Friday, September 30, 2011

Resistance, Rebellion and Death

I was invited to attend the Galien Foundation conference in NYC this week.  They are planning on it evolving into the Davos of healthcare.  They have quite a slog. So here is one issue we discussed.  Only between 50-75% of prescriptions are filled, 30% of those taken as prescribed and only 15% refilled as directed.  So someone points out the 'compliance' for things made by Apple is phenomenally higher. Why is it?  One is so important and the other almost trivial. Apparently, I was the only semiotician in this crowd of CEOs, CMOs, and big pharma board members.  So, I had to comment, yes, out loud with a mike, that it was pretty obvious. Apple signifies hip, cool, young, healthy, high status and medication is a simple reminder of the phenomenal reduction is status, the "anti-Appleness" of the patient.  In the end, it is requiring the patient to affirm their horrible status everyday.  As Certeau taught us, it is the 'inversion that animates resistance'.  The 'non-compliant' patient is just that.  In the act of not taking that medication, they assert their rejection of the imposed status, reclaim their personhood in the face of a machine they cannot resist otherwise, the perpetual documentation of their failure to be "successful," to be healthy, to be young.  It is the only act they control.  After this comment, delivered at the end and shrugged off by the moderator with the comment "Public Health people have been working on this for years..." several folks approached me to concur, the best comment, from a health care policy lawyers was, "I can;t believe someone actually used the word 'semiotics' in this kind of meeting!  Never heard that before and it was exactly right."  Two of the panelists even stopped me to chat about it.  But it is so obvious. Medicine embraced science as a social stepping stone, out of the lower class and into the highest.  So all the transactions of clinical medicine can be characterized as power relations, where the only act of rebellion that remains is to refuse what is in your hand.  But refusing medication can mean death.  So what is unusual about revolutions entailing that kind of sacrifice?  Here is to all those risking death to salvage their self-esteem. Maybe "The Rebel:" should be required reading in medical school.  But maybe not.

Monday, September 26, 2011

Gaming the Pharma Model

In a great frenzy of activity, researchers showed that a component of red wine appeared to improve longevity and decrease chronic disease in several animal models.  So compelling the evidence, Glaxo Smith Kline paid $720 Million for the company, Sirtris, that did the work. 

Even the Sirtris founders, who were now GSK employees, created an outlet to sell the compound as a nutriceutical (albeit in low doses) and GSK had to force them to give up their on-line company.  It is a great read, all in all, about what can go wrong in the race to find the 'silver bullet' for any disease, much less a host of them.  Not only that, but, in the end resevatrol turns out to be an unlikely candidate for anything, save the emotional interest in pharma producing 'silver bullets.'  But as you know from reading here and everywhere, the wholly non-linear and complex nature of, well, nature, precludes, in general, these kinds of single solutions to complex problems.  Creating health is the outcome of multiple, simultaneous events, most of which we can only 'nudge' in the best direction.  Health, like disease, is a trajectory through time, not a problem in plumbing or simple engineering.  But hope springs eternal.  And apparently, so does money to support the dream.  Like geopolitics, our discourse on health is riven by minute, local activity which, in aggregate seems to point to some underlying logic, principle, or postulate that can be discovered by reducing the problem to some set of simple parts, like a lawn mower engine.  And, no matter how we try, like Leonard Cohen sings, "You can add up the parts, but you won't get the sum."  Why?  'There's a crack, a crack in everything.  But, he reassures us, 'that's how the light gets in'. Listen to it. Anthropologist, I think, are in the business of light, no matter how small the cracks.

Sunday, September 18, 2011

Evidence-based Medicine


If you look at a dollar bill, there is a pyramid on it, with many an arbitrary and even conspiracy-like interpretations.  But it is really an icon for evidence, at least in medicine.  So here we have the hierarchy of evidence in medicine, the kind of rationalized approach that we may think, or desire, at least, to create a kind of medical practice that has a familiarity and similarity everywhere we might go.  Sort of standardizing care, like a McDonald's.  Everything is the same, with allowances for local types of disease, say Lyme Disease in the Northeast or the plague in the Southwest, some places might have expertise in the lobster roll and others might add green chile to a burger.  But hidden within is the unavoidable truth that like regional tastes, the more 'standardize' a treatment is based on the 'best evidence', the less likely it is to apply to an individual case.  I might eat at a McDonald's in Albuquerque, but that doesn't mean I even like green chile, or even know what it is, as I hail from the Northeast. The assumptions fit a population, like evidence from a randomized, controlled, double blind study, or a review.  But, for any one person in that 'group,' the assumptions may not fit.  This is the tension between medical practice and medical knowledge.  The knowledge can be standardized, but practice is an individual act, the history and condition of the patient meet another set of conditions and histories, that of the clinician.  An example from neurosurgery:

In a traumatic brain injury patient, presented at rounds, the dutiful residents present the case to the attendings. "Pt. X has a TBI, brain stem involved. We did X, Y, Z and then used anti-hypertensives to keep her blood pressure below 160..."  The Chairman interrupts, "Does her BP want to stay there or are you fighting or keep it there?"  The residents hesitate, trying to ascertain why that statement is made.  The Chairman mercifully continues, "If the patient wants her BP to be higher, she is telling you that she is trying to perfuse her brain and she needs the higher pressure..."  The resident responds, "In these cases, a BP above 160 could lead to a stroke..."  The Chairman interrupts, "But that is the point, if she needs more perfusion and you prevent it, what's the difference?  It is another kind of ischemia (lack of blood flow)."  This is another kind of 'stroke, so to speak, no blood flow due to medical intervention rather than the unwanted stroke.  The outcome is identical.  The residents look around, not knowing whether the 'evidence-based' approach is beyond reproach.

This vignette, repeated in medical rounds around the world is the collision between experience and evidence.  The individual case reveals itself as an anomaly, outside of the hierarchy of evidence and concealed in the hierarchy of experience.  The practice of clinical medicine is like a walk in the city.  The city planners (the evidence-based medical approach) lays out the 'design' to the highest efficiency.  But the individual walking through the city, like the clinician, has desires that may not conform, nor should conform to the existing path, the evidence.  In architecture, these divergent, but necessary paths, are called 'desire lines'.  Each patient, in the hands of the skilled clinician, create unique paths, to get from disease to health. But without the rational constraints of only evidence.