Several years ago, I wrote about my observations of tobacco’s role in the economy in the years when tobacco was more socially acceptable and medically approved. My conjecture was that tobacco provided a means for many workers to tolerate their routine jobs. Tobacco provided a stimulant to continue working past the natural urges to take a break or slow down. It also provided a sedative to calm the disgust in the repetitiveness of the work. If my conjecture were true, widespread tobacco use during the first half of the 20th century may have supplied the additional workforce needed for the industrial boom of that period. Without tobacco, there would have been lower and less reliable labor force participation.
This must have been studied somewhere. A quick search returned results that overwhelming discussed the labor involved in producing tobacco instead of the tobacco involved in producing labor.
Actual labor force participation rates became higher after social and medical norms discouraged the use of tobacco. I recall earlier explanations the declining tobacco use reduced the number of sick days and sick workers. The trends also follow other trends such as increase in women participating in full time jobs, and also the availability of more jobs that are less physically demanding as before.
In short, I have no data to back up my conjecture. It is just a hunch I have. Tobacco enabled people to continue to work despite their inclination to quit their jobs and their willingness to adjust to a lower living standard. Later in life, the consequence of tobacco led them to early deaths for many. There were many stories of the sadness of families dealing with the loss of the primary wage earner that managed to provide the family with a good standard of living. In those stories, the claim was that had the worker not smoked, he would be around to continue to share this wealth with his family. I always suspected that for many, had they not smoked when they were younger, they never would have achieved that status in the first place. The family would have been less appreciative of his contribution.
From a data perspective, I always felt that the winning argument about the problems with tobacco left out the potential benefits. Tobacco enabled workers to work when they otherwise would not have worked, or at least not have worked as consistently during their youth when they were more restless and reckless.
The science provided evidence that tobacco causes a variety of disease conditions, and especially lung cancer. It is not a direct causal relationship because many people who smoke heavily never develop the diseases ascribed to tobacco. Instead the argument is statistical. Smoking populations are more prone to these diseases, and this vulnerability increases in the sub-populations that smoke more. Reducing tobacco use results in fewer diseases over all. The claim does not have to show that reducing (or avoiding) tobacco use necessarily helps the individual.
With the successful change in social and medical acceptance of tobacco use, we accepted a new model for medicine.
Earlier, the public’s expectation from medicine is that it would address the each specific patient’s complaints. The patient and the patient’s family would be satisfied with a result that extended the life or eased the suffering even if the underlying condition was not understood or curable.
Now the model is to treat patients as populations. The goal is to achieve some improvement in the overall statistics of the population. In pursuit of that goal, the outcomes of solitary individuals becomes less important as long as there are decreasing proportions of the bad outcomes over time. The tobacco issue falls into this category. There is no way to know if tobacco use will kill or even harm a particular individual, but we do know that the population overall has fewer health issues if everyone stopped smoking, or never started.
Earlier, the primary physician invested much effort to get to know the patient including the patient’s life circumstances. The physician would listen to the complaints and then prescribe some action that should optimize the situation by easing the complaints with as little disruption to lifestyle. In particular, doctors prescribed fewer drugs to address complaints. Part of that reason was that there were fewer drugs available, but another part is that the doctor had more options available through a broad knowledge of the patient’s life.
Now, the primary physician’s role is to diagnose the patient. A diagnosis of some predefined condition is necessary before any treatment can start. Instead of spending time to get to know the patient’s broader life challenges, the modern physician concentrates on testing and evaluation to justify a precise diagnosis. With a successful diagnosis, the patient joins a pool of patients with the same condition. From that point forward, the treatment options are optimized for the entire population. There may be some adjustments to accommodate the particular patient’s tolerance to the treatment, but the treatment options themselves are constrained under the name of evidence-based medicine.
What matter to modern medicine is the overall efficiency. If there are 100 patients with some diagnosis, the goal is to get as close as possible to saving all 100, even if the best we can achieve is fewer than half. Modern medicine accepts the losses as being the best we can do with that particular diagnosis, and also that the treatment is the best balance for the greater good. Any other treatment would have seen more losses.
While it is admirable that modern medicine can extend more people’s lives, it is also admirable that the older medical practices could improve individuals’ quality of life. By understanding the person’s life situation, the earlier doctor could make an individual assessment of the risks and benefits of a treatment. He can see that this is not a good time for the person to start an aggressive treatment, and the condition appears to have a low likelihood of causing death. The earlier doctor more readily took a watchful waiting approach for disease conditions. He may see that there is a condition that might become dangerous, but it is not dangerous now. Given the stresses and challenges in the patient’s life, it could be better to not add the burden of a treatment.
Modern medicine cannot tolerate even low likelihoods of causing harm. The patient now belongs to a group identified by the diagnosed condition. The modern medicine’s priority is to achieve the highest survival rate for that group. Early treatment is more efficacious than later treatment. Also, if we remove the lower risk patients from the treatment regimen, then that will skill the results to poorer outcomes. We need to include healthier patients in the treatment to offset the severely unhealthy.
