March 29, 2005
Countercultural medicine
I'm currently reading Nation of Rebels, by Joseph Heath and Andrew Potter, both Canadian philosophy professors. Various publications, including The Atlantic Monthly have picked up on it recently, and it's a brilliant read. I've a few issues with their discussion of Hobbes and Freud, but on the whole it's an accurate and scathing critique of the counterculture by two progressives who are rather annoyed that the soul of progressive thinking has been hijacked by pot-smoking, patchouli-smelling, incense-burning, organic-food-buying hippies.
The following excerpt is from the chapter entitled "Thank You, India", a reference to the Alanis Morissette song "Thank You" in which she reveals how she's been using an entire culture as a backdrop and foil for her own personal explorations. The chapter itself is on the exoticism present in the counterculture and its inherent, anti-Western bias. Including this excerpt here probably violates several different kinds of copyright, but that's never stopped me before, so here goes.
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Nowhere is the temptation toward exoticism more evident - or more lucrative - than in the burgeoning "alternative medicine" industry. Any town in North America with more than a few thousand inhabitants has by now a full complement of naturopathic practitioners, reiki therapists, homeopaths, crystal healers and magnet therapists. Like "alternative" sports, "alternative" music, and "alternative" culture generally, "alternative" medicine is big money. In 1997, Americans spent an estimated $30 billion on alternative health care. (To put that in perspective, Canada's "socialized" medical system cost the government a total of $55 billion in 1997 and provided comprehensive basic health care to every citizen of the country [about 30 million]).
The concept of alternative medicine is essentially a byproduct of the critique of mass society. According to its critics, the medical establishment is simply on branch of the "technostructure", like the educational system or the prison system. The hospital as an instutition bears all the hallmark traits of mass society. In fact, it can easily be seen as the nightmare of technocratic domination. The hospital is an impersonal, bureaucratic institution, where patients are literally entered into the computer at the entrance, assigned a number and given an identification bracelet. The internal structure of the organization is stratified by class, with each group identified by a distinct uniform. Doctors (mainly men) give orders to nurses (mainly women). THe overall approach to health care is one that favors technological intervention and instumental control of disease. Diagnosis and treatment are almost entirely guided by statistical reasoning, not by the particular situation of the individual patient. If you want to feel like a cog in a machine, just go to a hospital. [The authors are unfortunately largely correct in this analysis. Emergency departments are even worse, most of the time.]
Many critics of mass society found the insutitional style of the medical system so sinister that they began to question the reality of disease. Just like those who questioned the reality of mental illness, many critics began to wonder whether the sick were really all that sick, or whether the hospital wasn't just part of a plot to control the population through "medicalization" of social deviance. In many ways, the success of modern medicine contributed to this simply by eliminating or curing the most deadly diseases. This makes it much easier to doubt their seriousness, because they are no longer part of our daily life. We have no idea what it was like living in Europe as the plague swept through town, killing half of the population. Penicillin has taken care of that. We have no idea what it is like growing up in a world where people are forced to flee the city periodically to avoid smallpox epidemics. Vaccination has taken care of that. And we have no idea what it is like giving birth in a society where 10 to 15 percent of women die in childbirth. Modern surgical techniques have taken care of that.
In this context, it is easy to imagine that there is something suspicious about the way medicine is practiced. "Why should I get my child vaccinated against polio?" people say. "When is the last time you heard of anyone getting polio? It's probably just pharmaceutical companies trying to make a profit." Or, "Why should I go to the hospital to give birth? When is the last time you heard of anyone dying in childbirth? It's probably just male doctors trying to control and suppress women." Or, "Why should I buy pasteurized milk? When is the last time you heard of anyone getting sick from drinking milk? It's probably just propaganda from the same people who brought us Velveeta and Wonder bread."
This sort of reasoning can be even more fun if one adopts a Freudian perspective [as the authors argue most countercultural pundits do, largely in ignorance]. The obsession with cleanliness, disinfection, and the extermination of invisible germsn is easy to dismiss as simply the expression of an anal personality disorder, a mistrust of everything that is natural, sensuous, pleasureful. Herbert Marcuse, speaking in all seriousness, decribed the practice of surgery as "sublimated aggression." In other words, Marcuse thought that the surgeon's real desire was to kill and dismember the patient. Unfortunately, that's against the rules, so the surgeton settles for the more "clinical" solution of cutting the patient up, rearranging the pieces, and putting him back together again. [It should be noted, however, that surgeons are some of the most confident and aggressive people you're likely to meet.]
