Let's Stop Running Scared

The panel's first step was to define "normal" bone density as that of the average 30-year-old woman. Next, the experts chose as their cutoff for osteoporosis a statistical point that was slightly below the bone density of their normal 30-year-old -- a definition they admitted was "somewhat arbitrary." Finally, they came up with a completely new disease -- osteopenia -- for bone density that fell somewhere between that normal 30-year-old and their arbitrary definition of osteoporosis.

Voila -- 30 percent of post-menopausal women suddenly had a disease that needed to be treated early in order to prevent a problem -- hip fracture -- that wouldn't occur for many years, if ever. According to the new guidelines, millions more women now had osteopenia, which their doctors needed to watch like hawks so that their patients could be treated once they progressed to osteoporosis. Merck then took the added step of helping doctors buy DEXA scanners, X-ray machines needed to scan your bones to get that all-important diagnosis.

Along with osteoporosis and osteopenia, we now have a whole raft of pre-diseases that doctors want to screen us for -- and that drug companies are only too happy to remedy. There's pre-high blood pressure and pre-diabetes, which your doctor can supposedly diagnose even when your blood sugar is perfectly normal. If you've been to the dermatologist lately, maybe you had some "pre-cancerous" spots removed. These may well have been actinic keratoses, which, despite the scary name, almost never develop into an aggressive form of skin cancer. Get them removed if they're unsightly, but there's no cause for alarm if you don't. Then there's the mother of all pre-diseases, high cholesterol -- which is a risk factor, for heaven's sake, not a death sentence. Yet one creepy Pfizer ad for the anti-cholesterol drug Lipitor that appeared a few years ago used a female corpse to exhort women in their 50s to get their cholesterol checked. Know your numbers. Ask your doctor. Be afraid -- be very afraid.

What's lost in all of this is the belief that we can cope with life, or really, that we can live in the face of its abiding uncertainties.

In the 1983 movie "The Year of Living Dangerously," a character named Billy Kwan explains the significance of the Indonesian sacred-shadow puppet plays. Called the wayang, the plays are set on a screen that represents heaven. The puppets' shadows are their souls. "The unseen is all around us," says Kwan, "the right in constant struggle with the left, the forces of light and darkness in endless balance. . . . In the West, we want answers for everything, but in the wayang, no such final conclusions exist."

In our desperate desire for protection against the ambiguous and unseen nature of disease, we have allowed our physicians and the drug industry to medicalize everything from heartburn to heartache. We want answers, even when there are none. We look to medicine to bring relief from the terrible unknowns of aging and its inevitable losses, even when the answers have been manufactured to sell a drug. And we are now so thoroughly convinced of medicine's power that anyone who doubts the wisdom of medicalization risks being labeled a "therapeutic nihilist," one who rejects medicine in its entirety. But you can't spend most of your career reporting on medicine, as I have, and fail to marvel at its many wonders -- or to feel compassion for those who are truly ill.

At the same time, I can't escape the sense that we are paying a heavy price when we broaden the definition of disease to encompass so much of life. For one thing, there's no such thing as a free lunch when it comes to medical treatment. Every drug you can name, from aspirin to Zocor, has side effects -- some potentially more serious than the diseases they are supposed to prevent. Fosamax, for instance, can cause necrosis (death) of the jawbone. What's more, there aren't any valid scientific studies to show that treating osteoporosis early will prevent fractures down the road. The drug can also trigger serious heartburn, for which you can take an antacid such as Nexium, but that makes you more susceptible to pneumonia.

The other price we pay, of course, is that medicalization has created its own side effect -- anxiety. (There's a drug for that, too.)

Thanks anyway, but I think I'd rather not spend the rest of my life obsessing over what might kill me. When I fall ill, I'll seek treatment. I will get my blood pressure checked, because there is clear evidence that keeping it under control will reduce my chances of a stroke or heart attack (though even that is no guarantee). I'll probably get the occasional mammogram, although their value has been much overstated.

I have no plans to monitor my cholesterol, undoubtedly to my doctor's consternation. Why bother? I'm already watching my weight, exercising regularly and eating a healthful diet, and I don't want to take medications that offer little if any protection against heart attacks for people whose only risk factor is elevated cholesterol. If I fail to get eight hours of shut-eye, oh well. There's always tonight to catch up. My bones will just have to crumble quietly on their own, because I have no intention of taking a drug whose benefits are uncertain and whose risks are all too real.

As for anxiety? I think I'll take care of that by tuning out the medical scare talk.

brownlee@newamerica.net

Shannon Brownlee is the author, most recently, of "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer."