Given my previous curmudgeonly rants about the general uselessness of mammograms I was pleased, nay, delighted when when the Canadian Task Force on Preventive Health Care issued new guidelines – ever-so-gently suggesting that perhaps this pop culture myth that ‘mammograms save lives”, especially that of younger women, is a crock. Naturally they phrased it in dry, epidemiologic language, but you’d thought the poor geezers had suggested women shouldn’t be allowed to vote.

The response, anecdotal, I’ll grant you but shrill, emotive and generally overwhelming was: Well! How dare you condemn women to death you dreadful guideline-writing scum you. Letters poured into newspapers and editorials pilloried the Task Force – the inevitable line was “having a mammogram saved my life”.

Politically incorrect and uwomanly of me it may be, but my first thought was, ‘Really?! How do you know? Given that a teensy mass that couldn’t even fill the head of a pin is now called a cancer and the person who’s had it a survivor?’

Perhaps less vocal people felt relieved that the Task Force had articulated what they had thought all along, that it may not be such a splendid thing to squish your breasts between two metal plates once a year even as you ended up dosed with radiation but I don’t know.

As far as I’m concerned the Task Force didn’t go far enough. They clearly stated that women who had the BRCA1 and 2 genes or had a family history continue to have regular mammograms, even as early as 40 and added that older women, those over 70, should also be screened. They politely did not say, trust us, if you have cancer you’ll know it. Ideally, a mammogram will find a fast-growing cancer early. By and large, it won’t. What it will find is what all those cancers that don’t want to be found, the bits and pieces of slightly abnormal tissue we all have – and which will be found if we go looking for trouble. Which is essentially what screening is.

Alas, screening is all too often confused with ‘cure’. Or ‘treatment’. Which screening simply cannot be. Screening is a way to make obvious something that was there that we didn’t know about, theoretically to ‘catch’ something dangerous early. As if.

But, hey, we’ve got the runs for the cure and all those pretty celebrities (and nonentities) going on the telly to lecture us on how we should all be focused on preventive care and take our radiation. Or have someone thrust a sharp object up our colon. Yes, sharp. The kind of thing that can slip and perforate the bowel and have you in the ICU faster than you can say colonoscopy.

But I wax incoherent.

So, once again, a brief lesson in how cancerous cells evolve. Cells divide over the course of their and our lives; with each division the odds of a ‘mistake’ increases. Which is why cancer is generally a disease of old age. The more those cells divide the greater the odds that something will go askew and result in what, if found, we will call cancer or pre-cancer or some damn fool thing. (Of course as we get older our cells divide more slowly which is why most older people die with cancer not of it.)

Then we attack what we’ve found with all the tools of the early 20^th century: radiation, surgery and harsh drugs. True, a handful of cancers are actually treatable with some new meds, usually fairly rare cancers, and a few drugs can increase life span. We are better at targeting and focusing and not killing quite so many non-cancerous cells. But the reality remains that we’re still focused on zapping and poisoning and cutting out cancers, just as they were in close to a hundred years ago and, barring the smoking/lung cancer connection, no closer to understanding why some people get cancer and others don’t.

That’s the question we should be asking and flinging money at, not mammograms.

Of course why the guidelines come as a shock to anybody I do not know, since we’ve known, definitively, since the 90’s that mammography is a crude screening tool at best. Plus, for women under 50 the risk benefit ratio is beyond ridiculous. (What we really mean by that, of course, is women who have not yet gone through menopause not women under 50 but we do love our decimal groupings – maybe it’s that counting-on-ten-fingers thing, so much easier). In other words, the number of false positives, biopsies to confirm one does not have cancer and actual false diagnoses are phenomenally high. (That last one, by the bye, simply refers to the women who end up being told they have cancer when they do not and end up in that most dismal of all “treatment” regimens for no reason at all.)

We have also known for a long time that not all cancers want to be found; that in fact over-diagnosing and over-treatment are rife when public policy institutionalizes screening, whether it’s PSA testing or colonscopies or mammograms.

But the emotional anecdotes continue to mount as individuals tearfully ask why the rest of us (and that nasty Task Force) would condemn them to death. Ah, easy there sport. Nobody’s condemning you to anything. Yes, women do get breast cancer. We have all had a friend or relative die of the disease. (Yes, including me. I sat with her as she died.) But simply because something happens does not mean it’s an epidemic or a scourge.

