The Technology of Medicine
Item
- Title
- The Technology of Medicine
- Creator
- P K Sethi
- Date
- 1989
- extracted text
-
03
COMMUNITY HEALTH CELL
47/1, (First FloorjSt. Marks Road
BANGALORE -560 001
BACKGROUND PAPER VIII
XV ANNUAL MEET OF MEDICO FRIEND CIRCLE
THE TECHNOLOGY OF MEDICINE
P .K
SETHI
I have chosen this occasion for sharing some of my
concerns about the direction which the so-called modern system
of medicine is taking in our country. I must confess that I am
witnessing this scene with an increasing degree of despair.
I am not referring to the many distortions and unethical
practices which have crept into our profession. There has been
a general decline in the moral values of our-entire societal
fabric and it would be unrealistic to expect that the medical
profession could have remained untouched in this pervasive
environment. This is in no way a defence or an apology for what
is going on. I do believe that our profession is such mat it
would be wrong for it to emulate the greed of our consumer
culture and it should be the duty of our professional bodies to
restore the respect with which the healing profession! was treated
by the society in the past.
My concern,at present, is with somethigg different. It
relates to our understanding, at a conceptual level, of hat
constitutes the technology of medicine and about technological
choices in a developing country such as ours. Some of „.i
spectacular achievements of the so-called science-fj otica
medicine in the west have made us, the inheritors of tn.e western
tradition, rather proud and arrogant. We have deluded ourselves
into believing that the use of hitech in medicine is a very
scientific system of medinine . This has already led, ird is
rapidly leading almost at an exponential rate, to make medical
treatment increasingly expensive and so out of reach of the
common man. Furthermore, we have become increasingly intolerant
of systems of health management which have not emerged from the
west.
Frankly, I always feel a little uneasy when a claim is
laid that modern medicine has a strong scientific base and it
has already achieved a high-technology status. It seems to' me
that the use of expensive and complicated gadgetry Ln medicine
• is being equated with sophistication and good science. Cne can,
with good reason, question these basic assumptions. It is only
very recently, perhaps since the last century, that a scientific
approach in medicine was initiated and this has resulted, indeed,
in some quite remarkable and impressive achievements. Gv?
■ understanding of vitamin-deficiency diseases, some cor'-on
endocrinal disorders and controlling many formerly lethal
bacterial infections are some such examples. But a careful
retrospective medical audit should make us a little more humble
and less extravagant in attributing the improvement in the
so-called health indicators- infantile mortality, life expect
ancy etc - to purely medical interventions. And there are a whole
lot of common ailments, you would agree, whose mechanisms
we have not yet understood and which therefore necessarily
have to be treated rather empirically.
One can reel of examples after examples where v.v have
quite unjustifiably credited many improvements to purely medical '
intervention with little justification. Let me remind ycu of
some . The annual death rate from respiratory tuberculosis in
the state of New York was an appalling 700 per "10,000 copulation
in 1812. By 1882 , when Robert Koch discovered the tubercle
bacillus, the annual deaths per 10,000 population from t.iis
• disease had already Pome down to 370. Surely, merely discovering
the germ could not be credited with this fall. In 1910, before
the first T.B.sanatorium was opened in U.S.A., and afterall its
benefits could be attributed tn sunh generpli+i <»«
v.-.c+
(2)
already dropped to 180. By 1946, whan streptomycin, the first
effective drug which could act on the tubercle bacillus was
made available, the death rate had come donw to 48.
In other words, a decline from 700 deaths in 1882 to 48 in
1946- an almost fiteen fold drop - had been achieved before we
were able to develop the first effective drug against tubercle
bacillus, So what are we taking the credit for ? The reasons
for this improvement can really be attributed to social and
economic factors.
We must not also overlook the fact that bacteria and
viruses have also had their own biological ups and downs. Why
is leprosy,9 which was once widely prevalent in Europe- and
accounts of leper colonics outside town limits can be encountered
in numerous books dealing with medieval Europe- not seen there
at all? Why has plague, which was such a scourge in our ovm
country within living memory, now seldom talked about? Where have
scarlet fever, or erysipelas or for that matter, syphilis which
so dominated the undergraduate curriculum of my own student days 9
gone? I think it is necessary to pause and reflect on some of
these phenomenon before hastily tying up all such improvements to
our own interventions. Drawing such conclusions is unscientific.
Scepticism, on the other hand , is one of the hallmarks of good
science.
