ARE WE BARKING UP THE WRONG TREE
Posted by bmhegde on 1
“Time has come” the Walrus said, “to talk of many things-cabbages and kings…”We could now add to this list diseases and drugs, health and man, in addition. Man has been here for thousands of years in hundreds of generations; naturally diseases have been around for as long. Modern medicine must have originated nearly five thousand years ago on the banks of the River Nile in Egypt, mostly as magic, sorcery and witchcraft! It evolved through many generations and geographic areas to its present state. The latter is called modern “scientific” medicine.Ever since medicine was accepted as a scientific discipline in the European Universities in the early part of this millennium along with physics, chemistry and natural sciences, medicine has been following reductionism like all the others.
Man, being dependent on nature for his very existence, is a part of this cosmos. Consequently, he would have to depend on all other species on this planet, in addition to working as a whole with all his organs in tandem. Reductionist science that looks at bits and pieces to study the whole would naturally give wrong signals in human affairs, or for that matter, in any other dynamic system.1 Quantum physics did show this truth very elegantly. Both Schrodinger’s cat hypothesis and Werner Heisenberger’s uncertainty principle have brought to fore the role of the human consciousness.2 Medicine has to follow quantum physics in search of the truth.3 It is time to take stock of the prevailing situation and go forward to look at human beings as a whole, both in the realm of diseases and their management, lest medicine should continue to bark up the wrong tree.4
Diagnosis and management strategies depend on many imponderables. When a patient sees a doctor expecting to get the right diagnosis and treatment in addition to an accurate prognosis, the doctor is in a dilemma if he were to tell the whole truth. Since many diseases have their own time frame, most patients get better despite the fact that physicians have been predicting the unpredictable all these days! With the human genome having been unfolded, doctors could get a better grip on the initial state of the patient for better prognostication. Time evolution in a dynamic system, like the human body, depends on the total initial state of the organism. Reductionist science has given the medical profession a fairly good knowledge of the phenotype, what with all the physical findings and biochemical parameters along with the scanners and imagery. This knowledge, added to the genetic pattern that would be available for clinical use in the near future, would sharpen the predicting capacity, although the mystery of the human mind still would hamper “total knowledge of the initial state” for correct predictions.5
The present scenario is quite depressing. Modern medicine has gone to the market place riding piggyback on technology resulting in health care costs escalating beyond the wildest imagination, making even the rich nations incapable of footing the bill. There also is the “inverse care law” in operation. While diseases are more common in the poorer segments resulting in the poor paying for their poverty with their lives, medical care is mostly concentrated around the rich and powerful who do not need it so much. The distribution of doctors also follows the same rule.6There is a thriving business around drugs and technology leading to ethics being sacrificed in the market place. Research data are being faked in some cases and the surgical procedures in many areas far outnumber the real scientific indications. Cardiac interventions stand out clearly as being overused.7
Despite the inability to predict the future correctly using the present day phenotypic features alone, the “well” in society are not left alone. This brings to mind the lamentations of Late Sir Robert Hutchinson: “God, give us deliverance from not letting the well alone!” Studies have shown the futility of routine screening procedures, many of which are not capable of predicting the future. Medi-business in that field, however, is very fruitful.
