Pathologising Physiology

Pathologising Physiology

The intent of this essay is to reveal and analyse a fundamental flaw that exists in the modern western medical model; how it came about, and what steps can be undertaken to remedy it. The alternative is that to continue with this deeply embedded flaw modern western medicine, or MWM, will continue an imbalanced orientation with far reaching effects. These effects, at an obvious level, include spiralling health costs, professional disillusionment, increasing fear in the populace, and desertion to alternative medicines that may lack the necessary education and discipline to deal with this. At a deeper level the effects could be the breakdown and even demise of our current health system: although this breakdown may, for reasons beyond the ones presented here, be a more wide-reaching process in society across many disciplines.

The signs of this difficulty extend beyond the more immediate ones outlined above identified within the health system. The psychological position in the profession is of the progressive diminution of the mind into an epiphenomenon of the body and its treatment in the same mechanical manner. Socially there is a breakdown of the relationship between doctor and patient, with his or her increasing separation from the wider community in which his or her health problem is embedded. Issues of power, control and politicisation are rampant and the influence of industry, particularly the pharmaceutical, is disproportionate (discussed in the companion paper, The Pathology of the Pharmaceutical Industry). MWM medicine is not keeping pace with other scientific disciplines, philosophy (which has gone beyond the identification of mind with brain that is still evident in MWM), or the arts; remembering that until recent times medicine itself was seen primarily as an art rather than a science.

The disconnection with other major cultural streams, apart from the arts, is also evident. Up until recent times the priest and doctor had a close liaison, even to being in the one person. This relationship has broken down, as has the significance of non-physical and hence spiritual factors in an overall picture of health and wellbeing. And, last but not least, the almost complete negation of environmental factors, particularly poisoning, is a serious concern and even affects our consideration of pharmaceutical medicines.

It is obviously too simplistic to see the issue we are about to discuss as the main problem and the one whose rectification will see a restoration of a balanced health and medical system – although it would go a long way. But such consideration will have a rippling effect into associated areas so that the house of cards may be slowly dismantled and reassembled more correctly before it comes crashing down. From a theoretical perspective it may be that such a crash is inevitable and even a prerequisite for a new health system or paradigm to emerge. However, even if that is the cause, some prophetic intuitions may provide some of the patterns that could assist in any restructuring process in a creative manner.

I am going to use my own experience as a background to this essay. Far from negating the conclusions that are drawn from it as being personal and therefore invalid, I believe the converse is true. Insights, ideas and creative alternatives commonly stem from a personal base; it is just that this is often ignored in their acceptance because such a basis is considered to flaw their objectivity. It is about time the god of objectivity was seriously questioned; after all, he has been in modern physics for a considerable time and become relativised as a consequence. It is time to do this here. So, my story is entirely valid and relevant. Stories are in general: Again, in my experience it is stories that heal more than all our technology and medicines.

The choice to read medicine at university was the result of some intense synchronicities that occurred at a transitional nature of my life and marked by significant other events in and around my personal life. Armed with a place at Oxford University, which may have been jeopardised by wanting to study medicine instead of natural sciences, I remained adamant to what I saw was a “calling” and was given a place. In hindsight, given my current predilections, it may have suited my personal inclinations to read the combined physiology, psychology and philosophy course. However, medicine it was and is, and the other branches of psychology and philosophy have been pursued independently with further research, training and academic output. It is as if there is an inevitability, a destiny to remain in medicine, even if not in practice.

At Oxford the so-called pre-clinical studies of some two years were conducted with academics, not medical doctors. During this period, prior to being introduced to training in clinical studies, the delivery of anatomy, physiology, biochemistry, pathology and the like was eclectic and in the social company of students in other non-medical and non-scientific disciplines. This is a relatively unusual situation; preclinical studies are commonly delivered by medical doctors and the student boy is entirely of medical students. My experience was therefore more wide-reaching and conducted in an enquiring and intellectual creative environment.

By contrast when I went to Saint Bartholomew’s Medical College on London and the prestigious old hospital there for my clinical studies I was to receive a rude shock. I was now entirely in the company of medical students who had also completed their pre-clinical studies but, apart only a few others, had not pursued these studies to an independent degree in physiology prior to entering the clinical phase. My grounding in physiology has stood me in good stead, although out of step with most in the profession. It has given me an appreciation of the body as an exquisitely balanced self-regulated machine that medicine, in general, has lost sight of… and this is a major concern that we are going to explore further in this essay.

