by Jo Marchant
So every oncology patient at the Mayo Clinic is given three simple questions when they check in—they’re asked to rate their pain, fatigue and quality of life on a scale from one to ten. Sloan says even this simple intervention is helping doctors to act on problems they might otherwise miss. Quality of life, for example, might sound like a vague psychological measure but it turns out to be crucially important for physical survival. “We know that if you score five or less on that question, the risk of you dying from your cancer doubles,” says Sloan.20
A growing network of buildings in the U.K. called Maggie’s Centres offers a very different approach, yet still guided by the importance of patient experience. Intended as places where people with cancer can go for practical, emotional and social support, they aim above all to “lift the soul.” The centers are designed by leading architects (including Frank Gehry and Zaha Hadid) to be welcoming, homely, intimate, beautiful—the opposite of many conventional hospitals. Visitors can chat to other patients; consult an oncology nurse or psychologist; get advice on nutrition or money; or just sit in the garden with a cup of tea.
I’m not aware of any randomized controlled trials comparing how patients who visit Maggie’s Centres fare compared to others. But as one advocate argues in the British Medical Journal, “If any of these buildings contributes to a pleasantly thoughtful or reflective moment for any of its users, a moment with friends or relatives, or a moment of hope and calm that they otherwise wouldn’t have had then they have already achieved something wonderful.”21
—
THIS IS the point at which I’d love to conclude that thanks to studies and projects like these we are witnessing a revolution in medicine, in which we’ll soon fully understand the role of the mind in health and will come to see the human aspects of care not as an add-on luxury, but as a central, guiding principle towards improving patient outcomes. Unfortunately, the odds are stacked against that happening.
One obstacle is the way in which research is funded: more than three quarters of clinical trials in the U.S. are funded by drug companies,22 who understandably have no interest in proving the benefit of any approach to care that might reduce the need for their products. Pills and medical devices are clearly a more attractive business proposition than hypnotherapy or biofeedback. The enthusiasm for physical interventions goes beyond market forces, however: almost all public money goes to conventional drug research too. The annual budget of the U.S. National Institutes of Health (NIH) is around $30 billion, for example, of which less than 0.2% goes towards testing mind–body therapies.23
The bigger problem, I’d argue, is a wider, deep-seated prejudice against the idea that the mind might have the power to heal, or to keep us well. The materialist worldview described in this book’s introduction—which prioritizes physical test results and interventions, and sees subjective experience as a distraction—still reigns supreme in science. (Sloan recalls that when he carried out a study showing that some terminally ill cancer patients in palliative care rate their quality of life just as high as healthy people, the first response of reviewers was that “the patient must be wrong.”) Ignoring subjective experience is great when you’re trying to eliminate bias from your scientific experiments but is not always helpful in caring for patients, when psychological and physical wellbeing are inextricably entwined.
Western medicine is (rightly) underpinned by science and trial evidence, and to many policy-makers and funders, physical interventions just “feel” more scientific than mind–body approaches do. Bioelectronics researcher Kevin Tracey is now enjoying millions of dollars of private and public funding to pursue his idea of stimulating the nervous system with electricity, even though as I write this, his largest published human study is in eight people. Gastroenterologist Peter Whorwell, by contrast, can’t persuade local funding agencies to pay for his IBS patients to receive gut-focused hypnotherapy despite decades of positive trials in hundreds of patients.
“I think there is a double standard,” says Howick, of the Center for Evidence-Based Medicine. “A common stick used to beat non-conventional trials is that they’re lower quality,” he says. “It’s not true.” Mindfulness has been subjected to hundreds of well-designed trials, he says. A 2005 analysis of 110 homeopathy trials found that they were of higher quality than equivalent studies of conventional drugs.24
This ingrained resistance to mind–body interventions is something I’ve heard about over and over again while researching this book. Even when scientists have funding, they often have to fight the surrounding culture in hospitals and universities just to conduct a trial.
Elvira Lang told me how the local ethics committee at Harvard responded to her plans to study patients undergoing keyhole surgery. “I remember a time when I had two trials pending for the committee,” she says. “One trial was on reading a script to patients to relax during the procedure. The other was carotid artery stenting in the very early days, where the way that trial was designed you had a pretty good chance of killing some people. The carotid trial was approved in no time! But the hypnosis trial, it took forever.”25
Meanwhile perinatal nursing expert Ellen Hodnett met resistance when trying to test whether women suffer fewer complications giving birth in an “ambient” environment—with dim lighting, projected scenes from nature and a mattress on the floor—compared to a conventional hospital room, dominated by technical equipment and a bed. Most hospitals she approached flatly refused to make the requested changes, she says, even though the medical devices would still have been close by. “Anybody who takes this on has an awful lot to overcome in terms of provider beliefs and attitudes to even allow the trial to go forward.”26
In a medical system based on evidence from trial results, the medicine we end up with depends on the trials that are carried out. So perhaps it’s not surprising that in Western medicine, there is little attempt to nurture and harness patients’ psychological resources. Despite their best intentions, medical professionals are working within a system that prioritizes access to medical technology and allows increasingly little space for the human aspects of care.
