As we begin analyzing the data from our studies and I search for ways to quantify the value of our data, I am repeatedly struck by how the business of modern medicine, especially modern pharmaceutically based medicine, has been conceived of, constructed, and is evaluated on a false and outdated premise of separateness. The notion that a disease is a completely discrete entity, that the disease process is linear and that one medication or set of medications impacts only the specified disease, predominates. This is just not so. Life is complicated, disease is even more complicated, and with the exception of perhaps the outright physical trauma of a limb or the need for immediate decision-making in acute or emergent care, nothing is as simple as the one drug, one organ system perspective from which we measure modern healthcare.
As an example, data from our studies are showing complex clusters of adverse reactions that are multi-system and often evade existing diagnostic categories. The symptoms themselves appear to cluster in ways that are unique and will inevitably lead to a deeper understanding of medication reactions, and hopefully, illness itself. For now, however, they appear to defy the logic of current diagnostic categories. The symptoms never quite fit neatly into a single diagnostic box that defines the disease course or guides a treatment plan.
Instead, the symptoms fall into multiple and sometimes contradicting disease categories, and rather than drill down to an appropriate diagnosis, the individuals in our studies have been assigned a long laundry list of apparently, co-occurring diseases; none, accurately characterizing the scope of their illness. When one disease does not capture the full breadth of symptoms, the trend is to add another. If that doesn’t work and when the interaction between the medications creates more unexplainable symptoms, add yet another diagnosis or three or five. Soon the patient has many active diagnoses, with multiple medications to go with. One has to wonder, how so many individuals can have so many diseases at once. Since, I suspect the laws of probability, and indeed, human physiology are contrary to the current multi-disease trend, it leads me to believe that the western model of defining and treating illness, as anatomically and genetically discrete entities, has reached the limits of utility. A paradigm shift may be in order.
Paradigms, especially in medicine and science, are often guided by forces that determine the limits of what can be known, or more cynically, what are considered acceptable pursuits of knowledge and science versus the flights of fancy of fringe scientists. In this case, I would argue that the forces controlling what can be known are those who profit directly from the current diagnostic system – the pharmaceutical industry. The deeply entrenched conflicts of interest between these corporations, policy makers, regulators, politicians, academic institutions, academic journals, medical societies, patient organizations, media organizations – the very ‘thought leaders’ that determine what is valid and what is not – lends credence to these suspicions.
And by every measure, what is currently valid, are the simplistic and discrete categories, with easily identifiable lists of medications for each, where additional diagnoses equal more medication possibilities or in economic terms more product sales opportunities. Whether the symptoms within these disease categories overlap with each other or even represent a true disease process seems to have little bearing on whether a medication can be fit to match a certain set of symptoms and linked to a diagnostic billing code. The diagnostic billing code becomes at once the arbiter of defined diseases and of what can be known about a particular disease. If there is no billing code, read no product or medication opportunity, the disease doesn’t exist, but if there are multiple, overlapping disease categories, no matter how poorly defined or distant from what the patient may actually be experiencing, there is product opportunity, and therefore the disease, or more likely, the diseases he or she is experiencing, exist. And, if the criteria for defining a particular disease can be relaxed to include more patients and to maximize prescribing opportunities, well then, that is even better.
Consider the most recent recommendation by the American Heart Association and the American College of Cardiology to reduce the risk level for heart attacks necessitating a need for increased prescriptions of statin drugs. The change in guidelines will mean more Americans will be diagnosed with heart disease necessitating prescriptions for the cholesterol lowering drugs, a boon to the drug industry. In a few years, epidemiologists and those who study healthcare trends will report a predictable increase in the number of Americans with heart disease, more money will be poured into preventing heart disease with more medications prescribed and so on. It’s a fantastic business model, control the definition of disease to control the market for products. Will more Americans have heart disease? Not likely, but changing the diagnostic criteria, changing the billing code, to open product markets will give illusion of increasing illness and this benefits the manufacturers of these products.
Unfortunately or fortunately, depending upon which side one is on, lowering the threshold for prescribing opportunities does more than simply increase the number of patients to be given a particular diagnosis, it opens up additional product markets or diagnostic opportunities when the side effects of the primary drug kick in and necessitate treatment. In women, for example, statins increase the risk of Type 2 diabetes. By lowering the criteria for diagnosing heart disease and prescribing statins to more patients, not only will we see an increase in the rates of heart disease in a few years, but because the research tabulating disease rates rely on the diagnostic billing codes, we will also see a corresponding increase in the rate of Type 2 diabetes, most likely created by the increased use of statins. Similarly, because the medication used to treat Type 2 diabetes elicits a corresponding reduction in vitamin B12 levels, which present as a heterogeneous set of neurocognitive symptoms, in a few years, we’ll also see an increased rate of mental health conditions indicated by the growing rates of psychotropic medication prescriptions. And so on.
To be both the arbiter of what is known and can be known, to control the definition of disease and the guidelines for prescribing, is a brilliant business model, but one that does nothing to improve human health, further medical discovery or scientific understanding. Indeed, the survival of this model relies entirely on maintaining the facade of anatomical separateness in disease processes and on not recognizing the totality of medication effects across an entire physiological system. This model relies on remaining ignorant of the inter-connectedness of disease processes and by association the possibility of broad based ‘complicated’ medication reactions.