Despite these sorts of extreme condemnations of the medical system, the counterculture itself had very little to offer in the way of an alternative. (What does "individualistic" or "rebel" medicine look like?) Thus the natural tendency was to turn toward non-Western cultures, and to interpret their medical practices as the antithesis of everything that was wrong with the West. As a result, an enormous interest developed in Chinese, Indian, and other Eastern traditions. Each of these was seen through the lens of the countercultural critique. While Western medicine was focused on disease, Eastern medicine was holistic; while Western medicine was technological, Eastern medicine was natural; while Western medicine separated mind from body, Eastern medicine treated the whole person.
The result has been a predictible distortion of how medicine in non-Western countries is actually practiced. In every major medical tradition in the world, there has been a deep division between so-called allopathic and homeopathic approaches to health [see here for my discussion of this distinction]. The concept of "disease" comes from the allopathic tradition, which blames ill health on specific causal factors, such as a virus, a bacterium, or a tumor. The homeopathic tradition, on the other hand, regards health as a type of equilibrium of the whole organism, and illness as a state of disequilibrium. Thus, from the homeopathic perspective, the concept of "disease" is a crude simplification. There is no single cause, no "disease vector"; there are only more or less balanced states of the total organism.
Prior to the scientific revolution, homeopathic theories tended to dominate medical thinking in all cultures, including the West. Traditional Chinese medicine posited a type of energy called qi; illness occurred when the balance of yin and yang was disrupted, and medical intervention was aimed at restoring this balance. Indian ayurvedic medicine is based on the archaic idea that the body is made up of five elements: earth, air, fire, water, and ether (the latter being the substance that was thought to fill the spaces between the stars). When these elements go out of balance, the person suffers. The tantric tradition identifies a set of seven chakras, or energy centers, which are the key to wellness. And, of course, the Galenic tradition posited a ste of four humors, and identified the balance of these humors as the key to good health.
Here is the crucial point: the Galenic tradition is the original Western medical tradition - in completely dominated Christian and Islamic civilization until the 19th century. It is also impeccably homeopathic and holistic. Like Chinese and Indian practitioners, Europeans believed that the body was composed of fundamental elements: earth, air, water, and fire. On energy system in the body corresponded to each element ()In the Galenic case, blood, phlegm, yellow bile, and black bile). The balance of these elements determined not only physical, but also spiritual and mental health. Medical intervention involved correcting disequilibria, through diet, herbal remedies, and occasional physical interventions. (This is why bloodletting was so popular in Europe until the 20th century - it was the prescribed holistic therapy for rebalancing the humors. This is why it is still endorsed by ayurvedic medical practitioners.)
All of these homeopathic systems of thinking have broad structural similarities. This is not an accident. They all developed before there was any real understanding of human anatomy (much less biochemistry) and before the discovery of microscopic organisms like bacteria and viruses [I would add that the vast majority of people who support alternative medicine today are also ignorant of these things]. Thus the debate that gets played out between Western and Eastern medical practice is in many ways quite misleading. Each culture has its own allopathic and homeopathic traditions. The reason that allopathic techniques became dominant in the West is not due to any specific cultural predisposition - Western medicine was homeopathic throughout almost its entire history. Allopathic thinking became dominant because of its stunning success at preventing and curing disease.
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Imagine setting up a store to seel "holistic" Galenic remedies. Imagine offering leeching as a remedy for cancer. Imagine literally trying to sell people "snake oil." Imagine trying to convince clients to opt for trepanation - boring a hole out of the skull - as a cure for headaches. People would instantly detect fraud. Why? Because we all know this stuff doesn't work. Somehow, in the case of archaic Western medical techniques, our fraud radar seems to function perfectly well [eh, not exactly: chiropractic and 19th century German homeopathy are doing just fine]. Yet when it comes to archaic Eastern techniques, our critical faculties seem to abandon us entirely. This is unfortunate. After all, selling medicine to desperately sick people based on false promises of a cure is one o fthe lowest forms of human malfeasance imaginible. The mere probability that it is occurring should be sufficient to provoke indignation. The fact that the treatments often do no harm to the patient is beside the point; what matters is that many of the most vulnerable people in our society are being exploited [as a rule, highly educated people do not opt for alternative medical options].
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Ok, I can't even tell whether you agree with everything in there or not, so no scathing personal attacks here. :)
The point of 'natural' medicine is that often people have problems that are not serious enough to require the intense and impersonal medical care provided by hospital based health care. Your body's natural healing processes take care of many of those, and there is some evidence that natural remedies assist in the process (even if it is just a placebo effect). Part of the problem is that many people assume anything going wrong at all requires a trip to the emergency room, just in case. That means lots of problems (particularly childhood illnesses; it is hard to watch a child suffer and not intervene somehow) that could heal naturally are dealt with by intervention of some sort. To counteract that unnecessary intervention, some people swing all the way the other way, and refuse all aspects of modern medicine.
