“SCIENCE-BASED MEDICINE”?

7 05 2010

I spent quite a bit of time last month doing something unusual for me–following the comment thread on a blog post.  The post was on a site called “Science-Based Medicine,” and its author (whose name I feel no need to repeat, as she is an avid self-promoter) seemed to be an M.D. version of Ann Coulter, full of venom about what she regarded as “unscientific” medicine and quick to make ad hominem attacks on anyone who disagreed with her.

The discussion she sparked was long and far-ranging, and so I kept reading to see if anybody had already made the points I felt were missing.  They were never addressed, but the acrimony grew so great that the blogger in question left the SBM site, and so there was no chance for me to contribute my observations in the context in which they arose.   I think they are very important considerations, and so I am presenting them here, in hopes that my point of view will be helpful to those who are in a better position than I to influence the future of medical practice in this country.

First, some disclosure: I have had a heart attack and a couple of strokes, been hospitalized for them, and am currently under an M.D.’s care and taking prescription medications.  I wish I could deal with my condition using only natural/non-prescription remedies, but my Andrew-Weil-style doctor encourages me to stay with my prescriptions, and I do.  So, while I am skeptical of mainstream medicine, I recognize that it has some value.  I might not be here without it.  In fact, the circumstances surrounding my birth, which was a C-section, make it absolutely clear that I would not be here without mainstream medicine.

Now for the critique.  I would like to begin by questioning whether our current medical model is best referred to as “science based.”  Science undoubtedly has a great deal to do with it, but I think perhaps the initials “SBM,” which the “Science-based medicine” blog uses as a kind of shorthand, should be replaced with “PBM,” with the “P” standing for pharmaceuticals, procedures, patents, profits–and petroleum.  Also, I think the “scientific” basis of modern medicine is perhaps too narrowly focussed, and a truly scientific medicine would include things currently considered “externalities,” to borrow a phrase from economics:  environmental effects, sustainability issues, and affordability.

As I read through other posts on the SBM website, I came to understand that the Ann Coulter clone had been a bit of an anomaly, and that the other bloggers on the site are much more level-headed, sincerely committed to combatting what they perceive as pseudoscience, but still lacking awareness of  my concerns about the future of medicine.

Let’s look at my first four “P’s”–pills, procedures, patents, and profits.  These are the economic foundations of modern medicine.  For-profit drug companies, whose primary obligation is a good return to their stockholders, are constantly on the lookout for new diseases to treat and new, patentable drugs to address these diseases.  Thus we have, for example,  the spectacular rise of psychiatric drugs, the widespread administration of antibiotics to farm animals, and the common use of concentrated female hormones as a method of birth control and a “treatment” for aging.

All these pharmaceutical uses were approved by the appropriate government agencies, who duly studied the scientific evidence for their efficacy and safety.  Unfortunately, we are now realizing that the studies did not go far enough.  There was no consideration of the consequences of  large amounts of these substances entering the environment–where, it turns out, they wreak havoc.  Male animals that live in estrogen-tainted water are becoming feminized; animals living in water that is a tea of mood-altering psychiatric drugs are losing their natural, and necessary, aggressive tendencies, and pervasive antibiotic use has–surprise!–led to the evolution of ever more stubbornly antibiotic-resistant bacteria.

But the expensive, extensive testing regimen that our government demands has had another unintended consequence–there is no profit in testing unpatentable herbs, and no profit in testing or promoting lifestyle counselling that will not only earn nothing for a drug company, but cost it sales as people  become less dependent on pharmaceuticals.  Insurance companies, for example, will gladly pay a doctor $1,000 or more for the minute or two it takes to insert a heart stent, but will balk at shelling out money for the time a doctor would spend helping a patient develop healthier living habits.

Admittedly,  such things are difficult to test scientifically.  People aren’t really all that much alike; fail to recognize an important variable, and test results may be meaningless.