With this background complete I will move on to the main proposition, which is that the physiological aspect of health is being increasingly negated and inappropriately being collapsed into a pathological model. More properly there is a kind of spectrum along the lines of health to illness (physiological disturbance), excluding disease (pathology). In this picture disease represents a radical discontinuity from illness, as will become apparent. There are many and varied reasons for this disturbed position but, rather than take a systematic and analytical approach to these reasons, I will randomly move through various facets that impact on this central proposition, in no particular order and without intending exclusivity.

Probably the major impetus to the imbalance is the rapid rise of science and technology over the last three hundred years or so, particularly in the twentieth century. At the same time there has been a relative decline in the importance of religion, art and faith. The outcome is that terms like rationality, logic, empiricism, and facts have come to dominate their opposites. Originally the promise in the area of medicine was great, but has since plateaued. However that has not stopped our collective optimism (although this is also now on the wane) that has developed into arrogance and hubris. Because of the initial early success with disease management as a result of this model the net has increasingly widened to include all forms of illness and disorder, but whether this is legitimate is open to all sorts of scrutiny and criticism, and it is the argument here that it is fundamentally not legitimate.

It could be argued that this rise has paralleled our psychological maturity, even arrogance, at the level of ego: being the centre of our consciousness in the world in the world, even to the arrogance that God or the gods are now superseded and redundant; certainly they are relativised. As this position represents the height of individuality the thing that it will most fear and which disease portends, is its own mortality. In this light the bodily symptoms that accompany illness will be interpreted – through fear – as portending disease and hence the spectre of death. It is here that my point above about the radical discontinuity between illness and disease may be important. As illness is disturbed physiology it represents a movement away from a healthy balance, but is not alien to it. It requires a restoration of balance, for which the symptoms of illness are an indicator.

However, because the discontinuity between illness (physiological imbalance) and disease (pathology) is not recognised, then physical symptoms of disturbance are read as if they are symptoms of impending disease. This is a view that illness will lead directly to a disease on the lines of the symptoms. The irony is that if illness is treated this way then it may lead to disease (though not necessarily the one the symptoms may point to), because the body remains in a permanent state of imbalance and may stay in a state of stress, which then leads to disease as a consequence. It could be further argued that the disease orientation of medical management would fix a state of physiological disturbance at that end of the health to illness spectrum and thus predispose the body to a stress-related disease.

I am not implying here sinister means in the practitioner or profession, I am pointing out how the above distortions lead to these sorts of scenarios. The profession is, in general, operating in the patient’s best interests, although political, legal and pharmaceutical driven forces do compromise this position, and sometimes considerably. However, it must be remembered (by reference to my personal background) that usually doctors are taught by doctors and the orientation from the onset of training is pathological. This is, of course, where medicine has made its greatest advances and if doctors confined themselves to these parameters, then there would be no problem. But, because of all the intersecting factors outlined, they are drawn into dealing – predominantly at the general practice level – with physiological disturbance, which they are poorly equipped at differentiating from disease, and so they use their pathologically trained lens of expertise to look at physiological disturbance and are drawn – often with other pressures, including those of the patient – into making a disease diagnosis, although this may often be spurious and defensive.

This situation is not helped by the above-mentioned forces and their influence. The media take a scare-mongering role; various well-meaning interest groups put pressure on early detection, and the internet provides the next best investigation and treatment (on the same site, no doubt). Testing – or pathology investigation – that tries to assess normality has an impossible task. The orientation toward laboratory investigation is pathological, even in name, and has come to define a problem beyond the time-honoured criteria of a good history and physical examination.

The pharmaceutical industry exerts enormous pressure, often profit-driven, and has an excessive influence on the post-graduate education of the medical profession. Patients have come to see drugs as a magic bullet, when this is far from the case. The so-called “side effects” should alert us to the fact that they are not a magic bullet, but they are actually poisonous to the body and adding to the stress.

It is well beyond the scope of this essay to explore the mental and emotional factors that stand behind physical illness and disease, even to mental problems themselves, but stress is a significant factor in the genesis of disease and which all the above situations serve to reinforce. Because, in general, disease occurs as a disease from onset, it does not somehow mature into disease from physiological disturbance. We are chained to the god of causality, and this is but one way to skin the cat of disease emergence; there are many others, and better embraced in the emergent holistic philosophy and its application to medicine.

