SOCRATES: I’m back.
ROSE: What took you so long?
SOCRATES: Sorry, a sporting interest has distracted me…Where were we?
ROSE: You were going to give me my report card back.
SOCRATES: Ah yes! Well, it’s mixed…
ROSE: I could sense as much.
SOCRATES: You see, Geoffrey, I think that you let your political sensitivities get ahead of your science.
ROSE: What do you mean?
SOCRATES: Let’s reflect on the tension between individual freedom and social constraints, a topic which you naturally discuss. You would agree that people have diverse viewpoints about what is an appropriate constraint on individual freedom and what is not, wouldn’t you?
SOCRATES: People can disagree both on the kinds of constraints that are appropriate, as well as the degree to which a given constraint should be allowed. For example, some people may be very comfortable with military conscription when the nation is facing a certain level of perceived threat, yet readily object to mandatory vaccination even if the nation were to face a serious health threat.
ROSE: I grant you that, although this particular position seems quite irrational to me.
SOCRATES: I’m not saying that it is rational or not, I’m only pointing out that people do hold different opinions on the subject, and those opinions cannot be placed on a simple scale. Other people may favor both military conscription and mandatory vaccination. For the most part, most will be able to articulate some reasoning behind their position. One can disagree with a given position, but you cannot outright accuse people of being irrational for holding a certain position. One’s choices in that regard are complex and governed by a number of factors.
ROSE: Including social conditioning!
SOCRATES: Yes, but you yourself admit that social reality is not strictly determinant of individual behavior (1). In that, you seem to have some reservation about Emile Durkheim‘s theory, although some scholar’s have highlighted some commonality between your perpective and his. A bit further in your book, you jab at Margaret Thatcher and her view that “society does not exist, there are only individuals and families.(2)”
ROSE: That’s a most appalling moral viewpoint and I still can’t get over that we allow ourselves to elect governments with such disregard for the effects of social conditions on people’s behavior and chances in life! But where are you going with this?
SOCRATES: Would you agree that your political views gravitate toward the cluster of opinions that might be called progressivism? In general, that worldview calls for social reforms, support for welfare programs, particularly in health care, and dislike of militarism.
ROSE: Socrates, if your point is that my political views have shaped my preventive strategy, I think you really missed my point.
SOCRATES: It is, and I don’t think I have. But let me ask you point blank: you don’t think your research shaped your political philosophy, do you? Nowhere in your book, which is quite personal, do you mention any sort of “conversion” in your worldview as a result of your work as an epidemiologist.
ROSE: I think that’s correct. My views, like those of most people, were formed by the time I was a young adult. But I tell you this, Socrates, nothing in my work has challenged my political convictions. If anything, my research has affirmed them.
SOCRATES: That’s pretty much where I was going, Geoff. Let me take you back to the first chapter of your book, which we have not really covered and where you lay out the foundation arguments for your interest in prevention.
ROSE: I didn’t think there would be anything controversial there!
SOCRATES: That may be precisely why the chapter is worth examining. You start the very first paragraph of your book with a simple observation, if I may quote:
Few diseases are the inescapable lot of humanity, for a problem that is common in one place will usually prove to be rare somewhere else. Cervical cancer is twenty times commoner in Colombia than in Israel, 10 per cent of Indian children die before their first birthday whereas in Western countries 99 per cent of babes survive, and according to UK census figures 3.1 per cent of adults in Wales report that they are permanently sick, compared with only 1.2 per cent of residents in southeast England. There is no known biological reason why every population should not be as healthy as the best.(3)
And you end the chapter with a pithy remark which you call “The Humanitarian Argument:”
It is better to be healthy than ill or dead. That is the beginning and the end of the only real argument for preventive medicine. It is sufficient.(4)
ROSE: What’s wrong with that and why are you smirking?
SOCRATES: It’s because it seems you are taking issue with the one thing I’m most famous for!
ROSE: Come again?
