Friday, January 27, 2012

Worried Sick: The Age of Anxiety

   It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, ...

Charles Dickens,  A Tale of Two Cities 

     Dickens' words, written in 1859,  could aptly describe contemporary society's experience of health and modern medicine, miraculous or mistaken, death defying or dubious.  This is a curious state of affairs when one considers the remarkable success medicine has had since the Second World War. A timeline of some medicine's greatest hits reflects this golden age:

Penicillin 1941 
Cortisone 1949
Smoking identified as cause of lung cancer and Tuberculosis cured with streptomycin and PAS 1950 Chlorpromazine for schizophrenia and the first intensive care unit 1952 
Open heart surgery and polio vaccine 1955  
Cardiopulmonary resuscitation 1956 
Endoscopy 1959 
Oral contraception 1960 
Levodopa for Parkinson's disease and hip replacement surgery 1961 
Kidney transplantation 1963 
Stroke prevention programs and coronary bypass grafting 1964 
Heart transplantation 1967 
Prenatal diagnosis of Down's syndrome 1969
Neonatal intensive care 1970
Cure of many childhood cancer 1971
CAT scanner 1973
First test-tube baby 1978
Coronary angioplasty 1979
Helicobacter identified as cause of peptic ulcer 1984
Thrombolysis for heart attacks 1987
Triple therapy for AIDS rendering it a nonfatal illness 1996
Viagara therapy for impotence 1998

     The previous 2,000 years had seen no significant therapeutic discovery for the scourges of infant mortality, infectious disease, surgical death, cancer, heart disease or mental illness. In 1900, 30% of all deaths occurred among children aged less than 5 years.  By the end of the century, that percentage was only 1.4%. In 1900, the three leading causes of death were pneumonia, tuberculosis, and diarrhea, which (together with diphtheria) caused one third of all deaths. Of these deaths, 40% were among children aged less than 5 years. At century's end these diseases were scarce. Heart disease and cancers accounted for more than half of all deaths, with only 4.5% attributable to infectious disease.

     The 20th century witnessed a 30 year increase in life expectancy.

     And yet, despite these unprecedented advances, more people feel uneasy about their health today than in 1900 or 1940.


     I believe that two events on the hit parade of 20th century medical accomplishment can explain much of the paradoxical loss of confidence in our health; the discovery that smoking caused lung cancer and the realization that high blood pressure caused stroke.

     Let's take them one at a time.

     The revelation that smoking, a nearly universal postwar habit, caused a fatal illness introduced the idea that health was tied to lifestyle. A habit that seemed to cause no harm in the short term could kill you. From that time forward, people had to wonder what other behaviors might prove lethal. 

     The impact of connecting high blood pressure to stroke was more insidious. Hypertension is usually silent, causing no symptoms. You go about your business feeling fine. Prior to the discovery that high blood pressure causes stroke, it was fair to presume that if you felt well, you were well. Suddenly how you felt was no guarantee. You no longer had to be sick to visit a doctor. In fact, annual visits became the norm. 

     The remarkable medical breakthroughs of the latter half of the 20th century also fostered a view that medicine's domain had no limits. All human problems could be remedied by the mighty medical establishment. This expansionism brought annual crops of new diagnoses and new vulnerabilities.
The long arm of medicine now reaches into our living rooms where big pharma describes symptoms and cures on the television, lest we thought we were well. 

     The most conspicuous example of such thinking today is the conceptualization of obesity as a medical illness. Bullets cause bleeding but cannot be understood as a medical issue. Obesity's roots lie in bad foods and inactivity, not failures of medicine. The solution will  not be gastric stapling or a pill.

     No doubt, part of this bizarre way of thinking can be owed to the origins of medicine. It has been a field of fixing what's broken. Only recently and reluctantly has it begun to embrace prevention. But there is no question that now our habits are the leading cause of illness. More americans are unhealthy today than in 1900 despite medicine. And we are a more anxious lot, fearful that our cell phones, water bottles, foods, air, are all potential killers. But none of this is in the medical realm.

     Perhaps we must look to those most gifted at changing people's behavior. That has never been the doctors. Madison Avenue and the admen, pop idols, sports icons. We must enlist them as health evangelists if we are ever to see anything like the progress of last century. 





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