Indeed, test results can apparently change over time.  When they were first introduced, drugs such as Prozac got high marks from double-blind tests; now, when those same tests are repeated, Prozac’s effectiveness in alleviating depression is about equal to placebo, with the ironic twist that the effects it does have sometimes lead to manic episodes that draw its users deeper into a tangled web of mental illness and psychiatric pharmaceuticals.

Can you say, “gateway drug,” boys and girls?

But the real 1,600 pound gorilla in the room with “science based medicine” is the 5th P–petroleum.  From lab research to production to promotion to distribution, mainstream medicine is deeply dependent on a substance which, according to a number of deeply concerned investigators, is about to be in much shorter supply–and increasingly shorter supply–than it has been.

As our access to petroleum diminishes, the plant-based remedies that the good doctors at SBM have so haughtily dismissed will be all that is affordable or available to most people.  The 35% C-section rate that they consider “acceptable” will, in the absence or unaffordability of hospital care, turn into a 35% death rate unless the “woo-woo,” as they call it, of the intimate bond between a midwife and a pregnant woman is thoroughly understood and appreciated.

Let me explain that a little more.  As some of you are aware, I was a participant in “The Farm” community during its heyday in the 70’s and early 80’s. Midwifery and home birthing were an integral part of our program.  The Farm’s midwives, dealing with a physically random selection of pregnant women, had a remarkably low C-section rate–1.8%.   Episiotimies were likewise rare. How did they do it?

The foundation of the Farm midwives’ birthing philosophy is “the same kind of energy that put the baby in there is the kind it takes to get the baby out.”  That doesn’t mean voluptuously erotic–just relaxed and open.  Women in labor were not hooked up to a battery of medical devices.  They were encouraged to get comfortable with their partner, if they had one. (The birthings I helped my wife through included hours of  delightful deep talk, cuddling and making out.) Nobody was in a hurry, but at the same time, the midwives were sensitive to the delivering woman’s state of mind, because doubt and fear, as much as physical discomfort, can keep a woman’s labor in check.  When psychological issues came up, there was enough trust and communication between the midwives, the mother-to-be, and if necessary, the father, to work through the blockages and get the baby moving again.

The thing about this is, that it can’t exist without the right attitude and level of sensitivity.  A “skeptic” can be incapable of perceiving what is obvious to those who are more open-minded, just as a colorblind person sees black and white where the rest of us see many colors.   There is a science to putting people at ease, but there is also an art involved, and art resists quantification.

The overall lesson, for me, from the Farm Midwives’ intense personalization of birthing, is that the relationship between the healer and the one in need of healing (although being pregnant is not in any way a “disease”) can be as important as the technique applied.  Sure, aspirin or antibiotics work no matter who gives them out, but not everything is simple.  In fact, most things aren’t simple.  We need both the science of knowing what to do and the art of knowing how to do it.

Meanwhile, our planetary gas tank is just about empty, and everything we have been doing that was based on having plenty of fuel is going to have to change.  So, if medicine is truly going to call itself “science-based,” it had best be looking to the future, and coming to a good understanding of how to transition into a post-peak oil medical practice that will know which plant-based medicines really work and be a lot more focused on lifestyle, prevention, and self-care than on thousand-dollar-a-month pills, million dollar machines,  and complex surgical procedures.  It’s not that I’m prejudiced against high-tech medicine–it’s just that it looks to me like what we know as mainstream medicine is going to become increasingly unaffordable if not downright unavailable as the cheap fuel/raw materials boom fades into history.

We are going to have to accept that medicine in the future will be much more about palliative care–that is, making people comfortable–than it will be about heroic, energy-intensive life-saving surgeries.  We are going to have to change our basic medical aim from the avoidance of death at any cost to supplying simple ways to ease suffering and teaching dignified acceptance of our inevitable exit from these fragile bodies.

Q.E.D?

music:  Grateful Dead, “Black Peter”








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