Sunday, May 15, 2011

Placebo: How a sugar pill became a poison pill. Part 8 pf a continuing saga...

Read Part 7.

Healthcare apologists insist that medicine's true impact on longevity has been blurred by “lifestyle issues” that, in recent decades, worked to offset those gains. They note, for one thing, that up to a third of adults now meet the clinical definition for obesity. That line of argument slyly ignores the many positive ambient changes in the American way of life that should have produced even m
ore robust longevity numbers than we now see. Among them:
A cleaner environment. Amid the latter-day carping by environmentalists about vehicular emissions and greenhouse gases, it's easy to forget the challenge posed by mere breathing at the dawn of the Industrial Revolution. Pollution-control insiders divide the history of American environmental management into four periods, the first of which, 1900-1950, is tellingly labeled “the smoke era.” American city dwellers gazed up into a sky so clogged with soot that in theory a keen-eyed observer could count the particulate matter-per-cubic-foot as if in some bizarro variant of bird-watching:

“Soot-filled industrial cities of the East and Midwest blackened skies in the early part of the 20th century. Emissions were first detected, and regulated, by sight [emphasis added]... By 1950, visible emissions from many industrial sources were controlled...and the effects of different air pollutants on health were being discovered.”
—from
Will the Circle Be Broken? A History of the U.S. Ambient Air Quality Standards,” in a 2007 journal put out by the Air & Waste Management Association
Over the second half of the 20th Century, many erstwhile steel or coal towns, formerly blighted by industrial pollutants, made a spectacular resurgence and today uphold high standards for clean air and water.

Ever-improving rules governing occupational health and safety. The 1970 advent of both OSHA (Occupational Safety and Health Administration) and MSHA (Mine Safety and Health Administration), plus independent rating services like the International Organization for Standardization, have wrought a wholesale rethinking of how factories and warehouses operate. The Economic History Association portrays the U.S. as an “unusually dangerous” place to work prior to the 1930s, describing early factories as “extraordinarily risky by modern standards”—though still safer than railroads or mines. On-the-job fatalities nowadays are a fraction of what they were as recently as the 1950s. Far fewer Americans work with the toxic substances—like benzene, asbestos, and trichlorethylene—that gave rise to so many “unexplained” cancers during the 1960s and 1970s.

Better insights about proper nutrition. Americans may eat too often at McDonald's and KFC, but in general, many more of them than in days past make a good-faith effort to work fruits, vegetables, vitamins, fiber and other desirable nutrients into their family's diets. This trio of factors alone could be expected to help Americans live longer even if no one ever went to a doctor for anything.

And, of course—the elephant in the room—there's the significant decline in cigarette smoking since the days when Gerald Ford was clanking golf balls and banging his head on airplane doors. As the 1970s drew to a close, 40 percent of Americans regularly used tobacco products. The number had dropped to 24 percent by 2009. Cultural taboos and legislated constraints on where that remaining 24 percent lights up have materially reduced the exposure of the rest of us to second-hand smoke: Some parents may still smoke three packs a day, but they don't usually do it in their cars with their kids present. Coworkers, air travelers and diners can go about their business without having cigarette smoke waft over them from an adjacent cubicle, seat or booth.

Medicine's true impact on the battle against top killers like cancer and heart disease cannot be properly reckoned without taking such (literal) atmospherics into account. As was the case a century ago with TB, any ostensible successes may have less to do with medical intervention and more to do with the broader context in which those interventions are taking place.

But then, all of this sound and fury, all of this bickering over contextual variables and decimal places, may be just a diverting numbers game that misses the larger point by failing to address the real-world consequences of those few added years for the people who must live them. Over the objections of the AMA and other groups representing healthcare interests, the World Health Organization has begun publishing an alternate longevity statistic, Health-Adjusted Life Expectancy (HALE). The HALE index suggests that if medicine is adding years of life, it is also adding years of pain and disability—at a roughly one-to-one ratio. Today's “increased lifespan” too often becomes a nonstop dirge of repetitive surgeries, the suffering of chemotherapy and radiation, the embarrassment and despair of incontinence and/or impotence. In too many cases, death, when it comes, is merciful.

Deeply troubled by that prospect, Dr. William J. Hall of the esteemed Highland Hospital Center for Healthy Aging in Rochester, New York, observed in a 2008 issue of The Archives of Internal Medicine: “Longevity is a Pyrrhic victory if those additional years are characterized by inexorable morbidity from chronic illness, frailty-associated disability and increasingly lowered quality of life.”

To be continued...


Read Part 9





5 comments:

RevRon's Rants said...

I can especially relate to the latter part of this posting, Steve. What it comes down to for me is, at some point I may well have to make the choice between 1) spending tens of thousands of dollars (or more) on treatments that might - MIGHT - extend my life for a year or so, yet make that year one marked by pain, indignities, and a generally miserable excuse for life, or 2) spending some of that money to experience things I truly enjoy and can share with those dear to me.

Comes right down to it, I would opt to spend some bucks to make my remaining time as good a party as I can. Nobody gets out alive, and I'd rather live well and die quickly than linger through months or years of "diminishing returns." Hell-raiser to hospice just sounds so much more humane... for myself and those who care about me.

Christoph Dollis said...

"many more of them than in days past make a good-faith effort to work fruits, vegetables, vitamins, fiber and other desirable nutrients into their family's diets."

Hopefully we'll make more of an effort to work other healthful nutrients into our nutritional panoply, such as saturated fat and dietary cholesterol.

Moving on:

"But then, all of this sound and fury, all of this bickering over contextual variables and decimal places, may be just a diverting numbers game that misses the larger point by failing to address the real-world consequences of those few added years for the people who must live them."

Bingo. My grandma is facing such issues now, in real time. She's not the only one, of course, and I'm sure your loved ones are, and perhaps you and I will.

My answer is more freedom and less government and societal coercion in what we do with our own lives and how long we choose to live them. If we choose to eke out every last moment to the best of our abilities, so be it. If not, then people other avenues whether you'd take them yourself or not.

roger o'keefe said...

This is an impressive series, Steve. If it were a book, I would buy it. (I have a feeling it was meant to be?)

Christoph Dollis said...

Obviously a typo in the second to last paragraph of my comment.

I can't remember how I meant to word it, but my point is we should be allowed to choose for ourselves how long we wish to live.

By all means encourage others to live longer, to overcome hardship, to deal with pain and grief, to find the good in life.

But don't force them, or shame them if they choose otherwise.

a/good/lysstener said...

I'd like to second Roger's comment. This series is brilliant and much more "book worthy" than 90% of the books being published, IMHO.