By Shannon Brownlee
Sunday, March 30, 2008
Felt a little short of breath the other day, walking up a hill. Uh-oh. A nugget of worry lodged for a moment in my mind. At 50-something, I'm in decent enough shape. I don't smoke. I walk several miles most days, and I can still beat my 40-something friend at tennis. Not exactly a candidate for a heart attack. But still. I've read all those stories about women like me, the ones with no risk factors for cardiac disease who were suddenly hit with an attack.
Maybe you've had the same worries -- wondered whether some sharp little twinge was heartburn or a heart attack, whether that nasty headache was caused by tension or a stroke. Almost everyone I know who has hit middle age spends a certain amount of time fretting about this or that ailment. My husband and friends and I used to talk about politics, science, religion, kids. Now no dinner party is complete without at least a few minutes' discussion of cholesterol levels, the merits of walking vs. running, or whether or not snoring is a sign of sleep apnea.
It's not as though we're actually sick. Oh sure, a couple of us have high blood pressure, and a dear friend has a serious chronic disease. We all know at least one person our age who has died of cancer or a heart attack. As a medical reporter, I've met many people who suffer terribly from life-threatening or debilitating conditions, and I know that eventually nearly all of us will be hit with a serious illness.
But most of my friends and I, like most middle-aged Americans, are a remarkably healthy lot. If I asked my friends how long they plan to live, I'd bet they'd answer like the respondents to a recent UPI poll, which found that a majority of Americans believe they'll live well into their 80s and beyond -- even though the average U.S. life expectancy is 77. It's not that we fear we're in imminent danger of death, but that we think we have to be hyper-vigilant about disease to put it off as long as possible.
That's what worries me. By constantly reminding us to be on the lookout for illness, doctors and the media have made many Americans feel more anxious. I'm not so sure their warnings have made us any healthier, but they have decidedly eroded our sense of well-being. We worry about every ache and pain; we fret that the least little sign of sadness in a teenager is a symptom of clinical depression. But in viewing so many aspects of ordinary human experience as treatable diseases, we may have granted medicine more power than it deserves -- or is good for us.
I realize that's a contrarian view of medical progress. But think about all the messages we constantly get from the medical world and the media: Watch your weight. Know your cholesterol. Learn the warning signs of stroke. Get more sleep, or you'll have car accidents. That mole on your back? Could be melanoma. Feeling constipated? Might be ovarian cancer. Take the test. Know your numbers. See your doctor.
In case you've missed the point, there are headlines like this one that appeared in Forbes magazine: "Medical Symptoms You Shouldn't Ignore." And a new book: "Body Signs: From Warning Signs to False Alarms . . . How to Be Your Own Diagnostic Detective" -- a compendium of symptoms ranging from dry skin to excessive hiccupping that could signal serious conditions. The book's mission is to "alert you, warn you, maybe even scare you into going to the doctor."
Scaring people, of course, being the operative idea here. Patient advocacy groups such as the American Cancer Society have long believed that the way to improve the nation's health is to increase "awareness" of this or that disease, and the best way to increase awareness is to frighten people into their doctors' offices. As early as 1936, the American Cancer Society was using slogans like "No one is safe from cancer" in an effort to get women to go in for a breast exam.
Today, patient-advocacy groups routinely sound the alarm about whatever condition they're trying to eradicate, either by inflating the number of people affected or by exaggerating the danger. The National Sleep Foundation, for example, a group dedicated to encouraging Americans to get more rest, recently released a poll claiming that a whopping 75 percent of us are so sleep-deprived that it's interfering with our sex lives. That's one heck of a lot of sleepy, undersexed people, and it's pretty hard to believe, given that the National Institutes of Health find that at most 21 percent of the population has recurrent insomnia. A few years back, at least one breast cancer patient advocacy group was claiming their disease as the No. 1 killer of women. In reality, far more women die of heart disease, followed by lung cancer.
Striking fear also serves pharmaceutical companies, which want you to worry about diseases, because people who worry are more likely to go to their doctors and ask for drugs than people who don't. It turns out that much of what we -- and our doctors -- think we know about many health problems has been shaped by drugmakers and their marketers. Take "condition branding," one of the most brilliant and widely used marketing techniques for selling drugs. Condition branders use "information" about medical conditions to forge links between disease and treatment in the minds of both patients and doctors. If they have a drug but no condition, they will simply invent a disease. I've been reporting this for years.
One of the best examples is "osteopenia," a diagnosis that millions of women my age are given every year. Osteopenia is supposedly the precursor to osteoporosis, the gradual loss of bone that happens to most of us as we age. Advanced osteoporosis can make women vulnerable to hip fracture, a serious event when you're old and frail because it often heralds a series of complications, such as pneumonia, that can ultimately lead to death. Millions of women are treated for osteoporosis with drugs that can slow bone loss, thus reducing the risk of hip fracture. Or so the logic goes.
The problem is, osteoporosis and osteopenia aren't really diseases. Before the 1990s, doctors decided that you had osteoporosis if you were elderly and you broke a bone. When the pharmaceutical company Merck came up with its anti-bone-loss durg Fosamax, it wanted a broader market than just elderly fracture patients. The solution? The company helped fund a panel of medical experts to create diagnostic criteria for osteoporosis so that a diagnosis could be made before the patient actually broke a bone.
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.
Shannon Brownlee is the author, most recently, of "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer."