A Plague on All Your Houses

 

 

I still remember a seminar I went to years ago in university. It was part of a nebulous course on ‘Health’ that some of us took as a soft route on the way to a bachelor’s degree. It was reputed to consist of essays and a true or false final examination. Also, because the class was small, it was amenable to division into even smaller numbers for several interactive sessions.

There were five of us and a teacher’s aide at the one I remember so well. We were all fresh from high school and, at least in those faraway days, used to being lectured at, rather than actually contributing to the subject matter. The topic that day was Disease, and I remember being mildly interested, but expecting only a list of the usual culprits, complete with causes and treatments -memory fodder for later regurgitation, I suppose.

“What is disease?” the TA started, as soon as we were seated around a rather small wooden table.

One of us -I don’t remember his name now- rolled his eyes and smiled. “Sickness,” he answered, rather smugly.

She smiled in return, as if he’d fallen into her trap rather too easily. “Okay, but haven’t you just used a synonym -defined it in terms of itself?”

He stared at her for a moment, obviously confused. “Well… then, how about saying disease is an abnormality of an organ or a system caused by germs -probably particular germs depending on the disease.”

Her face relaxed and her smile broadened. “Now we’re getting somewhere.” She leaned forward on the table. “Let’s get more specific for a moment. Let’s take tuberculosis… Anybody know the cause for TB?” She glanced around the room, determined to involve us all, apparently.

I looked up at the wrong moment, and she brushed my face with her question and pinned me to my seat with another smile. “Do you know the cause of TB…?” she said, locking eyes with me.

There was no escape. “Uhmm…” I felt embarrassed at being singled out, but the question seemed fairly straightforward. “It’s the tubercle bacterium, isn’t it?”

She sat back in her chair, and shrugged nonchalantly. “Is it?” She said, softly and with just a hint of gentle sarcasm. But her eyes were still sitting on me, and I could tell they meant no harm.

“Tubercle bacillus?” I corrected myself, remembering that people sometimes called it that.

“So…” she glanced around the table again, lifting the weight off my shoulders. “Would you all agree that TB is caused by a bacterium -a bacillus?” she added, looking at me once more. Everybody nodded.

“But don’t some healthy people have a positive skin test for it -the Mantoux test?” she continued.

We all nodded, most of us unwilling to show that we hadn’t known what the test was called.

“So, why is that?” She paused to see if any of us had an explanation, but when nobody said anything, she continued. “If the bacterium Mycobacterium tuberculosis is present…” she slowed down even more for effect. “… if some of us have it… and it causes TB… then why don’t those people have TB?” She straightened in her chair and leaned on the table with her elbows as she searched our faces for the answer.

But she was greeted by blank, albeit confused expressions around the table.

“If disease is caused by the acquisition of a bacterium, then what stops some people from acquiring the disease?”

This was new territory for us, and yet, her eyes stopped at me again. “Our defense mechanisms -the immune system…?” I suppose it wasn’t exactly a scholarly response -even in those days we’d all heard of vaccinations and antibody production.

She started nodding. “Okay, but what makes the immune system strong enough to resist?”

“VSG?” someone said, and immediately blushed because he had obviously taken a leap in the dark with the initials.

She smiled reassuringly. “BCG -Bacille Calmette-Guerin, to give it its full name?” He nodded, presumably relieved. But even in those days, there was some doubt as to its effectiveness, so she merely shrugged again. “But the person may never go for the skin test and so never know she has the bacterium…”

She stared at me again, for some reason. “Well, suppose they’re in good condition -healthy, I mean?” To tell the truth, I didn’t really know what I meant.

“But doesn’t ‘healthy’ mean free of disease? Isn’t that another tautology…?” She walked around the table with her eyes again, but this time more slowly. “So, might there be other causes of disease -apart from the infecting agent, I mean?”

I remember some of us looking at each other, as if we were beginning to understand where she was going with this.

“Where -or maybe under what conditions- do we see a lot of diseases like TB?”

I suppose I remember the seminar so well, because she kept looking at me when nobody else answered. “You mean if somebody’s poor, or living in unfortunate circumstances? Poverty…?” I managed to mumble, hoping that was what she was after.

I still remember her smile.

It was a seminal moment for me, and maybe one of the reasons why I eventually went into Medicine. But it all resurfaced when I happened upon an article in the CMAJ (Canadian Medical Association Journal) from January 22/18 with the rather long and certainly uninviting title, Effect of provincial spending on social services and health care on health outcomes in Canada: an observational longitudinal study: http://www.cmaj.ca/content/190/3/E66

Its thesis, was that spending on health care is escalating so significantly it will soon be unaffordable. The question then, was what to do about it. The study ‘used retrospective data from Canadian provincial expenditure reports, for the period 1981 to 2011, to model the effects of social and health spending (as a ratio, social/health) on potentially avoidable mortality, infant mortality and life expectancy.’ And after using various methods to analyze the figures that I didn’t even try to understand, like ‘linear regressions, accounting for provincial fixed effects and time, and controlling for confounding variables at the provincial level.’ decided that ‘Population-level health outcomes could benefit from a reallocation of government dollars from health to social spending […].’ Or, as they worded it more succinctly in their concluding paragraph: ‘The results of our study suggest that spending on social services can improve health. Social policy changes at the margins, where it is possible to affect population health outcomes by reallocating spending in a way that has no effect on the overall government budget.’

It made me wonder, though, why, if I learned the same thing many years ago, did it still need investigation? Were we so wrong back then? So naïve…?