Wednesday, January 6, 2010

A HUNDRED YEARS OF FLEXNER, PART TWO


After John D. Rockefeller, Andrew Carnegie, and Abraham Flexner made science the basis of medical training, healthcare achieved mind-boggling advances. Would these men have imagined in their wildest dreams that today, a century after Flexner’s report, smallpox would be eradicated, hearts would be almost routinely transplantable, and most joints would be artificially replaceable?

Biomedicine’s impressive success, though, is ironically its obstinate ceiling: we’ve benefited by living longer, so are now old enough to develop the intractable diseases of aging. In other words, the entire picture of disease has qualitatively changed. Flexner’s scientific approach, wonderful though it once was, is decidedly less effective now.

Since the mid-twentieth century, disease changed in a couple of ways. First, increased life span favored the emergence of incurable disorders. The child whose life was saved by penicillin in 1945 is now seventy years old, and noticing that he or she—sorry to put it so bluntly—is beginning to fall apart.

Aging, along with its natural deterioration, is a permanent given. We’ll never, ever be able to abolish it. Any attempt reminds me of the apocryphal story about the Long Island Railroad, which, having determined that most fatalities in rail accidents occur in the last car of the train, removed the last car of every train. Doesn’t quite compute, does it? And neither does the myth that we can remain robust until we’re a hundred, have one last night of wild sex and then die peacefully in our sleep. No matter how long we live, we’ll age. As a matter of fact, most of life extension amounts to prolongation of oldness.

The complaints of the elderly aren’t due to disease as much as to plain old wearing out. Nothing—reflexes, memory, sphincter tone, the immune system, you name it—functions as well as it once did. There’s nothing to “cure” here. We can and should ameliorate symptoms as we can, but that’s the best we can do with our medicines.

The other major change in disease is that so much of it currently results from unhealthy living. I mentioned in an earlier blog that when I ask my colleagues what fraction of their patient clientele suffers from diseases brought about by noxious diet, inadequate exercise, toxin exposure, unskillful management of stress and relationships and the like, they all tell me “the majority.” Most of these disorders, including hypertension, atherosclerosis, emphysema, and type two diabetes, are as chronic as the disorders of aging—in other words, incurable.

We docs wind up, then, trying to address today’s incurable diseases with the cure attempts of the 1930s. It’s like trying to drive in a nail with a screwdriver. We apply increasingly complex, expensive, invasive and hazardous technologies with predictable futility.

Instead of pretending we’re exclusively scientists, we’d do better to temper science with therapeutic communication. That means helping those with pathogenic lifestyles understand the consequence of their choices and make healthy alterations.

It also means helping older patients to live with their diseases and become comfortable with the admittedly difficult notion that deterioration and death are a normal part of life.

That’s a spiritual, not scientific, challenge. Many years ago, I was sick with something that threatened imminent quadriplegia. Mighty scary. Friends supplied me with well-meant suggestions. My bedside table got piled high with books, healers’ business cards, diets, affirmations, and crystals. None of it meant much to me. But at last someone sent me a two-thousand-year-old Taoist poem. The aging poet bewailed organs failing, one after the other, a long lament, and concluded, “But on the other hand, what does that have to do with me?”

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