“If only I’d known … “  I’ve heard it a lot, that phrase, when people talk to me about their various medical misadventures. ” If only” someone had realized the potential consequences of that surgery or those drugs or that ostensibly innocuous test – before they’d done it. Maybe they’d have asked for a second opinion or talked to a few people who had done the same thing. Waited. Not assumed that it was safe and easy, like the brochures promise. Except of course most of us don’t know – so we go ahead. It’s only later that we realize that everything carries a risk; all drugs have side effects; all medical interventions are ambiguous.

The popular narrative is self-assured, authoritative and leads us to believe that medicine Knows. Knows why we get sick, how we get sick. The problem is, most of the time it does not. Particularly when it comes to prevention.

Acute illness – well, as a rule it does OK but the model is different. Let’s face it, if you’ve just fallen off a ladder and heard an ugly “crunch”; you have a temperature of 42C and a stiff neck and are delirious; if you are doubled over in agony with abdominal pain – the risk of what could happen without medical intervention is probably far worse than the alternative. So you rightfully race to the ER and get help – do whatever it takes.  Hey, I’m with you; when  I’m deathly ill I’m not stopping to look at statistics or evidence or googling “abdominal pain”, I want Dr. House.

The problem is when we extend this model to prevention. That’s when we’re walking along, singing a merry song – having a good day thank you very much – when our glance idly falls on some seemingly innocuous headline or pamphlet or poster warning that You Are At Risk. A ticking bomb, in fact, unless you do something immediately. You need that blood pressure checked, those glucose levels looked (diabetes on the rise you know), your cholesterol measured. You need to head over to that mammography clinic post haste. Or if you’re a guy, you need to have that PSA looked at. Or a bone density test. In other words, you need to engage in “pro-active” health care. Most people naively believe that this is good advice – and that’s when they can get into trouble (and many realize medicine is nowhere near as blindingly accurate in this as most of us think).

On television, on web sites, on the radio – whatever it is, whether it’s drama or news, it’s all presented with authority. Implication: we know what causes heart disease, we know how breast tumours evolve into cancer, we know how normal physiology morphs into pathology.

The trouble is we don’t.

And unlike those doctors on House or Mercy or whatever the medical show du jour happens to be, the outcome in real life is rarely neat and often not pretty. Contrary to what the news items tell us, it’s not all overwhelmingly positive and very little is “miraculous” or a true “breakthrough”.

Here’s where the risk/benefit thing kicks in. If you’re in pain, sick and feeling like hell, you don’t care what the risks are. It has to be better than whatever’s going on right now. Plus, that high temperature and stiff neck could be meningitis – which could kill you in less than 48 hours if you don’t get antibiotics. That crunch in your spine could mean paralysis. That abdominal pain could be appendicitis. Whatever the down side of the surgery, the side effects of the drugs, well, they probably aren’t worse than death.

But when we merrily head over to the clinic to have our blood checked for lipids, we are assuming that those panels of experts who’ve decided that anything above or below X is bad and wrong and abnormal know what they’re talking about. We assume that “they” know what ideal blood pressure is for a person of our age and weight and size; a person who eats the way we do and has the family we have; is, in other words, us. When we docilely head over to have mammograms and PSA testing as we’re bid, well, that’s where it gets tricky.

Take cholesterol. True, in a fairly smallish subset of people, hyperlipidemia or the tendency to create more cholesterol than the body needs, will create problems. Often, these are the folks who have had one or more close relatives drop dead of a massive coronary at a young age, say 50. Interestingly, often there is a geographical connection – people from northern countries such as Scotland seem to have this tendency.

What evidence there is (and virtually all of it comes from drug companies) does tell us that after a person has had a heart attack, lowering cholesterol with medication does seem to reduce their risk of a second one. But in people who’ve never had a heart attack, what is called  primary prevention? Not so much.

Not that you’d know it from the television ads for statins and other cholesterol lowering meds on TV that here in Canada we get from across the border. (Direct-to-consumer ads are only allowed in the U.S. and New Zealand – all other countries ban them.) They make it sound as though it’s a moral imperative to take drugs if your numbers aren’t right. In fact, cholesterol is needed for normal physiologic functioning. It protects against infection and not having enough, as Finnish researcher Ravnov has shown, can be dangerous.

(For more see his site: http://www.ravnskov.nu/cholesterol.htm and also the Cholesterol Skeptics site: http://www.thincs.org/ which includes hundreds of names of physicians, researchers and other bit ‘names’.  Also see “Should we lower cholesterol as much as possible?” in the BMJ (3 June 2006; Vol 332, pp 1330-32)

What they don’t tell you is how many of those expert panels the makers of these drugs have funded. Or that the whole idea behind cholesterol as a risk factor came from the Framingham study, a longitudinal study begun in the late 1940’s in Framingham (Massechusetts), in a report where a researcher hesitantly noted that it seemed as though cholesterol might be a factor in heart disease. (That was what the Framingham study initially was looking at, cardiac disease and why its incidence seemed to be on the rise at that time. And, they wanted to test out some cool new technologies that were being developed like the electrocardiogram.)

Science deals in probabilities, in maybe’s; it is a dynamic process. Individuals are not statistics and what works for one may very well not work another. Plus, medicine is just as prone to fads and fashions as anything else. Unfortunately, too often in the culture we have it descends into dogma.

And that isn’t healthy.

