Open Heart (15 page)

“And the most important element in our ability to be useful,” Rich says, “and to continue to test old and new hypotheses, and so discover those things that, as with Herrick, allow us to be
increasingly
useful, remains what it has been since I began as a medical student:
listening
.

“Listening to the patient has been, is, and will continue to be, I believe, the hallmark of medical diagnosis, the most fundamental element in the practice of good medicine. Wasn't it Osler who said, ‘Listen to the patient—and the patient will give you the diagnosis'? Well, he was right. For it is the careful taking of a history—and the
active listening
and observing that accompanies this—that enables doctors such as Herrick to see what's really there and what others, alas, too often do not see.

“This,” Rich says, “is what I continue to believe is and should be at the true heart of medicine—the time-honored
art
of medicine—and, alas, it is fast disappearing.”

In the years before Rich and I were born, and before cancer and heart disease had become our major killers—in the years when infectious and respiratory diseases were still the primary causes of death, and when doctors often had few resources at their disposal other than listening and consoling—the deaths of infants and children were grimly commonplace, and rates of infant and child mortality substantially, grievously higher than they are now.

In 1900, of the fifteen leading causes of death, infectious diseases accounted for 56 percent of the total.
^*
When total mortality from
all
causes is taken into account, the three cardiovascular-renal conditions—heart disease, cerebral hemorrhage, and chronic nephritis—came to only 18.4 percent.

Between 1900 and 1904—the year my father was born—death rates per thousand for white males and females under the age of one were 154.7 and 124.8. (Comparable rates during these years for non-white Americans—mostly blacks—were more than twice as high.) The mortality rates for white males and females between the ages of one and four during these same years were 17.2 and 15.9, and for nonwhites 40.3 and 30.6.
^*
However, by 1940—two years after I was born—the infant mortality rate had fallen by nearly 75 percent, while in the one-to-four-year age group, the figures had fallen even more dramatically (to 3.1 per thousand for males and to 2.7 for females).
^*
Moreover, infectious disease had become a minor cause of mortality.
^*
Whereas mortality rates for measles, whooping cough, and scarlet fever, for example, were 13.3, 12.2, and 9.6 per hundred thousand in 1900, in 1940 they were, respectively, 0.5, 2.2, and 0.5.

During the first half of the twentieth century, average life expectancy for Americans rose nearly 50 percent, from 47.3 in 1900 to 68.2 in 1950 (comparable figures for blacks were 33.0 and 60.7). In the second half of the century, figures for average life expectancy continued to rise, and infant and child mortality rates continued to decline, but they did so to a much lesser extent. From 1950 to 1998, however, life expectancy rose by only slightly more than 10 percent—from 68.2 to 76.5 for the total population, and from 60.7 to 71.1 for blacks, while infant mortality declined from 29.2 in 1950 to 7.2 in 1998. And while, in 1900, more than 3 out of every 100 children died between their first and twentieth birthday, today fewer than 2 in 1,000 do. Moreover, the American Academy of Pediatrics reports, “nearly 85% of this decline took place before World War II, a period when few antibiotics or modern vaccines and medications were available.”
^*
(Note, though, the unexpected finding that, based on 1998 figures, the United States had the slowest rate of improvement in life expectancy of any industrialized nation.)

Just as Rich catalogues the remarkable advances he has seen in the treatment of heart disease since 1959, when he began his medical studies—the advent of monitors that can detect potentially lethal heart arrhythmias, of the cardiac care unit, of medications that break up clots and prevent atherosclerosis, of pacemakers, ventricular
assist devices, electronic defibrillators, and of various new surgical procedures (bypasses, transplants, angioplasties, stenting)—so my other friends list the new means they have at their disposal for treating disease and the symptoms of disease: drugs and regimens that control high blood pressure, effective analgesic medications for the management of rheumatic disorders, remarkable diagnostic aids such as MRIs and CAT-scans, powerful medications that can put diseases such as AIDS, depression, schizophrenia, Huntington's chorea, multiple sclerosis, and various cancers into short- and long-term remission.

Not only can we now prolong life in ways that were previously not possible, but we have, especially in the last quarter century, developed effective ways to enhance the day-to-day quality of the lives being prolonged. Twenty years ago, as Rich and Dr. Hashim acknowledge, little could have been done for me. I would most probably have died, or if not, might well have been seriously disabled for the rest of my life.

But the optimism bred a half century ago by the elimination of many childhood diseases, and by the gains we have made since then, has also, in the practice of medicine, become responsible for dangerous illusions, false hopes, and wasteful policies.

The belief, for example, that
all
conditions are amenable to “cure”—the various “wars” against diseases that attempt to persuade us that we can “battle” and “conquer” diseases the way we battle and conquer wartime enemies—by “mobilizing” resources, and “attacking” alien invaders (bacteria, viruses)—tends to distort our medical and human priorities, and to show little insight into how the biological world actually works, and how scientific advances come into being.
^*
It also elevates the seeming
science
of medicine above the
art
of medicine both by greatly exaggerating the power of technology (often mistaken for and confused with “science”) to improve and save lives, and by falsely dichotomizing the science of medicine and the art of medicine.

One effect of this is that we often begin and end by treating patients not as people—individual human beings with unique histories and identities—but as interchangeable humanoid vessels in which various diseases, along with treatments and cures for diseases,
will interact in predictable, uniform ways. Such beliefs are championed by drug companies, medical groups, and hospitals in public relations and advertising campaigns that continually deluge the public with claims made no less dubious and misleading by their familiarity and vagueness.

