The Medicine

by Karen Hitchcock

The evidence is mounting that these supplements, taken in the absence of true deficiency, may cause harm: more cancer, more heart attacks, more broken bones. Too much vitamin D (hypervitaminosis D) causes dangerously high calcium levels in the blood, which leads to confusion, muscle weakness, vomiting, kidney stones, bone demineralisation and pain. Too little and your bones grow thin. But it is not yet clear whether or not low vitamin D causes other kinds of disease. Many observational studies have shown that people with poor health have low levels of vitamin D, but there’s no hard proof that the low levels cause the poor health. If you’re sick, you tend to stay indoors and have lower levels of vitamin D. It will be a number of years until we start to see the results of the first large randomised controlled trials of vitamin D supplements versus placebo on all kinds of non-skeletal health outcomes. Maybe a small supplement will prove beneficial for the great Western goal of health-tweaking. But megadoses or extreme deprivation cure nothing and cause real harm.

  Vitamins are good, but if you have access to adequate amounts of real food and a bit of sun, you’ll likely get all the vitamins your body needs. There is no pill to cancel out smoking, inactivity or drinking a bottle of whisky a day. Fresh produce drenches your cells in things we can’t bottle. The truth is pedestrian: if you want to live well and long, be born in the right place and time, cross your fingers, eat lots of vegetables, and go for a walk. The miracle cures almost always turn out to be lollies or poison.

  Too Many Pills

  At a literary festival, during a discussion of how medicine reflects the values of the society in which it is practised, an interviewer asked me if I thought there would ever be a time when mainstream and alternative medicine would become “truly integrated”. We’d been talking about attitudes towards the elderly in hospital, and his question took me by surprise. “Truly integrated?” I asked. He nodded enthusiastically. “By which you mean the integration of Western medicine and alternative therapies?” He kept nodding and smiled at me, as if I was surely one of his gang. “No,” I said. “I don’t think they can be.”

  It’s an interesting concept, “alternative medicine”. Alternative to what, exactly? Is it like the right versus the left in politics? If something is defined in contradistinction to something else, how can the practices be “integrated”? It has been said many times: there is no alternative medicine. There is only medicine that works and medicine that does not work. If an intervention is proven by empirical science to work, it is no longer considered “alternative”. It becomes medicine.

  When I was in medical school one of my classmates was a naturopath. He planned to become a GP and practise integrative (or “complementary”) medicine. He would set up shop and use vitamins, herbs and homeopathy in conjunction with pharmaceuticals. He’d take your blood pressure, and diagnose your organ dysfunction by examining your irises. He walked like a monarch, somehow managing to look down at you even if you were taller. He never lost his cool, not even when professors stood at the front of the lecture theatre taking an atom bomb to everything he held true.

  We mixed in the same social circle: the misfits and miscreants. I liked him but his arrogance drove me nuts. We argued, about homeopathy in particular. Homeopathy adheres to three main principles: a disease can be cured by giving a patient an infinitesimal dose of the same disease; treatment should be individualised; and one should use the minimal possible dose of any treatment. The last two principles are perfectly sound and in theory should be followed by all doctors. However, in homeopathy, the minimal possible dose involves diluting medication to the extent that not a single molecule of the active substance remains in the final pill.

  I’d ask him, how can the concept that water has the capacity to hold “memories” of substances it has encountered be “integrated” into medicine? Medicine is an empirical science that believes molecules are either present or absent, and if they are absent they can have no effect. The theoretical basis of homeopathy – I would say – is fundamentally incommensurate with everything we know about chemistry, biology, physiology and disease. It hadn’t once proven effective in multiple large, double-blind randomised controlled trials. It was preposterous.

  He’d tilt his head ever so slightly sideways and look sad: for my ignorance, for my future patients and for me.

  Disillusionment with Western medicine is not uncommon in Australia. When, back in the ’90s, I told a dancer friend of mine I was applying to medical school, her eyes widened, her mouth opened and no words came out. Another friend placed her hand gently on my forearm, leaned in and said she was seriously worried about me: what had gone so very wrong that I would consider that?

