The medical profession in Idaho was built on the shoulders of giants. One such giant was Dr. Charles “Fuzzy” Stuart. Dr. Stuart was a WILLIAM OSLER FELLOW at The Johns Hopkins School of Medicine. Dr. Osler was one of the founding fathers of American Academic Medicine. When Dr. Stuart came to Idaho, he was one of the original oncologists at the Mountain States Tumor Institute (MSTI) at St. Luke’s. Dr. Stuart was smart but most of all wise. Two sayings from Dr. Osler he related to me, both of which I believe have relevance in clinical medicine and public health.
The first quote: “Give somebody a chronic disease and have them take meticulous care of it and they will outlive everybody”. The second he would say to patients both who were cured of their cancers and who were obsessed with recurrence and those who were only going to have a short time to live: “You can either start living or start dying, the choice is yours”.
Another giant in the field of medical oncology Columbia University Professor and a recent Pulitzer Prize winner Siddhartha Mukherjee has voiced similar views in the Wall Street Journal Review, about the similarities between a cancer diagnosis in a patient and the public health issues facing society today with the Covid virus. “In recent weeks panic over the latest turn in the contagion has been spreading like well, a contagion, creating a special place in the anxious imagination”. Fear can easily become delusional, and when trying to develop a mitigation strategy based on coercive compliance public health specialists have created “anxious imaginations”. This has become a process to which the media has become an accessory.
Cancer and a pandemic are both diseases of risk. Because of technology and advances in science risks in both fields are better able to be quantified, but our tools are far from perfect. Dr. Mukherjee warns that in trying to detect risk we can unleash “pervasive anxieties”—-a feeling of “being under siege by the future”. In the cancer world the word “previvor” has evolved to mean a person who has yet to experience an illness they may or may not develop. Today we live in a world that everyone expects to develop Covid, and many people expect to develop the most devastating of symptoms. David Scadden also a clinical oncologist, wrote a best-selling book called CANCERLAND that described a place where people begin to feel all encompassed by their disease. In the past only those with a diagnosis of cancer were allowed to be members of “Cancer land”, but with improved surveillance technologies citizenship is open to everyone. By pulling individual citizens into the always increasing domain of surveillance and testing, they encourage people who are at low risk and without the disease to become dependent not on themselves but on “the experts” in and out of government. As Dr. Mukherjee puts it “As the shadow of future illness dilates and magnifies, so too do the shadows of anxiety and dread”
The hope of identifying a disease in an at-risk population is alluring and beneficial to those most vulnerable. In the WSJ Review the name of Erving Goffman was mentioned so I looked him up. He uses the term “total institution” to describe a community of similarly situated people that sever their ties from other groups of people… Mr. Goffman saw this happening in hospitals, prisons, private schools, and professional organizations. Over time these communities morph—converge and breakup and reform many times over, leading to an “enclosed formerly administrated round of life”. I saw this happen in my own professional life with my family. I was many times still “in the hospital” when I was at home.
There needs to be rules as the “surveillance state” grows. Who should be surveilled and who should be isolated? Who should be treated? When? Where? Rules need to be made as to when surveillance, mitigation, and treatment begin and end. “Give someone a chronic disease and have them take meticulous care of it”. A world in which chronic medical risk could be managed by an outside agent would be utopian and totalitarian. Be aware of those who promise utopia even politicians and doctors. A risk factor world where we are not given the responsibility of managing our own risks may be worse than the disease. By increasing the surveillance state, we might decrease the risk of some diseases, while significantly increasing the number of healthy people undergoing medical treatment. The allocation of scarce resources toward wellness and not toward disease has been an ongoing debate for 100 years. Clinical medicine and public health both should have a place at the table in this debate. But most of all citizens and patients should have a voice. We know best what is best for ourselves. If the pandemic has taught us anything it is that a top-down administered health care system doesn’t work unless one has the money and means or influence to access that system early on.
The fear of our own anxieties, along with the promise of protection from “experts” against a dreaded disease—cancer or Covid, can of themselves be difficult to mitigate. The surveillance culture may in fact be the beginning of a new illness, a new self-imposed chronic disease. Because of the surveillance culture the lines between wellness and illness will be blurred. A vaccination card may become a passport into the new world of “well-illness”. The hospitals and insurance carriers will figure out how to code and bill for this new disease. The margins are far better if one takes care of patients who aren’t sick. There will be a new “mantra”. Test as often as possible. Treat as little as possible. Sick people and those on the margins will suffer the most. Remember Governor Cuomo sending 30,000 sick patients back to nursing homes many who reinfected well but at-risk elderly residents who were being tested weekly? Test but don’t treat!
We have a chronic disease that only we individually can mitigate and treat. Science and medicine can point us in the right directions, but the choices are ours not theirs. It is time to follow Dr.Osler’s and Stuart’s advice: “It is time to start living” Covid is a chronic disease that with meticulous care, we can all live a long time. That is what the “experts” in government, public health, and the media aren’t saying. I for one believe more in us than I do in them.
People like Dr. Cole and the 850,000 physicians and scientists including me, that signed the Greater Barrington Project have defined individual risk and used mitigation and treatment strategies that empower individuals not systems. The doctor patient relationship is at the center of such a system, not a Governor’s Advisory Board or Health District.
MIGA “Fight Like Hell”