Let us also not forget that modern medicine itself has
become a disease producing agent, sometimes of a most virulent
kind. The entire gamut of Iatrogenic diseases needs to be’
debited from our account of achievements. I would not dwell
on this point, but a mention does need to be made about this
pathogenic role of medical intervention. I could not better
the statement by Carl Sandburg who wryly commented after an
illness, " T took so much medicine that I was ill for a long time
after I got well".
While i hold no brief for all that is practised under the
broad category of traditional or oven ' folk' medicine, I am
clear that, by and large, most medicine, oven as it is being
practised today in the affluent societies of the west, also
remains largely empirical. The external £acado of modern medicine
does overwhelm us; the inside contents have so far remained
rather weak and tentative. What a family doctor or a general
practioner was supposed to do in the past, with very little
technological backup, a modern hospital is attempting to replace 9
by making use of overchanging and more impressive gadgetri es.
This has resulted in a very expansive system of health care.
The increasing use of electronic digital display systems, which
often throw us off-balance by figures which claim to be accurate
to the fourth decimal point, are not merely deluding us into a
totally misplaced faith in the great accuracy of our observations 9
a fallacy which has been and needs to be repeatedly remembered,
■ but much more importantly, such systems by themselves, do not
help in the conceptual understanding of disease processes. I
need hardly remind you that using an electronic blood pressure
instrument does not make for a better understanding of hyper
tension than the old fashioned mercury manometer. But, and here
lies the catch, so enchanted and pre-occupied we become with the
visual impact of what we see, that vie are diverted from our
primary endeavour of reflecting on the basic phenomenon of health
and disease. Enter an operating room where an open-heart surgery
is being performed. The scenario, with oscilloscopes, the heart
lung machine, and all other technological gadgetries literally
sweeps us off our feet. .7e get so caught in this drama that we
almost stop thinking about the basic issues which lead to such
interventions.
Contd.. 3
*
(3)
Medicine, as a scienoe, is very young indeed. This is a
view not held by a small man like me but of some of our profound
medical thinkers - Rene Dubos or Lewis Thomas.. Lewis Thomas,
who heads the prestigious Sloane-Kettering Institute of Cancer
Research in New York, and who has been sharing his deep under
standing of complex biological phenomenon, written in inimitable
and lyrical prose in his periodic essays in the Naw England
Journal of Medicine has recently come out with his autobiography
where he, the son of a New York general practitioner, scans the
development of medicine from the time he accompanied, 'as a child,
his father on his daily home visits in the early years of this
century tp the present scenario. The title.of his book "The
Youngest Science - Notes of a Medicine Watcher" is revealing
and underscores the point I an making. I recommend its reading
as a chastening reminder of our fallibility and limitations.
The Npn-Technplp^ic.?,.l .Functions. p f_Me/lic itoe:
It is rather humbling to realize, though one need not be
apologetic about the fact;, that some of the most valuable
components in the art of healing still remain, and hopefully would
continue to remain, non-technological. This is the 1 supportive1
role which healers- have always been called upon to perform.
This is what providing comfort and reassurance is all about.
The actual methodology used has little to do.with the casual
mechanisms of disease and while some may argue that this role
perpetuates superstition and often obstructs progress, it cannot
be denied that this supportive role is a very important andej
necessary function of medicine all the same. Call it 'placebo
effect' if you like or invoke the induction of endorphins to
explain and legitimize' it.s success in a painful situation, its
value cannot be denied. In fact, a lot of research in medicine
ultimately leads to finding a legitimate explanation for practices
which our forerunners had found to be useful mainly as a result
of accurate observation and correlation.
It is in this context th.it one has to understand and respect
the beliefs and culture of different societies and not reject
traditional healing methods, as outright quackery. It seems
rather unreasonable to force the belief system of a western
society into very different, but in no sense inferior belief
systems of say, eastern societies.
During the last decade or so, a very significant realization
by scientists who are working at the frontiers of medicine and
physiology is taking place. This has to do with the "Mind-Body"
relationship. The Nobel neurophysiologist, Roger Sperry, has
demonstrated that thought changes .matter and has called for the
recognition of such "top-down" processes- He has shown that
perceived meanings are., translated into actual bodily change.s.
These-"Top - down'' influences are contrasted with the usual"
. .".bottom-up" processes which are assumed in medicine to be the
only ways in which physiology can be affected-.