“Discover the
Only
Cholesterol Medicine Proven to Do All This,” states a February 12, 2001, full-page ad in the
New York Times
for Pravachol. There follows a checklist contending that Pravachol will lower “bad” cholesterol, raise “good” cholesterol, “extend life by reducing the risk of a heart attack,” and also reduce the risk of first and second heart attacks, strokes, atherosclerosis, bypass surgery, and angioplasty. At the top of the page, this suggestion: “Clip this ad and bring it to your doctor.” (The United States remains the only industrialized nation that allows prescription drugs to be advertised directly to the public.)
^*

In widely dispersed print and television ads for Zocor, Dan Reeves, an NFL football coach, confides that “suddenly, lowering my high cholesterol became even more important than football.”
^*
After undergoing emergency bypass surgery, Reeves reports he “had a full recovery, and was even able to coach [his] team in the biggest game of the season four weeks later.” Having learned to “take better care of [himself]” he advises the following: “When diet and exercise are not enough, ZOCOR can help people with high cholesterol and heart disease
live a longer life
by reducing the risk of a heart attack” (italics added).

Columbia Presbyterian and New York Weill Cornell Cancer Centers claim, in typically militaristic language, that they have been “at the forefront of the fight against cancer” and are now “working together to defeat this relentless disease.”
^*
In “one of the boldest initiatives ever undertaken,” they offer “new hope that the fight will be won” because at these cancer centers “experts” are helping to “uncover genes that cause cancer—essential to conquering the disease.”

And America's Pharmaceutical Companies, the public relations firm that represents the drug industry (“leading the way in the search for cures”), proclaims that “pharmaceutical company researchers are working hard to discover breakthroughs that will help
to make many illnesses and diseases a thing of the past and bring more patients new hope for a better tomorrow.”

Phil is blunt concerning such seemingly unexceptional claims and the false hopes and illusions they inspire, as well as the fact that patients, with increasing frequency, are coming to their doctors and demanding the medications they have read and heard about: mostly what have become known as lifestyle medications (Viagra, Prozac, Paxil, Rogaine) and the statins (Lipitor, Mevacor, Pravachol, Zocor), whose ads repeatedly suggest, in addition to banalities about “new hope,” “new cures,” and “better tomorrows,” what has
not
been proven: that these drugs will “extend life” and enable us to “live longer.”
^*

“I call it the Ponce de León thing,” Phil says.
^*
“Everybody's selling you the fountain of youth—eat this and don't eat that and you'll live forever. Take this medication, or exercise so much and so much every day, or have your doctor test you for this and perform that procedure and prescribe this form of therapy or that regimen and you'll feel better than ever, get rid of all your bad feelings, and live forever. And if these things aren't enough for you, there's always cryogenics. It's insane.”

“The belief that disease can be conquered,” Gerald Grob comments, “reflects a fundamental conviction that all things are possible and that human beings have it within their power to control completely their own destiny.”
^*

“The faith that disease is unnatural and can be conquered,” he continues, “rests on a fundamental misunderstanding of the biological world. If cancer is the enemy, then the enemy is ourselves. Malignant cells, after all, are hardly aliens who invade our bodies; they grow from our own normal cells.”

“Inflated rhetorical claims to the contrary,” he insists, “the etiology of most of the diseases of our age—notably cardiovascular disease, cancer, diabetes, mental illnesses—still remains a mystery.”

Then too, as my friends explain, not only do
most
diseases—including those that, in terms of mortality, predominate in our time (cancer and heart disease)—appear to have multiple causes (very few diseases are genetic in origin, and of those that are, most are
quite rare, and even fewer are caused by single genes), but they are intimately bound up with the simple fact of aging: that we are mortal, we grow old, and we die.
^*

Writing in the
New England Journal of Medicine
about ways publicity for medical research often encourages us to deny the reality of death and aging, Daniel Callahan, senior fellow at the Harvard Medical School and director of International Programs at the Hastings Center, a research institute that addresses ethical issues in health, medicine, and the environment, quotes William Haseltine, chairman and chief executive officer of Human Genome Sciences.
^*
“Death,” Haseltine has proclaimed, “is a series of preventable diseases.”

“The tacit message of the research agenda, is that if death itself cannot be eliminated,” Callahan comments, “then at least all the diseases that cause death can be done away with.

“From this perspective,” he continues, “the researcher is like a sharpshooter who will pick off the enemy one by one: cancer, then heart disease, then diabetes, then AIDS, then Alzheimer's disease, and so on.”

The “thrust of the research imperative against death is to turn death itself into a contingent, accidental event,” Callahan submits, and one result of this way of thinking is that it “promotes the idea among the public and physicians that death represents a failure of medicine.”

“Since we are a self-replacing entity,” William Haseltine informs the
New York Times
, “and do so reasonably well for many decades, there is no reason we can't go on forever.”
^*
He explains: “The fundamental property of DNA is its immortality. The problem is to connect that immortality with human immortality and, for the first time, we see how that may be possible.”

When Phil and I discuss my mother, who has been diagnosed with Alzheimer's disease and has been in a nursing home since 1992 (by which time she no longer knew who I was; for the last four or five years—I am writing this in the summer of 2002, shortly before her ninety-first birthday—she has not recognized even her regular nurses), Phil shakes his head.

“Sometimes I don't understand why Alzheimer's is such a big
deal,” he says. “As we get older,
lots
of our systems begin to wear down, and that seems natural to me. In the old days, see, when her memory got bad and she couldn't take care of herself, Aunt Edith would live with one of her children or a brother or sister, and when people got together she would usually sit quietly by herself, and if anybody asked about her, the family would say, ‘Oh that's Tante Edith—she doesn't remember things so well anymore, but she still bakes great strudel.'

“I mean, why are all these young people jogging and working out on treadmills and in health clubs all the time? Why is everyone on these diets all the time? Why do old men take up with young things, and women get boob-lifts and face-lifts? It's the Ponce de León thing if you ask me—thinking we can cheat the angel of death and stay young forever.