Science, politics, and the public health

Reflections on why wealth hasn’t bought us more health, and related topics.

Shortly before starting this weblog, I published an essay (in response to Sally Satel’s P.C., M.D.) with which I was rather pleased. On re-reading it two years later, I’m a little bit less pleased with it as a literary production, but the ideas in it still seem right to me.

On the theory that one or two of my readers might have somehow missed the the May/June 2002 issue of Society, I’ve posted it here.

Science, Politics, and the Public Health.

Here’s a sample:

Perhaps it was inevitable that the adoption of science as a quasi-official religion, and all the varieties of corruption that resulted from that adoption — from “junk science” in the courtroom to politicians using the need for “more research” as a delaying tactic — would lead to an anti-clerical backlash and the development of various heresies. In the case of medicine, though, there are more immediate factors supporting the market for bunkum.

Some of those causes are more or less beyond the reach of policy. For example, now that doctors make a practice of giving patients bad news (on balance a good thing, if you ask me), some patients and their families will be strongly motivated to disbelieve what they are told. And since prognosis always has an error band around it, there will always be enough anecdotes of people given two months to live but still around fifteen years later to keep hope alive. (Again, this would be less of a problem in a population used to thinking in terms of error bands, but that gets us back the problem of science teaching.)

But another reason people embrace quasi-medical pseudoscience is that current medical science is grossly deficient when it comes to knowledge of, and means for studying, the relationship between conscious and unconscious mental processes and the processes of somatic disease and its healing. Part of the problem here is the tyranny of the double-blind clinical trial, which is a useful convention to prevent scientific deception and self-deception but which was not brought down by Moses from Mt. Sinai.

Double-blind methodology is, among other things, a way of making sure that the patient’s opinions and attitudes, hopes and fears, don’t influence the outcome and thus obscure the operation of whatever mechanism is being tried. But then how does one study the effects of opinion, attitude, hope, and fear, which are obviously important in determining outcomes, though no one knows quite how? Now that firewalking has gone from being a vague rumor to being something tourists learn to do in a day, perhaps it’s time to start paying some systematic attention to the medical version of the mind-body problem, with a view to developing techniques to improve patients’ ability to use their minds to resist and repair disease processes.

Of course that sounds vague; perhaps, if we start to spend some noticeable fraction of the medical-research budget on such scientific puzzles as how a hypnotist can make the warts disappear from half of a patient’s face, rather than letting the tiny “alternative medicine” budget get eaten up studying nutritional supplements while all the real money goes into fancy imaging, genomics, and drug trials, maybe ten years from now someone will be able to formulate the problem more precisely.

The revolution in molecular biology has had spectacular results, with more to come, and it will be a cold day in Hell before anyone gets a Nobel Prize for studying the role of, for example, suggestion in therapy. But as long as it’s only the charlatans who pay attention to the fact that patients have emotions as well as biochemistries, patients are going to keep seeking out the charlatans.

At least it should make a nice change from reading about torture.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com