Finally, health policy is not clinical practice. Policy, guidelines, are simply a way for institutions to recommend what appears to be best practice. This does not mean that individual women cannot have mammograms or that individual doctors cannot counsel individual patients to have them. It simply means that a blanket policy recommending all women over a certain age undergo a procedure that is neither benign nor risk free is not a good idea.

Furthermore, something the Task Force did not mention, probably because they did not know it, is that women prior to menopause go through a phrase of life called perimenopause. Perhaps you’ve heard of it. It’s the years leading up to the cessation of the menstrual cycle when some women have hot flushes and mood swings and can get depressed and irritable. Estrogen levels fluctuate during this time and estrogen, boys and girls, is a hormone that causes cells to proliferate. It does that in the uterus during the menstrual cycle and also in the breast. So, the risk of a false positive raises commensurately for perimenopausal women because higher estrogen = lumpy breasts. More often than not these will resolve, go away, with time as an elegant Scandinavian study demonstrated some years ago.

So tell me again why women in their 40’s would want to subject themselves to this? Oh yes, because they believe in the medical model and the linear nature of physiology. Worst, we have all been subjected to such a barrage of pink ribbons and nonsense about prevention that women honestly believe the dratted technology actually works.

For my part, a certain weariness sets in as I watched this play out, not to mention the inevitable expert huffily saying, look, it’s science and you can’t argue with that. Actually I can. But this is one time the best-guess statistics, hypothesis testing, and empirical data all back up the physiology and common sense.

But I guess a lot of women have decided that the Forces of Evil want to take their mammograms away. How does one explain the Forces of Evil have a lot more on their mind these days than women’s breasts?

According to yesterday’s Globe and Mail, a report from the Vancouver Police Department identifies the deinstitutionalization of the mentally ill as a major problem for police, who have become de facto mental health workers.

“We certainly have identified individuals that we wonder whether it would be healthier – both for themselves and the community – if they were in institutional care,” Vancouver Police Department Inspector Scott Thompson is quoted as saying at a press conference. “The difficulty,” he added, “is that [that] is a medical question. That’s not within the realm of policing.”

Ah, but there’s the rub. It’s not a medical question or medical issue or even a medical decision. It’s a political and economic and sociocultural one.

When the decision was made to – for all intents and purposes – shut down the single major institution this province had for the mentally ill, Riverview, it had nothing to do with the doctors and nurses and social workers; it was a decision made at the Ministry of Health and provincial and federal level. It had to do with the general tenor of the times, notions of autonomy and individual rights  – not to mention a way to save cold, hard cash.

To some extent it was in reaction to the authoritarian, pseudo eugenics-type of position taken in earlier decades where the mentally ill were forcibly sterilized, forced to undergo horrible procedures (like frontal lobotomies – driven by the enthusiasm of a single nutty doctor incidentally) and unethical experiments on prisoners and others considered somehow lesser human than the rest of us.

Now the chickens have come home to roost. The downtown east side is a morass of misery and it is the police and the justice system who increasingly have to deal with people who are incapable of making rational choices for themselves. People who live next door to drug addicts and pushers and pimps.

Yes, it is a disgrace and yes, many of the people are sick and would do far better in the wooded confines of Riverview Hospital. But we’re closing Riverview (the scuttlebutt is that the land is worth a mint and that plays a major role as well)

Many years ago I wrote a document for and on Riverview; I spent a few days wandering the grounds and halls, talking to psych nurses and doctors and patients and all kinds of people. I watched as mentally ill individuals happily wandered through the garden and attended art therapy and crafts workshops. If they had a bad episode there were medical professionals on hand to help.

But.

As a society we decided a long time ago that we couldn’t afford it, that it wasn’t a viable alternative, that it wasn’t the way to do things.

Now the police are unhappy about how it’s all unfolded and most of us don’t like it much either. But it’s not a medical decision. Or even a personal one – talk to the families of schizophrenics or people who feel fine on meds and decide they don’t need them any more, become psychotic and head for the hills. Even if the hills are only in their mind.

Mental illness is complex and misunderstood – but it’s not medicine that’s let us down. It’s ourselves.

For years I have been whinging on about the overuse of medical technologies, in my writing, teaching, speaking (occasionally stooping so low as to corner a hapless victim at some dull cocktail party who’s made the mistake of innocently asking me what I do/am working on). And finally, the Archives of Internal Medicine has backed me up with a new, elegantly designed study from a group of physicians in Israel.

(Oh North America, why do you ignore the nuanced questions? Why is it that American and Canadian researchers confine themselves to reductionist questions like Pax2-dependent transcription activation and other such unpronounceable minutae, leaving the critique and analysis to the Israelis and Finns and Norwegians and Dutch and so on?)