Whether it is the recognition of the role of Type A
personality in heart disease or blood cholesterol levels, the
influence of meditation on hypertension or cardiac arrythmias,
the new discipline of "psychoneuro-immunology" where fluxes of
neurotransmitters affect neural input to lymphoid tissue,,
they all point to a new appreciation of an ancient insight:
Mind and body are not entii’ely separate, entitities, and thought
is a potent force in the world of the body. And so the meanings
we take from our world-view cannot be ignored.as factors in the
equations of illness. We have so far paid only lip service to
the "soil -and seed" concept and concentrated mainly on the seed
component. Soil has never got the importance it deserves because
J
J
1
-
•
•
.
(4)
These bits of information provide a new legitimacy to the
so-called non-technological functions of medicine.
A very careful and honest heart searching is necessary by
advocates of modem, institutional system of health care to
analyse how much of their success depends on a totally nontechnological intervention, Once this intellectual cob-web is
removed, a restructuring cm lead to a more humane, less
expensive and a socially just system of health care.
WHAT IS HIGH TECHNOLOGY MEDICINE ?
The examples which are often cited of the spectacular
advances in medicine - organ transplants, coronary bypass
surgery, joint replacement surgery - really stem from the fact
that we have not understood the basic causal mechanisms of most
diseases. We do not .know why coronary arteries get choked, why
kidneys fail, what causes rheumatoid arthritis which may ulti
mately lead to joint destruction necessitating their replacement,
or indeed why cancer occurs. We deal with the aftermaths and so
we resort to some very expensive technical interventions which
are really fire-fighting methods. If we understood the basic
causes of these diseases, such expensive methods would not be
needed.
The converse is also true. Whenever one has to resort to
very expensive systems of treatment one can safely assume that
we have not fully understood the basic disease process.
How then can one label such interventions as high-technology
medicine? In fact, this level of technology is, by its nature,
at the same time highly sophisticated and profoundly primitive.
It is true that the individual instruments or machines may use
some of the latest ideas in basic sciences or applied engineering
technology, but as far as medicine is concerned'these machines do
not unravel the mysteries of disease. I think we are all the
time equating such technology transfers from other disciplines
with high science medicine. I would categorize such interventions
as ''half -way, .technology" •
The true "high-technology" medicine, to my way of thinking,
is where the basic disease processes have been unravelled and
then treatment quickly becomes simple, inexpensive and effective.
It is so effective that it seems to attract the least public
notice; it has come to be taken for granted. But this is the
genuinly decisive technology of modern medicine, responsible for
some of our great achievements.
Let us distinguish, therefore,
therefore, between half-way technology
versus high science medicine. The former is impressive but
expensive and does nothing to the disease process per se: the
simple much less expensive and directly
latter is disarmingly simple,
affects the disease.
Of course a lot of expenses may be incurred in research
work which ultimately leads to a*more fundamental understanding
of various issues which lead to or influence the disease mecha
nisms. Modern research is not .an inexpensive business but if
I have to use scarce resources for health care, this is where
I would put my money. Also, it is worth reiterating that the
crucial instrument needed for such work is an incisive intellect
which is capable of raising the right kind of questions.
What we need to support and encourage is the creation of an
environment where some fearless and pointed questions can be
raised without the risk of being smothered by some powerful
lobbies representing the interests of the medical-industrial
complex.
Contd
5
(5)
TECHNOLOGICAL choices in developing countries
THE TECHNOLOGY FILTER
It has been repeated, ad nauseum, that there is a very
intimate relationship between technology and society, each
influencing the other. V/hat is often overlooked, however, is
the peculiar stratified societal structure of developing count
ries with a top ten percent of elite who are represented by the
urban, affluent class and' a bottom ninety percent of poor urban
or rural masses'- The top ten percent weild political power and
are the decision makers; the bottom ninety percent do not matter.
The top ten percent, many of whom have imbibed 'the life
style, the culture and the value systems of the west, look to
the advanced countries- and want that their country should have
the same kind of medical facilities as are available in the west.
Being the decision makers, they exercise control over what
Prof. Amulya Reddy calls a "technology-fj. 1 ter" - a filter through
which societal needs have to pass' to create a technology demand.
This filter allows only the needs of the ten percent elite to
pass to our technology and research institutions which in turn
look to the west for their inspiration. The needs of the bottom
ninety percent. are constantly ignored or shelved. Thus we get
into a_dilemna. Even if we learn to distinguish between the
high visibility, expensive half-way technologies of dubious
value, from real high-tech medicine, the decision makers would
always favour half-“ny technologies, becoming a victim of -some
high pressure sales campaign by the medical-industrial complex
of the west which treats health care as a market commodity.- And
so we witness our scant resources being frittered away in having
our hospitals being increasingly equipped with gadgetry such as
CAT scans, intensive care units, linear accelerators, NMR1s etc.