In the U.S., “physicians have become part of an assembly line of care,” says Bill Eley, associate dean of Emory University School of Medicine in Atlanta, Georgia. “We are increasingly pushed to see more patients in less time.”27 It’s a trend he fears is contributing to a loss of empathy among medical professionals (and in turn to scary rates of depression and burnout).28 Appointment times are squeezed to cut costs, even though the country spends nearly $3 trillion a year on health care; that’s 17% of GDP, more than anywhere else in the world.29 Meanwhile prescription drug use is dizzyingly high. Almost half of all Americans are on medication,30 most commonly for cardiovascular disease and high cholesterol (both of which are influenced by stress), with nearly 60% of adults aged over 65 taking five or more different drugs at any one time (18% are on at least ten).31
Of course, physical interventions—from drugs to heart surgery—are crucially important. When my baby son suffered a lung infection, the antibiotics he received quite possibly saved his life, and I couldn’t have cared less about his consultant’s bedside manner. The ability to cure and prevent childhood infections, in particular, is a gift those of us in developed countries are now fortunate enough to take for granted.
But the main threats facing us now are not acute infections, easily cured with a pill, but chronic, stress-related conditions for which drugs are not nearly as effective. We’ve seen that in many cases, painkillers and antidepressants may not work much better than placebo. The top ten highest grossing drugs in the U.S. help only between 1 in 25 and 1 in 4 of the people who take them; statins may benefit as few as 1 in 50.32
Meanwhile medical interventions are causing harm that dwarfs any damage done by alternative treatments. In 2015, an analysis of psychiatric drug trials published in the British Medical Journal concluded that these drugs are responsible for more than half a million deaths in the Western world each year, in
return for minimal benefits.33 Medical errors in hospitals are estimated to cause more than 400,000 deaths per year in the U.S. alone—making it the third leading cause of death after heart disease and cancer—with another 4–6 million cases of serious harm.34 According to the U.S. Food and Drug Administration, there are another 2 million serious cases of adverse drug reactions in the U.S. each year, including 100,000 deaths.35
These statistics don’t include expected side effects and complications of medications and interventions (many of which, as we heard in chapter seven, people might not need under a different model of care), or the huge problems caused by prescription drug abuse, for example, or the rise of antibiotic resistance. The U.S. is the richest country in the world, yet even with trillions of dollars to spend it cannot match the life expectancy of a middle-income country like Costa Rica.
I am not advocating relying solely on the mind to heal us; but denying its role in medicine surely isn’t the answer either. My hope, then, is that this book might help to overcome some of the prejudice against mind–body approaches, and to raise awareness that taking account of the mind in health is actually a more scientific and evidence-based approach than relying ever more heavily on physical interventions and drugs.
Perhaps one day this realization might help lead towards a system of medicine that combines the best of both worlds: one that uses life-saving drugs and technologies when they are needed, but also supports us to reduce our risk of disease and to manage our own symptoms when we are ill; and when there is no cure, cares for us and allows us to die with dignity. I hope that such a system of medicine would respect patients as equal participants whose beliefs, experiences and preferences matter in their care; that it would no longer stigmatize those with unexplained symptoms; and that it would recognize that the vast majority of health problems we face aren’t physical or psychological—they are both.
The problems with modern medicine run deep; clearly they won’t all be solved by mind–body therapies. But trying to improve medical outcomes by treating patients as the complex human beings we are, rather than simply as physical bodies, seems to me to be not such a bad place to start.
—
THE IMPLICATIONS of embracing the role of the mind in health go beyond medicine, of course. For me, one of the most surprising—and shocking—revelations of the research described in this book was that the stresses of poverty and inequality are sentencing large sections of the population to lifelong chronic disease before they’re even out of diapers. It’s hard to disagree with the researchers arguing for social policies that aim to reduce those inequalities and in particular to support disadvantaged women of childbearing age. Meanwhile at the other end of the lifespan, projects like Experience Corps point to the potential of reframing aging as a resource rather than a burden.
But there’s one more insight that comes from understanding the links between mind and body. I’ve saved it until last because it’s not just about health, medicine or society but something more fundamental. It tells us something about what it means to be human.
Ultimately, the science is saying that rather than passively experiencing the world around us, as most of us assume happens, to a large extent we construct and control that experience. “Our bodies are not only receptors of information,” says placebo researcher Ted Kaptchuk. “We create the information.” It’s something that psychologists and neuroscientists are already discovering in other fields, such as memory and vision. Memories aren’t faithful recordings but dynamic productions that we adapt and rewrite each time we access them, while our perception of colors and shapes is highly dependent on previous experience and what we expect to see.
Now it’s clear this principle holds true for health too: our thoughts, beliefs, stress levels and worldview all influence how ill or well we feel. As fatigue researcher Tim Noakes told us in chapter four, “You don’t have to believe what your brain is saying.”
