barksy - the paradox of health.pdf

7/30/2019 Barksy - The paradox of health.pdf

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40. Bjo:rrum OJ Imrnunocn.:nnc . .""""il':oI"'" of mctIIhnoroe P"' ' ' ' ' ' ' ' ' " melIIodial _ y ",,,II """"""is p""-"'d on ;1III'IIU",,,,,,,,,ipilaliollon ~ I. BIOdIim 8iGpbys ACUI 1977; 472;J)S-9S.

41. BjeInImOJ . 8b.II


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THt: i 'AR ....UOX OF HEALTH - BARSKY"I. 318 No, i

r I,d by 1984 it had fallen to 10.6. (The pace of theecline has slowed since, however.)Modern biomedicine has enhanced ou r ability to

redict, detect, diagnose, and treat the array of dislses to which human beings are heir. According tolle estimate, in 1928 we ha d effective treatments orreventive measures for 5 to 10 percent of the 360lost serious diseases. By 1976 this figure ha d risen toetween 50 and 55 percent. 4 More recently, advances

medical care have been matched by advances inreventive medicine, health promotion, an d self-care,s an increasing proportion of morbidity an d mortaly ha s become behaviorally determined, many peopleave made notable changes in their health habits andfe styles. Ou r considerable success in combating cariac disease in the past 20 years serves as a good examIe. More than half the gains in this area have beenttributed to life-style changes - reduced dietary intke of saturated fats, decline in cigarette smoking,

'eigh t loss, an d physicale x e r c ~ s e . ' ;

T H E DECLINE IN WELL-BEING

During the past 20 to 30 years, people's subjective:nse of healthiness has not kept pace with improvelents in health status; indeed, it appears to have deined. According to nationwide polls an d communitylrveys, the proportion of Americans who ar e satisfiedith their h!:'alth an d physical condition has fallenom 61 percent in the 1970s to 55 percent in thetid-1980s,6People report more frequent and longer-lasting epi

>des of serious, acute illness now than they did 60=ars ago, despite th e introduction of antibiotics durtg the intervening period. In l a r g ~ - s c a l ecommunitylrveyS in the 19205, the average respondent reported82 episode of serious, acute, "disabling" illness perear, Asked the same question in the early 198Os,mericans reported 2.12 such episodes per year. 3 In:Jdition, P t ~ o p l enowadays i,a}' that l'ac:h episode ofisabling illness lasts longer - 19 days on the average,; compared with 16 days in the 19205.3

More r ~ c e n tstudies show the same trend. In 1957rid 1976. l;trge nationwide samples of adults wereIterviewcd about their health. Asked about common>rnatic symptoms such as dyspnea, palpitations, andain an d whrlher they felt healthy enough to do thelings thrv wanted ro do, men and women both reorted more ill healtJl in 1976 than thr\' had in 1957.''here was .tlso a decline in the p r o p o ~ t j o nof pooplcho reported no symptoms al all, o r almost none.1Anothrr recent trend is toward !uuger periods of

isability ~ r episode of illness. In surveys from thelI e 1950s through the late 19705, including the Naonal Health 11llt"rv1ew Sun'('Y, buth men an d WOmf"llisclosed subs tantia l increasf'S in disability.8,11 Th e toII numhers of days of restricted aCli\'ity and days incd li";r an:'" ;1110 ('hroni,' i l l p , , ~ ,h.l\"I" risl'n sharrh.nd th(' pmp


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W i FrI>. 18. 1988

reeted for inflation, the same prt-cipitous rise is evident: the per capi ta outlay for health care, in constantdollars, has gone from S292 in 1970 to S431 in 1986. 11Equally important, the proportion of the gross national product devoted to health has also risen - from 7.4

percent in 1970 to 9.1 percent in 1980, and 10.8 percent in 1986. I IThe emphasis on health is also seen in the strenuous

pursuit of the "healthy life style" and in widespreadattempts to reduce risk factors. Eighty-seven percentof adul ts say they have attempted to make at least onehealthful change in their lives. Sixty percent say theyhave adopted a more healthful diet, 46 percent havetried to lose weight, 45 percent have exercised more,and 44 percent say they have tried to control stress. 12Health has become a popular avocation: in 1984,4 ofthe top 10 hard-cover, nonfiction best sellers dealtwith diet or fitness,13 whereas in 1965 none did. 14Health resorts are increasingly popular vacation destinations, with a l2-fold rise in the number of guests infive years15; health fairs now rival boat and car showsin attendance. 16

There is a growing fascination with diet, nutrition, and weight loss. Surveys show people deeply concerned about the fat, salt, fiber, and sugar content of their food; they are interested in vitamin and mineral supplementation, most recently calcium. Th e fear of obesity is so strong that it has affected fourth-grade girls, 80 percent of whom are afraid of gaining weight and feel they weigh too much.17 Even some infants have been placed on overly stringent diets by parents unduly concerned about childhood obesity.18

Th e physical-fitness boom is another manifestationof our preoccupation with health. I t is widespread

among both women and men: one third of Americanssa)' they engage in regular strenuollS exercise,6 a groupthat includes more than 31 million serious joggers, 19,2026 million regular swimmers,21 and millions more whotake aerobics classes and lift weights. Of those whoparticipate in vigor ous phys ical conditioning, mostdo so for reasons of health. 19 This drive for physicalfitness fuels all ec.;onomic juggernaut involving exercise videotapes, health clubs, and personal fitnessinstructors.

