Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Chemical Illness is definitely an Illness
- John Fryer (12 April 2002)
-
Who feels better - people or patients?
- Shailendra Goswami (13 April 2002)
-
classification of non-disease
- j martin b dace (13 April 2002)
-
Medicalization
- Gurli Bagnall (14 April 2002)
-
DISEASE DEFINITION
- ashok chandra (14 April 2002)
-
Let's not profit from neuroticism and obesity!
- Regina Stroebele (14 April 2002)
-
Re: Chemical Illness is definitely an Illness
- Sheila Edwards (15 April 2002)
-
Non Non-Disease, a Creationist View
- Ronald J. Frankenberg (15 April 2002)
-
Sick in my own fashion, Cynara
- David C Taylor (15 April 2002)
-
congratulations
- Tim G Ashworth (16 April 2002)
-
Defining Disease using a Semantic Terminological Model
- Philip J Bayliss Brown (16 April 2002)
-
On non-diseases and medicalisation
- Kai-Lit Phua (16 April 2002)
-
In search of "non-disease"
- Andrew Singleton (17 April 2002)
-
Non-disease, BMJ and the Science of Medicine
- Abhijit Chaudhuri (18 April 2002)
-
Blasting the doctor-patient relationship
- Constantinos Paschalides, Christos S Zipitis, final year medical student, Manchester Royal Infirmary, M13 0FE. (19 April 2002)
-
Non-disease
- Bernard H Fookes (19 April 2002)
-
THE MEANING OF "DISEASE"
- Robert E Kendell (23 April 2002)
-
Sizing up the intersexed
- Iain Morland (28 April 2002)
-
sanitary terrorism
- manuel varela novo (1 May 2002)
-
Overweight is not a disease
- Annemarie Jutel (12 May 2002)
-
Patior (L)
- Simon R. Wilkinson (5 July 2005)
-
Some "non-diseases" listed in this article are ludicrous
- Nathan T. Vertuca (2 June 2009)
|
|
|||
|
John Fryer, researcher Sheffield
Send response to journal:
|
Sir, The classification of disease/illness is supposed to be rigid and the variance in replies is to be considered not trivial but of serious concern. The BMJ has hit upon a "raw" nerve that needs to be addressed in some degree of leisure and persistence in the 21st century. My interest is in the chemical cause of illness. By the very nature of illness the chemical needs to be "active". A human has inside him literally 1 000's of enzymes. The result of 1 000's of "active" chemicals interacting with 1 000's of enzyme processes results in illness which can manifest in a million different ways but often falls into broad groupings such as multiple chemical sensitivity. More contentiously we can identify ME and Gulf War Syndrome. After 40 years, one organophosphate chemical - diazinon - was finally withdrawn on December 5th 2000 by agreement of the manufacturer and the environment agency (EPA). We are only at the start of sorting out the harm of chemicals to our bodies. If it takes 40 years for just one chemical, we need to focus more closely on this new type of chemical illness before we all forget what harm is caused by overexposure to active chemicals. Alzheimer's Disease in the UK was but 4 cases in 1967 and today stands at nearly 1 000 000. This illness is definitely not a disease (infection) so is it chemical illness - most definitely. John Fryer Chemist |
|||
|
|
|||
|
Shailendra Goswami, DNB trainee-Medicine, Lisie hospital, Ernakulam, Kerala, India. Lisie hospital, Ernakulam, Kerala, India 682018
Send response to journal:
|
Dear sir, The clinical review-In search of "non-disease"- by Richard Smith, is very stimulating [1]. I am forced to think that had I said to some of my patients that they were not ‘patients’ but people having a ‘condition’ which needs a little bit of medical care, I think they would have felt much better psychologically. Labeling persons as ‘patients’ has got its own disadvantages: it affects their psychology- it depresses them more. Following question should make this assertion more acceptable. Which of the following sentences depresses you more? (a) You are a patient (b) You are a person with a condition that needs medical care. Who feels better: people or patients? Why should a pregnant lady be called a ‘patient’? What is ‘abnormal’ with her? Is pregnancy not ‘normal’? Similarly, why should ageing be called a disease? Is ageing not ‘normal’? I fully agree with the doctors who have voted that ageing, boredom, bags under eyes, ignorance, baldness, big ears, grey hair, ugliness, pregnancy and childbirth, penis envy, etc should be considered as non- diseases. People with these conditions will feel much better on seeing that their doctor does not consider them ‘patients’, but as normal human beings with a ‘condition’ which can be ameliorated (if possible) by medical care. References: 1. Richard Smith, the editor, BMJ: In search of "non-disease". BMJ 2002;324:883-885 ( 13 April ). |
|||
|
|
|||
|
j martin b dace, general medical practitioner waldron health centre, stanley street, deptford, london SE8 4BG, england
Send response to journal:
|
EDITOR - The concept of non-disease (1.) requires a 21st-century set of Koch's postulates, or at any rate a little more clarity. Here is an attempt at some working definitions: Illness: any condition associated with emotional or physical distress which the patient wishes to medicalise, for whatever reason; Syndrome: a collection of symptoms and/or signs which are associated with one another and which may or may not result from a single aetiology; Disease: an illness or a syndrome for which there is a well-established aetiology, or for which a medically definable aetiology is generally accepted to exist even if not proven (but excluding 'non-disease (boundary dispute)' as defined below); Non-disease (disputed aetiology): an illness or syndrome for which not only is there is no well established aetiology, but also the existence of a single aetiology is a matter of dispute (note that the existence of the disease as a pathological entity is disputed, but not the existence of the illness or syndrome; example: myalgic encephalomyelitis); Non-disease (boundary dispute): an illness in which there is disagreement about whether or to what extent it should be medicalised (examples: psychopathy, ageing, childbirth); to this list we may add: Illness by proxy: an illness as defined by relatives or by society or by the medical profession but not necessarily by the patient (example: homosexuality); and for completeness: Non-illness: any condition without symptoms which the patient wishes to medicalise (example: request for a sick note for hypertension). Dr Martin Dace - General Medical Practitioner Waldron Health Centre Stanley Street London SE8 4BG martin@dace.co.uk Conflict of interest: none. 1. Smith R, In search of "non-disease", BMJ 2002; 324:883-5 (13 April) -- |