The really new idea here, though, is that when it comes to health, our minds determine far more than our subjective experience of the physical world around us. Through changes in gene expression, for example, and in the way our brains are wired, the way in which we see the world helps to shape our bodies too. We play a role, then, in constructing not just our experience but our physical reality. And in turn, the health of our physical bodies influences the state of our minds. Inflammation induces fatigue and depression. Low blood-sugar levels make us short-tempered. Calming our bodies—by slow breathing, for example—improves our mood.36
Nearly 400 years after Descartes’ separation of the mind and body, we still tend to think of ourselves as logical, rational beings, with highly developed minds that allow us to transcend our biological, animal nature. The evidence shows something very different: that our bodies and minds have evolved in exquisite harmony, so perfectly integrated that it is impossible to consider one without the other. Terms like “mind–body” and “holistic” are often derided as flaky and unscientific, but in fact it’s the idea of a mind distinct from the body, an ephemeral entity that floats somewhere in the skull like a spirit or soul, that makes no scientific sense.
This integration means we’re not always as objective and reasonable as we might like to think. With our minds as well as our bodies shaped by evolution, we’re built to hold beliefs that aid our health and survival, not that are necessarily true. There are powerful evolutionary forces driving us to believe in God, or in the remedies of sympathetic healers, or to believe that our prospects are more positive than they are. The irony is that although those beliefs might be false, they do sometimes work: they make us better.
By understanding how our minds influence and reflect our physiology, perhaps we can finally resolve that paradox—and live in tune with our bodies in a way that is based on evidence, not delusion.
NOTES
INTRODUCTION
1. Nahin, R.L. et al. National Health Statistics Reports, no. 18, July 2009. Available at: https://nccih.nih.gov/sites/nccam.nih.gov/files/nhsm18.pdf
This report gives figures for use of complementary and alternative medicine (CAM) in 2007. It does not give figures for prayer. The previous report for 2002 did ask about prayer specifically for health reasons—it found that overall, 62% of adults had used some form of CAM (36% if prayer was not included).
Barnes, P.M. et al. National Health Statistics Reports, no. 343, May 2004. Available at: http://www.cdc.gov/nchs/data/ad/ad343.pdf
A report giving figures for 2012 was released in 2015, but did not include any cost data. With narrower definition than previous surveys, it found that 34% of adults had used CAM in 2012.
Clarke, T.C. et al. National Health Statistics Reports, no. 79, February 10, 2015. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr079.pdf
2. National Ambulatory Medical Care Survey: 2010 Summary Tables. Available at: http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf
This figure is for 2010.
3. Silberman, S. The Journal of Mind–Body Regulation 2011; 1: 44–52
At the time of writing, homeopathy is still available on the NHS in some parts of the U.K., see: http://www.nhs.uk/Conditions/homeopathy/Page262Introduction.aspx#available [accessed April 30, 2015]
4. The Oxford Dictionary of Medical Quotations (2004); Oxford University Press
CHAPTER ONE
1. Horvath, K. et al. Journal of the Association for Academic Minority Physicians 1998; 9: 9–15. Paragraphs 1–2 and 18–19 of this chapter are adapted from “Can Meditation Really Slow Aging?” by Jo Marchant, published by Mosaic, July 1, 2014. Available at: http://mosaicscience.com/story/can-meditation-really-slow-aging
2. A transcript of the Dateline program on secretin is available at: http://psydoc-fr.broca.inserm.fr/fora/aut_for1.html
Other sources for the story of secretin includ
e “Secretin Trials: A Drug That Might Help, or Hurt, Autistic Children Is Widely Prescribed but Is Just Now Being Tested” by Steve Bunk (The Scientist, June 21, 1999) and an open letter from Victoria Beck (available at: https://groups.google.com/forum/#!topic/alt.support.autism/InDCRgEwbJ4).
3. Telephone interview with Adrian Sandler, February 7, 2014.
4. Sandler, A.D. et al. New England Journal of Medicine 1999; 341: 1801–1806
5. The children in the secretin group went from 59 to 50; there was no statistically significant difference between the two groups.
6. Telephone interview with Bonnie Anderson, May 20, 2014. Now in her eighties, Bonnie can’t remember the exact date, but she thinks it was in 2005.
7. Interview with Jerry Jarvik, University of Washington, Seattle, May 7, 2014.
8. Telephone interview with David Kallmes, May 16, 2014.
9. Kallmes, D.F. et al. New England Journal of Medicine 2009; 361: 569–79
10. Anon. The Lancet 1954; ii: 321
11. Sandler, A.D. et al. New England Journal of Medicine 1999; 341: 1801–1806
12. Huedo-Medina, T.B. et al. British Medical Journal 2012; 345: e8343
13. Hardy, J. et al. Journal of Clinical Oncology 2012; 30: 3611–3617
14. Wartolowska, K. et al. British Medical Journal 2014; 348: g3253
15. Rosanna spoke to me in Italian; her words were translated into English by Elisa Frisaldi.
16. de la Fuente-Fernandez, R. et al. Science 2001; 293: 1164–1166
17. The Power of the Placebo, BBC2, February 2014
18. Benedetti, F. et al. Nature Neuroscience 2004; 7: 587–588