I grew up in the transition between when smoking was acceptable to when it was not acceptable. Even during my childhood, there was already an acceptance that smoking was not healthy. Even with that sentiment, there was an attitude including among doctors, that smoking was an option if the person felt he had to smoke to get through the day. The doctor would see his role is to check the person regularly. Some of that still persists today. Tobacco use is not illegal, and doctors do see patients who will not give up smoking. They too are watchful waiting, but the difference is that they are more likely to insist on the need to stop smoking. The patient is also penalized with higher health insurance premiums. The relationship was different earlier, the doctor would record that the patient is still smoking, but he would not make a big deal about it as long as there is good health currently.
The older practice had an inherent attitude of dealing with something when it becomes a problem. The modern practice is to deal with something before it becomes a problem. There may be wisdom in the saying that an ounce of prevention is worth a pound of cure. Those ounces get multiplied by all the possible things that can be prevented.
Modern medicine has relegated the full population into a patient status. Everyone has a risk factor for at least one disease. Every woman over a certain age is at risk of breast cancer and must be screened regularly. Every man over a certain age is at risk of prostate cancer and must be screened regularly. Everybody over a certain age is at risk of colon cancer and must be screened regularly. In the first two examples, the preliminary exams are done in regular doctor visit settings. The problem occurs when there is finding that needs follow such as gathering a sample for a biopsy. These procedures substantially disrupts everyone’s lives not just for the procedure but also the daily attention a person spend wondering what will happen next. The last example is similarly disruptive just to get the screening.
Recently, I see advertisements for further screening checking for other cancers, or conditions that precede strokes, heart failures, or failures of other organs. Each of these screenings has the potential to save lives. Modern medicine gets the reward of fewer lives lost.
My observation is what this is doing to people’s lives. Each procedure disrupts the person’s life. He has to show up for the procedure. In some cases, he needs to prepare in advance, or he has to wait a couple days for the effects of the procedure to flush out of the system. There is the additional spent contemplating the specific conditions being screen both before and after the procedure. There are numerous screenings and they need to happen regularly.
This is mostly a burden on older people. It seems to me that most people expect this, and few people are complaining about the inconveniences. The modern expensive health insurance premiums may even encourage their participation because they already are paying for it.
Just as modern medicine can emphasis the group statistics for judging the outcomes of certain practices, there should be a counter group statistics about what this is doing to the populations lives. In terms of disease, the individual experience does not matter as much as the overall population. A similar disregard to the individual’s attitude toward the screenings or treatments should apply when evaluating what this is doing to people’s lives. There is an excessive amount of time people are spending on health care. People are canceling or not pursuing potentially satisfying opportunities in order to accommodate the scheduling of their health care. This will eventually take a toll on the overall economy. There will be fewer great achievements because everyone’s calendar is splattered with medical appointments.
I believe that earlier medical practice had a superior appreciation for the opportunity cost of medical intervention. People live human life cycles. At each stage of life, people need to focus on things that have nothing to do with healthcare other than to strive to do those things in a healthy manner. It was the job of the medical doctor to not interrupt that focus, to only intervene when absolutely needed or demanded. People need to live their lives.
In addition to the above examples that primarily stressed screenings for older people, there is also an increasing preventive medical burden on younger people. Everyone is encouraged to get annual checkups that they are paying for through their premiums. Schools and Colleges require an ever expanding list of vaccinations, with recent ones needing annual boosters or variants. Each vaccine requires interrupting a person’s schedule and consumes time in the commuting and the waiting for the administration of that vaccine. Most vaccines have side effects that will linger for days afterwards. While not disabling, these side effects do impact a person’s life. In those days, they would have lived more comfortably without the vaccine.
We are entering an era where people will need to take vaccines on precise schedules. There will be specific days, scheduled far in advance when a vaccine must be taken. This will interfere with the person’s ability to plan things. They would need to be sure to be in town on the day of the scheduled vaccine, and they need to decline any opportunities that coincide with that schedule.
With the vaccines, modern medicine is following the tobacco approach. The individual’s benefit, risk, or cost is irrelevant to modern medicine. The important goal is the greater good of the population as a whole having a lower incidence of everything. In fact, it is fully acceptable and expected that some individuals may be specifically harmed by the approach. Modern medicine expects them to accept their sacrifice cheerfully for the greater good.
Older medicine recognized that the greater good is interfering as little as possible in people’s lives.
Throughout my life, I thought of modern medicine as an advancement over earlier medicine. Both were doing the same thing, it is just that modernity has a better practices. While modern medicine does have more and better options for treatment and prevention, it is not pursuing the same goals as older medicine.