|||
|
|
|||
|
Gurli Bagnall, Patients' Rights Campaigner
Send response to journal:
|
It is official at last! How comforting to know that our applications for mortgages and insurance will not be rejected now that big ears, ugliness and freckles are classified as non-diseases. With the de- medicalization of pregnancy, women might be wondering whether to call in the butcher the baker or the candle stick maker for the delivery, and who knows, in the not too distant future, butchers might have signs in their windows offering diabetics freshly harvested pig cell injections. Dr. Richard Smith ends his clinical review “In search of non- disease”, with the following: “Surely everything is to be gained and nothing lost by raising consciousness about the slipperiness of the concept of disease.” It seems to me, he missed the boat. I doubt anyone believed the listed 20 top non-diseases were diseases in the first place, and to examine de-medicalization, one must first look at medicalization. To demonstrate the point, I refer to a couple of lines in a movie entitled “Critical Care”. A young doctor asked the question, “If the patient has no chance of recovering, why proceed with the treatment?” His elderly colleague replied, “Where have you been, boy? It’s called REVENUE....” For many years, the pursuit of revenue has caused a gross increase in iatrogenic statistics. That makes it hard to accept the suggestion in Dr. Smith’s review, that malingering patients are in some way responsible for medicalization. It might even be regarded by some cynics as pure damage control. Dr. Smith maintains that once labelled with a disease, “You are a victim. You are not just a person but an asthmatic, a schizophrenic, a leper....” That may be, but society demands labels, and the medical profession demands that we fall into a category that can be labelled. If a label is not attached, then the sick are regarded as malingerers and denied the assistance that allows them to exist. A prime example is ME - victims of it, suffer far more than just the disease. One need go no further than this edition of the BMJ to find out a little about medicalization for the purpose of selling drugs, and the danger to which people who take the drugs, are exposed. I refer to an article in the education and debate section: “Selling sickness: the pharmaceutical industry and disease mongering” R. Moynihan, I. Heath, D. Henry. Strangely, it doesn’t mention malingering. Gurli Bagnall, Patients’ Rights Campaigner, Otago New Zealand |
|||
|
|
|||
|
ashok chandra, prof of medicine K G MEDICAL COLLEGE, LUCKNOW ,INDIA
Send response to journal:
|
Dear Sirs We have been taught and now teach that a disease should have four components A site of the lesion A nature A pathophysiology and A dysfunction and all together comprise of "a " disease for unless there is dysfunction there can be no dis-ease or if there is dysfunction as in ageing but no clear identifiable site or nature it cannot be disease. By default any situation where these four components are not there, there is no disease. This may be an attempt at oversimplification but conceptually sound, however there are many diseases which have not been fully worked up and all these four components are not known. Ashok Chandra |
|||
|
|
|||
|
Regina Stroebele, GP without accomodation D-81677 Munich /Germany
Send response to journal:
|
The problem should be viewed also from the point of those who suffer from and pay taxes for or work instead of "patients" thinking they have a right to be sick just because they are strongly neurotic or obese, e.g. I agree that an Alzheimer's disease patient is happier than a person recognising his severe "chemical" illness. But what about those having that "secondary" advantage of not being sane? I refuse to treat non-compliant persons wanting to be regarded as sick as long as they themselves are not willing to change anything within their lifestyle. And these, at least in my patients, are the majority of insuline resistant so-called diabetes patients and of those complaining about vertigo, insomnia and similar possibly psychosomatic disoders. |
|||
|
|
|||
|
Sheila Edwards, retired teacher PO Box 15825 Dubai UAE
Send response to journal:
|
Dear Editor There is growing concern about the toxic effects of chemicals on human health and well-being, as well as to non-human animals and the environment in which we live. As a society we are not sufficiently aware of what is being done to us by industry and regulatory authorities in this sphere.The indiscriminate use of chemicals and chemical pesticides are having a devastating effect on our health and on that of our children. Official statistics reveal that within the EU today, over one million people die prematurely every year as a result of consuming chemically-laden products. In addition, acute toxicity from prescription medicines now rate as the fourth leading cause of death in the EU, claiming 120,000 lives each year, a figure which could probably be doubled if we include the chronic,toxic effect of drugs. Many consumer products and prescription medicines have not been properly evaluated despite extensive 'safety' testing. Since toxic risk assessment is carried out using animal models, as has happened over the past 100 years, one must conclude, that reliance on the animal model for the study of toxic effects in man represents a clear danger to public health. We should rethink the proposed plan by the EU requiring 100,000 chemical substances to be tested on live animals, in order to assess their toxic risk for man and the environment.The projected tests, based on animal models, are scientifically irrelevant for human beings. This means EU regulatory authorities will continue to formulate public health policies on the basis of unreliable animal toxicity data, ignoring the much faster and far more scientific methods already available for assessing short and long-term human toxic risk assessment. The immediate adoption of these methods would add significantly to consumer safety and should therefore be considered by the EU as an absolute priority. In the US, the EPA requires more chemical toxicity tests on animals than any other federal agency. These tests involve forcing animals to eat, inhale, or be injected with chemicals. An undisclosed number of animals, likely to be in the millions, die slow and painful deaths in these tests. And with all that, the EPA has not banned a single industrial chemical in more than 10 years. Rather than working to reduce emissions and prevent human and environmental exposures to toxic chemicals, the EPA has instead chosen to establish "acceptable" exposure levels based on the results of misleading animals tests. The EPA pours millions of taxpayer dollars into cruel and wasteful animal experiments, while spending virtually none of its $500 million annual research budget on the development of non-animal test methods. Yours Sincerely S. Edwards |
