Anatomy of an Illness as Perceived by the Patient Page 7

  Basically, leprosy is the product of filth, poverty, and malnutrition. It is not, as is generally supposed, a disease of the tropics and subtropics. It can exist wherever unsanitary conditions, hunger, or poorly balanced diet exist. It has existed in countries as far north as Iceland. Scarcely a country in the world has been untouched by it. But the important thing is that it is eradicable, and its victims can be cured or appreciably helped and rehabilitated. And it can once and for all be rescued from the general ignorance and associated superstitions assigned to it over the ages.

  Medical researchers have given high recognition to Dr. Brand and his colleagues for their new insights into the nature of leprosy, but even greater accolades within the profession have come his way because of his work in rehabilitative surgery. He has been able to transform hands, long clawed and rigid because of nerve atrophy brought on by leprosy or other causes, into functioning mechanisms. Almost legendary in India is the case of a lawyer on whom he operated. For many years, the lawyer had been at a disadvantage in court. His gestures, so essential a part of the dramatic courtroom manner, were actually a liability; judge and jury were distracted by the hideously deformed and frozen hand. Then one day the lawyer raised his hand to emphasize a point. The hand was supple; the fingers moved, the gesture was appropriate. Paul Brand had operated on the hand, hooking up muscle and nerve connections to the forearm, then educating the patient to retrain his command impulses.

  Paul Brand and his staff have performed thousands of similar operations on patients at Vellore. But they have also gone far beyond surgery into what they consider an even more vital phase of the total treatment. This is psychological rehabilitation. A man who, as a leper, has been a beggar for twenty years is not considered to be fully treated at Vellore until he is mentally and physically prepared to be a useful and proud citizen in his society. At Vellore, handicapped patients are given the kind of training that will enable them to be as self-supporting as possible. They gain a respect for the limitless potentialities and adaptabilities of the human organism. They learn that even as little as a 10 percent mobility can be made to yield a high return in terms of effective productivity. And, in the Emersonian sense, self-reliance creates self-respect.

  It is not necessary, of course, to provide any precise assessment of the relative importance of the three main phases of Paul Brand’s work—taking the black curse and superstition out of leprosy, reconstructive surgery, and personal and psychological rehabilitation. All are important; all are interrelated. But one aspect of his work may perhaps be more evocative and compelling than any of the others. He is a doctor who, if he could, would move heaven and earth just to return the gift of pain to people who do not have it. For pain is both the warning system and the protective mechanism that enables an individual to defend the integrity of his body. Its signals may not always be readily intelligible but at least they are there. And the individual can mobilize his response.

  FIVE

  HOLISTIC HEALTH AND HEALING

  One of the results of the article in the New England Journal of Medicine was that I had opportunities to observe the holistic health movement at first hand. Leaders of the movement were good enough to say that I had had a holistic experience and that they hoped I might come to their meetings to talk about that experience as a way of reinforcing the beliefs of its members.

  My problem, however, was that I had said as much as I thought I ought to say about the illness itself. Besides, I was aware of the tendency of a few advocates in the movement to juxtapose themselves against the entire medical profession, and I couldn’t sympathize with this approach. While I agreed with the prime tenets of the holistic movement, I saw a need to build bridges across the gap that for so long had separated the physician and the public. Moreover, what to me was most impressive, as I explain more fully in the next chapter, about the thousands of letters I received from doctors in response to the NEJM piece, was the sense of an important new mood in American medicine. I believed that the holistic movement would be gratified by the fast-growing evidence that many doctors were attempting to diagnose and treat the patient in the context of all the factors—work, nutrition, family, personality, emotions, environment—that figure in illness or breakdown.

  In accepting invitations to speak or participate at these meetings, therefore, I sought—and received—permission to talk about the need to avoid a wall of separation between patients and physicians. It was true that the medical profession had allowed itself to become overly mystifying, even authoritarian, in its general relationships with the community-at-large. But there were genuine signs of a desire to inform and educate and not superimpose. Patients were being encouraged by their physicians to know as much as possible about issues involving their health. What was in the making, it seemed to me, was an expanding dialogue between the public and the profession on the proper division of responsibility between the two.

  Such a dialogue, I felt certain, would impress physicians with the seriousness and soundness of intent of millions of people who believe that the primary role of the doctor is to help people to prevent illness, and not just to overcome it. And people in the movement, I felt equally convinced, would be impressed by the large number of doctors whose philosophy and practice were based on the idea that the mind and body are a single organism, and that the treatment of either one should not be undertaken without respect for the totality.

  Great medical teachers have always impressed upon their students the need to make a careful assessment of everything that may interact in the cause and course of a disease. Hippocrates, the first major historical name in medicine, was both a theoretician and a practitioner. He tried to close existing gaps between the understanding of disease and its treatment. He was quintessentially holistic when he insisted that it is natural for the human body to heal itself, and that this process can generally take place even without the intervention of a physician (vis medicatrix naturae). He believed that the essential function of the physician—here again Hippocrates was being nothing if not holistic—was to avoid any treatment that might interfere with the healing process or that might do harm (primum non nocere).

