I’ve started reading Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer by Barbara Ehrenreich. She’s an interesting writer. Years ago she pointed out that Playboy magazine was promoting what was at the time an essentially gay lifestyle: life in the city, avoid marriage, swap out sex partners on a regular basis, be able to spend one’s entire income, appreciate art, food, wine, etc. Therefore they needed to have pictures of naked women to remind readers that this wasn’t a lifestyle reserved for homosexual men.
Her latest book is timely for those of us who are closing on Medicare eligibility and/or who have aging parents. She’s unimpressed with the bargain that Americans have struck with the health care industry, i.e., hand over 18 percent of earnings for a marginal net improvement in health over the most basic system and for, arguably, worse health than what is achieved in countries such as Singapore (4.5 percent of GDP devoted to health). [See my health care reform article from 2009, in which I ask “Who Voted to Spend All of Our Money on Health Care?” and point out that we could have a mostly paid-for life if we didn’t shovel most of our cash to the medical industry.]
From the author’s intro:
Most of my educated, middle-class friends had begun to double down on their health-related efforts at the onset of middle age, if not earlier. They undertook exercise or yoga regimens; they filled their calendars with upcoming medical tests and exams; they boasted about their “good” and “bad” cholesterol counts, their heart rates and blood pressure. Mostly they understood the task of aging to be self-denial, especially in the realm of diet, where one medical fad, one study or another, condemned fat and meat, carbs, gluten, dairy, or all animal-derived products. In the health-conscious mind-set that has prevailed among the world’s affluent people for about four decades now, health is indistinguishable from virtue,
I had a different reaction to aging: I gradually came to realize that I was old enough to die, … If we go by newspaper obituaries, however, we notice that there is an age at which death no longer requires much explanation.
Once I realized I was old enough to die, I decided that I was also old enough not to incur any more suffering, annoyance, or boredom in the pursuit of a longer life. I eat well, meaning I choose foods that taste good and that will stave off hunger for as long as possible, like protein, fiber, and fats. I exercise— not because it will make me live longer but because it feels good when I do. As for medical care: I will seek help for an urgent problem, but I am no longer interested in looking for problems that remain undetectable to me.
As it is now, preventive medicine often extends to the end of life: Seventy-five-year-olds are encouraged to undergo mammography; people already in the grip of one terminal disease may be subjected to screenings for others. 4 At a medical meeting, someone reported that a hundred-year-old woman had just had her first mammogram, causing the audience to break into a “loud cheer.” One reason for the compulsive urge to test and screen and monitor is profit, and this is especially true in the United States, with its heavily private and often for-profit health system. How is a doctor— or hospital or drug company— to make money from essentially healthy patients? By subjecting them to tests and examinations that, in sufficient quantity, are bound to detect something wrong or at least worthy of follow-up.
There are even sizable constituencies for discredited tests. When the U.S. Preventive Services Task Force decided to withdraw its recommendation of routine mammograms for women under fifty, even some feminist women’s health organizations, which I had expected to be more critical of conventional medical practices, spoke out in protest. A small band of women, identifying themselves as survivors of breast cancer, demonstrated on a highway outside the task force’s office, as if demanding that their breasts be squeezed. In 2008, the same task force gave PSA testing a grade of “D,” but advocates like Giuliani, who insisted that the test had saved his life, continued to press for it, as do most physicians. Many physicians justify tests of dubious value by the “peace of mind” they supposedly confer— except of course on those who receive false positive results.
Physicians see this all the time— witty people silenced by ventilators, the fastidious rendered incontinent— and some are determined not to let the same thing happen to themselves. They may refuse care, knowing that it is more likely to lead to disability than health, like the orthopedist who upon receiving a diagnosis of pancreatic cancer immediately closed down his practice and went home to die in relative comfort and peace. 9 A few physicians are more decisively proactive, and have themselves tattooed “NO CODE” or “DNR,” meaning “do not resuscitate.” They reject the same drastic end-of-life measures that they routinely inflict on their patients.