|||
|
|
|||
|
Ronald J. Frankenberg, Professor Associate, Brunel University 19,Keele Road, Newcastle ST5 2JT
Send response to journal:
|
Jean-Luc Godard famously said that although, of course, films had a beginning, a middle and end, it was not necessarily in that order. The AngloAmerican school of medical social (or cultural) anthropology which I helped to found distinguished between sickness ,the bodily disorders based on the social situation in which people most commonly found themselves (emphasised in modern times first by Virchow); illness a patient- or relative-perceived interruption to the flow of their functional health and finally; uncovered by the doctor after consultation, a disease, an episode with an end, a middle and a beginning, the first two of which doctors, with a little help from their nursing friends might influence. Later, I learned from Professor Howie (1979) that general practitioners often decided what to do or not to do (sometimes called prognosis) in the presence of the patient and why they had decided to do it (sometimes called diagnosis) taking thought after they had left the room, clasping prescriptions in their hands and holding advice in their minds. Ann Cartwright's first 1967 survey of General Practice in a period when Condoms were still called Preventatives (primarily of pregnancy, for STDs Clean Living was still the ONLY Real Safeguard) or French Letters felt that contraception was none of their business; By the time of her second (with Robert Anderson in 1981), the advent of the pill made it clear that it had become part of the prescription busines which was their very own. Similarly I learned from Hilary Thomas that while diagnosis of pregnancy with Xenopus toads was seen by GPs as a useful part of medical practice, a chemist shop and blotting paper, required no exotic (ectopic) expertise. When with Hugh Faulkner in the 1980's we asked Tuscans on behalf of their local health authority, their four greatest medical needs. They listed prevention of early pregnancies and motorbike accidents in youth and separation from their families in old age and as an afterthought, Cardiovascular disease. Diseases, then are processes the progress of which can be legitimately or effectively monitored and ameliorated by the medically qualified and licensed. No more illogical and unscientific than the biological definition of species, which I was taught in the sixth form, as anything which a properly qualified systematist recognised as such. Disease is what doctors "do" to and with their patients and other clinicians, it begins in and derives from practice, professionally and politically approved and often, if inadequately, rewarded. |
|||
|
|
|||
|
David C Taylor, Visting Professor Dept of Neurology Great Ormond St Hospital WC1N 2AA
Send response to journal:
|
Some years ago, and in The Other Place, I tangled with the use of language in which to connote the problems people brought to doctors (Lancet,1979 2, 1008-1010). An extended version of the arguments was given in "One Child" (ed Apley J & Ounsted C SIMP pub 1982).It was the product of a Sabbatical spent abroad where I felt that the language of human sickness needed revision and argeement becasue it was so central to what we thought we were doing. I drew attention even then, 20 years ago, to the fact that doctors had never been so successful in treating sickness but never so vilified for what they cannot do. What they cannot do is regularly magnified by what they can. Who else but a dotor is to tell people that it is not a dreadful disease that is making them sick? Twenty years on, and in a worsening environment of medicine, you see the issue as answerable by some sort of word game.I hope it is a serious game. The people who consult doctors do so because they think they are Sick. Let them be called that. Among them you will find all the sorts of variation of structure that have been referred to in the letters. But careful investigation might reveal a relevant sructural change, Disease. Or, they might only have a complelling story that cannot be structurally substantiated but has dire effects on well-being, Schizophrenia for example, an Illness. Or, as is most commonplace, they find that they are uncomfortably placed in their Predicament and their body is speaking up for them. Their distressing gut pain is one that speaks up for the deceit in their marriage or is a response to chronic abuse of trust. Furthermore, each human suffers their Diseases, expresses the ensuing Illnesses in their own, unique Predicament. Easing that Predicament might be more relevant than working on the Disease which might be past remedy. The Predicament alone is a powerful vector of Sickness, as many of those suffering in the war weary areas of the world would tell you. No conflict of interest |
|||
|
|
|||
|
Tim G Ashworth, retired pathologist 22 Limehouse Cut, E14 6NQ
Send response to journal:
|
Dear Sir, Medicalisation and non diseases Your new format BMJ has certainly come of age with the publication of the most recent issue [13 April 2002]. Congratulations! My only caveat to your otherwise admirable and comprehensive covering of the subject is that just as trainee teachers should be compelled to read Deschooling Society by Ivan Illich, so should medical students have his writings on medical matters as required reading and be examined on the subject during the course of their training. I am, yours sincerely, Tim Ashworth, retired Consultant Pathologist
|
|||
|
|
|||
|
Philip J Bayliss Brown, honorary senior lecturer in medical informatics Department of Medicine, St Thomas’ Hospital, Kings College, London.