Then again, it is not just researchers but us on this large continent, we who believe in high tech and guidelines, rules and benchmarks. We has seen the enemy and he is us, to coin a phrase. Our cultural template, our social world, our beliefs and values predispose us to believing in the power or science and technology; we love our smartphones so medical technologies – those lovely acronyms like MRI, CT and PET – must also be the royal road to answers. So we push push the doctor to send us for “tests” so we too can receive our god-given right to radiation.

What we inevitably forget (or just don’t know) is that what medical technologies measure are, at best, only pale imitations at best of the complexities of disease and illness.

When I remind students – seniors, undergraduates, their ages don’t matter – that “an MRI or CT scan can’t tell if that lump is benign; it’s a person, a human being who makes that determination” I can see that shock in their faces.  Because the seem to have forgotten that it is a fallible human being, prone to errors and fatigue and over- and lack of confidence who figures out the test, not the computer/technology.  And people can miss things, over- or under-report; people can exaggerate a problem because they’ve been sued or are in a hurry to get home and get to their child’s soccer game.  (Came as a shock to you too, didn’t it? You kind of thought technology trumped clinical judgement as well.)

Back to the Israeli study done by Liza Paley, MD along with physician colleagues Zornitzki, Cohen, Fredman, Kozak, and Schattner. They examined newly admitted patients to the emerg for 53 days, checking to see if the various tests and scans and so on ultimately aided in the final diagnosis. Sure enough, and wonderfully confirming my own cranky comments, they found that “more than 80% of newly admitted internal medicine patients could be correctly diagnosed on admission and that basic clinical skills remain a powerful tool”. In other words, with only a handful of old, cheap lab tests (which were found to be “crucial”) plus a detailed history and decent clinical skills, you could narrow down the diagnosis and figure out how to treat the patient.

In fact, up to 90 percent of correct diagnoses were the result of history, exam plus some basic blood work (hematology and chemistry, urinalysis, EEG chest x-ray – which, I would remind you, contains anywhere from a tenth to 1/400^th of the radiation of a CT scan.

These are not the tests we associate with medical high tech though. These are old tech, based on boring old 20^th century research. No genetic tests, no cool monitors or flashy gadgets.

“Our results do not mean that sophisticated studies need not be used after admission, but they do suggest that their choice should be guided by the clinical data on presentation,” wrote the authors  in the Archives.

Of course our complicity in all this, particularly in community medicine, was a not a part of this study; neither was our belief, our faith in the power of the technology; superhuman, infinitely superior to the biological brain and, of course, infallible. Stemming from our belief that disease somehow has an independent reality – that it is the “other”, evinced by our metaphors (“killing” the cancer, “fighting the disease) and attitudes – that is observable through “scientific” means, ergo technology.

In fact disease and illness are nothing of the sort. A manifestation of human frailty, highly individual and affected by everything about us and around us: who we are, who we were, our personal and family history; our lives and fears; our environment and social biases – all the many stresses and strains we’ve been exposed to, from what we ingested to what we’ve invested. Ultimately, what matters isn’t that label, that diagnosis, however much it might provide us with comfort, but the care we receive.

And that, boys and girls, is the art of medicine without which the science hasn’t got a chance.

An older woman of my acquaintance misplaced her watch recently. Not a big deal, you’d think. She found it a few days later with the help of a friend – unbeknownst to her it had slipped off the television and into a drawer. What got my attention was her extreme secretiveness, so convinced was she that people would suspect she had Alzheimer’s or dementia or what-have-you (because of her age).

Somewhat in the same vein I am often asked – in strictest, pain-of-death confidence – about a pain here, a twinge there; a slow-to-heal cut or some bleeding that my interlocutor is convinced is something dire, cancer probably. Almost always with some judicious questions I can reassure the person; the pain is probably a pulled muscle (if it doesn’t improve over time then perhaps further investigation might be called for), the blood loss benign (and common), the cut merely infected and in need of antibacterial care. The relief is inevitably palpable. Terror had literally been keeping the person up nights.

I don’t blame them. Everything they hear about health, and there is a lot of it around, is about something horrible. In truth, we are all so inundated health “news” these days, so saturated with medical “updates” – in every medium possible – that it’s virtually impossible not to become a hypochondriac at one point or another. Especially since medical problems are presented not in terms of real physiology which is messy, unpredictable and slow (but often very resilient) but in entertainment terms: Monster tries to eat New York, hero rises to vanquish monster, stuff happens, the end.

