Too Short for a Blog Post, Too Long for a Tweet 181

Here are a few excerpts from a book I recently read, "Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer," by Barbara Ehrenreich.

The paradox of the immune system and cancer is not just a scientific puzzle; it has deep moral reverberations. We know that the immune system is supposed to be “good,” and in the popular health literature we are urged to take measures to strengthen it. Cancer patients in particular are exhorted to think “positive thoughts,” on the unproven theory that the immune system is the channel of communication between one’s conscious mind and one’s evidently unconscious body. But if the immune system can actually enable the growth and spread of cancer, nothing may be worse for the patient than a stronger one. He or she would be better advised to suppress it, with, say, immunosuppressive drugs or perhaps “negative thoughts.” 

In the ideal world imagined by mid-twentieth-century biologists, the immune system constantly monitored the cells it encountered, pouncing on and destroying any aberrant ones. This monitoring work, called immunosurveillance, supposedly guaranteed that the body would be kept clear of intruders, or any kind of suspicious characters, cancer cells included. But as the century came to a close, it became increasingly evident that the immune system was not only giving cancer cells a pass and figuratively waving them through the checkpoints. Perversely and against all biological reason, it was aiding them to spread and establish new tumors throughout the body.

You can think of death bitterly or with resignation, as a tragic interruption of your life, and take every possible measure to postpone it. Or, more realistically, you can think of life as an interruption of an eternity of personal nonexistence, and seize it as a brief opportunity to observe and interact with the living, ever-surprising world around us.

Once I realized I was old enough to die, I decided that I was also old enough not to incur any more suffering, annoyance, or boredom in the pursuit of a longer life. I eat well, meaning I choose foods that taste good and that will stave off hunger for as long as possible, like protein, fiber, and fats. I exercise—not because it will make me live longer but because it feels good when I do. As for medical care: I will seek help for an urgent problem, but I am no longer interested in looking for problems that remain undetectable to me. Ideally, the determination of when one is old enough to die should be a personal decision, based on a judgment of the likely benefits, if any, of medical care and—just as important at a certain age—how we choose to spend the time that remains to us. 

As it happens, I had always questioned whatever procedures the health care providers recommended; in fact, I am part of a generation of women who insisted on their right to raise questions without having the word “uncooperative,” or worse, written into their medical records. So when a few years ago my primary care physician told me that I needed a bone density scan, I of course asked him why: What could be done if the result was positive and my bones were found to be hollowed out by age? Fortunately, he replied, there was now a drug for that. I told him I was aware of the drug, both from its full-page magazine ads as well as from articles in the media questioning its safety and efficacy. Think of the alternative, he said, which might well be, say, a hip fracture, followed by a rapid descent to the nursing home. So I grudgingly conceded that undergoing the test, which is noninvasive and covered by my insurance, might be preferable to immobility and institutionalization. 

The result was a diagnosis of “osteopenia,” or thinning of the bones, a condition that might have been alarming if I hadn’t found out that it is shared by nearly all women over the age of thirty-five. Osteopenia is, in other words, not a disease but a normal feature of aging. A little further research, all into readily available sources, revealed that routine bone scanning had been heavily promoted and even subsidized by the drug’s manufacturer.1 Worse, the favored medication at the time of my diagnosis has turned out to cause some of the very problems it was supposed to prevent—bone degeneration and fractures. A cynic might conclude that preventive medicine exists to transform people into raw material for a profit-hungry medical-industrial complex.

Then my internist, the chief physician in a midsized group practice, sent out a letter announcing that he was suspending his ordinary practice in order to offer a new level of “concierge care” for those willing to cough up an extra $1,500 a year beyond what they already pay for insurance. The elite care would include twenty-four-hour access to the doctor, leisurely visits, and, the letter promised, all kinds of tests and screenings in addition to the routine ones. This is when my decision crystallized: I made an appointment and told him face-to-face that, one, I was dismayed by his willingness to drop his less-than-affluent patients, who appeared to make up much of the waiting room population. And, two, I didn’t want more tests; I wanted a doctor who could protect me from unnecessary procedures. I would remain with the masses of ordinary, haphazardly screened patients. 

