14 Nov 2010
11 minute read
agk’s Library of Low Resource Medicine
Health models in the US are not monolithic; we make room for practitioners and consumers of “alternative and complementary medicine,” and researchers frequently revisit unorthodox practices hoping to locate and sift out treatment modalities that orthodox medicine would find acceptable. However, it is fair to say that for the majority of these consumers especially, and for practitioners as well, “alternative” medicine occupies only a single register of their experience; they make allowances for trips to the ER just like everyone else. There, they may find themselves confronted by the almost-rhetorical question that bedevils philosophers of medicine: Yes, but does it work?
The question is unanswerable. Or, rather, answering the question honestly requires more explanation than simply disregarding it. The answer is that there is no universal definition of what it means for medicine to “work.” All humans, regardless of culture, health care beliefs, or medical preferences, succumb eventually to trauma or disease, virtually always despite the best efforts of their physicians. Doctors of western medicine can expect to lose 100% of their patients, herbalists no fewer. What happens first is ultimately the question that matters, and here there is no objective science to guide us.
Consider the lives of two men.
The first lives an active life with good nutrition, smokes occasionally, and has regular physicals with his doctor. At age 35, he learns he has high blood pressure (he has known for a while that smoking and overweight make this likely) and begins taking medication that brings his systolic BP down to an acceptable range. He also has high cholesterol, which he attempts to manage with diet and exercise, but eventually at age 40 he begins taking a statin drug as well. His professional life goes well, and he moves into management, but his family life suffers proportionately and he divorces his wife and sees little of his children. Increasingly as he ages, he is screened for cancers and diabetes, which finally starts showing up as a series of intermittently high glycosated hemoglobin readings at age 55. At 56, he has a heart attack, but undergoes catheterization and recovers, returning to work in a week.
His second heart attack at 60 is harder on him, and he spends two weeks in the ICU. When he emerges, he has lost all but 25% of his ejection fraction, is unable to exert himself, and finds he must claim disability to get by. In addition, the years of smoking have caused enough cumulative damage to his lungs that he requires an oxygen tank and regular inhalers. He has saved money for retirement, but finds it dwindling and takes out a reverse mortgage on his house. At 63, he has another heart attack, milder, but chooses to undergo a bypass. While recovering from surgery, he contracts a drug-resistant pneumonia and suffers some sort of brain damage that may have been a stroke or a complication of sepsis, the doctors can’t say for certain. He is transferred to a nursing home, where he develops a reputation for being loud and unpleasant, pawing at nurses and yelling at his roommates. He has a series of UTIs, each more severe than the last, eventually developing severe sepsis and suffering a series of seizures. He is treated and survives to return to the nursing home, but he no longer interacts with the other patients, and only bellows incoherently when the staff bring him his mushy food. He lives to 85, suffers a final stroke, and dies.
The second also lives an active life with good nutrition, and also smokes, but has no physician, taking his dis-ease to his (spiritual officiant). Generally, he is content. He notices in his mid forties that he is less able to work, compared to his twenties, but considers this to be the consequence of aging. His minister suggests he ask to be transferred to a different position, and he takes a desk job with the same salary but less chance of advancement. He has what he thinks may have been a heart attack at 52, but takes aspirin and gets through it. Unfortunately, he finds that afterward he can no longer walk unassisted through the grocery store without stopping to catch his breath, and must ask one of his children to help him shovel snow from the walk in winter. By 55, his eyesight is starting to fade as well, and he spends more time at home reading large-print books and working on carving decoys – a long-time hobby. He moves to part-time at his job, and his wife takes on a higher portion of household bills. He continues to meet with his (spiritual officiant), who offers to let him lead the weekly study groups, where he learns he has some skill as a teacher. At 60, he wakes up with severe chest pain and shakes his wife, who calls his children to come to the house immediately. He dies before morning.
Who had better health care? The man who lived longer, caught more of his risk factors early, and interpreted aging as a series of correctable defects in the functioning of his body, at the expense of his psychosocial adaptation? Or the man who had his first heart attack younger, died younger, but interpreted aging as a series of cues to adjust how he experienced the world, and ended up having what might be considered a good life?
The answer is that there is no answer. The answer is it depends on what matters to you. I admit I tweaked this heavily; few comparisons are quite so stark while remaining culturally intelligible. These are both modern American ideals; for the most part, we all live the life of the first man while aspiring to the life of the second man, only we don’t want to die young or quit our jobs before we’re rich. The actual variety of health experiences between different cultures are much more subtle and confusing, and come off less as a goofus and gallant parable and more as baffling ethnography.
The question “does it work?” can’t be answered without first diving headlong into these alternative umwelts. For a certain sort of person, the lessons of the minister (I should find-replace that with “shaman” just to annoy one of my friends) worked perfectly to help the second man live the best he could under the circumstances; treating him aggressively with medicine and surgery in the model of the first would have added little beyond a few years of awkwardness to a basically successful life. To another sort of person, the minister/shaman/whatever’s lessons were useless because they didn’t permit the man to live long and treat his diseases. Arguably, however, the medicines the first man took – for blood pressure, diabetes, cholesterol, etc – did nothing to change the eventual sadness of his decline. Whether they worked depends on how you evaluate them.
Of course, most head-to-head comparisons establish the rules of evaluation up front – usually the question is, does this or that therapy modify this chemical marker associated with this defined diagnosis, within a given period of time. This is asking all health care modalities to conform to the goals of the first man, and probably also to the same outcome. If we instead evaluated treatments by the question can a harried grandmother manage this treatment for all her grandchildren using the resources at hand, the answers would be very different. If we evaluated treatments by asking does this work to bring social communities closer together, the answers would be different again. “Does it work?” doesn’t work.
----------------------------------------------------- from HUNT GATHER STUDY MEDICINE © My friend Anne's old blog, available via http at huntgathermedicine.wordpress.com -----------------------------------------------------
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