This book is written as a direct response to the questions my patients ask:
`Why is a good diet not enough?'
`Why are so many diseases - cancer, allergies, depression - on the rise?'
`Why do I need medication to stay healthy?'
`Why are there so many new diseases like autism, SARS and AIDS?'
My patients want to know the science that underpins a medical model based on health. Naturopaths, dieticians, herbalists seem to have a good grasp of what it is to be healthy - does this natural medicine have scientific merit?
If you arrive at the doctor's surgery saying `I feel great and I'd like a few tips on how to stay that way,' you will probably be met with bemusement. Your doctor would be likely to have a better idea what to do with you if you turn up with a disease. Doctors find it challenging to cure disease, but they tend to forget about health. The simple restoration of health may require only that we give the `good guys' - vitamins, minerals, essential fatty acids and others - a chance to do their health-giving work.
As a general practitioner I was often torn between received wisdom and a biochemical approach to my patients' problems. I sought professional training in `alternative' fields, although it grates that the scientific basis of nutritional biochemistry is labelled `alternative'. In grappling with my patients' questions, I had to challenge many of the things that I had been taught. As mainstream medicine becomes ever more dogmatic, its self-belief strengthened by the doctrine of evidence-based medicine, the voices of my patients begin to sound like the chorus in a Greek drama, sowing seeds of challenge and discontent.
Western nations are worrying about the problems of an ageing population. But current longevity predictions are based on a population born between World War I and World War II, for whom sugar, fat and motor vehicles were luxuries. By the time junk food came into being, their eating habits were well established. Pesticides did not permeate the food chain, and good husbandry prevailed in farming and horticulture. If we take into account the health trends in younger generations - the rising incidence of asthma, depression, obesity, and younger diagnoses of many cancers - we arrive at a frightening prediction: for the first time in human history, we have produced a generation which is not expected to outlive its parents.
Doctors throughout the developed world are beginning to question a health industry based on a model of `curing disease'. The role of the pharmaceutical companies in this `health' industry causes increased disquiet. This book is dedicated to my patients, to the doctors whom I have the privilege to teach, and other patients and doctors like them.
The doctors of today prescribe medicines of which they know little, to cure disease of which they know less, in human beings of whom they know almost nothing. - Voltaire
Progress is all very well, but it has gone on long enough. - Ogden Nash
THE WAITING ROOM
It is Monday morning in the waiting room of an imaginary general practice on the outskirts of the inner city. The patients include students from the nearby university, factory workers, shift workers, business people. Many ethnic groups are represented. Let us suppose that I work in this busy practice with four or five other doctors. We all get on well together and often discuss difficult cases with each other. All of us have areas of special interest in medicine, and we have a wide range of outside interests. Mine is a hobby farm in a bushland environment a few hours out of the city. These various interests form the subject matter of many of our lunchtime conversations.
In the waiting room on this busy morning are a group of typical patients who could be in any city, any suburb. Some have cuts or sprains from weekend sporting activities or need a routine check, but most have chronic health issues such as high blood pressure, depression, menstrual disorders, headaches.
My colleagues and I have recently been to courses on nutritional and `alternative' medicine. We felt that it was time we learnt about the safety of the things our patients are taking. Lately they have been asking us about treatments such as St John's wort and glucosamine. One of us has a pregnant wife who is taking vitamin supplements. Does my colleague know that this is safe? She eats well, why would she need them? Is there any scientific evidence?
My first patient of the day is Mary, 28 years old. She has come to see me because of chronic low-grade depression and a feeling of `just not being well'. She has a job which she enjoys and good friends. A two-year relationship ended amicably a few months ago, and she currently does not have partner. She says she wants her own space for a while. She eats reasonably well, although she admits to a sweet tooth and perhaps more coffee than she ought. She drinks a fair bit of tap water because she has heard that this will help to keep her bowels regular. She drinks alcohol within a safe range and is a non-smoker. She gets some exercise, although admits she hasn't had a lot of energy lately.
Her medical history includes mild asthma with seasonal exacerbations, for which she has a range of puffers. She uses at least one of these most days, but regards her asthma as fairly easy to control. Her bowels are usually okay, but if she's not careful she can become constipated. She is on the oral contraceptive pill although she has no current need for contraception. She has been on the pill on and off since she was 16 and says she is scared to come off it because she will have heavy cramping periods and her skin will break out. When she first went on the pill she was still at school and did not need contraception. The doctor she was seeing at the time said it would be the best thing for the cramps that were keeping her away from school one or two days a month, and it would also help her troublesome acne. At the time of commencement she had never had a migraine. She has had three or four migraines since, but the doctor thought that it was okay for her to take the low-dose pill.
