The Medicalization of Health

"The medicalization of early diagnosis not only hampers and discourages preventative health care, but it also trains the patient-to-be to function in the meantime as an acolyte to his doctor. He learns to depend on the physician in sickness and in health. He turns into a lifelong patient."

~Ivan Illich

"Medicalizing" is forcing conditions into familiar diagnostic categories for medical management.¹ Every complaint has an antidote, whether it needs one or not.

Treating natural consequences of living as diseases that must be vanquished, leads to too much treatment and too much dependence on the authoritative "professional." We tend to grant most, if not all of our decision-making authority to an expert in highly complex technologies. In the case of medicine, this often complicates the commonplace condition and prolongs self-limiting ones. Today, diseases and drugs are way oversold.

Moreover, a medicalized culture is highly charged and unstable due to too much faith misplaced in techniques and technologies. It is inevitable that even just one fatality from a "proven" drug can make the sky fall: product recalls, class-action suits, network nightly news segments, loss of stockholder dividends, and temporary loss of trust. Even the best and most established research pedigree of a drug or treatment cannot save it, once such a public event has occurred.

Modern clinical guidelines serve the physician or patient with needs, values, preferences, and complexities, setting them apart from one-size-fits-all treatments designed to help the imaginary average patient. What a patient wants, actually matters.

Enter the 21^st century, where comforting wounds, facing fears, and giving advice may be as effective and cost-effective as antibiotics and analgesics for many of the ills left unconquered. Chronic and degenerative diseases are not good candidates for magic-bullet cures. These diseases arise from a complex interaction of genes and choices. We are rapidly approaching a maximum obtainable life-span in these bodies, so the era of living long enough to die of something else is probably here.

With chronic and degenerative diseases and pain, "saving lives" gives way to a different kind of treatment and different measures of treatment success. Success is: quality-adjusted life years, patient adherence, cost-effectiveness analysis, and the degree and kind of change that suits the patient - not the payer, not the physician and not some objective standard.

The medical lineage reaches well back into Western thought. Aesclepius, the mythic god of medicine, intervened against nature for the benefit of humankind. His daughter Hygiea nourished physiological strength - nature - to throw off disease.² Neither perspective is "right;" both approaches complement each other; and many patients would like the choice.

Thus does medical science ignore the mundane and highly personal aspects of healing at its own peril. Medical care may become unaffordable, replaced by cheaper, automated computational algorithms for the primary care; or it may just be better in other countries. Institutionalizing, centralizing and licensing only one type of health care toolbox necessarily increases health care costs, reduces personal choices, and diminishes satisfaction - if history teaches us anything.

Instead of innovating health care financing and delivery, there is still entirely too much emphasis on breakthroughs and blockbusters.³ In the long run, waiting for "medical miracles" undermines public and personal responsibility for gaining and keeping health. It builds dependence and undermines independence. And it is not a good business strategy, either. As Kenagy and Christensen³ said:

"Rather than emphasizing technological advances to capture shrinking, highly competitive markets, healthcare providers should consider the possibility of reaching largely untapped sources of revenue through a service line that is more convenient and less costly to consumers with less intensive needs."

Re-thinking the basics of health care - who really needs what and when - is not addressed or rewarded by today's health care.⁴ And experts agree that medicine - the institution most in need of change - is the institution most resistant to change, in spite of its continuing scientific and technological glory.^5,6 At least some of the public is not dazzled by technological solutions for simple and common problems. They want health care, not medical care. Further, antibiotics and other drugs in human and animal use have broader public and environmental health impact. Just one more biological agent added to our environmental soup adds unpredictable consequences, as half-lives of drugs, their metabolites or their resistant strains^7-10 find their way into fish and oyster beds, on ocean beaches, or in fresh water lakes. Whether this deep penetration by new chemistry and bacteria that ignore antibiotics is ultimately a friend or foe to our descendants and us is a gamble we should be unwilling to make. In the end, titrating drugs into the world's oceans, food, and fresh water supply is a grand experiment that should be limited, to the extent possible.

Pharmacopeias sapiens

The human body does an admirable job of recovery and repair most of the time. This notion should be an operating principle in all of health care delivery, given that humans are the successful product of an extended and ongoing natural experiment. It is reasonable that we should encourage the accumulated evolutionary wisdom of 5 million human years and 4 billion years of life as our first strategy, whenever possible. Self-care must have been common among our ancestors, with the shamans called in only for the intractable, complex, culturally specific, demonic, or potentially fatal cases. Today, to the extent possible, responsibility for health must be restored to individuals and communities, and not just for the health of the patient, but also for the financial health of nations and industries.

People are inheritors of a deep and little-understood evolutionary wisdom. Sometimes this wisdom is consciously directed, as in resting when tired and eating when hungry; sometimes it is subconscious and autonomic, as when a cut heals. Innate wisdom can be overridden. We eat for emotional reasons. Resting can be delayed to pursue activities that are more profitable. Pushing ourselves beyond our physiological limits may be something we brag about, but is eventually reckoned with, depending on constitution. Humans have the freedom to override wisdom with beliefs, values, and willfulness. Understanding the consequences of unhealthy decisions and addressing them with self-remedies and advice is the best "medicine."

Chiropractors must decline the invitation to build patient dependency and establish a high priesthood of inaccessible and irrelevant knowledge. Treating the patient instead of the condition is still a "big idea" abandoned by most health care professionals.

References

1. Moynihan R, Smith R. Too much medicine? BMJ 2002;324:859-60.
2. Menke JM. Principles in integrative chiropractic. J Manipulative Physio Ther 2003;26:254-72.
3. Kenagy JW, Christensen CM. Disruptive innovation: a new diagnosis for health care's "financial flu." Healthc Financ Manage 2002;56:62-66.
4. Porter ME, Teisberg EO. Redefining competition in health care. Harv Bus Rev 2004;82:64-76,136.
5. Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations cure health care? Harv Bus Rev 2000;78:102-112,199.
6. Herzlinger RE. Why innovation in health care is so hard. Harv Bus Rev 2006;84:58-66,156.
7. Chee-Sanford JC, Aminov RI, Krapac IJ, et al. Occurrence and diversity of tetracycline resistance genes in lagoons and groundwater underlying two swine production facilities. Appl Environ Microbiol 2001;67:1494-1502.
8. Levy SB. The 2000 Garrod Lecture. Factors impacting on the problem of antibiotic resistance. Antimicrob Chemother 2002;49:25-30.
9. Ohlsen K, Ternes T, Werner G, et al. Impact of antibiotics on conjugational resistance gene transfer in Staphylococcus aureus in sewage. Environ Microbiol 2003;5:711-16.
10. Carlucci AF, Pramer D. Factors affecting the survival of bacteria in sea water. Appl Microbiol 1959:7:388-92.