What is really needed is balance. If I have a serious disease, I will both go to a doctor and try to improve my overall health by watching what I eat and how I live (sleep, exercise). That means I use antibiotics when I have pneumonia, but it may mean simply taking a lot of vitamin C and resting with a bad cold, even if the coughing is painful for a while.
The comment about 10-15% of women dying in childbirth struck me particularly. My wife has been to 50+ homebirths (no drugs, no doctors) in her midwifery training process. 90+% of those have no need of a hospital, and part of the training is to recognize and respond to those rare times when hospital intervention is needed. The problem with hospitals is that doctors are usually not trained to help well women have babies, they are trained to help sick women get the baby out as painlessly and quickly as possible. Thus we have an astronomical c-section rate, with most occuring unnecessarily. C-sections save lives. No question. But most women don't need one, and in many hospitals they have a better than 50% chance of having one anyway, just in case. The hospital looks at it statistically and makes sure that no one could possibly die in birth, but they do damage to a lot of people that could have a normal birth.
The point of all that? Modern medicine is great, saves lives, and I am glad the hospitals are available. I think it should be used as little as possible, and our medical establishment disagrees. That means I will find someone else to go to first whenever I need some sort of care, and maybe alternative medicine will help me. At the very least it is cheaper and more personal than a trip to the emergency room, and a good Natureopath / homeopath / chiropractor will tell you when that is where you need to go.
I think that's still within fair use limits. Sorry Ryan :)
Posted by: Evan Donovan at March 29, 2005 11:36 AMA couple of points. First, if you haven't already, read my post about how modern medicine actually manages disease. In every case that isn't treatable with either surgery, antibiotics, or nutritional supplements (vitamin C for scurvy, etc.), all medical science does is try and assist the body with its natural healing process. Got a virus? We'll try to keep your fever down and your body hydrated, but you're just going to have to get better on your own. Whether or not you view it that way, and it doesn't seem that you do, the vast majority of medical care provided by modern science is simply supporting the body, not intervening to do something it can't do by itself (again, surgery and antibiotics being the two big exceptions here). The fact that people treat prescriptions like invasive, artifical magic potions is their problem.
About "natural" birth: the reason your wife has seen so many successful homebirths is not because hospitals are unnecessary, but because a midwife is capable of providing most of the conditions needed for a healthy delivery, the single biggest of which is simple sanitation. Keep the place clean, and everyone does better. Furthermore, women in America are uniformly pretty healthy, and thus much better prepared for labor than women in ages past. The healthier the mother, the better the outcome, and we've got modern medicine to thank for being this healthy. The reason so many C-sections are done today is not because doctors have arrogantly decided that their surgical procedure is better than natural childbirth. On the contrary: any surgical procedure that can be avoided is a good thing, and any good physician will tell you this. The reason that C-sections are growing in incidence has to do with liability: if there's trouble with the birth - and there's some degree of trouble in every birth, even the ones that come of without a hitch - they're almost certainly going to be sued, and the odds of a better outcome in a troublesome birth are far better with surgery than without. Thus, if they don't perform a C-section, their liability - already higher than any other speciality - skyrockets. Don't complain to modern medicine about that one: kick your favorite trial lawyer.
The reason the "medical establishment" thinks that its way is best is because it's right. It's the only demonstrable way of doing anything for anyone. Do people find benefit from alternative sources? Sure. Why not? But as practitioners who have sworn an oath to take care of the sick, physicians would be deficient in their duties if they allowed people to seek unproven and possibly dangerous medical care for ill-defined problems. Another quote from the book:
"Although echinacea sales make up 10 percent of the American dietary-supplement market, a recent random sample showed that only 52 percent of products sold as echinacea actually contain the quantities advertised on the label, while 10 percent contain no echinacea at all."
You, as a consumer, don't have any way of telling which products are as advertisted, much less which products actually do anything. You step away from the quality protection offered by the "medical establishment", with its rigorous methodology for discerning medical fact from medical fiction, and that's the kind of thing you must expect. Is your friendly, neighborhood homeopath a fraud? He seems a nice enough guy. Odds are good that he's not deliberately trying to defraud you. Most probably aren't. But the thing is this: you have no way of telling whether or not he's ripping you off, and assumming he's an honest man, he doesn't either.