Her blood pressure went up a bit on the pill, but as it is in the normal range she and I have agreed just to keep an eye on it. We plan to do this regularly, because I am also treating her mother for mild hypertension. Mostly the pill controls Mary's painful periods but sometimes she has to take an anti-inflammatory. She is totally dependent on these when she is giving the pill a `rest'. At those times, she often has to take antibiotics for her skin as well. She gets mood swings around the time of her period, and thinks these are a bit better on the pill, although she suspects that her overall well-being is reduced. She has discussed with me her lack of interest in the things which used to give her pleasure. We have talked about an anti-depressant, but she is not keen to take that path yet.
There is probably a Mary in every doctor's waiting room every morning of the week, and few doctors would argue with the treatments she is on. After all, one in four Australians now has a lifetime expectancy of asthma, and although this is one of the highest rates in the world, other developed nations are not far behind. And it's known that certain illnesses such as asthma, migraine, depression, dysmenorrhoea and irritable bowel cluster together - in individuals, in families and in cultural groups.
So it's common for these conditions to occur together, and we've also come to accept it as normal. But have we accepted Mary's symptoms too readily? When we see whole families of asthmatics and migraineurs we think of shared genes, but how can such conditions be shared by whole cultures?
If we look at Mary, and the thousands like her, from the perspective of a hundred years ago, or of a rural dweller from the rapidly vanishing tribal peoples of the world, her diagnoses and treatments are nothing short of astonishing. Here she is, still in her 20s, a healthy individual, and yet she has been, or is, taking:
a beta adrenergic bronchodilator
oral or inhaled corticosteroids
synthetic oestrogen and progesterone
a non-steroidal anti-inflammatory pain killer
a specific anti-prostaglandins medication.
As if this is not enough, an antidepressant could soon be added if things don't look up. Most of her medications require a prescription, or at least dispensation by a trained pharmacist, in Western countries. A look at the associated list of side effects, precautions, drug interactions and warnings of use in pregnancy soon explains why. These medications are not to be taken lightly.
If we look at the various treatments Mary has had, there is no underlying pharmacological consistency. Each has targeted a specific problem. The bronchodilator she takes for her asthma is unlikely to do much for her mood swings or her tendency to constipation. If these conditions tend to cluster, it seems intuitive to expect that a treatment for one might have a favourable effect on the others - assuming that the relationship between the conditions is at least partly causal, which commonsense seems to dictate.
But Mary's medications lack logical connection with each other. Some are potentially incompatible. This incompatibility may be pharmacological - that is, the drugs themselves interact in a negative way - or it may be to do with the symptoms. The action of the steroid medication could well worsen the depression. If Mary is among the 20 per cent of asthmatics who are sensitive to aspirin, the medications she takes for her period pain may make her asthma worse. If she were a severe asthmatic this would rapidly become apparent, but as she is usually well controlled the overall deterioration over time may not be connected to her intermittent use of aspirin-like painkillers.
Even a few decades ago, patients like Mary would have had a much narrower range of medications at their disposal. There might have been something for her asthma, and some aspirin or paracetamol for her pain. Under the age of 40 or 50, only an unusually sick patient would have been taking more than a couple of prescription medications on a regular basis.
What is so bad in the human design that one in four now needs drugs in order to breathe normally? What is so maladaptive about a menstrual cycle that it regularly puts a significant number of women to bed once a month? Mary has not got asthma because she has a Ventolin deficiency, and menstrual cramps are not caused by Ponstan deficiency. Why does she - like thousands of others - have such a constellation of medical problems, and such a galaxy of pharmaceutical solutions to them?
These are the questions that we are beginning to debate in our lunchroom at work. To begin to answer them, we have to start a long way back, at the moment when some humans decided that hunting and gathering was too hard.
CHAPTER ONE: Medicine and Progress (extract 2)
WHAT CAN DOCTORS LEARN FROM VETS?
When I was in medical school, it was a standing joke that veterinary science was much easier than medicine because you could shoot your mistakes. Later, when farming brought me into contact with some rural vets, I wondered what it would be like to deal with owners whose livelihood depended on the health of their animals. Animals have kidneys, livers, hearts, like humans. What would you do if half of your cows needed blood pressure tablets and cholesterol-lowering agents? Would you mix them in the feed or put them in the drinking water?
It is not usually apparent that the health of the soil has a direct impact on the health of the humans and pets that are sustained by plants grown in it. On the farm this relationship is inescapable.