Legal factors have an inordinate place in MWM, such that they have an unreasonable influence on the behaviour of doctors in their management. This is said definitively and unambiguously; it is a source of serious concern. Of course there are strong arguments for the place of the legal surveillance of the profession, as negligence is beyond question. But there is an unrealistic perception in the public, reinforced by the aforementioned fear of death, that we can somehow conquer all disease and that any failure to do so represents at least a responsibility on the part of the doctor. Added to this is the fact that the legal profession then, with the support of the medical profession and its hierarchal vested interests, comes to define what is acceptable practice. The role of such factors as statistics, evidence and normality in this judgement is restrictive and often overlooked, or even open to question. This overall process tends to muzzle doctors who think outside the square or who are prepared to try managements considered inappropriate by the – conservative – profession.

And conservative it is. The profession has arguably the most powerful union in Australia and probably in most western countries. Medicine is therefore heavily politicised. This fact, and the other ones above, are not voiced to simply criticise the profession, they are voiced to show the sort of forces and attitudes that determine how an individual practitioner operates and conducts his or her practice, as well as the sort of pressures they are under in terms of performance and outcome.

Finally, a personal bette noir: The god of objectivity would have it that the relationship between doctor and patient be confined to just that; small matter that this is out of tune with a harmonious society, as symbolised in the image of the old village doctor. In a traditional sense the doctor who knows his or her patient beyond the confines of the consulting room has an appreciation of a multitude of other factors that impact on health, such as social, occupational, economic, and even highly personal issues. He or she is then far more capable of identifying health disturbances that are a consequence of these other factors, rather then seeing them as pointing to immanent disease. That this entertains a doctor – patient relationship that is more emotional and intimate is inevitable, but is precisely because of these factors his or her capacity to see further than the objective doctor in the consulting room that we need to consider, examine and integrate these issues.

To illustrate much of what has been written above it would be of value to explore some contemporary health issues that highlight some if not all of the points raised above. Obviously this list of issues cannot be global, although the same principles used in the following discussion can readily be used to examine any problem. For this reason I will contain the discussion to some very relevant and pervasive problems that are proving remarkably resistant to the management according to the principles of MWM. They will therefore have more immediate relevance for a broader spectrum of readers, as well as indicating an alternative pathway into the more inaccessible problems and diseases that haunt medicine. Finally, I admit that the “take” on these problems is personal and does not – obviously – conform to existing ways of looking at these or their management. They are not claimed to be unequivocally “right”, but should be seen as a basis for comment, further discussion and enquiry.

In the modern era we seem to have a complex of issues that afflict many in the west that come under a variety of names, such as Syndrome X or Metabolic Syndrome. Here there is a strong indication at the onset that the problem is related to disturbance with the use of the term “metabolic”, with the word “syndrome” that refers to a group of symptoms that characteristically occur together. These “symptoms” consist of obesity (and, characteristically, the inability to lose it); disorders of sugar metabolism such as “insulin resistance” up to and including the epidemic of diabetes type 2; disturbances in cholesterol profiles, and high blood pressure (hypertension). We have run into a difficulty already: although the definition of syndrome nominates these issues as symptoms, how often are they treated as diseases?

The first three of these characteristically occur together in varied proportions and degree of seriousness. From a biochemical perspective the disturbance in sugar metabolism is the key culprit and one to focus on, as the issues about weight and high cholesterol will often be reduced by focussing on this single fact. This is because the disturbances of sugar metabolism (that is, too much sugar) is related to the fact that we simply eat too much and not enough proteins or good quality fats. It’s that simple: the body is used to these energy sources in the correct proportion and we are currently way offline with this. The consequence is a strain on the ability to metabolise sugar (leading to insulin resistance, weight issues and the inability to shift it… because of the resistance, etc. etc.), which then clogs up the liver and gets stored as fat; fat people eat carbohydrates – sugars – not fats, to get fat. The excess sugars spill over into raised cholesterol and the cycle is complete. The outcome is metabolic disturbance that stresses the system and leans to the fourth symptom, high blood pressure.

As simple as that? At one level yes. As well as treating excess sugars or carbohydrates, we are also an increasing rate of couch potatoes (exercise helps correct all the symptoms) and we have lost the ability to go through the cycles of feasting and fasting; we simply feast all the time. We eat the wrong foods, not only in terms of the balance above, but also too much processed and convenience foods. These factors increase the metabolic load, the stress and… the blood pressure. Obesity is certainly a problem, but is a consequence of the others, so let us pick our way through them.