The distinction may be in the interpretation of the word disease. The older practice was closer to the root meaning as an unpleasant departure from normal healthiness. The goal was to maintain the healthy state for each individual or to return the body to a healthy state. In contrast, modern medicine changes it focus to the disease itself. Each disease needs to be controlled. It measures the disease by a precise diagnosis that produces a distinguishable population. Modern medicine strives to manage each individual disease in terms of the entire population with the same diagnosis.
Disease started out as an idea about a departure from good health. The doctors had knowledge of the various disease conditions and how to treat them, but the focus was on getting the individual back to an acceptable level of health. The priority was on the individual’s health condition. This can happen without actually curing the disease or eliminating the possibility of the disease.
Modern medicine inverts this definition. The goal of modern medicine is to cure each disease and ultimately assure that the disease will never appear again. With few exceptions, modern medicine is only partially successful. It is able to help some people but not all. In many cases, it is not able to help most people. This is acceptable as long as there is progress toward improvement. Progress is measured in statistics of increasing recovery rates for each disease. Individual health is important to modern medicine, but primarily for the modern medicine’s goal of using that success to improve the statistics. The individual’s actual needs and comforts are secondary to the statistics of the outcomes.
In modern medicine, there is an implicit obligation to participate. This obligation is like the various screenings and vaccination schedules that people are expected to follow. If a person is identified as a part of a disease group, he has a duty to cooperate with medicine. He should accept the offered services even though they are presented as subject to his consent. He should accept these services even if there is low probability of success. The task is for the broader project of improving medicine for the next generation of patients with similar problems.
I wrote about this several years ago when I wrote about the controversies of people declining further participation in the medical project. One example was people facing a terminal illness or a cancer where the treatment would disrupt normal life and still be unlikely to restore normal life. In both cases, the patients chose to enjoy their remaining good days and avoid the ordeal and stress of going through the medical system’s futile attempts to extend the life. The controversy was that such patients are being selfish because they were depriving modern medicine the opportunity to practice with the goal of eventually finding something that would help future cases. The other example discussed the Ebola epidemic at that time but from the perspective of how the disease obligates people to be treated. For that disease survival rates were low but they were possible. The problem is the risk of spreading the disease if not properly cared for. The person needs to go to a hospital setting even though they may be just as likely to die there. People would also be subject to treatments to try to reduce the symptoms that can more readily spread the virus.
These are examples where there is an obligation to participate in medicine. Instead of medicine being something that waits for a patient to request its services, medicine seeks out and captures its patients. Once a person become medically interesting, he is expected to cooperate with the medical practices. His own private weighing of the pros and cons is irrelevant. What matters is the broader goals of medicine, and those goals at least the possibility of helping him after all the inconveniences.
In recent years there is a growing movement of people to reconsider their medical needs. They are seeking out more traditional medical practices. They may explain the motivation to try out more natural remedies over the pharmaceutical varieties. I suspect they continue that route because the prefer the relationship they have with those doctors. The traditional medical approach is to pay attention to the specific needs of each specific patient. People want that kind of attention and individual focus from any doctor, and would welcome it from a more modern medical doctor that does prescribe drugs. The point is the focus on the individual instead of the disease. People want to go on about their lives. If in their particular case that is possible by living with the disease instead of curing it, then that is the route they may prefer. Because this kind of attention is not available from modern doctors, they seek it out from alternative sources.
This trend undermines modern medicine. In order to the best data for their ongoing improvements, they need to get access to patients with the particular disease. In particular, they need these patients in the earliest stage of the disease when the patient is comfortable enough to seek out traditional or alternative medicine. Modern medicine sees these alternatives at postponing a treatment and that will leave modern medicine only those who are most sick from the disease, and thus least likely to be cured.
Modern medicine is responding with a campaign to assure complete cooperation. The campaign started out by requiring everyone to get expensive health insurance that covers everything that modern medicine wants covered. The costs of the premiums provides incentive for people to use modern medicine because they already paid for insurance that only covers modern medicine. Soon there will be a health passport that would confirm the person has good health status from a modern doctor, and that includes confirmation of receiving the full list of vaccines. There is also an effort to regulate speech online so that alternative information does not compete against modern medicine information.
The broader objective is to require everyone to participate in modern medicine even when doing so will require sacrifices that are unnecessary from the individual’s perspective. The modern medicine has the mission of the greater good, to maximize the health profile of the entire population. Individual interests must be secondary to this most noble of goals.
Modern medicine grew out of older medicine by changing the focus from the individual’s wellbeing to the treatment of each particular type of disease that might affect any person. We are entering a new era of post-modern medicine that treats certain ideas like diseases. Any ideas that conflict with modern medicine must be diseased ideas. It is the job of post-modern medicine to isolate, quarantine, and eventually excise those contrary ideas.
The diseased idea is that modern medicine imposes unnecessary medical interventions that interferes with a person’s ability to navigate through his life. The way to eradicate this disease is to force everyone to participate in something that will not benefit them and could harm them. The population must be conditioned to obey anything that comes with the label of being modern medicine. It is for the greater good.