The importance of diet
Doctors who sit in with vets will notice one big difference between human medicine and veterinary medicine. Whether it is a sick household pet or an ailing stud bull, one of the first questions is always `What are you feeding this animal?' Although a `good diet' was discussed in medical school, we were never taught that this line of enquiry might help us when a child came in with his fourth middle-ear infection for the winter, or recurrent abdominal pain, or chronic constipation.
Would we confess to the vet that Rover had had Coco Pops for breakfast or routinely finished lunch with an iced donut? Zoos are bedecked with signs saying: `Do not feed the animals'. The zoo vet fears that we will give the animals the same junk food that our kids are eating on their day out.
CHAPTER TWO: The Politics of Health (extract 1)
It is almost 30 years since President Nixon famously declared war on cancer. Since then, billions of dollars, much of it wasted, have been spent around the world in almost every arena of the cancer drama. `Research', `screening' and `treatment' all receive funding and media attention. The exception is `prevention', the one area most likely to make a difference. Blame for the rising incidence of many cancers can be sheeted home to environmental and lifestyle factors. Few politicians are prepared to confront such influential forces.
War bulletins or propaganda?
It is hard to tell whether the cancer war is being won or lost. British epidemiologist Sir Richard Doll represents the optimists, claiming that cancer rates are steady and will fall as lifestyles become healthier. By contrast, the American epidemiologist Samuel Epstein claims that the cancer rate has escalated in recent decades to the extent that Americans now face close to a 50 per cent lifetime risk of developing cancer.
There are several reasons for such disparate views. One is the long delay between the events that initiate a cancer, and the cancer developing to a diagnosable stage. Any prediction made on previous trends by definition fails to take into account new factors. Also the parameters by which victory is judged vary. They can include:
reduction in the diagnosed rate of a common cancer
rise or fall in the rate of a previously uncommon cancer
an increase in the survival rate of people diagnosed with any given cancer.
When the war is going badly, should we add a positive spin to maintain morale? Or should we tell it like it is, and run the risk of losing public confidence?
Here are some of the factors shaping cancer bulletins:
An increase in the survival rate is often presented as a win, but it may just reflect earlier diagnosis.
Cure rates may rise, but if the rate of that particular cancer is also rising that `win' is a dubious advance. Cures for lymphomas and childhood leukaemias have improved spectacularly in recent decades, but the rates of these cancers are also increasing.
Causes may be found, such as cigarettes and lung cancer. However, city living is now regarded as the equivalent to smoking 10 cigarettes a day. It is hard to see such findings as a win.
Terms such as `five-year survival' are often regarded as indicating a cure, but they may only signify a delay in time of death. If much of the extra time has been spent sick and debilitated from the treatment, the value of such a `win' is questionable.
By using the tactics discussed in the section on clinical trials, real increases in survivor time are often represented by the more favourable relative values. The media too, prefers relative values. Everyone gets the cosy feeling that a cure is just around the corner.
CHAPTER TWO: The Politics of Health (extract 2)
Problems in Hormone Heaven
Then other evidence began to appear. Environmental scientists noted that in sites contaminated with the degradation products of plastics and pesticides, male animals were turning into females or having difficulty reproducing due to underdeveloped genitalia. The epidemiologists realised that in populations in which breast cancer was uncommon, women did not experience menopausal symptoms when their periods stopped. The Japanese famously did not have a term for the event. Soy products suddenly became popular in the West.
Early research had indicated that HRT was protective against heart disease, but now it looked as though HRT might be useful for people who already had heart disease but might increase the risk of those who did not. Further studies seemed to indicate that actually nobody benefited.
And then in July 2002 came the headlines about a halt in a major US study of HRT, because it appeared to cause a significant increase in the risk of breast cancer, stroke and heart disease.
The trial, involving 16,608 women aged between 50 and 79, was described as one of the biggest and best yet conducted. Interestingly, it was carried out not by a drug company but by a group called the Women's Health Initiative. The trial showed that for every 10,000 women taking HRT, eight more would develop invasive breast cancer, seven more would have a heart attack, eight more would have a stroke and 18 more would suffer from blood clots, than the women not receiving such treatment. This represented a figure of one woman in 250 having a life-threatening event in a five-year period as a result of treatment. These were ailments that HRT was supposed to be benefiting.
The trial was halted as soon as the risk for breast cancer was established. In fairness to HRT, it should be noted that there was a reduction in the number of cases of osteoporotic fractures and bowel cancer in the treatment group. The latter may be due to the mildly laxative effect of high levels of the hormone, as constipation is often linked with bowel cancer.