These have impressive s^b^lic^value as opposed to use - value.
It as obvious that this technology filter keeps on widening
the gap between che elite and the miasses and ends up with a
basically amoral system which leads to inequity. Ivan Illich,
one of the most incisive intellects today, while discussing the
much debated energy crisis in our world, brought out a very
perceptive point. The greater the energy consumption, he said,
the greater the inequity amongst men. Citing the example from
transportation, he says; "Tell me with what velocity you move,
and I will tell you who you are".
What Illich illustrated in his example of transportation,
is equally valid for the present day health care system.
NEEDED - A HUHaNE TECHNOLOGY
When we realize that health care is a very complex
business, where non-medical interventions also play a crucial
role'(adequate nutrition, clean drinking water, clean environment,
prevention of overcrowding etc.) and where the human function of
caring, empathy, family support are important, one can appreciate'
that the health (oi- disease ) caring system should be in -harmony
with the general philosophy of.life followed by any society.
There cannot be a universally applicable technology which would'
suit all cultures and equally, with changing societal structures,
there has to be an ongoing updating of what, in our classifi
cation, is the non-technological function of medicine. Why
should hospitals or old people's homes take over the functions
of what a family can and still provides in the under-developed
world? Such family roles, considered impractical in industrially
advanced countries, should be carefully nursed and encouraged.
Contd.... 6
(6)
This requires a demystification of professional knowledge,
Information should be shared with people. Raj Arolc, David
Werner, Zafrullah Chowdhary, Prawase Wasi, each of them, in
their own ways have shown how medical care and a healthy life
style can >e taught to ordinary people.
The present information sharing between the providers of
health care, i.e. us, and the consumers of our services - the
patients and their family, is asymmetric. We either do not
realize the value of such information sharing, or we do not
have the time and skills for such work. Our education in an
alien language has removed us from the mainstream of our people
and this has imposed a barrier to mutual communication and
understanding » We do not understand the idiom and the nuances
of the language of our common people and they, in turn, are
bewildered by our phraseology. We may talk of germs, while they
have visions of spirits or demons. We then view them as an
ignorant and stupid lot, I wonder whom .to pity. The fact that
we do not understand our own past, our dreams, our superstitions
and our belief systems surely is a severe handicap. Atl&st let
us realize that we have this handicap. But even this realization
is missing.
Of course, there is the everpresent urge to create a
mystique around us and our knowledge which gives us such power.
Thus there is a vested interest in witholding information from
others. This is a common attribute to all professions where
sharing of knowledge with others is supposed to lower our market
value. But then, this leads to a totally different aspect about
what Illich called "The Disabling Professions". I would not
dwell on this issue, pertinent though it is.
There is an increasing realization that we have created a
very mechanistic model of health and disease. We have been
overinfluenoed by Descarte’s vision of human body as a mere
machine and by Koch's postulates. This approach has worked well
in what one may label as unifactorial diseases. It is unlikely
that such concepts- -would be equally valid for multifactorial
illnesses..
While Koch's postulates served a very useful purpose in
a limited number of diseases, it has little relavence in
multifactorial illnesses. And so one should be able to postulate
nevz theories which can make for better understanding. This is
a phenomenon which is so characteristic of a scientific approach.
Nothing is infalliable in science. Newtonian mechanics had to
give way to quantum mechanics, to the theory of relativity, to
Heisenberg's law of uncertainty and so on. In fact, Karl Popper,
the great philosopher of science, has recently reminded us that
the major feature of science is its idea of falsifiability.
There is nothing like absolute truth. While this" is an accepted
mode of thinking.in subjects like physics or chemistry, we
medical people do become rather dogmatic. Indeed, someone has
Iseen compelled to visualize our large hospitals as medical
churches.
We need to understand this clearly and so we have to break
out of the restrictive confines of the medical worksh p which is
what a hospital is. We do need such workshops but they need not
overwhelm us. In our race for emulating the west, we are losing
the great tradition of empathy and human understanding which are
so valuable to 'the recovery process in- a person who is sick
The status and the role of a family doctor needs to be revived,
with the family members contributing significantly provided we
share information with them intelligently. I believe that
informed self-care should be ,the main goal of any health
programme or activity. Ordinary people, provided with clear,
simple information can prevent and treat most common health
problems in their own homes - earlier, cheaper and often better
than doctors. People with little formal education can be trusted
... 7
(7)
as much as those with a lot. And they are just as smart. Basic
health care chould not be delivered, but encouraged. This
requires a degree of sophistication in communication technology
which is missing altogether from our formally trained professional
structure. Lacking this, we lose a very powerful support system
which can be readily provided by our patients -and their families.
