David Healy: Shipwreck of the singular
Shridhar Sharma’s comment
Dr. David Healy, in the fascinating title of his paper, “The Shipwreck of the Singular”, has raised many interesting issues from the ‘the origins of a Dialectic, Industry, Asylum Psychiatry, Social Psychiatry, Biological Psychiatry, the Epidemiological Paradigm and Big Pharma Big Risk’. Naturally, when one covers such diverse fields, there will be some disconnect. But in his concluding paragraph, Dr. Healy makes an important observation, “Clinical practice is becoming degraded and there is an increasing need for clinicians to relearn the skills of listening to, seeing and touching patients”. It will have to engage with a biology that recognize organ rather than with bio-babble.
All the diverse areas mentioned in his thought-provoking paper, need careful consideration. Firstly, the concept of disease has often been influenced by medieval scholastic doctrines. The defining characteristics of three kinds: (a) Clinical abnormalities, (b) Pathological abnormalities of structure or function and (c) Noxious etiological agents. Hence, the concept of a disease depends on our choice of defining characteristics, for if that choice is arbitrary, e.g., the disease of tuberculosis will be defined by pathological or etiological characteristics or both, Plato’s realism or Aristotle’s nominalism. How they are reflected in the concept of disease. Platonic disease entity was unique, it commended the definite article in general parlance. Thus, people suffered from such diseases as the “pox” and “the dropsy”. While according to Aristotelian realism, diseases were regarded as particular natural or supernatural things, leading to an independent existence in our environment (e.g., miasmata, effuvia, astral influences from which the term influenza derives, evil spirits, sins and curses). There are, today still, traces of primitive theories in our speech when we talk of disease carriers (who are healthy themselves), of transmission of diseases, infection and heredity or prevalence of a disease in a community refers to something existing in a nominalistic reality, namely particular objects. Patient, person and diseases have no independent existence there. Later, in 1895, a German pathologist, Virchow, said “The disease entity is an altered part of the body in principle on altered cell or cell aggregate.” He stated, “Disease is a living entity, which has a parasitic relationship with the otherwise healthy body, to which it belongs and at the expense of which it lives. During the same period, some early bacteriologists as Dr. Ehrlich from Germany regarded diseases in a similar way as living entities, having an independent existence outside the body of a patient. As a result, it became customary to say that a patient has a gastric ulcer, a pneumonia, a depression and so on. This custom is now on the way out, as far as primary disturbance of metabolic functions are concerned, but there are pitfalls when nominalism is taken to extreme.
Secondly, what is not clear is the specificity of the relationship between particular psychiatric illness and particular physical disease. Only when this is known can research advance toward the identification of common factors that could have etiological significance. Evidence that physical diseases and psychiatric illness occur more frequently than would be expected by chance, can lead to improvements in identifying the population at risk. Sometimes psychiatric treatments may induce physical illness, e.g., diabetes, hypothyroidism, tardive dyskinesia, liver disease, sexual dysfunction, menstrual disorders, cardiovascular disorders like hypotension, ECG changes, tachycardia, parkinsonism, skin problems, retinal changes, nasal problems, urinary retention and other endocrine disorders.
There is also needless controversy about the social side of medicine and biology. It was Hippocrates, who stated that “Human well-being is influenced by the totality of environmental factors, living habits, climate and the quality of air, water and food”. And health results from the equilibrium among the body’s four humors and harmony between the body, environment and person’s living habits. This holistic view has persisted in many cultures. There is no contradiction. Further, culture is that complex whole, which includes knowledge, beliefs, arts, morals, customs and any other capabilities and habits acquired by a human as a member of a society. Thus, culture is a collective programming of the human mind that distinguishes the members of one human group from those of another. Culture in this sense is a system of collectively held values. And biology and culture act on one another as the conditioning parameters of neuro-cultural information. Culture conditions and stimulates biology, while biology conditions and makes culture possible.
Dr. Healy’s remarks on Social Psychiatry need some clarification. The term “Social Psychiatry” has a long tradition. In 1803, Reil in Germany introduced the word ‘Psychiatry’. After hundred years, in 1903, the term ‘Social’ was coined when Georg Ilberg from the Grob-schweidnitz asylum, in Saxony, in German, wrote a paper entitled simply “Soziale Psychiatrie”. Ilberg defined Social Psychiatry as a theory of the detrimental influences that affected the mental health of the whole population and as a useful means for their prevention (Ilberg, 1903).
Ilberg, at that time, suggested that about 60 to 70% all medical diseases exhibited a hereditary component. Today, Social Psychiatry is concerned with the relationship between disorders of mind and the human environment. It studies the forces which act at the interface between individuals and those around them and which may contribute to the onset course and outcome of mental disorders. There is, thus, a complex relationship between the molecular biology of the cell and the social environment.
While, History of Asylums is linked heavily with social and scientific attitudes towards mental health and the attitudes of those afflicted with mental illness, both of which have changed greatly over the past century. We know, and history shows that mankind characteristically treats its sick in accordance with the understanding which happens to be current. In 1891, William Farr an English statistician said the following words, “That is best system under which the greatest number of lunatics recover their reason in the shortest period of time” (Farr, 1891). By the mid-1950’s, the first Psychiatric drugs became available for the treatment of mental illnesses, such as chlorpromazine, which revolutionized psychiatric care and provided for the first time ways for many of the severely mentally ill to return to normal society. Later, effective treatments led to reductions in the number of patients in mental hospitals.
Today, with the emergence of the Global Health movement, the concept of evidence-based medicine, ‘Disease burden’ on economy and role of big pharma have certainly changed our priorities and traditional role of the health system (Stuckler et al, 2009).
I feel, today, Globalization is emerging as a big challenge to the mental health system. Globalization is a system which is dictated by an ideology. The ideology is that of “Market Force Economics”, where the invisible hand of the market mechanism is allowed to operate unimpeded”. “Big Pharma” is part of this ideology. Globalization is also an inexorable technology driven process, which is also linked to the ideology of economics. This new phenomenon is increasingly making the health service industry global. The global impact of technology on health and mental health has to be seen from two angles. It provides new tools, better drugs in the field of diagnosis, treatment and “New Hopes for the Patients” (Sharma, Sharma, 2012). Nevertheless, irrational diffusion of technology and over-use of expensive drugs has negative consequences. We must carefully examine related cost benefits and ethical questions. To grasp these aspects, it is essential to continuously assess growth of technology, role of big pharma, related economics and its appropriate use. Dr. Healy has timely warned and raised an important issue, which requires careful introspection by the professionals and policy makers. Problems can be the cutting edge that distinguishes between success and failure. They draw out our innate courage and wisdom to solve the problem.
Farr WR (1891) Stat. Soc. J 14, 17.
Ilberg G. Soziale Psychiatrie. Monatsschr Soz Med 1903; 1: 321-29, 393-8.
Sharma Shridhar, Sharma Gautam. Globalization: Challenges and Opportunities in the Field of Health and Public Health. Int. Med. J, Japan 2012; 19(4):282- 5
Stuckler D, Basu S, Suhrcke M, Coutts A, McKee M. Public health effect of economic crisis and alternative policy responses in Europe: an empirical analysis. Lancet 2009; 374: 315-23.
May 12, 2016