The advocates swung into damage control and reassurances came thick and fast. Ageing celebrities were dragged from their Botox appointments to endorse HRT. But the news was not good. With one-third of all of the women on HRT in Britain taking this particular Preparation, 1200 deaths or life-threatening events were assumed already to have occurred as a result of this `safe' elixir of youth.
CHAPTER SIX: A Systematic Approach to Disease (extract )
Our only health is the Disease,
If we obey the dying nurse
Whose constant care is not to please,
But to remind of our and Adam's Curse
And that to be restored, our sickness must grow worse.
T. S. ELIOT, Four Quartets
Sir Dennis Burkitt, who gave his name to the disease Burkitt's lymphoma, once famously declared that doctors were involved in a disease profession, not a health profession. He referred to hospitals as `disease palaces' and claimed that the size of the British medical budget could be halved by doubling the size of the British stool.
Perhaps Burkitt was oversimplifying, but we could argue that it was not by much. We can approach disease by looking either at the end result, or at the multiple processes that may have contributed to the end result - either symptoms or systems. By drawing attention to something that most people would prefer not to think about, Burkitt was dramatically highlighting the contribution of dietary choice to the national disease burden.
In this chapter I discuss the benefits of a systematic approach to disease. Later chapters examine various `end-point' or `fixed-name' diseases, demonstrating the benefits of the systematic approach. By looking for system designs, `alternative' medicine challenges evidence-based medicine. Many of us remember sitting in school trying to disprove the obvious - drawing diagrams to show that Pythagoras was wrong or that the shortest distance between two points was not a straight line. When we got it right, it was because we had discerned the natural order, the natural `laws'.
KISS: Keep it simple, stupid
Sometimes the simple is as far as we need to go. A solution is not better just because it is ingenious. The absurdity of ingenuity is represented by these examples:.
The rise in conditions such as asthma and peanut allergy is thought to be a result of lack of germ exposure in infancy. We have already discussed the idea that that when the immune system is unable to hone its skills on everyday germs, it develops those skills by reacting to pollens, animal hair or food (Chapter 3). One solution is to pass Junior around a bit more, allow him to be coughed on by siblings, worry less about Mogsy's furtive visits to his cot. But it has been seriously proposed that a vaccine could be developed to do the same job.
Scientists have discovered the mechanism by which `bad' cholesterol is converted into `good' during exercise. With a link established, you would think that people would be told to hop on their bikes and leave the car at home. But no - the good men and women of science `are working on a drug that could perform the same function'.
In 2003 the introduction of a `polypill' was proposed. This drug would break new ground in that it would be prescribed for healthy people. It would combine a number of prescription medications in a single pill intended to prevent diseases largely caused by poor diet and lack of exercise. As one cardiologist remarked: `When I first heard about it, I thought it was a joke!'
CHAPTER SEVEN: Some Fixed-Name Diseases (extract )
When we identify a disease by a name such as `asthma' or `hypertension', we risk the problem of semantic determinism. That is to say, the naming process itself presumes a cause. If we doctors were to apply the Burkitt approach instead, and tell patients to increase their stool size, what would happen? The addition of fibre, fruit and vegetables to the diet is the only effective way to increase stool size, and many diseases respond to such an intervention.
Once a fixed name has been given to a disease we tend to feel the name somehow explains the condition. Even today, there is no satisfactory explanation for the phenomenon of gravity, yet most of us are happy to accept that it is the reason we don't float off into space. The name is enough.
Most illnesses were named before we had any true understanding of causality. That the illness was a separate entity became embedded into the consciousness of lay people and doctors alike. Each disease was assumed to have a distinct cause, and consequently a specific treatment. Overlap between illnesses was a matter of curiosity. If such conditions co-existed frequently, then they became a `syndrome'.
`Syndrome X' is a good example of this. This term is shorthand for saying `junk food makes us sick all over'. Instead of this, we have a new disease. And to go with it, a whole new class of drugs.
For instance, I might send my patient Mary (Chapters 1, 4) to a psychiatrist for her depression, an asthma specialist for her asthma, and a gynaecologist for her heavy, painful periods. But what if these specialties no longer existed? If we were to reshuffle the pack of cards which constitutes the various medical disciplines, would we in the 21st century come up with the same nomenclature? Maybe we would have an essential-fatty-acid specialist who had been trained in the psychiatric, asthma and gynaecology wards to look at the manifestations of EFA deficiency. But this specialist would also need to know about magnesium, selenium and a whole host of other operatives, because all of these might be contributing to Mary's medical problems. Somehow the various disciplines would have to be approached as if in a grid. A deficiency in EFAs may contribute to each of 10 or 15 medical problems, but it will not be the sole cause of any of them.