  Hippocrates put his emphasis on the systematic organization and application of knowledge. He was troubled by the fact that a great deal of dogma and superstition were being dressed up as carefully authenticated principles in the practice of medicine. Lawrence J. Henderson, widely admired among modern teachers of medicine, described the essence of these principles in one of his famous Harvard lectures.

  Hippocrates was no casual ordinary observer, Henderson wrote, but a physician whose “skill depended upon both native capacity and long practice.… His success was great, and the whole history of science goes far to support the view that such a methodical procedure is a necessary step in the development of a science that deals with similarly complex and various phenomena.”

  This holistic principle has been restated many times as a basic guideline for sound medical practice. A half-century ago, Arturo Castiglioni, in his A History of Medicine, wrote that “the physician above all should keep in mind the welfare of the patient, his constantly changing state, not only in the visible signs of his illness but also in his state of mind, which must necessarily be an important factor in the success of the treatment. One would be blind not to recognize that before and even after the advent of modern scientific medicine there were great and able healers of the sick who were not men of science, but who had the ability to reassure the patient and thus favorably to influence the course of the illness. It is also obvious that there have been excellent scientists who were very mediocre practitioners. Thus history teaches that any division of the science and art of medicine is necessarily harmful to practice.”

  If holistic concepts are not new, how are we to account for the extraordinary new popular interest and its development into a national and indeed a worldwide movement? At least half a dozen factors are involved.

  Ever since the dangers of thalidomide for pregnant women we
re discovered, many thousands of people have become aware that modern drugs are not to be regarded solely in a life-saving role; they can be powerfully dangerous, even when taken as directed by the physician. Antibiotics made their appearance as miracle drugs; they were able to destroy potent microorganisms beyond the reach of other medications. But bacteria became inured and resistant to the antibiotics, requiring ever more powerful forms of antibiotic killers. This in turn made the human body increasingly vulnerable to the harmful effects of the antibiotics. The chain reaction was costly and destructive. So the physician had to weigh carefully the relative dangers and benefits. The same was true of steroid drugs. The dramatic and almost instantaneous improvements brought about by the cortisones had to be balanced off against disturbances to the endocrine system.

  There were other new drugs, more effective than ever before in preventing or combating hypertension, or in regulating the human heartbeat, or in restoring sluggish organs, or in combating unusual growths—all of them powerfully effective but each imposing penalties or risks. These dangers were often as great as, and sometimes greater than, the benefits; their use was therefore brought into serious question.

  The public’s awareness of these dangers rose very sharply in the 1960s and 1970s, as consumer consciousness expanded into the health field. The result was a growing distrust not just of the highly sophisticated new drugs but of almost all medications in general. People became attracted to the emphasis of holistic medicine on eliminating basic causes of breakdown and illness rather than on the use of hazardous drugs. It was felt that doctors had a tendency to overmedicate and to fail to maintain the necessary vigilance over patients who continued to take potent drugs long past the point where their use was indicated—often resulting in health problems even more severe than the ones for which the medication was originally prescribed. People tended to forget that much of the pressure on doctors to prescribe the exotic new drugs came from the public itself.

  In any case, the reaction against drugs became an important part of the appeal of holistic medicine.

  Inevitably, the distrust of powerful medication figured in the surging new emphasis on proper nutrition, which was seen both as a precondition of good health and as a substitute for drugs in the treatment of many illnesses. Books on nutrition found an eager audience. One author, Adelle Davis, produced a succession of books on nutrition that for a half-dozen years or more outsold everything between covers except the Bible. Carlton Fredericks’s radio program on nutrition found an audience in the millions. One of the fastest-growing magazines in America was Prevention, which put its dominant emphasis on health through proper nutrition, and which carried reports of the growth of the holistic health movement.

  The public became aware, as the result of the White House Conference on Food, Nutrition, and Health in 1969, and through the growing literature of protest against drugs, that medical schools failed to teach nutrition or at least to accord it the same importance in their curricula as physiology, pathology, pharmacology, anatomy, biochemistry, and so on. Actually, nutrition was not being ignored or bypassed, but was taught as an integral part of other subjects. Even so, the fact that it had no standing of its own in most medical schools ran counter to the public’s conviction that nutrition was at the very top of factors affecting health. And the more some doctors tried to combat this view—generally by asserting that the average food market shopping basket provided everything needed for a balanced diet—the more convinced people became that doctors were opposed to them on nutritional matters. The fact that so few doctors questioned their patients in detail about their food habits provided yet additional evidence on this point.

