Overdosed America (32 page)

If our model of heart disease prevention is dominated by reducing the number of LDL cholesterol particles migrating through arterial walls, then certainly the proper focus of care is the individual patient. But health is not just an individual phenomenon. There is a large ecological component that includes family, community, and cultural and social factors, as well as the physical environment. Just as
individuals are made up of multiple levels
of function, they are also embedded in these larger contexts that play an important role in their sense of identity, personal beliefs, and sources of meaning—all of which plays a large role in determining their health behaviors. As
Richard Lewontin
, professor of biology at Harvard University, says in
The Triple Helix,
“taken together, the relations of genes, organisms, and environments are reciprocal relations in which all three elements are both causes and effects.”

Besides the enormous volume of basic medical science to be learned in the first two years of medical school, one of the most important tasks is to learn the difference between a “patient” and a “person.” We all know that a person is someone who has “I-ness,” with consciousness and subjective experience, a sense of values and purpose, like ourselves. A patient, on the other hand, is a body in which the experiences of pain and disease are understood as objective phenomena, observable and verifiable by the tools of science.

A first-year medical student who had recently started to dissect her cadaver in anatomy class told me, “I don’t want to donate my body. I had gory dreams about desecration. It wasn’t right that I was learning so much from a process that I did not want my body to be subjected to after I die. I don’t think I could, knowing what goes on in the anatomy lab.” What goes on is a kind of black humor that only partially mitigates the discomfort students inevitably feel as they learn to relate to the human body as a thing devoid of personhood. Dissecting a cadaver in the anatomy lab is an important medical school initiation rite, the beginning of what Byron Good, a medical anthropologist at Harvard Medical School, calls learning the
“clinical gaze.”
The students’ way of seeing the human body, at least their patients’ bodies, is forever transformed.

As the students dissect their cadavers, they learn with a double-edged scalpel: at the same time that their knowledge about the physical body is expanding, their ability to relate to their future patients as people—with all of the feelings, fears, and yearning for meaning that they know in themselves—is shrinking. Professor Good observes, “
This means of interpreting reality
is both powerful, illuminating many disease phenomena and providing the basis for therapeutics, and at the same time profoundly ideological and often misleading.” The misleading aspect of the interpretation is what makes so many of us cringe when we find ourselves in the dehumanized role of patient. There is no place in the biomedical model for patients to have personhood.

According to philosopher John Searle,
subjective experience and consciousness
are not the kinds of things that can be studied directly by the tools of science—they can only be experienced. Sure, medical researchers observe with increasing sophistication the physical correlates of subjective experience, relying upon galvanic skin response (the lie detector test), electroencephalogram (EEG or brain wave) recordings, and functional MRIs of the brain. These objective observations can help us understand what kind of physical changes take place during different experiences, but they get us not a whit closer to understanding what it feels like to be that person whose brain we are observing, nor to understanding the meaning of the experience for that person. This is why the extrascientific qualities that define personhood (and contribute so much to the personal decisions that are usually the most important determinants of our health) tend to get discounted or diminished in the world of biomedicine.

And this is the rebuttal to the last principle of the biomedical model, the tacit assumption that all valid knowledge is amenable to investigation by the tools of science. We all know that we are not “things” like the cadaver in the anatomy lab, that we possess “I-ness,” and that our core of meaning and values is related to our sense of self and not to the kinds of knowledge that science reveals. Strict allegiance to the paradigm of biomedicine demands a hierarchical ordering of metaphysics with the facts that can be known by the methods of science alone at the top. A less constraining paradigm would
value different metaphysical perspectives equally
: One perspective is the body as a thing, that can be known by science. Another is the person, whose essence can be known directly only by first-person experience. And there is also a
mysterious and dynamic relationship
between the two that will, at least for the foreseeable future (and I suspect forever), keep the “art” of medical care from being rendered obsolete by progress in medical science.

The challenge
to doctors is to learn as much as possible about the scientific-technological skills of medicine, while maintaining the wisdom to integrate these skills into what are fundamentally moral and interpersonal relationships with their patients. It is only then that patients’ beliefs and values become legitimate concerns in their medical care, and only then that the doctor-patient relationship reaches its healing potential.

The greatest distinguishing characteristic of primary care medicine—family medicine, general pediatrics, and general internal medicine—is that the subject of care is the person, not a particular disease, not a specific body part, and not just a physical body. Though metaphysics is not a frequent topic of conversation in primary care training programs, all good primary care doctors know that their first responsibility is the ongoing care of the person.

This distinction
keeps primary care permanently at the bottom
of the status hierarchy within academic medical centers. In the arena of modern biomedicine, attempts to integrate the interpersonal aspect of healing into patient care are looked upon, at best, as an extracurricular activity, and not uncommonly with haughty derision—a petty distraction from “real doctors’” concerns with “real medicine.” This is the legacy of the Flexner Report: good medicine defined exclusively in the terms of biomedicine. If only
Sir William Osler
could return to help modern doctors understand once again that “It is much more important to know what sort of patient has a disease than what sort of disease a patient has.”

Pretending to care
about our health is often just part of the drug and other medical industries’ overall strategy to increase their sales. They dominate the medical journals, airwaves, newspapers, and magazines with “information” designed to convince doctors and patients that their products are essential for good health. They focus attention on the health problems and solutions that are the most commercially advantageous rather than most beneficial for our health. They even pathologize normal human experiences such as menopause and aging, reframing the transitions of a healthy life into medical problems that require diagnoses and drugs—and in the process alienating us from the meaning inherent in the landmarks of a healthy life.