  Mainstream medicine is charged with being reductionist, inhumane, non-holistic. It denies there is Lyme disease in the Melbourne CBD; fails to take chronic fatigue syndrome seriously; scorns patients who are convinced they have undetectable autoimmune or allergic conditions; and suppresses the fact that food, vitamins or ozone enemas might cure cancer and that immunisation causes autism. Doctors are arrogant, authoritarian and non-communicative. They cut, drug and dismiss. Western medicine keeps us sick for the financial gain of doctors and drug companies. Almost everyone could tell you a story of how medicine has failed them. Alternative medicine seems to offer an alternative. Integrative and complementary practices seek to improve mainstream medicine’s poor report card.

  Australians are keen users of all kinds of alternative health products and practices. A survey conducted by the guidance body NPS MedicineWise in 2008 showed that 65 per cent of Australians had used one or more “complementary” medicines in the previous twelve months. If we include self-prescribed vitamin supplements bought from the supermarket or chemist, then it is not a stretch to say that most Australians use some form of alternative treatment in their quest for health.

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  I have spent a lot of time wondering exactly what medicine, the discipline, has become. I’ve worked on the acute medical wards of a large city hospital, looking after patients who have been tipped out of ambulances into the emergency departments and are sick enough to earn a bed upstairs. On the wards, medicine can be powerful and life-saving. If someone has a clot or an infection or an arrhythmic heart, we have drugs that fix their problem. The surgeons can cut out or repair diseased tissues, allow people to walk once again by replacing disintegrated joints, sew in brand-new lungs and hearts. Cancer is obliterated or retarded. A heart is made to beat again. This is the television fantasy of medicine – where heroic doctors save patients with their bare hands, a few pieces of machinery and the medicine cabinet. And it happens, all the time. But on these wards we spend at least as much time patching up social catastrophes (drug overdoses, homelessness, violence) and the devastating effects of lifelong body abuse or neglect (poor diet, physical inactivity, smoking and alcohol) as we spend treating broken body parts or immediately life-threatening illnesses. Around a third of the elderly people on any ward are lying in their hospital bed because of a side effect of a medication they have been prescribed in good faith by a doctor. A medication that has been overdosed or prescribed unnecessarily or had an unexpected side effect and has thus made the patient sick.

  Australia is a rich country: we have access to immunisation and clean water. Our mosquitoes are not deadly. Most of us are not starving. Our ills reflect this. We have entered the age of the so-called non-communicable diseases: diabetes, cardiovascular diseases, cancer and emphysema, many of them attributed to our “lifestyle”.

  I sat through a lecture recently where an endocrinologist showed a map of Melbourne that plotted the incidence of type 2 diabetes by suburb. The lower the average socio-economic standing of the residents, the higher the incidence of the diabetes. The correlation was picture perfect. The action the speaker proposed upon pointing this out was to collect more data, to employ more endocrinologists, and to ensure those hospitalised with diabetes in these suburbs received better monitoring and treatment. I sat there quietly, face attentive, hands in my lap, wishing I could strangl
e someone: him, my colleagues, the government, myself. On the wards and in our clinics, we are charged with treating the consequences of politics and policy mixed with bad luck and individual choices: the consequences of social problems such as poverty, alongside the consequences of excess.

  The solution to diseases of lack and excess can’t possibly be supplied by medicine, and yet many doctors, researchers, politicians and funding bodies, and much of the population, seem to believe it can. It wasn’t the endocrinologist’s fault he didn’t raise his fist and call us to arms. He’s a doctor, focused on a pancreas that can’t keep up with the insulin needed to metabolise far too much sugar to supply far too much fat. He does what he’s trained to do: treat cells. Medicine wants to be of assistance.