Instead of treating them ns nuisances, we have to invite them.to
participate in something which deeply concerns them. Here again,
let us not repeat the same mistake and fall for expensive
communication gadgetry. What is important is the software. ,and
not the hardware. This colls for the medical profession.trying
to understand our societal structure, the ways of thinking of
our people, rhe social .'.nd economic injustice our common people
arc subject to, their language and idiom. An insight into those
areas cor.voi s a clever physician into a wise physician. I very
deliberate!’; make this distinction between smartness.and wisdom.
Please look around and try to locate this class of wise people.
They are becoming an endangered species and would soon bo
/
extinct„
Such a technology f medicine which is more appropriate,
more■humane• more philosophical , more scientific, less expensive
and therufoi • more equitable, more harmonious with our belief
systems, but ..ithout any place for superstitions and quackery
and which au.vients autonomous coping with illnessor death rather
than a ptssin. Indiffer•nt and expensive caring available in.our >
institucicna. systems, i- want we should try to develop.
Please do not imagine that I am advocating a return to some
thin'; "Swadc'"hi"
Sv.'adc '"hi in a romantic or fundamentalist manner, I am.
pleadingj for more
mor- science
science, more rentionality and more realism in
handling our own problems,„ I am also aware that it requires
hai war al- ' would meet withstiff opposition from vested
interests f-am within thj profession, from the elite of our
society and . ror. +be severs of technological gadgetries. But
I h^ve scar, uch exampl ?'i in various remarkable attempts in
dilloreuv pr . ;s of che ■'eve J oping world. I have personally
expc rierx-ed his during some of my own work .and hence I have
rccc.cn t..< e: . with an optimistic note.
Nothin - worthwhile is achieved without hard work and
■t hopefully it would moke the life of our
saorific.-,
patients eaf. .'or; "Patient car.'", remember, is "caring for
the patient' , A.fterall
this remains the entire purpose
of our existence.
r e f e.rB c.e ,s
1 -
ARG IE . M s. encl
AROJE R.
A comprehensive Rural Health Project in
Jamkhed.. In NEWELL, K.W. : Health by
the people. World Health Organization,
Geneva, 1975.
2.
AT1ING1R, E.O
High Technology: The pendulum must
swing back. World Health Forum. Lead
Article Vol.8 No.3 1987 (To be
published).
3.
CHOn-L- Y,
ZA/AR' OLAH
Basic Service Delivery in Under
Developing Countries : A view from
Gcnashasthaya Kendra 'in READINGS ON
POVERTY AND DEVELOPMENT - Ed..Bhasin,
K. and Vimala, R. F.A.O. Rome, 1980.
4.
CARLSl
RICK
The End of Medicine, Wiley Interscience,
New York, 1975.
Contd..... 8
(8)
5.
COUSINS, NORMAN
Anatomy of an Illness. W.W.Norton & Co.
Inc. New York, 1979.
6.
EHRENREICH, JOHN
The Cultural Crisis of Modern Medicine,
Monthly Review Press, New York, 1978.
7.
ILLICH, IVAN
8.
JORDAN, BRIGHTS
High Technology : The cose of Obstetries.
World Health Forum. Lead Article Vol.8
No.3 1987 (To be published).
9.
REDDY,. A.K.N.
Technology and Society. Lecture in Rural
Technology Course ASTRA, Indian Institute
of Science, Bangalore, 1982.
10.
THOMAS, LEWIS
The Youngest Science - Notes of a Medicine
Watcher, Bantam Edition. The Viking Press.
Nev/ York, 1984.
11.
TAYLOR, RICHARD '
Medicine out of Control. Sun .Books,
Melbourne, 1979.
12.
WASI, PRAWASE
Personal Communication Ramon Magsaysay
Award, Manila, 1981 .
13.
VERNER, DAVID
Where There is No Doctor. The Hasperian
Foundation* Pao Alto, California, 1977.
14.
DOSSEY, L.-.RRY
Meaning and Medicine; Future Directions Paper written for the Theosophy Science
Study Group of India, 1987.
✓
Medical Nemesis, Random House, Nev/ York,
1976.
I
Position: 1167 (6 views)