EYE OF THE BEHOLDER.
Posted by bmhegde on 1
I once glanced through an editorial in The Lancet entitled Could Epidemiologists Cause Epidemics?1 Stimulating title indeed! As I read on I could feel my thoughts so beautifully verbalised in the editorial. Story goes that two young epidemiologists predicted an epidemic of influenza in their country in one of their scientific studies. Lo and behold, the incidence of influenza did reach epidemic proportions very soon and their predictions were claimed to be a true warning and were hailed as a mile stone study in the media. It is only after serious efforts to reevaluate the epidemic data that the truth came out.
While the fear of the epidemic ran through the medical profession and also the populace, there was more labelling. Every fever in the intensive therapy unit became an influenza attack and people rushed to the hospitals with even questionable rise in body temperature. Concurrently, the incidence of pneumonia in the intensive therapy units went down proportionately. The final conclusion of the second study was that the apparent increase of influenza was not an absolute increase, but a spurious labelling error.
Similar serious studies have debunked the epidemiologists predictions of epidemics of coronary artery disease in this century. The story repeats here as well. Stehabens studies, published in The Lancet, have unequivocally shown that the apparent rise in coronary disease was due to increased labelling.2 Every sudden death was labelled as myocardial infarction. Large number of cardiomyopathies due to alcohol did result in sudden electric death, but the label of myocardial infarction was applied there as well. The story goes on and on. The Shopping Plaza blood pressure check ups threw up an epidemic of hypertension in America and sent sick-absenteeism skyrocketing. Recent studies of diabetes are trying to do the same. They are predicting a big epidemic of diabetes in the next century.3
While all this makes good business sense for the fix-it trade, it is a sad commentary on the truth in science. It is very logical that any disease-statistics applied to the normal healthy population should result in large false positives. While the debate about screening healthy population to predict the future may only be an academic discussion, the resulting treatment strategies could harm people in many ways. A revolutionary study of quality of life done in insulin treated diabetics clearly showed that the real relief came only to those patients who were symptomatic before treatment. For those asymptomatic diabetics there was, if anything, worsening of the quality of life with treatment. The million-dollar question, however, was if this reduced long-term consequences? The latter could not be answered by this short-term study. But the trend in the study showed that it did not do that either.4
The time-honoured logic that when a patient comes to the doctor with symptoms, it is the duty of the doctor to do his best for his suffering, even if the knowledge in that field, at that point in time, might not be unequivocally in favour of the line of management. We are on a very wet wicket when it comes to trying to fix things for the apparently healthy population, in the fond hope of preventing future suffering.
Let me remind the reader of the famous saying of a great medical brain, Sir William Osler, who said: patient doing well do not interfere! There is an editorial in the British Medical Journal warning doctors that screening could seriously damage your health! 5 The unhealthy life style of this century, not seen in the centuries gone by, could, of course, be changed for the better.6 This specially applies to our food habits at the present time, and the fatal smoking and alcohol habits. Sedentary living is another of our enemies. Monetary economy with its attendant greed and hatred could cut the very roots of good health!
Predictions of the future rarely come true even in field of other sciences, including the king of sciences, physics. Edward Lorenz, after bagging the Nobel for his innovative ideas of weather predictions, realized that weather predictions rarely came true! He, then, propounded the butterfly effect. Said he: after feeding all the data in the traffic rules of air currents into the super computer, if a butterfly were to move its wings in Beijing, there could be storms in NewYork after a month! This happens in all the dynamic systems. Doctors have been predicting the unpredictable, wrote Professor Firth in his mile stone paper in the British Medical Journal.7 In any dynamic system, like the human body, the future depends on the total initial knowledge of the organism. To predict the future of man one should know his phenotype (that is what our screening procedures do), his genotype, and his consciousness. We do not have any inkling into the latter two major aspects of human existence now. Even if we know any deviation in the phenotype, there is no truth in predicting that correcting the initial deviation in the body would hold good as time evolves to the benefit of the person. It could even go against him! We have been seeing this time and again in blood pressure screening, diabetes screening, and even cancer surveys. Truth can not be hidden for all times, although falsehood and mystery would drag millions by the nose at a given time.
Man seeth what he wiseth is an old adage. Man sees what he knows, right! Even the eye of the beholder could not tell him the real truth unless he examines the object carefully. This is the real meaning of science with its Sanskrit etymological root, skei, meaning just the same (cut into what you see). This reminds me of the famous Schrodingers cat. In the early part of this century when quantum physics upset the apple cart of Einsteins theory of relativity, first by his own student, Werner Heisenberg, with his uncertainty principle, and later by Erwin Schrodinger, an Austrian physicist, Einstein must have been very much hurt. His elephantine ego did not make him understand both these great brains. The very fact that he ruled that nothing could move faster than light showed his closed mind and arrogance. All quantum particles could move much faster than light! He claimed that if Schrodingers quantum physics is to be believed, this world would look crazy, but one would have to assess how crazy!
