08 Nov 2010
8 minute read
agk’s Library of Low Resource Medicine
The practice of medicine is cultural. This is a fact worth remembering. The science that underlies medical diagnosis and treatment, screening, prognosis, and prevention claims a sort of objective universality, and this is clearly its goal, but the actual delivery of care remains intimately dependent on the physical resources, life expectations, and priorities of the cultural context in which it occurs. The physical resources are the most intuitive: without electricity, computers, precision manufacturing, biochemical engineering, international distribution networks, standardized education, enormous manpower, roads, clean water, and reasonably dense population centers, American health care doesn’t exist. Anyone who has worked in a disaster area has seen this dependency up close.
Not only that, but the protocols and practices of American health care were developed expecting that these resources would be available and fairly stable. Without natural gas mining, salt domes, high-pressure cryogenic transportation trucks, etc, you can’t even keep the magnets in an MRI cold enough to work. However, appropriate standards of care require access to MRI machines, and often no equally sensitive and specific testing is available and familiar. Indeed, there may be no-one trained to, for instance, do an emergency exploratory laparoscopy within a significant area that is, nonetheless, well served by MRIs.
(This example is interesting because a few years back the US started running low on helium, the cryo agent in MRIs, and health care planners were faced with the possibility of runaway expenditures to keep the machines running. However, this isn’t the point of this series.)
Medicine is also dependent on the priorities of the culture in which it occurs. Every culture considers certain outcomes to be more valuable than others, and uses these to evaluate clinical decisions, treatments, and the adoption of technology and protocols. Modern western medicine in the US, for instance, places a high value on a long life expectancy, low infant mortality, minimal time lost from work due to illness and the prevention of disability overall, five year survival rates after cancer treatment, etc. When it comes to these endpoints, scientific western medicine is unstoppable, and we get what we ask for. There are other cultural priorities in western medicine as well: we consider it important that unusual behavior or abilities have a definable underlying physiological cause, and that behaviors not traceable to such a cause are the intentional choice of the patient, especially when they contribute negatively to health. We believe that doctors have ultimate responsibility in the practice of medicine.
We believe in an ideal, lesion-free body and equate “health” with “purity.” We aggressively detect and remove minute colonizations and dysplasias, in the belief that a body free of these will be less likely to die of cancer or massive infection. We will accept lower specificity as the cost of higher sensitivity in screening.
We believe in an austere baseline of pleasure, and do not consider it appropriate to use medical means to improve anyone’s sensorium above this. We may have scientific proof of the value of therapeutic touch, but it is highly inappropriate for a doctor to give a patient a back rub. We strictly segregate therapeutic massage from general massage (and consider “masseuses” one step removed from prostitution.) We closely monitor and stigmatize drugs that have the capacity to produce euphoria and restrict them to “legitimate” cases where a person is well below the appropriate baseline. Medical marijuana… hoo boy.
There are also several priorities we do not rank as highly: low cost, for instance, or the provision of health care within the home. We do not prioritize equal social relationships between doctors and their patients, and we do not develop diagnostics and medications with an eye towards their autonomous provision by family members. We consider the delivery of health care private, not public, and make no allowance for lay participants. We have a difficult relationship with “quality of life” – we allow hospice care, but only with great discomfort and periodically require studies that show patients actually live longer in hospice (thus fulfilling the longer life expectancy goal mentioned above.) We do not prioritize subordinating doctors to religious authorities or medical ethicists.
I say “we prioritize this” and “we don’t prioritize that” rather glibly here, but in fact like all aspects of culture, medical priorities vary from person to person, institution to institution. A Catholic woman, for instance, may opt not to undergo a selective reduction after IVF because she prioritizes the precepts of her religion above infant mortality. A midwife may deliver children at home, using older children and fathers as co-providers, and an adult with a terminal diagnosis may commit suicide rather than extend their life expectancy with a painful or embarrassing disease. Ultimately, these varied expressions of belief and values conflict with the standardizing pretenses of “scientific” medicine (scare quotes because there is nothing unscientific about home birth or suicide – only different measurable outcomes) and it seems inevitable that everyone involved in medicine, as a student, provider, or patient should have some misgivings about the process.
Identifying these cultural contexts for medicine is not the same as criticizing them. Most readers here probably read the first list of positives (life expectancy, low infant mortality etc) nodding their heads; this is because by and large, your values and mine, and those of our doctors and (if you are a current or future provider) our patients overlap. Rather than imagine a “true” set of goals (or a “realistic” set, or a “scientific” set) we should accept that we have, and live in, the culture we have, and this is fine for the most part, as long as we recognize that there is no universal.
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