The heroic angle is ever present. We will discover the gene that “causes” cancer (Really? How’s that working out?), tweak it and presto! Problem solved. Well, not right this instant of course. Oh, and did we mention there are these fibres in those bags you now use to carry groceries that can cause beri beri? Oopsy woopsy.

That’s not how physiology works.

From the immune system to neurons, our physical selves advance, retreat, retrench; go forward one step and back two (even with something ostensibly simple like a flu virus). Age on the one hand creates fragilities, on the other speaks to great endurance (hey, there are a lot of chances to die before you hit 75). Physiology is complex, dynamic and infinitely changeable, even in the same person, from one moment to the next.

The root of this reductionist thinking came after the second world war when money and attention, not to mention serious institutional support, went towards medical research, the National Institutes of Health, Health Canada and the like. And our focus, as the late Yale epidemiologist and physician Alvan Feinstein wrote, turned away from the person (patient) and towards disease. Plus, we started flinging large sums of money at medical research which, in turn, began singing its own praises, which is hard to do unless you create a bogeyman you are battling.

So, nobody mentions that we live longer, healthier lives (in the developed world) than any generation ever. That over half of all people over 65 are alive today and doing very well thank you very much. What we do hear is that there are umpteen dreadful diseases out there, skulking, lurking.

So we freak out over minor aches and pains and mumble “Oscar material” when some fellow played by James Franco heads into some canyon and gets stuck. Look, I’m glad the fellow saved himself and yes it must have been dreadful but the real story is not dramatic but in the day-to-day lives of all those amputees who have to cope with getting on with their lives. The real story isn’t in the escape but life after that idiotic daredevil stunt. Except life with a disability is painfully difficult, often humiliating and can make even a grown man cry from frustration. Boring. Not at all Oscar material.

Is it any wonder real life, only too often – when it hits, as it always does – comes not only as a rude shock but as a personal affront?

Take another curmudgeonly peeve of mine. Violence. Movies, television shows, games – the level of gore has steadily increased even as our ability to emphasize or react in any appropriate form has gone down. Sure, I enjoy watching the evil genius get his or (more rarely) her comeuppance; I like a watching a building blow up and cops shooting at bad guys. What I do not enjoy is the inevitable desensitization these increasing levels of violence have on our collective psyches. (Or the noise: I seem to be the only person in the western world with intact hearing.)

It seems that we have all become so immune to the ugly impact violence has that even an essentially comic-book hero like James Bond is portrayed not as the suave Sean Connery straightening his cuff links after a dustup but is rife with fake blood and cringe-worthy torture scenes that make one feel vaguely ill.

Then. Then. (Here we have to pause for me to give a heavy sigh.) Then, the victim of aforesaid torture or flying bullet gets up and carries on. If he’s the hero, that is. Later, we hear that he was lucky, the bullet “grazed” the skin, it was just a flesh wound.

Pardon me?! What flesh would this be? Um, human? Frankly, I have yet to meet a real human being who was able to recover from even a kitchen accident in a day. (Hey, you try it. Make a deep slice in your finger as you’re chopping carrots or a slice of bread and you tell me how long it takes to heal. More often than not you’ll take the bandage off way too soon, the cut gets infected and starts to throb and the whole process starts all over again.[1]) The consequences of violence are so rarely seen as to be invisible.

No doubt this is why we get those news items of seven-year-olds firing on one of their pals in jest without realizing that real guns do real damage.

Physiology is hard. Healing takes time. Bodies are fragile yet amazingly resilient. It all depends on the person, the situation, the amount and place of the damage. Even a broken ankle can lead to a lifetime of causalgia (you don’t want to know – major, lifelong pain) and someone can fall off a cliff and survive with minimal injuries. It’s not possible to predict and it’s probably better not to try that last one. Politically, such attitudes end up reflected in the acceptance for President Bush’s redefining torture in defiance of the Geneva Conventions and in our nonchalance around so much global suffering – even as it convinces us that we’re dying from some dreadful disease – when all we’ve got is a hemorrhoid.

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[1] (First Aid note: when you’ve cut your finger or hand and the skin has healed over but it’s red, swollen and painful, what’s happened is that bacteria are trapped and your immune system is responding, but slowly. To help the macrophages along, you need to clean out the bacteria physically by making a tiny incision and letting the blood and pus ooze out. Sounds horrible but there’s physiology for you. Then soak in hot water with a drop of disinfectant, e.g. Dettol, or just water in a pinch.  Cover with antibacterial cream and bandaid.)