Although our society's fascination with health hashad many substant ial benefits, it has at the same timeeroded the sense of well-being. Paying increased attention to om"s body and one's health (ends to makeone assess them more negatively, with greater feelingsof ill health. Several investigations have shown (hatbodily awareness, self-consciousness, alld introspection are associated with a tendency to amplify somaticsvmptoms and to report being troubled by more symptoms. 22 - 2 +Studies in perceptual and experimental psychology suggest that, in general, the more aware people ar(' of their ('haracteristics and attributes. the morenegatively they assess them.:.!4 This appt'ars to be particularly nut' for physical attributes. bodily sensations, an d p


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-117ro t :l18 No, 7 TH E PARADOX OF HEALTH - BARSK Y

r : r e portrayed as ominous , t h ~h ~ r a l dof o m ~h ~ ~ t o -autologous blood transfusions are prescribed to imDre unrecognized or n d i a g n o s ~ dd i s ~ a s ~ _Feelings of prove athletic prowess, stimulants are given to supill health and disability a r ~amplified h ~ ne v ~ r yache press normal fatigue or sleepiness, sex-change surgery:s though[ to merit m ~ d i c a lattention, ~ r y t w i n g ~ is performed in anatomically normal trans.sc:xwr.b,iUld:nay be h ~prodrome of a malignant i s ~ ,when we of course t h e ~are tubal ligations, vasectomy, and aire told that every mole an d wrinkle desetVes s u r g ~ r y _ host of new lechniques to intervene in the normal

c o u r s ~of fenilization, conception, and intrauterinefhe Ihdlcallzatlon of Dally Life development.

Medical care plays an increasing par t in daily Hfe. M ~ d i c a l i z a t i o nmakes it possible to relieve many!\lthough this results in great gains in ou r h w t h sta d i s t r ~ s s i n gconditions that could not be remedied be-:us, it also helps to diminish ou r sense of weJI-being, fore, bu t it has a p a r a d o ~ c a lside effect. I t leads pe0-naking symptoms an d disabilities that ~ not curable ple to believe that more an d more of their discomforts,ieem w o r s ~than they used to seem, infirmities, and impairments are curable. Medical tri

Americans consult phys icians more f r e q u ~ n t l ythan umphs intimate a world in which whatever ails us can~ e r b e f o ~- for a broader range of problems an d for be treated away. This creates a problem of rising exess serious conditions. In 1982, the mean number of pectations: having come to imagine that somewhere.isits to the doctor p u person was 5.0. By COl'Itrast, in there is a treatment for almost everything that ails us,:he 1930s t h ~a v ~ r a g ecitizen m a d ~2.5 visits. 30 On e we experience ~ f r a c t o r ysymptoms an d residual im-:eason for this change ha s been an increasing willing pairment as insuppor table - as a m i s t a k ~ ,an injus

less to go to the doctor with minor symptoms an d tice, a failure of medical care. 11IDess seems all theJenign illnesses, such as musculoskeletal an d sinus more disturbing because we think it need no t have:omplaints and gastrointestinal symptoms.' At pres h a p ~ e dat all. Because we expect so much from:nt, in 30 to 60 percent of the visits to primary c a r ~ medical care and preventive medicine, and because:lhysicians, no serious medical condition is found to we have invested so much in them, we become fruslceount for the patient's symptoms. 31 Among the out- trated an d disappointed b y medicine's achievements,:latients cared for in such settings, 25 to 40 ~ r c e n t substantial though they are. Incurable ailments andlave no serious medical diagnosis. 31 Infections of the trivial infirmities alike seem more noxious an d dis-:1pper respiratory tract ~ now th e most common sin abling once they are thought to be avoidable, unneces~ l e disorder ~ n c o u n t e r e din genera l medical prac sary, or remediable. 34

jce. 32 Th e threshold for seeking medical attention has Studies of obesity and disfigurement illustrate wellliso been l o w ~ r e dfor more serious illnesses. For exam this n e g a t i v ~effect of unfulfilled expectations on well::lIe, women with symptoms of urinary tract infection being. Overweight people who t ry to reduce are moreIre estima ted to be five times more likely to seek medi dysphoric than people of the same weight who have:al attention now than thev were in the 1920s. 3 accepted their condition an d are not trying to lose