Of course all this unnecessary screening and testing happens because doctors order it, but there is a growing rebellion within the medical profession. Overdiagnosis is beginning to be recognized as a public health problem, and is sometimes referred to as an “epidemic.” It is an appropriate subject for international medical conferences and evidence-laden books like Overdiagnosed: Making People Sick in the Pursuit of Health by H. Gilbert Welch and his Dartmouth colleagues Lisa Schwartz and Steve Woloshin. Even health columnist Jane Brody, long a cheerleader for standard preventive care, now recommends that we think twice before undergoing what were once routine screening procedures. Physician and blogger John M. Mandrola advises straightforwardly: 

Rather than being fearful of not detecting disease, both patients and doctors should fear healthcare. The best way to avoid medical errors is to avoid medical care. The default should be: I am well. The way to stay that way is to keep making good choices—not to have my doctor look for problems.

When a pediatrician prescribed my second child an antibiotic for a cold, I asked whether she had a reason to believe his illness was bacterial. “No, it’s viral, but I always prescribe an antibiotic for a nervous mother.” The prescribing was, in other words, a performance for my benefit. Muttering that I was not the one who was going to be taking it, I picked up my baby and left. 

If a medical procedure has no demonstrable effect on a person’s physiology, then how should that procedure be classified? Clearly it is a ritual, which can be defined very generally as a “solemn ceremony consisting of a series of actions performed according to a prescribed order.” But rituals can also have intangible psychological effects, so the question becomes whether those effects in some way contribute to well-being, or serve to deepen the patient’s sense of helplessness or, in my case, rage. 

Western anthropologists found indigenous people worldwide performing supposedly health-giving rituals that had no basis in Western science, often involving drumming, dancing, chanting, the application of herbal concoctions, and the manipulation of what appear to be sacred objects, such as animal teeth and colorful feathers. Anthropologist Edith Turner in the 1980s offered a lengthy and lovingly detailed account of the Ihamba ritual performed by the Ndembu of Zambia. The afflicted person, whose symptoms include joint pains and extreme lassitude, is given a leaf infusion to drink, then her back is repeatedly anointed with other herbal mixtures, cut with a razor blade, and cupped with an animal horn—accompanied by drumming, singing, and a recital of grudges the patient holds against others in the village—until the source of the illness, the Ihamba, exits her body. 

Does this ritual work? Yes, insofar as the afflicted person is usually restored to his or her usual strength and good humor. But there is no way to compare the efficacy of the Ihamba ritual to the measures a Western physician might use—the blood tests, the imaging, and so on—in part because the Ihamba itself is not something accessible to scientific medicine. It is conceived as the tooth of a human hunter, which has made its way into the victim’s body, where it “bites” and may even reproduce. If this sounds fantastical, consider that, as an agent of disease, a “hunter’s tooth” is a lot easier to visualize than a virus. Sometimes at the end of the ceremony one of the officiants will even produce a human tooth, claiming to have extracted it from the victim’s body. And of course the opportunity to air long-held grudges may be therapeutic in itself. 

Most of us would readily recognize the Ihamba ceremony as a “ritual”—a designation we would not be so quick to apply to a mammogram or a biopsy. The word carries a pejorative weight that is not associated with, for example, the phrase “health care.” Early anthropologists could have called the healing practices of so-called primitive peoples “health care,” but they took pains to distinguish the native activities from the purposeful interventions of Euro-American physicians. The latter were thought to be rational and scientific, while the former were “mere” rituals, and the taint of imperialist arrogance has clung to the word ever since.