Send response to journal:
|
The notion of non-diseases raised by Smith [1] has interesting parallels with recent debates of the representation of clinical findings according to their semantics in formal coding schemes for use in electronic medical records. The issue is critical in the design of terminologies as they are increasingly used to populate clinical databases with significant effect on data retrieval for patient care, audit, research, decision support, epidemiology and management (e.g. the use of the International Classification of Diseases (ICD) for national and international comparisons); and commercial databases determining, as Smith highlighted, eligibility for insurance and employment. Opinions of what constitutes a disease or non-disease vary between professions, cultures and over time. For example homosexuality was classified as a disease in ICD-9th Revision but removed in the 10th Revision. Previous reports would assert that the use of a formal semantic terminological model of disease provides a valuable conceptual framework upon which judgements can be measured. [2] A disease can be defined as a class of concept describing states in which there is an explicit or implicit pathological process causing a state of altered homeostasis, which may have both a causative agent and an associated morphological abnormality e.g. amoebic abscess of liver. A distinction can be made between a disease (e.g. diabetes mellitus) and an observation of a finding either “in vivo” (e.g. short stature), or “in vitro” relating to a sample (e.g. raised blood glucose level). In some circumstances this distinction is subtle if not pedantic. The finding of “unable to hear” is different to the disorder of “deafness”, as the former may have many causes some of which are temporary e.g. occlusion of the external auditory canal by wax. A key principal that is hidden in this issue is that of pathography which has diminished as a subject for consideration in modern medicine. Pathography as Harris [3] has highlighted is the study of the natural history or behaviour of disease including the healing process. He argues that only with a full appreciation of pathography can the applicability of any intervention and its success be evaluated. Thus a further covert utility of identifying the notion of a disease is that the clinician is able to predict possible future behaviours and outcomes which are informative when judging the options of treatment plans with the patient. The explosion in bio-informatic data particularly with the delivery of the human genome project has also challenged many pre-conceived ideas about what is and is not a disease. The rich variability in our genetics makes a mockery of the use “normal” and “abnormal” and pushes us to re- define predisposition to disease in terms of deterministic and probability values. Whilst the concept of a disease is certainly “slippery” it is also a nettle worth grasping. 1 Smith R. In search of “non-disease”. BMJ 2002; 324: 883-5 2 Brown PJB, Sönksen P. Evaluation of the quality of information retrieval of clinical findings from a computerised patient database using a semantic terminological model. J Am Med Inform Assoc 2000; 7: 401-412. 3 Harris CM. Seeing sunflowers. JRCGP 1989; 39: 313-9. |
|||
|
|
|||
|
Kai-Lit Phua, Senior Lecturer in Community Medicine International Medical University, Plaza Komanwel, Bukit Jalil, 57000 Kuala Lumpur, Malaysia
Send response to journal:
|
Dear Sir As a medical sociologist, I read with more than passing interest your editorial on “non-diseases”. The definition given for a non-disease is “a human process or problem that some have defined as a medical condition but where people may have better outcomes if the problem or process was not defined in that way”.1 The editorial also mentioned the “increasing tendency to classify people’s problems as diseases”1 or what sociologists call the “medicalisation” of social problems. Good examples of medicalisation include “gambling addiction”, “sexual addiction” and “domestic violence”. There is a concept from contemporary sociology that may be a useful tool for healthcare professionals when pondering over the issue of diseases, non-diseases and medicalisation, i.e., the “social construction of reality” approach. Using this approach, one is reminded that certain conditions are defined as “diseases” in some societies but not in others, and that definitions can change over time within one society. Thus, a non- disease such as overweight/obesity has been medicalised in countries such as Britain and this medicalisation is probably linked in some way to increasing rates of eating disorders such as anorexia nervosa among females and even some males (note that I consider overweight/obesity to be a non-disease while acknowledging that it is a risk factor for certain diseases such as diabetes mellitus). Interestingly enough, in traditional Samoan society, overweight/obesity in women is considered to be desirable and such women are considered to be “beautiful” in the eyes of Samoan men. A very fascinating case of social construction of reality indeed! The chances are that this traditional notion is changing or even disappearing with increasing “Westernisation” of Samoan society. The usefulness of this concept is illustrated when we apply it to other phenomena such as “substance abuse”, e.g., we witness the gathering strength of the anti-tobacco movement in the United States today as a result of public health concerns over the effects of tobacco on smokers and bystanders. However, in the past, tobacco smoking was not considered to be an unhealthy practice and was even associated with sophistication. Another example would be the negative perception of the contemporary American public toward drugs like heroin, cocaine etc. In the past, such drugs were not considered dangerous and were added to cough syrup (heroin), patent medicine (morphine) and even Coca Cola (cocaine)!2 I rest my case. Competing interests: none References: 1 Smith R. In search of non-disease. BMJ 2002; 324: 883-5 (13 April). 2. Savage D. Panacea one day, poison the next. http://www.smh.com.au/news/0001/01/world/world11.html |
