalized medicine: we had personalized medicine before our for-profit healthcare system forced doctors to treat patients like widgets in a production line. Science, which deals with populations, will never be able to predict with certainty how this patient with this set of circumstances and this personality will respond to this disease and this treatment. There is no better set of tools with which to approach patients than clinical acumen, with all its individuality and craftsmanship and appreciation of individual history.

The goals of science, too, are incompatible with the goals of an office visit (or home visit, for that matter). Science studies populations because it seeks to develop principles and models of behavior, whether of prions or planets, quarks or quorums. Science thus valorizes theoretical understanding over practical know-how. But any social or biological process or event will inevitably be far more complex than the schemata we can devise, prospectively or retrospectively, to explain it. “Thin,” formal schemata imposed from the top down ignore, and often suppress, precisely those practical skills that are needed for success.  

The experimental temper of “prescientific” peoples, often impelled by mortal threats, resulted in many important, health-preserving practices. South American Indians discovered that chewing the bark of the cinchona tree was an effective remedy for malaria, without knowing that its active ingredient was quinine or why it worked. Western Europeans knew that certain foods consumed in the early spring could relieve the symptoms of wintertime scurvy, without knowing anything about Vitamin C. The ‘discovery’ of vaccination was actually a refinement of many decades of a practice known as variolation. And, of course, the whole body of Chinese and Ayurvedic medicince arose through centuries of painstaking observation. 

This kind of practical knowledge, based on experience and “stochastic” reasoning, is not merely the now-superseded precursor of scientific knowledge. It is the mode of reasoning most appropriate to complex material (such as health and illness) where the uncertainties are so daunting we must trust our (experience-honed) intuition and feel our way. Yet the Western, imperialistic, scientific view dismisses practical know-how as insignificant at best (“anecdotal evidence”) and as dangerous superstition at worst (all alternative medicine).  We are taught to do nothing that lacks the imprimatur of a scientific study—despite the cautionary history of professional medical advice urging the consumption of Coca Cola (before the cocaine was removed!), reassuring us that tobacco was healthful, warning against the dangers of exercise for women, urging hormone replacement therapy, then retracting it, then urging it again, ad infinitum.

My contention is that we are fundamentally in error when we look to science to dictate our choices. We are like the passive patient before the unimpeachable authority of Dr. Marcus Welby: we want the good doctor to tell us what to do.  Hard experience has toppled doctors off their pedestals for many of us, and we realize that we have to take responsibility for our own health, our own relationships to our bodies and our minds. 

Similarly, the principles that should govern our relationship with the environment have been with us for a very long time. In my next post, I will bring a bit of history to bear on our current debates over regulation.

* * * * * * 

[1] In fact, I made a comment to this effect once on Dominique Browning’s blog, and my point was promptly proven by another commenter who defensively quoted an abstract from a scientific paper in support of his climate-change-denying position, when in fact the paper in its entirety led to an opposite conclusion.  Sometimes the problem is not specialized knowledge or language so much as the fact that lay people—or even other scientists—don’t bother to read the whole story and think through it critically. I didn’t argue the point, not wanting to take over the comments section on another person’s blog, but Ms. Browning issued a firm correction. Still, it’s proof of my argument here, that, basically, a little knowledge can be a dangerous thing.

This phenomenon is mirrored in the medical sphere, where specialized language serves to obscure concepts to the unitiated, with consequences varying from inducing passivity in the patient to creating irritation, non-compliance and misplaced suspicion toward the physician.

[2] The value of these discoveries has not been unmitigated—consider the over-use of antibiotics in agriculture, and the consequent problem of antibiotic-resistant organisms—but that is subject for another post.

[3] Eric Cassell, The Nature of Suffering and the Goals of Medicine (2004).


  1. i so appreciate your succinct observations about how reductionist approaches to disease-cellular to communal-and the privileging of "scientific" knowledge has really undermined health. My husband's daughter is currently studying Ayurvedic medicine in India. Prior to that she worked in hospitals in Boston and Portland, Oregon. Certainly there is much to appreciate about our scientific knowledge, but it is incomplete and limited as you describe. I've shared a link to your site with Ivy, as i know she will find your observations align with her own experiences. thank you pamela

  2. I don't know nearly as much as I would like to about the Ayurvedic tradition; how did Ivy select that particular path, and is she also exploring other Eastern medical practices?

    One of the other trends that interests me is the professionalization of caring. My observations over time suggest to me that people look more and more to physicians and therapists (and hairdressers, masseuses, etc) to feel held, cared for, listened to as they enjoy less meaningful interactions with work and community. One problem with this, regarding physicians, is that people also take less responsibility for understanding their own bodies and what makes them work well. We all ultimately have to be students of ourselves, because no one else will every really know what it is to inhabit our particular bodies, with all their idiosyncracies.

  3. How about a 'family doctor franchise'? It is not Starbucks that we need on every block, but a primary care facility for non-emergency and preventive care; a place where people feel comfortable visiting, are treated well, are comfortable while waiting, and could even develop a sense of community. It is the notion of a 'third place,' developed by Starbucks, but for the health care industry