Physicians have an excuse for flouting the normal rules of privacy: The human body is their domain, sometimes seen, in the case of women’s bodies, as their exclusive property. In the middle of the twentieth century, no woman, at least no heterosexual laywoman, was likely to ever see her own or other women’s genitalia, because that territory—aka “down there”—was reserved for the doctor. When in 1971 a few bold women introduced the practice of “cervical self-examination,” performed with a plastic speculum, a flashlight, and a mirror, they were breaking two taboos—appropriating a medical tool (the speculum) and going where only doctors (or perhaps intimate partners) had gone before. Many doctors were outraged, with one arguing that in lay hands a speculum was unlikely to be sterile, to which feminist writer Ellen Frankfort replied cuttingly that yes, of course, anything that enters the vagina should first be boiled for at least ten minutes.

Well before the revival of feminism in the 1970s, some American women had begun to complain about the heavy-handed overmedicalization of childbirth. In the middle of the century, it was routine for obstetricians to heavily sedate or even fully anesthetize women in labor. Babies were born to unconscious women, and the babies sometimes came out partially anesthetized themselves—sluggish and having difficulty breathing. Since the anesthetized or sedated woman could not adequately use her own muscles to push the baby out, forceps were likely to be deployed, sometimes leading to babies with cranial injuries. There was, however, an alternative, though obstetricians did not encourage it and often actively discouraged it: the Lamaze method, which had originated in the Soviet Union and France, offered breathing techniques that could reduce pain while keeping the mother and baby alert. In the 1960s, growing numbers of educated young women were taking Lamaze classes and demanding to remain awake during birth. By the time of my first pregnancy in 1970, it would have seemed irresponsible, at least in my circle of friends, to do anything else. 

We were beginning to see that the medical profession, at the time still over 90 percent male, had transformed childbirth from a natural event into a surgical operation performed on an unconscious patient in what approximated a sterile environment. Routinely, the woman about to give birth was subjected to an enema, had her pubic hair shaved off, and was placed in the lithotomy position—on her back, with knees up and crotch spread wide open. As the baby began to emerge, the obstetrician performed an episiotomy, a surgical enlargement of the vaginal opening, which had to be stitched back together after birth. Each of these procedures came with a medical rationale: The enema was to prevent contamination with feces; the pubic hair was shaved because it might be unclean; the episiotomy was meant to ease the baby’s exit. But each of these was also painful, both physically and otherwise, and some came with their own risks. Shaving produces small cuts and abrasions that are open to infection; episiotomy scars heal more slowly than natural tears and can make it difficult for the woman to walk or relieve herself for weeks afterward. The lithotomy position may be more congenial for the physician than kneeling before a sitting woman, but it impedes the baby’s progress through the birth canal and can lead to tailbone injuries in the mother. 

So how are we to think of these procedures, which some doctors still insist on? If a procedure is not, strictly speaking, medically necessary to a healthy birth and may even be contraindicated, why is it being performed? Anthropologist Robbie E. Davis-Floyd proposed that these interventions be designated as rituals, in the sense that they are no more scientifically justified than the actions of a “primitive” healer. They do not serve any physiological purpose, only what she calls “ritual purposes.” The enema and shaving underscore the notion that the woman is an unclean and even unwelcome presence in the childbirth process. Anesthesia and the lithotomy position send “the message that her body is a machine,” or as Davis-Floyd quotes philosopher Carolyn Merchant, “a system of dead, inert particles,” in which the conscious patient has no role to play. These are, in other words, rituals of domination, through which a woman at the very peak of her biological power and fecundity is made to feel powerless, demeaned, and dirty. 

In one sense, childbirth rituals “worked.” The women giving birth were often traumatized, reporting to Davis-Floyd that they “felt defeated”9 or “thrown into depression”: “You know, treating you like you’re not very bright, like you don’t know what’s going on with your own body."  Yet, having submitted to so much discomfort and disrespect, they were expected to feel grateful to the doctor for a healthy baby. It was a perfect recipe for inducing women’s compliance with their accepted social role: rituals of humiliation followed by the fabulous “gift” of a child.