|||
|
|
|||
|
Andrew Singleton, Research Scientist Dept General Practice, St George's Hospital Medical School, Cranmer Terrace, London SW17 0RE
Send response to journal:
|
Dear Sir, Like all good editors you generate curiosity as a catalyst for reflection, whilst reinforcing the norms of your publication by controlling the context of that reflection. In generating a debate to define “disease” from “non-disease”, you reinforce the belief that “disease” is “real”, and that the consigning of all other experiences to a social category requiring alternative social resolutions is “natural”. In so doing you reinforce the supremacy of the medical taxonomy thereby running the risk of constraining the debate. For example your emphasis on modes of access to health care directs thought about disease to functional aspects of health care rather than the embodied experience(1) of the patient. Given biomedicine’s lack of homogeneity (see Helman’s case of pseudo- angina(2)) different specialists employing their own historically grounded interpretations of dis-ease (biochemical, genetic, immunological etc), are likely to ensure your debate generates a mixed repertoire of authoritative claims. If we employ the notion that the association between a word and the phenomenon it represents is arbitrary, and only made “real” through common consent and continual usage, the ascendancy of one label over another rests with the power of its advocates. Thus the power invested in your readers’ argument may become the focus for debate, at the expense of attributes embodied in the patient’s experience. The dualism you uncritically reify may then, merely serve to illustrate the current biomedical hegemony(3) and the epistemological process that maintains it. The danger then is that the ensuing debate may fail to address the ontological issue that I have inferred you desire. Readers may provide responses depicting what doctors think they should treat, rather than what and why they treat. Given that health belief and behaviour (both professional and lay) are structurally and culturally constructed(4), your paper may well have benefited from a broader context. Reference to the current social structure and the concerns that motivated your raising of this issue, would serve to have located the discussion in both spatially and temporally for example. Given that differing societal groups hold differing perspectives then interpretations of “disease” are flexible. Unqualified, “disease” has become recognised as a metaphor(5) representing the discourse in which doctor input may be channelled into a wider societal debate about the provision and delivery of health care. However, when qualified by your association of it as the polar opposite to “non-disease”, it may perpetuate the outmoded metaphor representative of a discourse that promotes the dominance of this debate by the doctor. Reference List 1. Csordas TS. Embodiment and Experience. Cambridge: Cambridge University Press; 1994. 2. Helman C. Disease and pseudo-disease: a case history of pseudo angina. p. 293-331. In Hahn R, Gaines AD, editors. “Physicians of western medicine: anthropological approaches to theory and practice. Dordrecht: Reidel; 1985; 3. Turner BS. Medical Power and Social Knowledge. 2 ed. London: Sage; 1995. 4. Frankenberg R. Medical anthropology and development: a theoretical perspective. Social Science and Medicine 1980;148:197-207. 5. Kleinman A. Patients and Healers in the context of culture. Berkeley: University of California Press; 1980. |
|||
|
|
|||
|
Abhijit Chaudhuri, Senior Clinical Lecturer in Neurology University of Glasgow
Send response to journal:
|
The debate on the "non-disease" and the theme issue was interesting. BMJ chose its own in-house definition of a "non-disease" with the primary aim of showing how life problems become increasingly labeled as diseases with medicalisation. This review, and the discussants of the theme issue have clearly succeeded in addressing the social and economic complexities associated with the present day health problems. However, BMJ is guilty in its omission of the science of medicine from the discussion on what may be a "non-disease". Central to the discussion on non-disease lies a simple question: how a new disease is born? When James Parkinson had described the disease carrying his name in 1817, he had little idea about the pathology of the disease or indeed, what treatment might be effective. He did not use a model of any "known" disease to explain the symptoms of his patients. One might have argued in the 19th century that he was reporting a non-disease contributed by the "modern" life style of post-industrial revolution era. In contrast, the identification of prion diseases has been remarkably rapid. Clearly, it was the "medicalisation" of the developed world that established the identities of Parkinson's and prion diseases, leading to very effective therapies in the former by turn of the last century. Genetic technology (another by-product of medicalisation) has both expanded and contracted the traditional boundaries of "diseases". It has also revealed what may be geneticist's definition of a non-disease. I assume that the name of Victor McKusick is not unfamiliar (may be less familiar than Illich to some)and it is of considerable interest to see how non-disease has been defined in the McKusick's text on the morbid anatomy of human genome(renal glycosuria is an example). The scientific definition of disease is more complicated than what the social scientists have offered in this issue. Athersclerosis may be considered as a complex disease by some whereas others might consider it to be an inevitable biological process in life assuming significance only when associated with end-organ diseases. While