  Alongside the non-communicable diseases there is another kind of epidemic in the West: feeling unwell inside a body that medicine deems pristine. Studies show that around 30 per cent of patients who present to specialty outpatient clinics are suffering non-organic symptoms that impair function but are not caused by a dysfunctioning body. In some neurology clinics, the proportion of patients who suffer non-organic symptoms reaches 50 per cent. More than half of the patients in any kind of medical clinic will list fatigue as one of their most troubling symptoms. GP practices are inundated with patients suffering vague symptoms such as aching bones, sleeplessness, irritability, lack of concentration and persistent dog-tiredness that are not attributable to any disease. Why do so many “medically well” people feel so sick? As doctors, we do what we can. We can construct narratives of cellular causation that elide the social, the interpersonal and the political. I have sat through lectures by experts who beam PowerPoint slides with impressive diagrams of neurotransmitter pathways they say lead to the feeling of what would once have been called simply “despair”. A doctor tells me authoritatively that falling in love is merely dopamine fucking with the brain. The mysteries of human consciousness and our intricate connection to our world and those around us – the subjects of centuries of philosophical thought – are reduced to a handful of chemicals acting on a cell in an individual. We’ve become adept at inventing new “diseases” – chronic fatigue syndrome, female hypoactive sexual desire disorder, attention deficit hyperactivity disorder, irritable bowel syndrome, social shyness disorder, fibromyalgia – to account for bad feelings housed by well bodies. And we prescribe truckloads of drugs to fix them. This is our field, after all. So charged with fixing everything, this is what we treat: cells. And we are ably assisted in our task by one of the most profitable industries in human history: the pharmaceutical industry. As Ray Moynihan, Iona Heath and David Henry have written in the British Medical Journal, “There’s a lot of money to be made from telling healthy people they’re sick … Pharmaceutical companies are actively involved in sponsoring the definition of diseases and promoting them to both prescribers and consumers.”

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  Walk through the vitamin aisle of any pharmacy or supermarket and you are offered plastic bottles filled with the promise of better sleep, greater sexual potency, increased energy, and relief from pain, depression, fluid retention, PMS, hunger and joint degeneration.

  The supplement industry is worth more than $1.5 billion a year in Australia. The former CEO of the Australian vitamin and supplements company Swisse, Radek Sali, has been quoted in The Guardian as saying, “If it’s not harming anyone and it is making people feel healthier and happier, why wouldn’t we have more of that?”

  We buy mountains of vitamins that the majority of us do not need, that do not work, and that – despite Sali’s cheery claims – have the potential to cause harm. Many supplements contain more than the recommended daily dose of a vitamin or mineral that we are not usually lacking in the first place. Vitamin E supplementation has been linked to an increase in all-cause mortality. Taking only a few times the recommended daily dose of Vitamin A can cause nervous system, liver, bone and skin disorders, and birth defects when taken in pregnancy. Vitamin C in large doses causes diarrhoea and kidney stones. Zinc excess causes iron and copper malabsorption. Too much vitamin D causes hypercalcaemia. Beta-carotene increases the risk of lung cancer. Iron, severe toxicity. B6, nerve damage. Potassium overdose causes cardiac arrest. What are we seeking to treat with our hypervitaminosis? Do most of us really feel sick?

  I saw Marie, a middle-aged, educated woman, in one of my specialist public clinics. The clinic is for patients who suffer debilitating fatigue or other symptoms – pain, paralysis, collapse – that have remained inexplicable despite multiple specialist reviews and much investigation. Marie was suffering extreme fatigue, gastrointestinal disturbances, constant aches in a constellation of ever-changing body parts, and sleeplessness. She’d seen a rheumatologist, a cardiologist, a naturopath and an acupuncturist and found no relief. I asked about her marriage, work and family. She felt revulsion towards her body and her husband, was deadly bored with her part-time work, and binged on large amounts of junk food multiple times a day. Her physical examination and blood tests were all normal. She was desperate to feel well. She told me she only ever felt well at a health retreat she visited three times each year: “I feel completely transformed after just one night. I can think, I can sleep, I have no pain.” She asked me if she might be suffering from chronic fatigue syndrome, perhaps that was her problem? I said I didn’t think so. She looked at me. “Then I think I need an antidepressant.”

  How tempting, to pull out the script pad and pretend the drug should just about cover it. How difficult to say no: to her requests for the diagnosis and the drug. I asked her if she thought that she could attempt to bring some aspects of the health retreat into her life instead of taking medication. I suggested a psychologist, massage, perhaps a course in meditation. I knew she could pay for such treatments. She sighed and said, “Can’t you just give me the script?”

