I'm still reading Frances's book. Slowly taking it apart, and all that. I admit it, I'm not all that quick-witted. It takes me a while to mull through a concept. Neurotic perhaps, and dull maybe, but that's who I am and what I've got to work with.
Something Frances said in his Saving Normal is bothering me a little bit. The preventative health care model is supposed to save lives. It's supposed to reduce the cost of treatment, but it often has the opposite effect according to him and others. There is empirical support for his view. Applying unneeded testing, and making those tests sensitive enough that they dragnet great swaths of humanity that doesn't suffer from disease, and never will is a costly endeavor. I think it's built on the social need to eradicate disease before it threatens the entire population. Obesity is one great big example (no pun intended) of this concept.
Most people will find a happy medium through exercise and diet, although there is a propensity for umami (fatty foods) and salt. These are obvious proclivities when evolution has designed a desire to keep and hold resources for later use. Obesity is that very drive taken to an extreme, but testing for obesity and aggressively treating it is causing a great deal of harm, and not just within the realm of medical treatment.
The current President of the APA, Dr. Bennett Johnson, called obesity the disease "that is going to bankrupt our country." How is this appropriate? Fat jokes are already a problem, ala bullying on schoolyards, and a thousand other places, including college campuses, and college classrooms, e.g. NYU prof Geoffrey Miller. Fat shaming is a problem that produces more pathology than it does healthy behaviors. So why this aggressive stance?
In the medical model, as I like to use my personal experiences from time to time, when my wife was unfortunately the owner of a fairly large ovarian cyst, we have staples, bands, and other treatments that aren't just aggressive but dangerous to combat this social ill. In the waiting room of the surgeon who (thankfully) removed the tumor, but also (irresponsibly) removed my wife's staples too early and thus caused a gaping, permanent scar and high probability of infection that could have proved fatal there were always women discussing how their gastric band had unintended consequences.
At one point do the risks outweigh the benefit, and aren't we far beyond that point in the US? What has the preventative model earned us on the front in the war against obesity? Our society seems focused on using inappropriately risky and often harmful methods instead of focusing on preventative measures that: a) are proven to work, b) are cheap to produce, and c) are tempered by reasonable expectations of outcomes.
The suggestion that the market will be there, and the bullying will be there, doesn't save my wife's surgeon, or Dr. Bennett Johnson from scrutiny. In so many areas, even in known cancer risks like smoking, aggressively treating the disease is causing more harm in anti-social attitudes, reaction formation, and prejudice than it is producing desirable results.
Using smoking as an example may be taking this argument too far, but it does make the point rather well. Much like the War On Drugs, and Nancy Reagan's "Just Say No" policy, and aggressive social campaign, it proved to be ineffective, costly, and produced the opposite outcome from the desired result. It was a joke. A laugh. A reason to smoke pot, not a reason against it.
Preventative strategies often mask deeper attitudes that direct behavior. Much like the war on drugs, and the war on smoking, I believe that there is a puritanical philosophy that drives the fear, and mistrust of liberal, democratic values. The authoritarian personality is a prime example of this notion of the Prodestant Ethic: that one treasure's one's body as a gift of god, works hard, offers fealty to authority, and does not question the nature of things or the consequences of the social order.
I think that preventative medicine is very much like giving an island to lepers and then letting them die off slowly. It reduces personal responsibility toward the collective, rationalizes a just world hypothesis, and feeds racist and prejudiced attitudes. Lest we forget the Iraq debacle, prevention is often practiced against ghost-like problems that match symptoms but do not match degrees and do not define prognosis.
And while we're discussing prognosis, let's consider psychopathy. There was a time when, in the disease model, that a disease was defined by it's prognosis meaning that what one could expect to occur defined a disease, or a disease was the product of it's outcome, not it's symptoms. Symptoms are the visible signs of disease but they are not, themselves the prognosis (or what will occur).
Considering the difference between secondary and primary psychopathy the formation of symptoms is not the only difference. The difference lies also in prognosis. Wherein secondary psychopathy one can expect a degree of self-healing given the right amount of time and circumstance, the same cannot be said of primary psychopathy, yet they are considered the same disease with merely like symptoms. This, I think, was the rationale behind adding antisocial personality disorder to the DSM. But by not including psychopathy in the DSM the differentiation never occurred even though, in this one case, we know that epigenetic expression of a particular gene, mono amide oxidase or MAOA is the cause.
Primary psychopathy and secondary psychopathy (APD) are different diseases because their prognosis, and their constructs are different even if they share some like symptoms. It seems lazy to me to not define it such when the tools are available, through even something as simple as an interview is capable of defining the difference between the two. Nevertheless, in APD, and Bipolar, among others, we have these overlaps of several different individuals with different diseases with different causes and different prognosis all lumped in the same boat together as one massive whole that society would really enjoy throwing down a completely different hole (now that was a pun).
This type of lumping is irresponsible where diagnosis defines treatment, and social stigma is very real even inside therapy sessions. Therapists are, after all, people, and subject to the same bias, and projective tendencies as the rest of us. These tendencies, are, however, forgotten. Chalked up to evidenced behaviors even though they exist inside the system of perceptions of the patient. Yes, therapists and doctors, you cannot help but act in a particular way once you've labeled your patient which demands certain characteristics from your client. Voila', we have yet another suggestible, but normal patient diagnosed and lumped in a box by yet another suggestible, but well trained therapist. And no one is paying attention.
Marvelous.
These two problems, although they seem distant, feed into each other to create bias. Frances's concept of diagnostic creep, and the problems inherent in preventative care have produced a situation that does not serve patients or normals. These situations serve several bottom lines. Not just big pharma.
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