The impatient patient
In his column for Inside Higher Ed, reviews a book by Barbara Ehrenreich that punctures cherished myths about the medical and wellness industries.
IN THE event that other developments on the world stage haven't left you in a state of quivering anxiety, the Centers for Disease Control and Prevention put out a report this week that ought to do the trick. The CDC statement bears the title "Containment of Novel Multidrug-Resistant Organisms and Resistance Mechanisms--United States, 2006-2017," which soon translated into headlines such as "'Nightmare Bacteria' Are Trying to Spread in the U.S., CDC Says."
We've been hearing about the rise of antibiotic-resistant (AR) strains of diseases for decades. They now kill more than 23,000 Americans per year. More troubling than that is the discovery--from a new program of screenings--that 11 percent of health-care workers in contact with patients with AR infections were "colonized" by the strain in question. That is, they were carrying around the highly communicable and hard-to-treat germs without themselves exhibiting any symptoms. And AR-enabling genetic material can be transferred from one disease to another; diseases previously treatable with antibiotics can mutate into tougher form.
Summing up its findings for the general public, CDC underscores the efficacy of early detection and containment of AR pathogens. But almost two years' warning that it was coming seems not to have slowed down a bacterium reported in England last month under the horrifying moniker "super-gonorrhea."
BLIND CONFIDENCE in the powers of early detection and preventative medicine is the main target of Barbara Ehrenreich's Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer (Twelve). In some ways, it is a book-length sequel to "Welcome to Cancerland," her unforgettable essay from 2001. There, in recounting her diagnosis and treatment for breast cancer, Ehrenreich's instincts as a muckraker kept her in a standoff with what she called "cancer culture": while the medical protocol left her depleted and nauseous, the New Age-tinged demands for positive thinking felt insipid and infantilizing.
"What sustained me through the 'treatments,'" she wrote, "is a purifying rage, a resolve, framed in the sleepless nights of chemotherapy, to see the last polluter, along with, say, the last smug health-insurance operative, strangled with the last pink ribbon...I will not go into that last good night with a teddy bear tucked under my arm."
At that point, Ehrenreich was 60 years old. Natural Causes is the work of a writer who can see her 80s approaching at not too great a distance, and who has come to certain conclusions. She is, she says, "old enough to die," although in no great hurry to do so, and considers it "an achievement, not a defeat, and the freedom it brings is worth celebrating." She declines "to incur any more suffering, annoyance or boredom in the pursuit of a longer life," she says. "I eat well, meaning I choose foods that taste good and that will stave off hunger for as long as possible, like protein, fiber and fats. I exercise--not because it will make me live longer but because it feels good when I do. As for medical care: I will seek help for an urgent problem, but I am no longer interested in looking for problems that remain undetectable to me."
Such a decision has not been possible, let alone necessary, for very many people throughout most of history. Life expectancy in the United States over the past 150 years has nearly doubled, and it continues to increase. The all-too-American default attitude holds that more is better, pretty much by definition, but extending the length of life without regard to its quality sounds like a recipe for hell on earth. Ehrenreich's concern is that medicine has grown both so powerful and so profitable that many procedures have become practically automatic and unquestionable. In particular, patients have grown accustomed to undergoing "tests and examinations that, in sufficient quantity, are bound to detect something wrong or at least worthy of follow-up"--procedures the reliability of which are sometimes dubious, with serious consequences from false positives.
An example is the extreme rate of overdiagnosis for thyroid cancer: up 70 to 8 percent of the surgery for it performed on women in the U.S., France and Italy in the '00s is now determined to have been unnecessary, leaving patients with a lifelong dependence on thyroid hormones. Just as excessive reliance on antibiotics gave rise to "nightmare germs" they are ineffective to treat, the effort to steal a march on every medical vulnerability as you age can boomerang.
But overtesting is, by Ehrenreich's account, ultimately more a symptom than the real problem. Moving from social criticism to scientific popularization and contemplative digressions on how we situate ourselves in the natural order, she finds that both medical science and the self-help culture are prone to exaggerating the possibilities for human control over life, health and long-term success in the pursuit of happiness. She puts it this way:
Our predecessors proceeded from an assumption of human helplessness in the face of a judgmental and all-powerful God who could swoop down and kill tens of thousands at will, while today's assumption is one of almost unlimited human power. We can, or think we can, understand the causes of disease in cellular and chemical terms, so we should be able to avoid it by following the rules laid down by medical science: avoiding tobacco, exercising, undergoing routine medical screening and eating only foods currently considered healthy. Anyone who fails to do so is inviting an early death. Or to put it another way, every death can now be understood as suicide.
Which is ridiculous, of course, as is the point. In a section of the book that reads as if the author is planting dynamite under every "holistic" institution ever to promote wellness, she challenges the popular understanding of the body as "a smooth-running machine in which each part obediently performs its tasks for the benefit of the common good." There is evidence to the contrary in the behavior of the immune system, and we might do better to picture a norm of "conflict within the body...carried on by the body's own cells as they compete for space and food and oxygen. We may influence the outcome of these conflicts--through our personal habits and perhaps eventually through medical technologies that will persuade immune cells to act in more responsible ways--but we cannot control it."
Control is a short-term proposition, at best, while our long-range chances were best put by whoever designed that T-shirts that read "Exercise. Eat Right. Die Anyway."
First published at Inside Higher Ed.