Think about the whole herbal supplement thing for a minute. Pfizer makes billions selling its little blue pills for certain male *ahem* problems. Why? Because they work. You think if finding a reproducable solution to a problem when which there is enormous demand for such was as simple as tweaking a few traditional remedies that they wouldn't have tried it? You think that if garlic really does anything for blood pressure that the active ingredient wouldn't have been isolated decades ago? Apsirin is a relatively simple compound that's pretty easy to synthesize. Nothing all that complicated about it. Companies have been selling it for years and have made untold fortunes from it. Big-pharma has a vested interest in finding any chemical compound with health benefits, and don't think they haven't tried the easy things already. The reason echinacea isn't prescribed by doctors is that it doesn't do a blamed thing.
Posted by: ryan at March 29, 2005 12:42 PMYa, we disagree on a number of key points, although I agree with you that our general health has been improved by modern medicine. And I did read your other posts on this topic. The funny part is that I agree with you on most of the social and political issues you have discussed here, but on this topic you and I have different experiences with the medical field. I never bother posting when I agree.
Do you actually believe the statement that modern medicine is "the only demonstrable way of doing anything for anyone?" Seems a bit broad, especially since you would probably say that the medical establishment defines both whether a treatment is "doing anything" and what is required for the treatment's effect to be "demonstrable." It sounds very biased and appears to simply be an appeal to the authority of medical science.
The task of any professional, medical or otherwise, is to advise his clients. The final choice is always the client's responsibility (and right). So a doctor can tell me if he thinks that a treatment would be helpful or harmful, but he can't prevent me from seeking another opinion, or even deciding that he is wrong. The best thing a doctor can do in a non life threatening situation is tell me where to get more information so I can make my own decision. The only time a doctor can make immediate and final decisions about my care without my input is when the situation is immediately life threatening.
Informed consent is a buzzword, but one that might be worth thinking about. Most drugs these days have to come with a long list of possible side effects as well as telling you what they are supposed to do. Medical procedures are supposed to be discussed with patients in the same way. Most natural remedies make much smaller claims about their healing powers, but are less potently harmful as well. Viagra works for many, but watch the commercial and listen to the side effects again. Certainly looks to me like there might be reason to check out other options.
What is actually in supplements is a false advertising / consumer protection concern. It is just under a different (and admittedly less stringent) regulatory body than the FDA. False advertising of the bottle's contents is still illegal.
And a final question; how do you know with such certainty that echinacea does nothing? Is there a study or some research that you could point me to?
Posted by: Jeremy at March 29, 2005 02:43 PMAnother possible reason for an increase in C-section rates is that women whose bodies are genetically disposed to need C-sections (via skeletal structure, e.g.) no longer die in childbirth, thus allowing the reproduction of more women who are genetically disposed to need C-sections.
In other words, having difficulty in childbirth used to mean that you would die. It doesn't anymore. Thus, any genes that may have led to said difficulty are passed along.
But wait, would that lead to an actual _increase_? I don't know. It's a thought.
Posted by: nick at March 29, 2005 03:22 PMI know it sounds biased. Partially, that's because it is. I'm studying to be a physician, so it'd be pretty nuts if I didn't think that allopathic medicine was the way go to, eh? But when I say "demonstrable" that isn't biased. There's a pretty clear and rigorous definition of the word "demonstrable" when used in any epistemic sense, especially in a scientific context. It means, simply, that the effect in question must be both reproducible and not attributible to external sources. When I say that modern medicine is the only demonstrable way of doing concrete productive things for sick people, I mean it.
You're correct in that a physician does not make choices for the patient. You're also correct that a physician cannot forbid a patient from seeking a second opinion or a completely alternative method of care. That isn't what I was saying, and I'm confused as to why you're bringing this up. All I was getting at is that it would be unethical for a physician to recommend unproven therapies to his patients. It would also be unethical for a physician who is aware of situation in which a person under his care is taking highly suspect therapies to not advise the patient that the therapies in question are either totally bogus or, at best, unproven.
Don't get me started about side effects. There are side effects to everything that you consume, pharmaceutical or otherwise. The side effect of too much water is either diluting the nutritional value of the food you eat by flushing nutrients out faster than the body can absorb them as the kidneys go into overdrive, or, well, drowning. There are demonstrable side effects for taking too much vitamin C: it's carciongenic. There are proven side effects for certain herbal supplements that interfere with medication intended to regulate blood pressure. Sure, Viagra can have side effects. But that's because it's a *cough* potent chemical, unlike the herbal remedies it replaces, which are pretty innocuous. Still, the human body is so complex that any compound or element you throw in there is going to have more than one effect.