participating in the debate, few contributors have also confused the issue of syndromes and diseases; a syndrome may be a convenient term to describe the common symptom(s) of a number of diseases (e.g. carpal tunnel syndrome) rather than being representative of a single disease. Thus, the term "disease" or "non-disease" is not appropriate for a heterogeneous syndrome (e.g. Parkinsonian). Contrary to its original promise, BMJ did not offer us a "biography of the top ten voted non-diseases". This might have been due to the fact that the voted list did not match the expectations of the BMJ editors. However, a scrutiny of the final list offers interesting reading. The top candidate,ageing, is a "non-disease" when viewed in the context of the normal life events wheras an accelerated or premature aging (e.g. Cockayne syndrome) is surely part of a disease process. Similarly, ugliness (ranked tenth) may or may not be a disease depending on how this is interpreted by the physician. Cosmetic disfigurement may be the primary reason for medical contact in Neurofibromatosis-I or Sturge-Weber syndrome (at least in my experience), and it is a sobering thought that the research in NF-I was propelled by the patients' group in the 1980s that rapidly led to the discovery of one of the key genes in human biology. Were NF-1 patients wrong in medicalising their problems? The concept of a disease goes beyond the simple social or economic issues surrounding its diagnosis. It is also not the obvious by product of medicalisation of symptoms in the 5% population at the tails of the bell-shaped curve of normal distribution. Patients wonder about a "disease" when they encounter valid experience beyond what is perceived as normal. It is usually the physician's interpretation whether these symptoms define a disease; an agreement is finally reached in the vast majority of cases. The assertion that the concept of a disease is a "slippery slope" may not necessarily be true provided the physician knows to wear the right shoes while walking the path. And where there is disagreement, the physician, like the patient, has an equal chance of being right or wrong. |
|||
|
|
|||
|
Constantinos Paschalides, Final year medical student Undergraduate Office, Manchester Royal Infirmary, M13 0FE., Christos S Zipitis, final year medical student, Manchester Royal Infirmary, M13 0FE.
Send response to journal:
|
The theme issue on “non-disease” is admittedly very interesting, and well worth the effort of BMJ's editors1. However, we cannot but wonder what would be going through a patients’ mind if they were to read their doctors' views. Their hair would stand! “Is this what my doctors are thinking of me?” That would be a real blast to the doctor-patient relationship. We could extend this a bit further, as being a doctor does not preclude you from being a patient, as well: “Is that what my colleagues think about me when I entrust them with my problem?” We would also like to argue that to some extent being an “unhappy doctor2” could have its roots in the patients’ realisation of how empathic their doctor is towards them. So a tip for doctors: hide this BMJ issue from the waiting room, and leave your prejudices at home! References: 1. Smith R. In search of "non-disease". BMJ 2002;324:883-885. 2. Edwards N, Kornacki MJ, Silversin J. Unhappy doctors: what are the causes and what can be done? BMJ 2002;324:835-838. Constantinos Paschalides, Christos S. Zipitis
Competing interests: None. |
|||
|
|
|||
|
Bernard H Fookes, Retired B74 2RG
Send response to journal:
|
(My computer would not cut & paste my full response, but my last sentence summarizes my point) Perhaps if people died of bags under the eyes we should by now understand the histo-pathology |
|||
|
|
|||
|
Robert E Kendell, Retired psychiatrist Edinburgh EH10 5AT
Send response to journal:
|
Disease is indeed a "slippery" concept which has never been adequately defined, despite being medicine's most fundamental term. What is more, doctors are generally unwilling to think seriously what they mean by disease, either because they are convinced its meaning is self- evident, or because they want to be free to be inconsistent. For this reason it may be more profitable to examine the circumstances in which attributions of disease status are bestowed (eg hypertension and alcoholism in the 1950s; attention deficit hyperactivity disorder in the 1980s), or occasionally withdrawn (homosexuality in the 1970s), rather than searching fruitlessly for an agreed formal definition. This approach has convinced me that what our profession, and the general public, really means when it accepts a condition as a disease is a) that it is an undesirable state of affairs, and that attempts should therefore be made to prevent it developing or ameliorate its consequences; and b) that the medical profession and its technologies seem more likely to achieve these desirable goals than other available professions and institutions - such as the criminal justice system (treating the condition as crime), the Church (treating it as sin), social work (treating it as a social problem) or beauticians (treating it as an aesthetic blemish). This implies that the availability of an apparently effective treatment often precedes, and is more fundamental than, the detection of pathology. And it explains why we have acquired so many new diseases in the last 20 years - because of the great expansion in the scope of medical technologies, particularly a much wider range of potent drugs. It also leads to the prediction that, as effective pharmacological treatments become available over the next decade, obesity will, like hypertension before it, come to be generally accepted as a disease in its own right rather than simply as a human waakness that predisposes to other diseases. [I have no competing interests to declare.] |
|||
|
|
|||
|
Iain Morland, Associate Lecturer in Culture, Literature and Media Cardiff University CF10 3XB