SOCRATES: Come on, Geoffrey! You took elementary logic, didn’t you? How do students learn the basic form of a syllogism?
ROSE: All men are mortal, Socrates was a man, blah, blah, blah. I get it… but again, what’s your point?
SOCRATES: You claim that “few diseases are the inescapable lot of humanity” and you contrast being healthy with being ill or dead. But while no single disease is the inescapable lot of mankind, some disease surely is, don’t you agree? Sometimes, being dead is the healthiest thing that can happen.
ROSE: I see your point, perhaps I was over-emphatic on this. But what does that change?
SOCRATES: You approach things with the enthusiasm of a positivist.
ROSE: That’s absurd! Positivism was discredited as a general theory and I do not hold that everything can be reduced to quantifiable phenomena.
SOCRATES: Did I touch a nerve? I don’t want to apply a label to you, Geoff. I didn’t accuse you of being a positivist but only of having the enthusiasm of one. And that’s a natural and sometimes laudable inclination, provided it is kept in its proper boundaries.
Look who you quote in the second paragraph of your book:
Epidemics appear, and often disappear without traces, when a new culture period has started; thus with leprosy, and the English sweat. The history of epidemics is therefore the history of disturbances of human culture. (R. Virchow, quoted from Ackerknecht, EH. Therapeutics from the primitives to the 20th century) (5)
My point is this: Like Virchow, you start off your inquiry with a view that disease (and perhaps much of evil) is the result of faulty social structures. Consequently, the solution lies in improving the social structures. For Virchow, most disease was infectious or nutritional, and he could directly relate epidemics to social problems of hygiene, war, poverty.
ROSE: Not a bad insight, if you ask me.
SOCRATES: Yes, but with the improvement in hygiene and water sanitation and the development of vaccines and antibiotic treatment, infectious epidemics vanished but, low and behold, other diseases began to surface: hypertension, coronary disease, diabetes. What’s worse, those newcomers affected the rich! One couldn’t easily invoke “disturbances of human culture” here. It was back to the wrath of God!…Until, of course, the risk factor concept was introduced.
ROSE: So far, so good, Socrates, no objection to what you are saying.
SOCRATES: Except that the risk factor is a puny substitute for the germ theory of disease. Here we have Koch’s postulates, there we have the p value. Here we have a single etiologic agent, there we have “multifactorial” muck.
ROSE: Well, that’s reality. What do you want us to do? Sit around until we find the cause of heart disease?
SOCRATES: I understand that you’re limited with what you have to work with, on the one hand. On the other hand, easy adoption of the risk factor concept opens many doors! And for you, that was your opportunity to connect social determinants with health and make achievable what Virchow dreamed to see established: that “Medicine is a social science, and politics is nothing else but medicine on a large scale. (7)”
In other words, you found in the risk factor a scientific justification for your political inclinations.
To summarize your theory: Disease occurs at the tail end of a continuous risk factor curve —> Entire risk factor curves can be seen to “shift” when social conditions vary, accounting for the changing prevalence of disease —> Social conditions themselves can be viewed as continuous risk factors curves and ultimately account for the majority of diseases —> In order to prevent disease in a meaningful way, we must tackle social “inequities.”
ROSE: Not a bad formulation. I like it.
SOCRATES: Perhaps you were conditioned to liking it by your pre-existing political convictions. Pasteur may have said that “chance favours only the prepared mind,” but a mind that is too prepared to anticipate certain patterns can be fooled by its observations. It seems that you were so keen on demonstrating the nefarious effects of social problems that you quickly latched on to your idea of shifting distribution curves, but overlooked many holes in your theory.
ROSE: And what holes are we talking about?
SOCRATES: I already highlighted the problems with your view that every disease follows a continuum, as well as the problem of not always knowing what shape the distribution curve follows (which you concede). There is also the problem that epidemiology cannot usually establish causation—and you concede this point as well.