Besides consulting doctors for less suious condi weight. 39 Th e belief that normal weight is attainable:ions, patients now consult them for conditions that seems to be o ~ disturbing than not aspiring to thin-were previously considered unsuited to medical treat ness in th e first place; admitting a dislike of one's size' T 1 ~ n r .St"Vt"ral observers have noted (and d ~ c r i e d )a and trying hard to alter it makes it more intolerable.:listorical trend toward r ~ d a s s i f y i n gdMant and un- Studies of facial disfigurement show something simijesirable forms of behavior as diseases, rather than lar: minor deformities cause as muc h or m ~ anguish:rimes or religious transgressions,:'!3-35 Examples of than defects too major to be corrected. 38 On th e othu'his medicalization of behavior include alcoholism, hand, the most grossly deformed or a n d i c : a p ~pe0-irug addiction, child abuse, an d some forms of im ple, for whom cure was never a possibility, have often;ulsive \'j!..lience,36 Physicians are also asked increas learned to accept their defects,ngly to "treat" physical conditions that are not dis

C o N C L U S I O N:ases in {he traditional sense - baldness, unattractivearial fra{ures, breasts that are too large or too small, P h y s i c i a n ~must be alert to the paradox of medicaldtigue. and jt"{ lag. With an estimated 500,000 cos progress. ~ o . \ , clinicians an d teachers, we need to

netic operations performed in the United States in point ou t that there is no one-to-one correspondence1986, plastic surgery is one of the fastest-growing between objective health status and the subjective pu -nedical speciaities. 37 In addition. 80 percent of those ception of healthiness. In shaping public policy, ad-Nho go to orthodontists now do so for cosmetic ministering programs, an d dealing with the media,' e 3 s o ~ s ,:IR physicians musl bear in min d the negative side effects

Th e mental health mon'mem has brought a grea ter that ca n accompany 3n intensified emphasis on health'ange of emotional distress and maladaptive person and heightened expectations of medical care. OthertlilY STyles to psychiatric artention, along ",;th dif wise, when massive health care expenditures, strenui c u h i t : ~il l s('xual pert():';n,.n{;(, st"lf-asse.f1ioll. :wel ous f'fforts 3 : risk-factor mod ific3til.'m, and conscien)cwpational functioning, Finally, medicint" 'has ac tious visits 1(, the doc lor fail to enhance well-being,lllirrd I n ! ' ('apabilitv of "In'alin!!:" perfC'Cdv normal disenchantmt'IH and disillusionment with medical:haracteristics and tuncUUIIS, Anabolic steroids an d care aloe li;"',';:_ it , gr"w,

\

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http:///reader/full/visits.30http:///reader/full/visits.30http:///reader/full/symptoms.31http:///reader/full/symptoms.31http:///reader/full/diagnosis.31http:///reader/full/diagnosis.31http:///reader/full/remediable.34http:///reader/full/remediable.34http:///reader/full/remediable.34http:///reader/full/condi%EF%BF%BDight.39http:///reader/full/condi%EF%BF%BDight.39http:///reader/full/corrected.38http:///reader/full/corrected.38http:///reader/full/speciaities.37http:///reader/full/speciaities.37http:///reader/full/visits.30http:///reader/full/symptoms.31http:///reader/full/diagnosis.31http:///reader/full/remediable.34http:///reader/full/condi%EF%BF%BDight.39http:///reader/full/corrected.38http:///reader/full/speciaities.37


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As a society, W ~ must be careful lest our mr-dicaladvanc es make us all the more uncomfortable wit h theafflictions that remain unconquered. Physicians mustbe careful not to foster this way of thinking or uhimately to accept blame for it. We need not curb thepursuit of health, bu t only pay more attention to cultivating subject ive feelings of wel.J-being as well.

Ib:n::RENcEsI. Depanmenl of HeaIlh and H _ Sc:mc:es. Public HcaIdI Senicc. HeaI!b.

UDiu:d StalC:S; 1985. WasbillgIDo. D.C.: Gow::ramr:mPriAIiIIIOffice. 1985.(DHHS ~ 110. (PHS) 86-1232.)

2. Roprs DE. BIcncIon RJ. The c:IIIapIg A:me:riaulMatdl . . ..... . : sumaimesIhiDp F I beDa:. lAMA 1977; 237:I7J0-4.

3. Shcncr E. Bedside 1DIIIIIII!f'S: die IIVUbIed hisIory of doclOl$ aM patic:ar:s.New Yori:o SimoD &: ~ . 198.5.

4. Bco::sc.P8. Oae I!uI!idRd ....... of Amc:Ii

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