Mary's treatment remains compartmentalised. As we tack through the illnesses which follow, let us observe how many different specialists Mary and her family might end up visiting just for the lack of a systematic approach.
CHAPTER NINE: Mental Health and Neurological Disorders (extract )
If the doctors of today do not become the nutritionists of tomorrow, then the nutritionists of today will become the doctors of tomorrow. - Anon.
As mental illness asserts itself as one of the main concerns of Western medicine, it takes on the problems of the fixed-name approach to disease. The international standard text, The Diagnostic and Statistical Manual of Mental Disorders, is now in its fourth edition, known as DSM IV. Over time, DSM has certainly has served a purpose, but its approach highlights the pitfalls of semantic determinism.
For example, if `depression' appears to respond to an anti-depressant, and that anti-depressant happens to raise levels of serotonin, then depression becomes a serotonin-deficiency disorder. Doctors note the effects of Prozac and other SSRI medications but this reductionist approach bypasses the complex workings of the brain. The following trenchant commentary by Californian philosopher Dominic Murphy applies to physical medicine as much as to psychiatric medicine:
The DSM is designed to be atheoretical. It doesn't talk about causal theories of particular disorders. It doesn't say that there isn't a theory of what a mental disorder is, but it is designed to avoid causal theories. People sometimes use the phrase `Chinese-menu approach' to characterise the DSM: to meet a certain diagnosis, you have to have two out of four from list A, three out of six from list B plus either C or D, and so on. I think that philosophy of science suggests that you really can't have a satisfactory classification without it being based on some causal understanding of what you're classifying ...These false distinctions result from the divorce between psychiatry and neuroscience [my italics].
CHAPTER TEN: Some Conclusions (extract 1)
I am a little world made cunningly
Of elements, and an angelic sprite.
- John Donne
How wisely Nature did decree,
With the same Eyes to weep and see,
That, having view'd the object vain,
They might be ready to complain.
- Andrew Marvell
The metaphysical poets of the late 16th century, of whom Andrew Marvell and John Donne are representative, had an intensely spiritual view of the natural world. Of particular interest was the way in which Nature mirrored itself at every level. Indeed, the image of the mirror was central to their poetry. So too was the idea of the universe as an infinity which could be contained (mirrored) within a drop of dew or a teardrop.
It is unlikely then that these metaphysicists would have had difficulty with the concept of themselves as a coral reef (Chapter 6: The Gut). In fact, this is an intensely metaphysical concept. Startling though the image may be, it is a way of saying that we provide a habitat for the many micro-organisms which live on and within us, and in turn we depend on them for health. Just as we see ourselves as a species within a larger ecosystem, so another species may live within us, our bodies constituting their habitat. Infinity expands inwards as well as outwards.
Even more confronting than sharing our bodies with gut and other bacteria is the fact that the very cells of our body, our DNA, host the remnants of the viruses that once invaded our ancestors and are now part of our own genetic makeup. Infinity stretches outwards and inwards in space, forwards and backwards in time.
This is both metaphor and reality, whether metaphysics or particle physics. We do not simply live in our environment, past, present and future - we are part of it, and it is part of us.
Since the term metaphysics is often used to denigrate something which is not adequately `scientific', perhaps it is an unfortunate framework for this discussion. After all, nutritional and environmental medicine is often criticised for its lack of `science'. But it is the thesis of this book that we spend a lot of time finding good `scientific' answers to the wrong questions. Perhaps there is something to be learned from these 17th-century metaphysicists who saw all life as connected, not only to other life forms, but to the soils, the oceans, the planets and even to a drop of dew. Now, through human ingenuity, even that drop of dew, a symbol of pristine purity, may have a molecule of PCB in it.
The extension of human exploration into outer space and into the deepest of ocean canyons encourages fallacious conclusions: if we can conquer these physical barriers, surely a cancer cure must be just around the corner. But to pursue a cure for cancer while we release more and more carcinogens into the environment is worse than bad science: it is no science at all.
CHAPTER TEN: Some Conclusions (extract 2)
The foods and natural medicines discussed in the last few pages strike at the core market of the pharmaceutical bestsellers. These natural medicines surround us in abundance. They are products whose evolution has taken place alongside our own: the local product is wondrously fitted to the local problems. In the Darwinian struggle, plants and animals only co-survived when there was mutual benefit.
This book argues that we have right in front of us solutions to the pressing health problems of our age - both of the affluent world and of developing countries. It is not the lack of a magic bullet which keeps us in poor health, nor the lack of scientific breakthroughs. Current scientific understanding enables us, more than any previous generation, to learn from nature. Such thinking is alive with possibility.