If diseases remain separate entities and medications work only on specified disease targets, then disease categories remain entirely under the purview of those who stand to benefit from prescribing opportunities. Data that link the onset of a disease to the use of a medication or redefine the scope of a disease process and medication target beyond a specified anatomical region can be easily dismissed. And that is where I find myself, having collected data that questions the accuracy of the current model of anatomically discrete, one medication-one target model of disease. Our data question a paradigm. What does one do with that?
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This article was published originally on November 18, 2013.
Ahh, Western medicine treating people as organs as opposed to holistic and traditional Eastern medicine treating people as wholes within a larger whole. How many Western MD’s ask about one’s family, diet, and life stressors? What about family planning, food safety, and managing debt. What about patients who need advice on caring for the their elderly parents and choosing schools for their child.
Whole person care! Wellness. Mind and body unified? Not in Western medicine.
It’s like biodiversity and deep ecology. It might seem like an easy thing, cutting one prized species from a rain forest. Eliminating one species for wood. But that species is key to thousands of species in the forest. Dozens of insects and symbiotic plants depend on that one tree. Again, if we take the ant away from the forest, or beetles, the forest fails.
Getting to the core of mind-body-spirit-community is difficult in a top down, consumer-driven, dog-eat-dog Capitalist society. The concepts of community of people holding the community’s values and health and safety, or communitarianism on a sociological level, or living with and caring for our own integrated and holistic bodies? All of these principles and ways of being have been shunted aside in Western medicine, Western thought.
Example: So a sick planet – one where 75 percent of all insects are gone in Germany, a more than 80 percent decline in the world’s flying insects – is like a sick person. As we learn more and more about the gut, about the beneficial and not so beneficial bacteria in the human gut, we learn how little things count in that microbiome.
And how little things, like krill in the oceans (a huge food source for hundreds of species, but one that is now threatened because of ocean acidification and the inability of krill and other larger crustaceans to develop, i.e. make shells) make for the key components of the food web. Imagine, the human body not treated as a whole – body, mind, spirit, community. Imagine our industrial medicine model? Imagine the millions of chronically sick people. Imagine.
Just reading E.O. Wilson gives one a sense of how we might look at wholes in the ecologies of our planet: from PBS, http://www.pbs.org/program/eo-wilson/
“EO Wilson – Of Ants and Men is a two-hour film about the life and extraordinary scientific odyssey of one of America’s greatest living thinkers, E.O Wilson. It is an exciting journey of ideas, but also an endearing portrait of a remarkable man; often dubbed “a Darwin for the modern day.” Starting with his unusual childhood in Alabama, it chronicles the lifelong love for the natural world that led him to Harvard and the studies that would establish him as the world’s foremost authority on ants.
But that was just the beginning. His discovery of ant pheromones in the 1960’s led him to start thinking about systems of communication in nature on a much grander scale. He was one of the first to start thinking about ecosystems, still a revolutionary concept at the time, and the ways different species fitted together inside them. His book, “Island Biogeography” and the word “biodiversity,” which he coined in the 1980’s, have since become the cornerstones of conservation biology, something he is very proud of.
This would have been enough for most scientific careers, but there was so much more to come. “
So, when do we have that wake-up call on holism and systems thinking? When do we see the body is more than the sum total of its parts? When oh when?
“Loss of insect diversity and abundance is expected to provoke cascading effects on food webs and to jeopardize ecosystem services.”
When do we see that our medicine in this country is shaped by patriarchy, by mechanistic thinking, forced upon us through managed health care, insurance companies, for-profit profiteers, AKA mercenaries of capital?
In the words of the author of Gut: The Inside Story, Giulia Enders “We live in an era in which we are just beginning to understand just how complex the connections are between us, our food, our pets, and the microscopic world in, on, and around us. We are gradually decoding processes that we used to believe were part of our inescapable destiny.”
This is just the gut she is talking about. What about all systems involved in our planet’s health, our communities’ health, our natural ecologies’ health, our own psychic and physiological health?
Keep questioning that paradigm, Chandler. Really. Throwing pain meds and antibiotics at someone who is experiencing great abdominal pain without having even a diagnosis is how this limited knowledge that Western for-profit medicine runs. It’s a broken paradigm for sure!
This is, in my view, completely accurate and should be the next paradigm in medicine. I agree that the problem is spreading the word. It really needs that the public must understand the principle behind it and force the issue. It will not come from the medical profession or the pharmaceutical companies.
There are many intelligent people “out there” like yourself who have the capacity to reduce their observations to paper. That, I suppose, is the easy part. The difficult part is distributing these very lucid ideas and analysis into the domain of the general public. I for my part spread the information around to as many friends and acquaintences as posssible. Keep these observations coming. Many people are listening. Cheers
There are many intelligent people “out there” like yourself who have the capacity to reduce their observations to paper. That, I suppose, is the easy part. The difficult part is distributing these very lucid ideas and analysis into the domain of the general public. I for my part spread the informaton
Brilliant… well put
Thank you, I try.
A very interesting piece. Lovely to see things thought about in a non trivial way for a change