Cross sectional studies of cohorts in quantitative research many times lead to wrong conclusions because of the inherent defects in the reductionist science. Small cohorts many times give favourable results, while larger number of patients included in the study could reverse the outcome.8 Drug trials are another area where short term follow up data in small groups of patients could be belied in long term prospective studies of larger numbers.9 Qualitative research involving many of the non-quantifiable data has been shown to be useful in certain areas.10 Routine labelling has resulted in over diagnosis and a distorted view of epidemics of degenerative diseases. While epidemiology has been useful in unraveling the mysteries of communicable diseases, the same does not hold good in the field of chronic degenerative diseases, where at times “epidemiologists could cause epidemics.”11 Using mortality statistics and false labelling of dangerous diseases spurious increases in the incidence of certain diseases like vascular diseases are being projected. This frightens the public and enhances anxiety levels in society.12
Philosophically the major role of medicine is to allay anxiety, patient anxiety of disability and death and doctor anxiety of having done enough or not. On the contrary modern medical predictions, especially in the realm of chronic diseases, makes man more anxious.13 Lots of educated people die everyday worrying about the possibility of falling a prey to one of the killer diseases and do not enjoy living at all. Happiness is living dangerously. If one wants everything to be absolutely safe life would become miserable. Present day regular check ups leave very little time for any one to enjoy life to the full. In one sense there are no well persons in society at all. Well man would be the one who has not been properly investigated!14
Long-term follow up of large cohorts of people has upturned most of our predictions about the risk factors and their management. More and more studies throw up various negative attitudes like hatred, depression, anger and jealousy as powerful risk factors for major killer diseases like cancer, stroke, and heart attacks.15 All is not well with the risk factor hypotheses. Modern technology has replaced the time-honoured skill of listening to the patient. Doctors have no time to “waste” listening to the woes of their patients. They have to get on with their scanners and x-ray images, forgetting that the shadow is not the man. “If you listen to your patient long enough, he will tell you what is wrong with him” was the strong conviction of a great physician of yester years, Lord Platt. Some students of Lord Platt investigated this statement recently using modern technology. They showed that the statement holds good even today.16 Listening adds the missing third dimension to the organisms initial state of health, the human mind. "Diseases present through the personality of the patient.” wrote Sir James Spence.
In the midst of all this confusion there seems to be a ray of hope in the distance horizon. The new science of non-linear mathematics and chaos has opened up new avenues in human health and illness. Using this science and assessing the patient more intimately probing his mind one could get a better grip on the situation. In addition, prediction becomes more accurate as time evolution follows non-linear mathematics. All the organs in the human body are interconnected and “mode-locked” to one another. The system with the most dominant rhythm controls other organs. Breathing is the most dominant rhythm in the body. Ancient Indian system of medicine, Ayurveda, stressed this very much using the Vedic non-linear mathematics. Recent studies using modern technology has shown how proper breathing techniques could even change tissue oxygenation in-patients with intractable heart failure. Heart rate variability is another parameter that follows non-linearity and gives much better assessment of cardiac function at a given time. Newer patterns of HRV, using computerized “wavelet analysis” of the surface ECG recorded continuously over a period of fifteen minutes, gives much better and detailed analysis of the myocardial state at that point in time. Since it is non-linear this has a better predictability.17
A healthy child has marked heart rate variability with breathing, sinus arrhythmia. The variability gradually decreases as age advances or as the heart muscle gets damaged. Keeping a child’s heart even in old age is one way of keeping oneself fit. Breathing exercises originally perfected in the Yoga system of Ayurveda helps keep healthy HRV for a long time even in elderly people.18
Another area that needs change is the present preoccupation with quick fixes for every minor deviation from the so-called normal range. There could not be any parameter that is constant in a dynamic system like the human body.All biochemical parameters have to, per force, keep fluctuating. Loss of this constant fluctuation gives better indication of the state of health rather than a given measure falling within a narrow range at a particular point in time. This applies to blood pressures, blood cholesterol and many others. Experience has clearly shown that long term prospective studies did not show significant benefit by our efforts to lower any of these parameters to the expected normal ranges, although short term benefits in symptomatic patients deserves our attention. Better prediction of future trouble could be assessed by studying the above parameters over a longer period of time keeping a watch on the rate of variability of the levels similar to the HRV discussed above.
Many of the quick fix drugs have also shown disappointing results. Comparing the antioxidant vitamin combinations of AC and E given to postmenopausal women in Canada compared to a similar cohort of matched controls given extra fruits and vegetables over a period of five years showed the futility of those quick fixes in preventing cancer and heart diseases. On the contrary the incidence was significantly less in the fruit and vegetable-eating group.19
Be that as it may, the cohort studies of matched controls are flawed from its beginning. Control studies, claimed to be the best way to study drug effects and many other areas in medicine, do not reflect the real future events. As discussed earlier time evolution being dependent on the complete organism-genotype, phenotype and consciousness, controlled studies only match the phenotype. Many of those studies, if not all of them, have given wrong signals.20
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