Not only do I reject the torment of a medicalized death, but I refuse to accept a medicalized life, and my determination only deepens with age. As the time that remains to me shrinks, each month and day becomes too precious to spend in windowless waiting rooms and under the cold scrutiny of machines. Being old enough to die is an achievement, not a defeat, and the freedom it brings is worth celebrating.
Why is medicine so bad? White males are substantially to blame:
According to critical thinkers like Zola and Illich, one of the functions of medical ritual is social control. Medical encounters occur across what is often a profound gap in social status: Despite the last few decades’ surge in immigrant and female doctors, the physician is likely to be an educated and affluent white male, and the interaction requires the patient to exhibit submissive behavior— to undress, for example, and be open to penetration of his or her bodily cavities. These are the same sorts of procedures that are normally undertaken by the criminal justice system, with its compulsive strip searches, and they are not intended to bolster the recipient’s self-esteem. Whether consciously or not, the physician and patient are enacting a ritual of domination and submission, much like the kowtowing required in the presence of a Chinese emperor.
[Based on my conversations with friends who are non-white non-male physicians and dentists, I’m not sure that the author would be happy with these immigrants or children of immigrants from India and China. Despite their double-victim status (immigrant/person-of-color plus female gender ID), these physicians do not seem to be any more respectful of the American masses than are my white male physician friends. In fact, they often use harsher and more direct language when discussing what they perceive to be the personal failings of their welfare-dependent patients and their less-than-brilliant or less-than-rational patients.]
Ehrenreich points out that it is we who should be calling doctors deficient, not vice versa. The “science is not settled” for a lot of the stuff into which we pour huge amounts of money, time, and suffering:
As for colonoscopies, they may detect potentially cancerous polyps, but they are excessively costly in the United States— up to $ 10,000— and have been found to be no more accurate than much cheaper, noninvasive tests such as examination of the feces for traces of blood.
There is an inherent problem with cancer screening: It has been based on the assumption that a tumor is like a living creature, growing from small to large and, at the same time, from innocent to malignant. Hence the emphasis on “staging” tumors, from zero to four, based on their size and whether there is evidence of any metastasis throughout the body. As it turns out, though, size is not a reliable indicator of the threat level. A small tumor may be highly aggressive, just as a large one may be “indolent,” meaning that a lot of people are being treated for tumors that will likely never pose any problem. One recent study found that almost half the men over sixty-six being treated for prostate cancer are unlikely to live long enough to die from the disease anyway. They will, however, live long enough to suffer from the adverse consequences of their treatment.
In 2014, the American College of Physicians announced that standard gyn exams were of no value for asymptomatic adult women and were certainly not worth the “discomfort, anxiety, pain and additional medical costs” they entailed. 16 As for the annual physical exams offered to both sexes, their evidentiary foundations had begun to crumble over forty years ago, to the point where a physician in 2015 could write that they were “basically worthless.” Both types of exams can lead to false positives, followed by unnecessary tests and even surgery, or to a false sense of reassurance, since a condition that was undetectable at the time of the exam could blossom into a potentially fatal cancer within a few months.
As in her previous works, Ehrenreich is good at finding big trends:
It was the existence of widespread health insurance that turned fitness into a moral imperative. Insurance involves risk sharing, with those in need of care being indirectly subsidized by those who are healthier, so that if you are sick, or overweight, or just guilty of insufficient attention to personal wellness, you are a drag on your company, if not your nation. As the famed physician and Rockefeller Foundation president John H. Knowles put it in 1977: “The cost of sloth, gluttony, alcoholic intemperance, reckless driving, sexual frenzy, and smoking is now a national, and not an individual, responsibility.… One man’s freedom in health is another man’s shackle in taxes and insurance premiums.”
I’m hoping that some other folks here will pick up
Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer and then we can have a real discussion about it!