The truth, as we have seen, is that the benefits of medical care are real but limited, and more is by no means always better, and is often worse. These awkward facts get shoved into the background of our common wisdom by the bright lights of advertising and medical news that shine incessantly on the “breakthroughs” in medical progress and the drugs that you should “talk to your doctor about.” By saturating our sources of information, the medical industry has convinced most Americans that the answer to almost every health problem can be found in a brand-name pill or high-priced medical procedure.

That’s the bad news. And it’s very bad, costing Americans hundreds of billions of dollars a year and, even worse, compromising our health and quality of life. But there is good news, too—and it’s enormously good: the evidence from study after study, including gold-standard randomized clinical trials, shows that we can usually do a great deal more to maintain our own health than the medical industry, particularly the drug industry, promises it can do for us.

The goal in this chapter is not to reject medical care, but to use the best available scientific evidence to place it in the proper perspective. Exposing the distortions of commercially driven medicine is an essential part of this process, but still it is important to remember that about two-thirds of our medical care is beneficial and even lifesaving. The challenge in determining optimal medical care is to identify the boundary between the effective care that truly improves health and the commercially driven care that at best misdirects our efforts to stay healthy and at worst is actually harmful (like routine hormone replacement therapy). These research findings may surprise you—and will probably surprise your doctor even more.

Most postmenopausal women worry about their bones becoming fragile. The National Osteoporosis Foundation states the problem succinctly: “Osteoporosis is often called the ‘silent disease’ because bone loss occurs without symptoms. People may not know that they have osteoporosis until their bones become
so weak that a sudden strain, bump, or fall
causes a fracture or a vertebra to collapse.”
Twenty percent of all women over the age of 50
have osteoporosis and another 40 percent have osteopenia, thinning of the bones that puts the women at risk of developing osteoporosis.

What causes osteoporosis? Healthy bones undergo constant remodeling to repair minor injuries, maintain strength in response to stress, and provide the body with a reservoir of calcium. The bone remodeling process is accomplished by a balance between the activity of cells that absorb the calcium out of existing bone, called osteoclasts, and cells that lay down new bone, called osteoblasts.
In women, this balance changes
somewhere between the ages of 30 and 45, so that more bone is absorbed than is replaced, leading to the net loss of calcium. As women (and men to a lesser degree) age, the mineral density of their bones naturally decreases, which can lead to osteoporosis.

Hip fractures are by far the most feared consequence. Data from the National Osteoporosis Foundation show that 24 percent of people who suffer a fractured hip die within one year; a quarter of those who had been living independently require long-term care; and only 15 percent are able to walk across a room unaided six months later. A bone mineral density (BMD) test can quickly determine the degree of bone loss in a woman’s skeleton and whether or not she has osteoporosis or osteopenia.

If you are a woman who has reached the age of 50 and has not yet had a bone density test, you are probably thinking about calling your doctor to schedule one as soon as possible. And you are probably comforted to know that there are a number of new medications on the market that can reverse age-related bone loss for women who have osteoporosis or who are at high risk of developing it. But you may want to read on before making the call.

Most women were not even aware of the risk of osteoporosis before the early 1980s. As discussed in
Chapter 5
, this changed largely as a result of an
educational campaign initiated in 1982
. Researchers from the British Columbia Office of Health Technology Assessment point out that the campaign succeeded by addressing women’s growing interest in preventive health care and their fear of aging. But it wasn’t until 1993, when a study group hosted by the World Health Organization established clear-cut definitions of osteoporosis and osteopenia, that doctors were provided with straightforward criteria to make these diagnoses and upon which to base their treatment recommendations. According to the WHO study group, a woman has osteoporosis when her
bone mineral density (BMD)
, as measured by a simple x-ray test, is 2.5 or more standard deviations below the average peak bone mass of healthy young adult women. This is defined as a T score of -2.5 or less. Osteopenia is diagnosed when a woman’s T score is between -1.0 and -2.5.

So far this may sound compelling, but a closer look presents a very different picture: The definitions developed by the WHO Study Group are based on the assumption that the young adult skeleton is healthy and that as people age, their bones become progressively more “diseased.” The study group’s criteria, however, ignore the fact that loss of bone mass is a perfectly normal part of aging, especially in postmenopausal women. Simply on a statistical basis, according to the WHO study group’s definition, about half of all women at age 52 who have BMD tests will be diagnosed as having osteopenia, and this percentage goes up quickly with age. Similarly, according to the WHO study group’s definition of osteoporosis, about half of all American women will have the “disease” by the age of 72.

WHO’s definitions transform the majority of healthy postmenopausal women whose bones are aging normally into “patients” having or being at risk of having a frightening bone “disease.” A decrease in T score is usually no more a measure of disease than is the greater amount of time it takes an elderly jogger to run a mile than it did when she was at her peak performance. This reframing of normal aging into a pathological process is reminiscent of Dr. Robert Wilson’s successful campaign to convince women and their doctors that menopause was not a natural event but a hormone-deficiency disease. We fell for that, hook, line, and sinker, with great harm to many women, and only later discovered that Dr. Wilson had been funded by the drug companies. In this case, however, the source of information is the trusted World Health Organization, on which public health officials in every country rely for health information and policy recommendations. Can’t we trust that its recommendations are free of commercial influence and in the best interests of women around the world? Unfortunately, we cannot.