musings on women's health

Are my emotions mine? That is, do they live inside me, or are they things that are shared -exist between me and others, in other words? Are they more the combination of genetic predisposition and situational features which are dependent on societal norms that we were taught from our early years at home and in the community?

It seems to me that it is an important point: where should we direct our efforts if we feel  emotions are getting out of hand? Is simply treating me sufficient, or am I the fabled canary in the coal mine? I’ve been retired from specialist medical practice for some years now, and I can feel my loyalties shifting. It’s not that I have joined the dark side, or anything -more that I can see both sides better from the border.

If we are to confront medical skepticism, it is a good idea to examine it from a historical perspective. I found a helpful essay by Bernice L. Hausman, professor and chair of the Department of Humanities at the Penn State College of Medicine in Hershey, Pennsylvania: https://aeon.co/essays/what-explains-the-enduring-grip-of-medical-skepticism

Early in her explanation, she writes that ‘while medical therapeutics have advanced considerably, many current treatments are also aggressive… Consider the expansion of disease categories to include personality quirks and body types, side-effects that demand further medications, drug interactions that are deadly, and medical supervision of things left well enough alone. If 18th-century medicine lacked a scientific basis, our problem might be too many therapies for our own good. The expansion of treatment has led to a critical response – ‘medicalisation’, which describes a skeptical approach to mainstream medicine’s social role in defining health.’

Indeed, what is ‘health’? Is it merely a state of being free of injury or illness, or is there something else involved as well? Something that medicine often fails to address: who has the social authority to decide what constitutes health -not so much for society as a whole, but for the individual? And how it should best be treated, for that matter?

Take an old example: TB. The proximate cause, of course, is the tuberculum bacillus, Mycobacterium tuberculosis, but in some sense the bacterium is merely opportunistic. The ultimate, or distal cause may well be something like impaired immunity from malnutrition or poverty. So, which cause should be addressed -the proximate one, of course, but should we leave it at that? Is it enough to rub our hands and say ‘done’? For that matter, to whom should we look for a remedy?

But, the problem is still with us -for example, the current pandemic of Covid 19 with its massive social and economic upheavals. From time to time, there has been promulgated the exculpatory mantra that the virus knows no boundaries; the virus does not discriminate, unlike our political borders. But of course it does. The communities of colour -African American and Latino, in America at least- seem to be disproportionately affected. Why? Well, there are a few obvious factors at play. ‘African-Americans have higher rates of underlying conditions, including diabetes, heart disease, and lung disease, that are linked to more severe cases of COVID-19′. And, ‘They also often have less access to quality health care, and are disproportionately represented in essential frontline jobs that can’t be done from home, increasing their exposure to the virus,’ according to a report (May30/2020) from NPR.

And, from the same report, ‘Latinos are [also] over-represented in essential jobs that increase their exposure to the virus… Regardless of their occupation, high rates of poverty and low wages mean that many Latinos feel compelled to leave home to seek work. Dense, multi-generational housing conditions make it easier for the virus to spread.’ Of course, by now that is old hat… isn’t it?

I suspect I saw it differently when I was in practice, but perspective is often beguiling -the old aphorism about the hammer and the nail, perhaps? ‘In Medical Nemesis (1975), Illich [the intellectual iconoclast, Ivan Illich, a Croatian-Austrian Catholic priest] made a starkly prescient argument against medicine as a dangerous example of what some call ‘the managed life’, where every aspect of normal living requires input from an institutionalised medical system. It was Illich who introduced the term ‘iatrogenesis’, from the Greek, meaning doctor-caused illness. There were three levels of physician-caused illness, as far as he was concerned: clinical, social and cultural. Clinical iatrogenesis comprises treatment side-effects that sicken people. Social iatrogenesis describes patients as individual consumers of treatment who are self-interested agents rather than actively political individuals who could work for broader social transformations to improve the health of all.

But, cultural iatrogenesis is the one that interests me the most, I must admit: that ‘people’s innate capacities to confront and experience suffering, illness, disappointment, pain, vulnerability and death are [being] displaced by medicine.’

Illich thinks that ‘medicine takes a technical approach to ordinary life events, hollowing out the rich interpersonal relations of caring that defined being human for millennia.’ But to be fair, Illich still felt that ‘Sanitation, vector control, inoculation, and general access to dental and primary medical care were hallmarks of a truly modern culture that fostered self-care and autonomy.’ He was more concerned with the impersonal bureaucracy that surrounded medicine. An interesting criticism, and one that I also share -albeit one that seems to stem from the medical system as he saw it from south of our Canadian border.

And yet I think the thrust of Hausman’s essay was more a reaction to the disillusionment that followed the initial promise of modern medicine. Things like delegating the definition of health to professionals who have a vested interest in defining it in a way that seems to mandate the continued need for them. I think this view is unfair, but, given Illich’s iatrogenesis concerns, I can see how that attitude might seem plausible.

Have we doctors been -are we still- sometimes too aggressive in our treatments, too arrogant in our knowledge, too certain of our advice, and too resistant to alternative approaches? I’m not suggesting that we cave to pseudoscience, or acquiesce to theories just because they are currently fashionable; Science is never perfect, and is open to change. But still, primum non nocere is a good aphorism to guide us: First of all, do no harm. I seem to remember promising something like that in my medical oath…