Send response to journal:
|
Editor—So, patient anxiety about penis size is not, in fact, a disease.[1] What about medical anxiety? For the last fifty years, the size of a child’s phallus has been the principal decision-making criteria for physicians responsible for intersexed infants.[2] Harvard Professor of Surgery Patricia Donahoe’s 1991 guidelines for the management of intersex explained that, “The decision to raise the child […] [with XY karyotype and testes] as a male or a female is dictated entirely by the size of the phallus.” [3] In the same year, the authors of another set of guidelines for intersex surgery stressed the “inadequacy” of male infants whose genitalia are smaller than most no less than six times in a nine-page article.[4] If anxiety about penis size is not a disease, but nevertheless has been a critical factor in intersex management, what exactly is the nature of this anxiety? John Money, the leading advocate of early surgery on intersexual babies, has written that, “The primary deficit [of a small penis]—and destroyer of morale—lies in being unable to satisfy the partner.”[5] This may be true. But as the tacit grounds for assigning a child’s sex, it is inappropriate. Any treatment which draws on this assumption presumes an indexical relation between a penis’s size, its ability to pleasure a partner, and the gender identity of its owner. The relation between these elements then informs the assignment of sex. This reasoning is paradoxical because rather than taking sex as a starting point, it deduces sex on the basis of gender identity, which is in turn inferred through genital heterosexuality. The child is sexed retrospectively on the basis of their presumed future heterosexual relationships—relationships which are in turn considered to be organised around and authenticated by penis-vagina penetration. That this is not always the case—not only may people be homosexual, but they may also be heterosexual and nonchalant towards penis -vagina penetration—means that to justify the surgical modification of atypical genitalia in these terms is profoundly unempirical. Anxiety over genital dimensions is not a proper disease, so genital modification is not a proper treatment. The ethical challenge which paediatric medicine now faces is not simply that of managing intersex newborns differently; it is that of accounting for past treatment which is wrong not because it was malicious, but because it cannot be undone. 1. Smith R. In search of “non-disease”. BMJ 2002;324:883-5 (13 April). 2. Kessler SJ. Lessons from the intersexed. New Brunswick and London: Rutgers University Press, 1998. 3. Donahoe PK. Clinical management of intersex abnormalities. Current Problems in Surgery 1991;28:519-79. 4. Coran AG, Polley TZ. Surgical management of ambiguous genitalia in the infant and child. Journal of Pediatric Surgery 1991;26:812-20. 5. Money J. Psychologic consideration of sex assignment in intersexuality. Clinics in Plastic Surgery 1974;1:215-22. |
|||
|
|
|||
|
manuel varela novo, neuropsychiatrist, private consultant c.c. Bárcena 2-2 .Vigo 36204 .Spain
Send response to journal:
|
Absolutely of course. My warmest congratulations. 1-We speak of sanitary terrorism.
All it has disturbed is the ill medical relation, as denounced in the chapter of two editions of the text " Riesgos del personal sanitario" and in the third edition to be published by McGraw. A very old practitioner. |
|||
|
|
|||
|
Annemarie Jutel, senior lecturer Otago Polytechnic, Dunedin, NZ
Send response to journal:
|
Richard Smith points out how diagnostic categories provide a framework for approaching medical and social problems, but not always to the benefit of the individual patient. Smith’s critical review of “non- disease” provides an excellent starting point for identifying a range of problems which earnest consumers of medical care, as well as physicians, may attempt to medicalise in order to achieve a normalising outcome. In so doing, he uncovers how value systems profoundly influence both medical practice and the demands consumers make upon it. Ageing, cellulite, baldness and penis envy figure on a list of “non-diseases” identified in Smith’s survey as “human process(s) or problem(s) that some have defined as a medical condition but where people may have better outcomes if the problem or process was not defined in that way” (p. 885). This is not to say that medicine is without blame in the reinforcing of social values; it is a powerful social institution. In 1972, Irving Zola argued that medicine exercises social control by medicalising much of daily living, “making medicine and the labels ‘healthy’ and ‘ill’ relevant to an ever-increasing part of human existence.” . While seeking to make the world a better place, and its occupants happier people, the medical corps reinforces the values that drive individuals to seek help for non- disease. Medical historian, Elizabeth Haiken, points out how the “inferiority complex,” formulated by Viennese psychologist Alfred Adler, was a regular catch phrase in both lay and medical circles in the middle part of the last century. This “disease” provided a justification for cosmetic surgery: “patients who developed inferiority complexes because of physical defects would find their economic status adversely affected, because those suffering from such complexes were unable to present themselves with the confidence necessary to ensure success in a competitive world.” Linking physical abnormality to psychological problems became the rationale for a range of surgical practices, including the normalisation through the removal of “ethnic stigmata” including operating to avoid having a “Jewish nose.” However, drawing the line between what constitutes a legitimate medical concern, and what reflects social anxiety about deviation from an enunciated norm is often a difficult task. This is compounded by the fact that physicians and medical researchers are not themselves immune to, or