What baffles me and the medical establishment (of which I am not yet a part) is that people who are terrified of clearly identified and fully-disclosed side effects of FDA approved medications will drop thousands of dollars on untested herbal supplements whose side effects are unknown. Tell me how much sense that makes. "Oh, I'm scared of the 0.5% risk of a well described and mild side effect in the medication my doctor prescribed me, so I'm going to take this other thing for which no one has any data about how serious side effects can get or how frequently they occur." Sheesh.
So, echinacea. Until now, I've not done all that much reading on the subject. I based my opinion in my previous postings on the fact that though it is held by many to have medicinal benefits, no reputable drug company sells it, it is not regulated by the FDA, and is not used in the treatment of any major or minor disease. This I know.
As far as actual research goes, here's what about two minutes of surfing uncovered. Here's a JAMA abstract which indicates that echinacea was found to be of no benefit for treating upper respiratory infections, an ailment which it is commonly held to be effective in treating, and was actually found to be associated with an increased risk of rash. Here's a quick list of common herbs used in supplements and some of their known side effects. It is known to cause liver damage if used consistently for a period exceeding 8 weeks. It has been shown to promote phagocytosis, but the clinical benefit of this is unclear at best. In short, if it does do anything, it's not much, and any benefits are pretty much canceled out by the associated risks. The reason no one is pursuing it as a serious medical product is that there's no reason to believe that it has any value.
Posted by: ryan at March 29, 2005 03:31 PMHi Ryan,
I'm the guy whose copyright you're violating above, but don't worry about it. Nice to see the argument getting some play.
My sister-in-law is a midwife, and my wife is a surgeon, so I get to see a lot of this stuff up close. Part of the reason home deliveries go over so well is that women who are likely to suffer complications usually get identified before they go into labour -- e.g. placenta previa seldom goes undetected unless a woman has had almost no prepartum care (less often the case in Canada than the U.S. obviously). Similarly, older women are more likely to go to hospital (and will be counselled to do so).
As for the rates of C-section, its a bit more complicated than just "defensive medicine." In Canada, medical liability is almost a non-issue, but C-section rates are also high. A lot of it is a product of selection again -- high-risk cases go to hospital, low-risk cases stay home. Ultrasound screening makes it easier to tell the two apart, so C-section rates in hospitals go up. Furthermore, cases that start at home but progress badly end up in hospital, where again the C-section rate goes up.
But the other, MAJOR factor, has been the increase in average birth weights, primarily due to improved maternal health. Back when women were smoking and drinking during pregnancy, they had lower birth-weight babies on average, and so had an easier time squeezing them out. Nowadays, all these super-health conscious non-smoking moms are growing giant babies, and can't get them out. This creates a certain delicious irony: of the women I know who have had babies, it is the organic-food eating, natural remedy-popping, hospital-phobic ones who have required the C-sections (including my midwife sister-in-law). The ones who just relaxed and followed their doctor's orders had uncomplicated deliveries (including my wife).
Incidentally, in Canada a midwife bills a minimum of $1000 for her services. General physicians, on the other hand, make just slightly over $500 for ALL of the prepartum checkups and the delivery. I know the situation in the U.S is quite the opposite, but in a public health case system like Canada's midwifery is a clear-cut case of private medicine for the rich, a nice example of how countercultureal "rebellion" can be very good business.
Finally, on the subject of "no drugs" that Jeremy mentioned. My wife's dentist once asked her, before drilling one of her cavities whether she wanted to have it frozen or not. My wife, having a freakishly high pain threshold, and having always wondered what it felt like to have a tooth drilled, declined the anaesthetic. I like to tell this story, whenever women mention to me that they want to have a "natural" childbirth, without an epideral. Usually they squirm in discomfort at the very thought of dentistry without anaesthetic, and question my wife's sanity. To which I then reply "so how fucking crazy much you be to want to have a child with no pain control?" -- the pain of childbirth being, by all accounts, several orders of magnitude greater than that of dental surgery. Why is anaesthetic for dentistry regarded as one of the unquestioned benefits of civilization, yet we still stigmatize the choices of women who opt for pain control during childbirth? (Feminists used to say: if the pope was a woman, abortion would be a sacrament -- perhaps we should adjust the slogan: if men gave birth, epiderals would be in the bill of rights.)
So I know that this conversation is long dead, but I stumbled across a most relevant arguement...
http://www.smbc-comics.com/index.php?db=comics&id=754#comic
Posted by: Rob at March 9, 2007 04:06 PM