  At the same time, the general practitioner has had no way of keeping up with fast-developing new knowledge, let alone the vast array of new technology and techniques. Even as they made allowances for these facts, however, the public felt uncomfortable about the extent to which specialization was changing medical practice. People saw a contradiction between the traditional view of the doctor as a reassuring father figure who took care of all their medical needs, and the pluralization of the doctor-patient relationship brought about by specialists who presided over separate parts of their anatomy. Holistic medicine has tried to counteract this trend by putting emphasis on the integrating factors.

  The emergence of specialists was connected to the burgeoning new medical technology, giving many people the impression that the doctor was an auxiliary of the machine. Patients found it difficult to accept the new impersonalization produced by the new technology. Moreover, the machines pronounced verdicts with a finality that seemed to run counter to one of the oldest rules of medical diagnosis: always allow for the fact that certain individuals may have all the signs and symptoms of a particular disease, yet may be atypical or even completely free of that disease. In any case, holistic medicine put its emphasis on human contact and human warmth, regarding medical technology as generally cold and unappealing.

  There has been a need in the nation for increasing the number of doctors who would serve rural areas or work in inner-city community clinics; yet the large majority of medical school graduates have been attracted to specialized practice in the big cities. Doctors are criticized for seeking the big incomes that metropolitan centers make possible, but this criticism doesn’t take into account the fact that a large number of medical school graduates have to pay off tuition debts that often exceed $50,000. It would be a mistake to doubt the sincerity of students who say they would be far more disposed to work in country clinics if their massive educational debts were not hanging over them. Whatever the justification, the fact remains that people who need doctors the most are least able to get to them, or, if they do manage to get to them, are least able to meet the general level of fees in private practice.

  The rapid rise in the educational level of Americans was reflected in the ability of many people to inform themselves to a far greater extent than ever before about health matters. Many millions of Americans got into the habit of following medical developments. In their own relationships with physicians they no longer were disposed to accept medical decisions unquestioningly. They tended to evaluate doctors according to the willingness of the physician to enter into a mutually respectful dialogue with them.

  Enough verifiable data have appeared about the ability of the human mind to play a major role in overcoming illness to make this entire field enormously attractive to laymen. It is manifestly true that interest in these matters outruns systematic knowledge; many people eagerly snatch at new findings or speculations having to do with the reach of the mind. And they are disappointed when they discover that their doctors are not equally well-informed or excited about such developments and prospects. With each new popular book on the potentialities of the human mind or on its influence over the autonomic nervous system, the gap has widened between the public and the medical profession. Not all doctors, of course, are disdainful of the new trends. The biochemical manifestations of mental powers are being well documented. Competent observers have written about yogis in India, for example, who were trained to slow down their pulse to a few beats per minute, or who can order their skin to resist burning from hot surfaces. I myself have witnessed such demonstrations in India, so I know them to be true. But systematic scrutiny of such phenomena has lagged behind popular interest, the result being that the entire field has been colored by guesswork and extraordinary claims. Out of it all, however, has emerged the undeniable evidence that the human mind can be trained to play an important part both in preventing disease and in overcoming it when it occurs. The entire biofeedback movement has gained in stature as the result of such new research. In any case, many thousands of Americans are pressing for greater emphasis—by the medical profession—on mind-body interactions and the attack on illness.

  To be sure, these are not the only elements involved in the burgeoning growth of the holistic health movement. But they constitute both the main structural props and the rallying points for the growin
g interest of the educated public. Underlying these ideas, of course, are the traditional essentials of health that have always had a strong place in medical canons—proper nutrition, adequate exercise, enough sleep, good air, moderation in personal habits, and so on.

  At the various holistic health conferences I attended, I became aware of a troubling contradiction. A movement based on the concept of wholeness was itself becoming unwhole. Two dozen or more schools or approaches of varying validity, not all of them compatible and some of them competitive, were crowding the center of the holistic stage. Some conferences on holistic health seemed more like a congeries of exhibits and separate theories than the occasion for articulating a cohesive philosophy. Generally included were exhibits or presentations from acupuncture, astrology, graphology, numerology, clairvoyance, biofeedback, homeopathy, naturopathy, nutrition, iridology, pyramidology, psychic surgery, yoga, faith healing, vitamin therapy, apricot kernel therapy, touch encounters, chiropractic, self-massage, negative ionization, and psychocalisthenics, among others.

  The inclusion of all these approaches in the same paragraph creates an impression that acupuncture, for example, is on the same level as astrology in the treatment of illness. The same is true when they come together in a conference or exhibit hall. I recognize that many people believe that astrology is a valid guide to treatment of serious illness. I respect their right to that opinion, but I would not want to take the responsibility for advising anyone who is seriously ill to forego the soundest medical advice obtainable. In any case, it is difficult to think of a unifying principle that can tie together nutrition and graphology in a systematic approach to good health. Indeed, the danger of fragmentation and general diffusion in such a coupling is all too real. The parts seem to be at odds with a movement based on the need for an integrated approach to health. One of the dangers is that the movement tends to take on the character of the least workable and reputable of the contending parts.