Basic biochemistry will show how the excess of sugars lead to the consequences outlined immediately above. Eventually the pancreas (which makes the hormone insulin to deal with the sugar) can’t handle the strain and so-called diabetes type 2 (DM2) is the outcome. Now let me tell you that in my lifetime DM2 has become an epidemic, when in my early career it was relatively uncommon. That is because there is a difference between the DM2 that is consequence of physiological disturbance and the DM2 that is a consequence of a primary failure of the pancreas gland itself. The former will respond to corrective metabolic measures, the latter usually does not and slowly progresses.

MWM does not differentiate between the two and puts them both in the same pathological basket. Of course there is some attention to the “lifestyle factors” that are implicated, but this is usually scant and sometimes trivialised. There is clearly a need to differentiate the disturbed physiology population from the disease proportion, but this is neither clearly nor adequately done. The use of drugs is commonly premature and lazy.

Eating fat in and of itself does not create a cholesterol problem. Firstly most cholesterol is manufactured in the body and is essential for the production of many hormones, testosterone and adrenal hormones (for stress) amongst them. Does the stress of eating a diet very sparse in fats lead to health problems related to stress? In my opinion and experience, yes. It’s a question of eating the right fats and knowing that it is the sugars that are the primary culprit. Of course, eating too much fat can be a problem, particularly when it is from the “bad” fat range, which is almost exclusively trans fatty acids (processed foods), but this is a minority player in the overall game.

Again MWM fails to differentiate, as well as not recognising the cause of the problem in the first place. The association – yes, association, not cause – between disturbed sugar and fat metabolism with heart disease is through the metabolic pathway. These are symptoms (remember the definition) not causes, so it is the metabolic picture that needs to be fundamentally addressed. The lazy way is to take drugs to lower the cholesterol. But this is a fool’s paradise, because whilst the cholesterol levels may normalise, the metabolic factors are still operating – a smoking gun. Also the wide range of sometimes serious side-effects are a cause for concern, as they point to the consequence of an absence of cholesterol in hormone manufacture and the poisoning effects, including depression. Also, and most tellingly, the evidence does not indicate that using them in a preventative manner for heart disease makes any difference.

Hypertension is inferred as a consequence of this state of affairs, although it should be recognised that the hypertension due to the disease of arteries is fundamentally different to the hypertension caused by a stressed system. It requires a little innovation to differentiate them, but it can be done relatively easily. Again, most hypertension is the direct result of a stressed body, either because of metabolic reasons or mental ones… commonly both. This is important to distinguish, because the long-term consequences of taking drugs for hypertension can affect many other systems of the body, including the sex drive and performance.

We’ll stop there, before a book is written. One major aspect that I would like to highlight is the role of physiological stress in all of the above. The point being that pathologising these problems leads to using medications that simply mask the underlying issues that lead to the syndrome in the first place. The blood tests and blood pressure readings may then be alright, but the system may remain significantly stressed and now not displaying the symptoms as a warning.

The consequence of this is that the stress may then precipitate or trigger a disease. It is common knowledge that a heart attack is precipitated by stress, so it is a wonder how many times this outcome is used to justify treatment in the first place. Stress has immediate effects on the heart and we can be “trained” to detect these very simply, sometimes using the heart rate as a guide is all that is needed. If sustained and the heart not being given a break, the adrenal glands will now kick in and use adrenal hormones, often in excess. This can lead to other stress-related problems and, if sustained, the adrenals slow down possibly contributing to the epidemics of chronic fatigue and fibromyalgia. Also the immune system becomes significant compromised and in danger of immune-related diseases, up to and including cancer.

It is also here that the mental state is highlighted, as this is another consequence of a depressed immune system, because this leads to depression per se. Of course, it is not the only thing that does, but of one thing I’m certain: serotonin deficiency is a consequence and not a cause. Maybe we’re burning up serotonin by stress the same way we’re burning up our adrenal glands? Also, if it were serotonin deficiency, then how come we still have an escalating epidemic when we have these supposedly great drugs – antidepressants – that boost serotonin levels?

There are many factors implicated in depression and, again, it is very important to distinguish the depression that is part of the stresses and challenges of life from one that appears more like a disease in its own right. From the discussion above it will not surprise us to find out that the latter is definitely in the minority, so the former needs to be considered “psychological disturbance” to correlate with the physiological disturbance category, and managed under the same principles.

With a little imaginative speculation it would be no surprise that the management of these core physiological disturbances come down to some core principles. These could be nominated as diet, exercise and attitude, the discussion of each of which could fill in a book; and if you look at the health section of a bookshop, they have. We must leave the story here, though, as it is my belief that books can be effective only up to a certain point. We need the instruction of someone who has traversed the territory, who can mentor us on the path… an old-fashioned doctor maybe? But in a modern guise.