There is the problem of adequately defining what the “population approach” is and distinguishing it from the “high-risk” approach. One can define abnormal cut-off values for a risk factor such that its prevalence will be greatly increased and the distinction between the two approaches will be blurred.
In terms of trade-offs between implementing what is good “for the population” and the cost that must be borne by individuals for the benefits of the collectivity, although you acknowledge early on the “prevention paradox (8),” you do not deeply consider its moral implications. You only emphasize the potential benefits to individuals that the population approach can bring. And for all your claim that ‘personal freedom is paramount (9),’ you minimize the paternalism of your strategy.
Most importantly there is the problem of unintended consequences of population-based interventions: a minuscule error in judgment will have massive consequences. You did not live to see the rise in obesity in Western countries, which some researchers attribute to misguided dietary public health policies. You also missed the embarrassment felt by the medical community in finding out that the estrogen replacement therapy which you advocated to reduce osteoporosis and which others promoted to reduce cardiovascular disease led to countless increases in thrombosis, stroke and cancer cases. There are many such cases where expert opinion is convinced that the proposed intervention carries little risk and can reap great benefits, only to find itself dumbfounded by reality.
In terms of social and political changes, no one will dispute that poverty is the mother of all risk factors. But the remedy lies in understanding correctly what constitutes prosperity. The experiment to abolish inequalities has been carried out several times in recent history. The effects on health have been rather disastrous…
Finally, as much as you side-step the issue, the population-based changes which you advocate can only be implemented under the strong arm of government. I find your treatment of the role of government to be rather confused. The State cannot at once “protect the individual’s freedom” and carry out population-wide changes. Public health services have historically always emanated from the military. I’m afraid your attempts to shift curves are tantamount to a form of civil war.
ROSE: A civil war! That’s the last thing I intended! I even said that war is the largest threat to public health (6)!
SOCRATES: Then declare peace on risk factors and let doctors deal with them at the local level.
ROSE: What level would that be?
SOCRATES: The level of the examination table, of course.
ROSE: Is that all you have to say?
SOCRATES: I told you my report card was mixed, therefore there must be some good in all of this. I must tell you that your observation that blood pressure curves can “shift” is most provocative in light of the Platt vs. Pickering debate.
Contrary to what you, think, that debate was never really settled. The fundamental question about the ‘nature of hypertension’ remains essentially unanswered to this day. The dispute fizzled in the early 70’s primarily because of therapeutics. Once the blood pressure could be lowered safely, no one cared any more if hypertension was a distinct disease or the tail end of a spectrum of normality.
For the most part, doctors continue to behave as if Platt was right. Public health advocates view high blood pressure the way Pickering did. There is a modus vivendi between the two position that masks a true underlying contradiction. Platt and Pickering cannot both be right! Perhaps that’s why the hypertension community seemed to now be tied into a knot and why the Americans have been unable to produce new hypertension guidelines in almost 10 years.
At any rate, if your observation that blood pressure distribution curves shift is correct, it raises questions of major proportion. For this insight, the medical community owes you a tip of the hat.
ROSE: Thank you Socrates, but where do we go from here?
SOCRATES: I’ll leave it at that, Geoffrey. I’m only wise enough to ask the questions. If you want to pursue this more, I suggest consulting the student of a student of mine. He would appreciate the opportunity to be once again solicited in mainstream academic circles.
- Rose ‘s Strategy, 2nd ed. p. 95-96
- Ibid p. 129
- ibid p. 35
- ibid p. 38
- Ibid p. 35
- Ibid p. 157
- R. Virchow, 1848 Die Medizinische Reform, 2. Quoted in Henry Ernest Sigerist, Medicine and Human Welfare, (1941) 93.
- Ibid p. 47
- Ibid p. 148
UPDATE: This series is now complete and consists of a total of 9 posts. Beginning with Post #3 I am aided in this exploration by a legendary cross-examiner who interviews Geoffrey Rose’s directly and in depth in an informal Q&A format. Quick links to the part are here: 1, 2, 3, 4, 5, 6, 7, 8, 9