Sunday, October 10, 2010

Treating the Disease vs Treating the Patient

While I was pursuing my History of Science studies at Notre Dame I took a seminar course on Medicine and Society.  My last two posts are from that class.  I came to hate that class and it was a large factor in my decision to drop out of the program, but I did learn some important lessons during it.  The crux of the message that the professor was trying to get across to us was the way that the medical profession dehumanizes the patient and ends up treating the disease, and not the human being.  If you want to see this message in a very disturbing but highly distilled form just watch the film "Wit" with Emma Thompson.

This lesson was reinforced for me this past week when I had to rush home to Ohio because my father was in the hospital.  He went in for something relatively minor but ended up in the hospital for a week being treated for another condition.  A condition that was due, in part, at least, to actions taken by the hospital staff in their treatment of his original issue.  I am not saying that the staff was malicious in their treatment, but they were aggressive and interventionist, so that rather than assuming that the change in his condition might be due to the drugs they had given him they kept chasing symptoms. It quickly became apparent that the treatment was reactive - x happened, so they did y, without ever really trying to understand the whole picture, the patient. In the end my father spent a week in the hospital and underwent a procedure that was probably not really necessary.

It is hard challenging the medical profession when you are a patient, they are so authoritative, and when there is something wrong you get swept up into their treatment course and it takes over your life.  I saw this myself when I was undergoing treatment for breast cancer.  I tried hard to be an informed patient and question the treatment but there was one week in which I had a CAT scan, a PET scan and two biopsies.  Everything checked out as fine, but that week was quite an ordeal, both physically and emotionally.  My oncologist's conclusion after all of that was that if you did tests and scans you will always find something that is odd, and if you let yourself, you will chase these oddities for quite some time before concluding that while odd, they are not dangerous or unhealthy.  My oncologist now uses me as a poster child for not doing more than is necessary.  He still feels bad about putting me through that ordeal. 

There is a lot of debate going on right now about how to fix the health care system.  Well, one of the things they should do is treat the patient, not the disease.  One of the hardest things about being a doctor is the process of diagnosis (this is actually a place where expert systems could be useful) and rather than being thoughtful or logical about ordering tests they just order a whole suite of them.  It is as if they are throwing a whole bunch of darts at a dart board in the dark, hoping that one of them hits the target.  That is simply not a rational or cost effective approach to treatment.  It isn't good for society and it isn't good for the patient.


Fertility, Class and Gender in Britain 1860-1940   
    Simon Szreter, Cambridge University Press, 1996

In the early part of the 20th century there was a growing awareness of a declining birthrate in the industrialized nations.  In Austro-Hungary and France the birth rate in some rural areas had begun to decline substantially during the 18th century, with similar declines taking place among the aristocratic and bourgeois groups as early as the 17th century.  In 1945 a theory of demographic transition was published.  It proposed three stages of demographic development: an initial pre-industrial stage of high birth rates and high death rates, an industrial phase of high birth rates and declining death rates (leading to substantial population growth) and a post-industrial phase of low birth rates and low death rates.

This theory was based upon a single case, that of Britain.  It utilized the findings of the 1911 census, which analyzed the fertility patterns of the British population from 1851-1911 and the newly released study conducted for the Royal Commission on Population that covered the period 1901-1946.  The 1911 census used what has become known as the professional model of social classification in which all male occupations are assigned to one of five grades (professional upper and middle class, intermediate, skilled workers, intermediate, unskilled workers).  The 1911 census analysis found that the higher the social class, the earlier and more rigorously it controlled its fertility.

This classification scheme was based upon three assumptions: 1) the occupation of the male head of household was the best way to classify families; 2) a primary division existed between the higher-status non-manual occupations (they were more professional) and the lower-status manual occupations (assessed according to skill) and 3) the fact that a single hierarchical social grading system was a valid classification scheme.  It should be noted that this scheme excludes women and their labor, both paid and unpaid.  It should also be noted that those living off private means, and thus listing no personal occupation, were classified alongside paupers in a residual category, labeled the unproductive class.

In 1869 Francis Galton published Heredity Genius in which he examined the families of ‘eminent men’ in England in an effort to determine the heritability of both mental and physical qualities.  He went on to coin the term eugenics in 1884.  By the end of the 19th century there was widespread concern that modern society was reversing evolution, leading to the degeneration of the English people.  This was partly driven by an increase in the recorded rates of lunacy from 2.26/10,000 in 1807 to 29.26/10,000 in 1890, (Mathew Thomson, The Problem of Mental Deficiency: Eugenics, Democracy and Social Policy in Britain c. 1870-1959).  By the first decade of the 20th century mental defectives became defined as the central eugenic threat facing the nation.  Greater social awareness plus universal education led to the growing realization of the presence of mentally deficient people in the population.  This heightened awareness coincided with growing fears about the fitness of the population.  In 1907 the Eugenics Education Society was formed.

During the period 1875-1883, the Anthropometric Committee of the British Association for the Advancement of Science provided an hereditary basis for the professional model.  The professional model thus acquired the status of an empirically tested theory.  Despite the fact that it was based upon unexamined social conventions it had been turned into a naturalistic theory of British society’s essential structure.

In the beginning of the 20th century an environmentalist counter movement emerged opposing the ideas of the eugenicists that the poor were poor because of the way they were, rather than because of social or environmental factors.  At the forefront of this movement were the Fabians who, although they shared a nationalistic interpretation of social Darwinism with the hereditarian biometricians, did not agree with them as to the causes or the appropriate political means to achieve the optimal nation.  They held that poverty was not the manifestation of inherited biological deficiencies but rather that the environment was responsible for the moral and material degradation of the working man.