Sunday, March 28, 2010

Medicine Men

Tied Up And On Display
Tied Up and On Display, Helsinki, 2005

Our society is over-medicalized. There's a gradual but relentless narrowing of the normal. What used to be thought of as just differences between people have acquired diagnostic codes and treatments. It seems as if a new syndrome or disorder pops up every week, with drugs helpfully provided by pharmaceutical companies to treat it.

On the other hand, medical science has completely revolutionized our expectations of a "normal" life. It's hard to even imagine that stepping on a nail used to carry a high likelihood of death from tetanus or septicemia. A strep throat is a minor inconvenience. Compound fractures can be set and treated to restore original function, often completely. Cancer patients often go into complete remission and end up dying of something else. Vaccinations have eradicated smallpox and turned many other lethal or debilitating diseases into rare occurrences or minor inconveniences. More important than that is the germ theory of disease, which got us to understand the importance of clean hands and boiled or otherwise purified drinking water, bringing mass killers like cholera and typhoid fever under control. 

Medical science has also led to an unprecedented understanding of how our organism works – how it goes wrong, what it needs to work well, what causes what. It can provide practical advice that, if applied, enables anyone to improve their odds of avoiding a variety of nasty diseases and maintaining their well-being and functioning far longer than ever before.

Any medical scientist will cheerfully admit that there's far more that we don't know than we do know about what makes us tick. The placebo effect, for example, has been observed in controlled studies for decades, yet it remains as mysterious as ever – and it seems to be getting stronger, at least in the USA. The scientific method is very good at finding correlations, and pretty good at finding causes – but only if the correlations and causes involve a manageable number of variables. 

When I was studying history, I came across the concept of proximate and ultimate causes. Proximate causes are identifiable factors that result in things happening shortly afterward. Ultimate causes are deeper, often hard to find structures that make it possible for the things to happen in the first place. So, for example, the assassination of Archduke Ferdinand in Sarajevo by Gavrilo Princip can be thought of as a proximate cause for World War I, whereas things like nationalism, colonialism, and various economic structures within and between countries can be thought of as its ultimate causes. It's very tricky to demonstrate anything conclusive about ultimate causes, precisely because they're often intangible, multitudinous, and interrelated in complex ways. I believe this is as true for medical science as it is for historiography. We can make rough, general inferences, but the more detailed we want to get, the harder things become to pin down. That means that the number of demonstrable truths is necessarily a small subset of actual truths, and much of the time, we're groping about in the dark.

Clinical practice is where medical science gets turned into action. It's at least as much an art as a science. Knowledge is certainly vital to it, but experience and intuition factor into it even more. It's pattern recognition, educated guesswork, intuition, and experiment. It's pretty significant that "evidence-based medicine" is something of a buzzword only now – the idea that doctors should prefer treatments that have been experimentally demonstrated to work, rather than rely on their experience and intuition. It's also significant that the concept is controversial – many clinicians argue that it just doesn't work like that.

What do you call alternative medicine that's been proven to work? MEDICINE!
– Tim Minchin

Our medical services are structured in a very particular way: to treat diseases. You go to the doctor when there's something wrong. You expect the doctor to behave like a car mechanic – find the part that's not working, and then fix it. For lots of things – like those killer bacterial infections – this works great. However, for lots of other things, it doesn't. The average GP in my neck of the woods spends about fifteen minutes per patient before sending them along, with or without a prescription. If we're dealing with a strep throat, that's more than enough. If we're dealing with, say, back pain, fatigue, sleeplessness, depression, digestive problems with no immediate, obvious cause, or, say, obesity, that's nowhere near enough. We have pills – or their equivalents – for many of these things, but they're crude instruments, like tuning a piano with a sledgehammer. These treatments are usually about the proximate causes rather than the ultimate ones – serotonin reuptake inhibitors for depression, muscle relaxants for back pain. 

I think medical science knows a lot more about the ultimate causes than it's usually given credit for, though. The doctor might prescribe you muscle relaxants for back pain, although he knows full well that what you really need to do is get off your ass and into the gym, then do some stretching or yoga, and then sort out that chair and desk of yours where you sit all day, plus maybe change to a firmer mattress. The trouble is that given the conditions in which he's working, the doctor has no way of getting you to do any of the stuff that you'd have to do to address any of the ultimate causes of that pain. A fifteen-minute consultation won't get you to change your habits. Naturally, this also means that there's a great deal more pressure to discover things that doctors can apply in fifteen minutes, rather than things that take more time to work, even if they're more effective and have fewer side effects. It's worse if the treatments don't actually cost anything, which means that there's nobody there to pay for the research to discover them and demonstrate that they work.

That's where the grab bag of stuff that's often labeled "alternative medicine" comes in. Personally, I dislike the label, since it lumps together everything from obvious woo like energy healing and homeopathy (which may still work, of course, if you believe in them – the placebo effect is really very powerful!), to bodies of experiential knowledge gathered more or less systematically over hundreds or thousands of years, such as Ayurvedic or traditional Chinese medicine. Acupuncture, for example, has been demonstrated to work for some things, even though you won't be able to find any of those meridians or measure the flow of chi by cutting someone up or putting him in an MRI machine. I'm quite sure that there's a great deal more that works (above and beyond the placebo effect) in each of these and other traditions, even though medical science hasn't gotten around to, or been able to, demonstrate it conclusively.

My conjecture is that stuff like meridians, chi, chakras, and what not refers to second-order phenomena – the way we experience our body-mind. This may be an effective way at getting at the very complicated stuff that's so hard to pin down in the lab. But that's really just speculation, not to mention a digression.

As I said in a comment in the discussion on my posting about New Age a few days ago, I only have a problem with alternative medicine if it stops people from seeking plain ol' medicine in situations where plain ol' medicine obviously and unambiguously works. It's not easy to stay healthy, and most of us laymen don't really have the intellectual tools to make genuinely informed decisions about what works and what doesn't – which is why we need doctors in the first place. However, I think it's vital to keep a mind that's both open and critical about this stuff, to make the best guesses we can about it. For many things, a visit to the doctor is the obvious thing to do. For many other things, you'd be better advised to seek out somebody who can help you help yourself. Whether that person is an Ayurvedic healer, a shaman, an energy healer, a homeopath, a priest, or some other physician you like better doesn't really matter, if she gets the job done. It's only a problem if she thinks she has all the answers and gets you to do harmful stuff as a result. 

That's not really all that different from a spiritual practice. Come to think of it.

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