  It is almost impossible to criticise our dependence on medication to treat non-communicable chronic diseases without seeming moralistic. Diagnosing the problem comes out sounding like a terrible lecture, a finger wag, a huge downer: you bad, greedy, lazy, selfish population. But the problem is not the result of the choices of a sinning bunch of individuals; it is the result of structural, societal and political design.

  Many of the diseases we suffer in Australia, the diseases causing hospitals and clinics to overflow, could – theoretically – be prevented. Most of the pharmaceuticals we swallow could – theoretically – be dumped. But we don’t have time to sleep or exercise or attend to our emotional needs. We want to drive, feast, drink and smoke. We don’t want to meddle with the food industry to curb advertising, or to manipulate pricing of the fresh and the junk. We don’t want to pay more taxes or direct funds towards decent welfare, social supports for the vulnerable, movement-promoting infrastructure or better education.

  I love medicine – the science, the practice, the hospital, my colleagues and patients – but I have come to hate most of our pills and the impossible expectations borne by them. In certain circumstances, medications save lives. Antibiotics cure severe infections that would have been universally fatal before their advent. People with heart failure can be kept alive for years with diuretics and beta-blockers. Adrenaline stops death from anaphylaxis. Thank god we have anticonvulsants. But many dispensed drugs will not save the life of the individual who swallows them. Statins, or cholesterol-lowering medications, are among the most common pills in our pharmacopoeia. And yet, 104 people who have high cholesterol but no known heart disease need to take a statin every day for five years in order to prevent one of those 104 people having a heart attack, a heart attack that would not have killed them. Eighty-three people with known heart disease need to take the pills for five years to prevent one of them from having a fatal heart attack. Each individual’s statistical benefit varies according to their age and medical history, but we prescribe these pills like crazy – presenting them to our patients without the statistics – and all of us swallow them in the belief that they will definitely have a direc
t beneficial effect on every individual.

  Most of the blockbuster pills tweak, they curb, they do nothing or they harm. Taken by a lot of people for a long time, they do save lives. But the broadly applied pharmaceuticals that address “risk factors” like high blood pressure, thin bones and high blood-sugar levels, and the drugs that are treating mild depression, anxiety and dementia, are mostly treating health problems that could be addressed in other ways: diet modification, weight-bearing exercise, weight loss, along with the social and structural changes that support these measures. All those shiny, fancy packets with zippy names that promise life, health and happiness. They promise exoneration from responsibility and consequence – both personal and political – like a priest in a confession box, telling us we’re all off the hook. Tiny white spitballs aimed at impossible targets, both large and small: gigantic sociopolitical problems as well as personal, middle-class dissatisfaction with life. We let the pharmaceutical industry dictate the pathways to health and we underfund access to physiotherapy, psychotherapy, social workers and rehabilitation.

  In 1848, the German pathologist Rudolf Virchow wrote, “Medicine is a social science … Politics is nothing other than medicine on a large scale.” Medicine has been charged with the job of curing all our modern ills: organic and non-organic. No wonder it is failing.

  A number of integrative-medicine GPs around Australia specialise in the treatment of chronic fatigue syndrome and related “diseases”. The patients present to these GPs with extremely common, vague physical symptoms for which they seek explanation, diagnosis and treatment. Many of these GPs will offer hard diagnoses, clear or convoluted explanations, and the hope of cure. For a few thousand dollars these doctors will diagnose you, compile the results of the countless non-Medicare-funded tests of your stool, urine, blood, breath and skin into a bound book, and start shovelling treatments upon you: expensive supplements and probiotics, multiple antibiotics taken for months or years, anticonvulsants, sun deprivation, steroids and bed rest. Their patients feel ill, their symptoms are real, but the cause of them is not a lack of vitamins, an undetectable infection or the sun. They do not have “systemic candidiasis”, which does exist but is only seen in the gravely ill, those with end-stage AIDS or organ transplant immunosuppression, and is not cured by avoiding sugar and mushrooms. They do not have “chronic Lyme disease”, “multiple-chemical sensitivity” or “myalgic encephalomyelitis”.