At the quantum level (sub-atomic level) whether we exist or not depends on someone observing us, the eye of the beholder. Schrodingers imagination threw up his cat in a sealed box. The cat lived there in the company of a triggering device and a decaying atom. The atom would decay in an hours time and trigger the alarm. One would know if the cat were alive or dead only after opening the box and seeing. Although Schrodingers cat provoked much discussion and debate in the world, a recent attempt by physicists to prove the theory wrong did not bear fruit. They tried to pass a mouse in front of the cat inside the box, but that did not make the cat mew, thereby proving that the question of life and death of the cat depended solely on seeing the cat after opening the box by the observer.
Medical scientists will have to learn a lot from quantum physics, including its elucidation of human consciousness as a sub-atomic concept. Mind could not be confined either to the brain or the heart as was done by our modern medical forefathers. The brain has only about a billion cells, but even a grain of salt has more than ten billion atoms. Consequently, brain cells could not be the seat of the mind. In the latter event even a grain of salt could not have been understood by the human mind! Mind and matter are two things that have been ignored by us for a long time with disastrous consequences for our patients.
Both in the Indian system of Ayurveda and, even, in modern medicine there have been attempts to stress the role of the mind in disease. William Harvey so graphically described the role of the mind in disease when he wrote in 1648 AD: "when in anger the pupils contract, in infamy and shame the cheeks blush, in lust does the member get distended and erected in no time! Indian science of Ayurveda had clearly stated that health depends on a happy mind to a very great extent:
Prasanna aathma indriya manah swastha ithyabhideeyathe
(Happiness of the soul, senses, and the mind keep you healthy)
We should spend more time and energy in trying to do most good to most people most of the time, by trying to alleviate suffering. Hippocrates did warn us about our responsibilities when he said: Cure rarely, comfort mostly, but console always. This is true even today! In addition, we have made modern medicine so expensive what with all our the screenings and gadgetry, that more than 62% of upper middle class Americans find it difficult to have health insurance. In a fee-for-service system, cardiac procedures generated billions of dollars each year. A high volume of procedures brought prestige and financial rewards to hospitals, physicians, and the vendors of medical equipment. This was the opinion expressed by an American professor of cardiology in a recent editorial in the New England Journal of Medicine.8 A recent UNIDO report showed that about 80% of the worlds population is still not aware of modern medicine. Recent scientific studies published by the Royal College of Physicians of London have revealed that many of the complementary systems of medicine could be scientific and, do have a role to play in health care deliver9
Let us be pragmatic in our approach to health care, taking a holistic view of health and disease, to bring succour to the suffering. We should not waste our energy and money in claiming to lessen the burden of illness by catching diseases young, a myth at this point in time. Let epidemiologists be more careful in predicting the unpredictable future. We still have millions of people in the world that need help for their suffering. If we look out for anything in particular with zeal, we, probably, get to see it more often. Consequently we feel like intervening, where angels fear to tread! This reminds me of what Mark Twain once wrote:
For a man with a hammer in the hand and wanting to use it badly,
Everything here looks like a nail needing hammering!
BIBLIOGRAPHY:
1) Editorial: Do epidemiologists cause epidemics? Lancet 1993;341:993-94.
.
2) Stehbens WE. An appraisal of epidemic rise of coronary heart disease and its decline Lancet 1987;I: 606-611.
.
3) Ramachandran A. The Scenario is not sweet. The Hindu, 30th Dec, 1998.
4) Goddijn PPM, Bilo HJG, Feskens EJM et.al Longitudinal study on glycaemic control and quality of life in patients with Type II diabetes. Diabetic Med. 1993;16:23-30.
..
5) Stewart-Brown S, Farmer A. Screening could seriously damage your health. BMJ 1997;314: 533.
6) Ornish D, Scherwitz LW, Billings JH. et.al: Intensive life-style changes for reversal of coronary heart disease. JAMA 1998; 280; 2001-2008.
7) Firth WJ: Chaos-Predicting the Unpredictable. BMJ 1991; 303: 1565-1568.
8) Krumholz HM: Cardiac procedures, outcomes, and accountability. N.Engl.J.Med 1997; 336: 1522-23.
9) Meade T: Science-based complementary medicine. Ed. Royal College of Physicians London, 1999.