unaffected by, the social values which compel their clients to consult in the first place, and nowhere is this more apparent than in the new clinical entity of “overweight.” While excess body fatness has been a concern in both medical and lay circles for centuries, with Hippocrates noting that fat people were much more likely to die suddenly than thin people, overweight is a new concept. Nineteenth century physicians viewed obesity in terms which emphasized visual and functional assessment, rather than measured weight. Although Adolphe Quetelet (for whom the Quetelet index, or BMI, is named) may have been involved in measuring bodies as early as the 1850s, his work was religiously and not clinically motivated, geared towards discovering evidence of God’s rules on earth . Obesity though was assessed qualitatively. Herrick referred to “increased bulk of the body, beyond what is sightly and healthy,” and Thomas spoke of an “excessive development of the adipose tissue.” Both the semantic and diagnostic differences between “overweight” and “obesity” have important consequences for medical practice and for social attitudes towards the body. While “fatness,” and “obesity” suggest largeness, high adiposity, and indeed, usually heaviness, “overweight” implies a notion of measurable excess and statistical deviance. With today’s focus on overweight, scales are accorded excessive importance in health monitoring. Few women are willing to put away their scales, and few doctors would place more value on a patient’s report of physical activity and diet than on the digital display of their body weight. Research shows that doctors are less likely to provide health advice to slender patients than to heavy ones. Dieting, obsessive exercise, and cigarettes keep many women artificially slim, despite the risks to health presented by this pursuit of slenderness. Furthermore, according to Gaesser, the consequences of the usually-futile attempt to lose weight may have far more serious consequences on health than moderate overweight or obesity, and a number of studies have shown that activity levels and dietary intake are far more important predictors of morbidity and mortality than weight. And finally, what may masquerade as welcome weight loss in a normally plump individual may often be ignored as a first sign of serious systemic disease. In the meantime the disease of “overweight” provides a fertile ground for exploitation. A media-focus on the risk of overweight underpins a multi-billion dollar diet, gym and pharmaceutical approach to weight maintenance, pandering to both medical and social beliefs about the perfect body. Overweight victims of this “disease mongering” become perpetrators, as much as those who take advantage of them, by fully internalizing the oppressive beliefs about how the healthy body should look and how much it should weigh. Enough already! Overweight is not a disease any more than slenderness is an indication of health. Like cellulite, or baldness, it is simply the way some people are. Rather than focussing on weight, we would do well to focus on helping our patients attain real lifestyle changes, including dietary modification and exercise compliance. Scales won’t help us to achieve this any more than they will inform us about health and well-being of the person they are measuring. Smith, R. In search of non-disease. BMJ 2002; 324:883-5 Zola, ID. Medicine as an institution of social control. Sociological Review 1972, 487-504. Haiken, E. Venus envy: a history of cosmetic surgery. Baltimore: Johns Hopkins Press, 1997. Quetelet, A. Anthropométrie ou mesure des différentes facultés de l’homme. Brussels: C. Muquardt, 1871. Herrick, SS. Obesity. In: A reference handbook of the medical sciences. Edinburgh: Pentland, 1889. Thomas, J. A complete pronouncing medical dictionary. London: Deacon, 1891. Kreuter, MW, Schaff, DB, Brennan, LK, Lukwago, SN. Physician recommendations for diet and physical activity: which patients get advised to change? Prev. Med. 1999, 26:825-33. Gaesser, G. Thinness and weight loss: beneficial or detrimental to longevity? Med. Sci. Sports Exerc.1999, 31:1118-28. See for example: Lee, DC, Blair, SN, Jackson AS. Cardiorespiratory fitness, body composition, and all-cause end cardiovascular disease mortality in men. Am. J. Clin. Nutr. 1999, 69:373-80., and Larsson, B, Björntorp, Tibblin, G. The health consequences of moderate obesity. Int. J. Obes. 1999, 5:97-116. Moynihan, R., Health, I., Henry, D. Selling Sickness: the pharmaceutical industry and disease mongering. BMJ 2002; 324:886-891. |
|||
|
|
|||
|
Simon R. Wilkinson, consultant child and adolescent psychiatrist Sogn Centre for Child and Adolescent Psychiatry, 0319 Oslo, Norway
Send response to journal:
|
Patients suffer, that is their defining condition. The etymology is from the latin for 'I suffer'. Patients need to know that they do not necessarily have a disease - and not everyone who has a disease is a patient. The central quality is the suffering. Patients are 'ill'. By defining people as 'sick' we need to distinguish between those having a disease, those who are ill and those who are in a predicament. Eventual failure to fulfill their social role determines their 'sickness' - and again this does not imply that they necessarily are 'patients'. But although I never expect to meet a patient who has understood these nuances, I will impress on them that patients do not necessarily have diseases. Competing interests: None declared |
|||
|
|
|||
|
Nathan T. Vertuca, Student Unemployed Currently
Send response to journal:
|
I can't take any medical journal seriously when it lists things such as Osteoporosis and Diabetes as "non-diseases." I'd be shocked if I went to a doctor who said, "Diabetes? PLEASE, get a real disease, THEN we'll talk." In some cases Diabetes may be preventable, but not in mine as I have type 1 Diabetes. It's demeaning to suggest that it's not a "real" disease. Competing interests: Diabetic |
|||