Etiology, pathogenesis and translational science beat drums to which modern medicine marches – with escalating cadence. Yes, there is cacophony on occasion and missteps, but we all wait for the next insight to trigger a wave of enthusiasm at the bench and beyond. “Disease” is no longer an elusive monster in the swamp of ignorance; “disease” is prey. It can be defined, parsed, deduced, and sometimes defeated.
Little of this pertains to “health.” Health does not objectify itself. Nor is it simply the absence of disease. Health has temporal and geographic dimensions. Health is inseparable from the context in which it is experienced. Health has a narrative laced with peculiar, often idiosyncratic idioms. Furthermore, there is a crucial difference between the health of a person and the health of the people.
Science has limitations when it comes to studying health. For one, the studying becomes a component of the experience of health. Nonetheless, we have accumulated a great deal of substantive information that serves to define the boundaries of healthfulness and offers options with salutary potential. Much of this reflects a century of considering the personal ramifications of gainful employment. Much of this falls under the purview of occupational medicine and should be a source of pride.
In 1994, I recorded a fictitious interview with the person whom I imagined to be the last well person on earth. (1) I mistakenly thought well people were disappearing and I wanted to call attention to their disappearance. I missed the big picture and now want to correct my misconceptions. Well people are not disappearing; instead, a new species of man is emerging: homo clinicus.
An evolution of the symbiotic relationship between man and medicine has been going on for some time. Lewis Thomas deserves the credit for an early spotting of the new species, first observed in America. He called our attention to this phenomenon in the 1970s.
Nothing has changed so much in the health-care system over the past 25 years as the public’s perception of its own health. The change amounts to a loss of confidence in the human form. The general belief these days seems to be that the body is fundamentally flawed, subject to disintegration at any moment, always on the verge of mortal disease, always in need of continual monitoring and support by health-care professionals. This is a new phenomenon in our society.
Recently published statistics show that the top-grossing medication in the U.S. for 2013 was the antipsychotic Abilify (aripiprazole) with over $6 billion in sales, narrowly beating out the previous few years’ winner, Nexium.
The past decade’s dominating pharmaceuticals have been Lipitor (atorvastatin) for high cholesterol and Nexium (esomeprazole) for acid reflux. Nexium was preceded at the top by Prilosec (omeprazole), and before that we had Pepcid (famotidine) and Zantac (ranitidine) somewhere near the top of the sales data.
A country’s medicine cabinets tell us something about its culture and its predominant issues.
From the late 1960’s to the early 1980’s the tranquilizer Valium (diazepam) was the top grossing drug. The 1965 US sales volume of tranquilizers was somewhere around 166 million prescriptions or 14% of all prescriptions filled in this country. Both “uppers” and “downers” were subjects of the 1966 best seller “Valley of the Dolls”. Valium rose to the top after the previous few years’ blockbuster tranquilizer Miltown (meprobamate) proved to have significant toxicity risks.
So, this country has gone from treating nervousness and suppressed emotions to heartburn and high cholesterol, the latter two sometimes self-inflicted through dietary indiscretion, and now back to psychiatric conditions like schizophrenia. True, there are other, “softer” indications for Abilify – bipolar disorder, treatment resistant depression and for chemical restraining of aggressive individuals, even children.
One cannot help but stop and reflect on this pharmaceutical sales phenomenon.
The postwar years, although portrayed in media as a time of health care advances, optimism and prosperity, were years of great anxiety. My own observation is that many of my patients and acquaintances who were children during World War II lack the emotional imperturbability of those whose childhood fell in the 1930’s, born in the early to mid 1920’s.