Two weeks ago President Obama signed what is being called an “historic” health care bill, and belated the United States is to have a sort-of-almost-maybe national health care system. Except that much like the Holy Roman Empire, which was neither Roman, holy nor an empire, US health care will not be universal (some fifteen million people are still left out in the cold), national (people still have to buy health insurance) or particularly historic, since everybody else in the western world got health care 40+ years ago. So, er, hurray.

comme-ci, comme-ca health care*

Of course everybody hates it.

The left because they maintain, not unreasonably, that Obama gave up the public option (early on he seemed to be harbouring the vain hope that it would lead to some bipartisan support) and as such Medicare, the existing system for seniors, was not expanded – which would have at least provided a kind of national health care without starting from scratch. Pity. That would have been the logical route. But nooo. Not in America. So, the basic, dysfunctional structure of American health care remains – and insurance continues to stand firmly between the patient and the health care provider.

The right hates it more and for a lot more reasons – although there’s some serious irony here since the genesis of this bill was the Republican proposal to counter what was dubbed HillaryCare back in the 90’s.

First and foremost, the right is cranky because a lot of them listen to Glenn Beck and Fox News and hang out at those tea parties where there aren’t any sandwiches, and they simply hate anything Obama does. More rationally, however, they object to the form of the bill, which forces individuals to purchase health insurance (which, if they can’t afford, the government will subsidize). Here they have a point, since you have to admit it does seem a touch undemocratic to make people buy something whether they want to or not.

Republicans add that the the bill makes no attempt to cut costs or deal with the ludicrous consequences of  litigation; this argument is true albeit disingenuous since if they had actually got involved, as Obama had asked, they could have added that in.

Business is not too keen on this bill either, probably because health insurance is currently provided, for the people who have it, through their employer, and business has no idea what this bill implies for them, and they loathe uncertainty.

(The bill would tie health insurance to the person, so even if they lose their job they keep their insurance. There is also talk of creating some kind of risk ‘pooling’ for people who are not employees but self employed or what-have-you. Plus, in theory at least, insurance companies will no longer be allowed to turn away people with pre-existing conditions – though I’m sure some clever lawyers are already figuring out other ways to reject people they think will cost too much. Too tall, perhaps or too freckled.)

My problem with this bill is its fundamental premise, namely that health care has to be administered by insurance companies. It’s a nincompoop idea and only one that a country besotted with business could endorse.

Insurance companies, boys and girls, are what are known as bu-si-nesses. This means that they exist to  make money: their raison d’etre is profit. If it were otherwise we’d call them, oh, NGO’s. Not-for-profits. (That’s what we used to call charities before we opted for the more unwieldy name.) Except that health care, medicine, is not and cannot be (ever!) a business. Economists long ago realized that it simply does not fit the market model.

Health care is not a commodity. You cannot make money on health care. Never mind that you shouldn’t. Why? Well, for those of you who missed Econ 101, I’ll explain. Please pay attention, there’ll be a quiz later.

The free market is at heart transactional: I make hand-embroidered doilies; you, for reasons that elude everyone else, like and want hand-embroidered doilies. So, I make them and you buy them from me. And we’re all happy. I, in turn, use the money I make to buy things I want/need, like food and shelter and some really cool stilettos. Supply and demand.

But (and here’s where it gets tricky), if a villager in China can make aforesaid doilies that are just as nice for a lot less, then you will get them from her so I will be out of business, unless I move my manufacturing to an even cheaper place, Bangladesh, say. This, in a nutshell, is the free market, which, in Adam Smith’s immortal baker metaphor, does not rely on the goodness of anyone’s heart but is inherently rational. As are consumers.

Now you and I both know that this is patent nonsense. Not only are most people not rational consumers, most of the time they  are crazy. Or, as a psychiatrist would say, stark raving bonkers. Why else would tens of thousands of people line up on Boxing Day to get a gizmo they don’t need? Or pay good money to buy a piece of bacon wrapped in a pancake with a list of ingredients too long to read? (I could go on but you get the picture.)

Even if consumers aren’t nuts their actions are often dictated by a lot of things other than reason, price and need. Otherwise nobody would ever buy a Kelly bag or have eighteen pairs of virtually identical black trousers. But for the sake of argument, let’s stick to the model – this is 101, remember, and we don’t have time to veer into behaviorial economics and all that complicated stuff like status and advertising and whatnot.

So homo economicus operates on simple efficiency and if he or she can afford it, they will get the best darn doily or car or house they can get. So, people with money get the nice stuff, the cashmere sweaters and the Prada belts, while everybody else makes do with Joe Fresh and H&M. That’s life according to economics.

Health care doesn’t work that way. Nobody gives up a trip to the Bahamas to check themselves into the hospital for a quadruple bypass for fun. That’s because, in economics-speak, health care is not a direct “purchase” but is subject to agency issues. In other words, there is a person or a group between the person and whatever is being bought, whether it’s a bypass or a prescription. When I feel sick, no matter how many internet sites I surf or friends I text, I really don’t know the reason; I need a doctor. Or a nurse. Or a faith healer if that’s what I happen to believe in. Even if I did figure it out the diagnosis, I can’t write myself a prescription or do surgery on myself. I need someone else, an “agent”, to confirm my choice. (In terms of that quadruple bypass I should really go back to the internet and do some serious research because there’s no evidence it is in any way preventive if I’m feeling all right, but that’s another post.)

Medicine, unlike cars and refrigerators and new tiles for the bathroom, is about a patient, a person who is sick and vulnerable and scared and in no position to make rational choices about anything. This is also why there are medical ethics and professional organizations and the Hippocratic Oath (though that’s just a metaphor, the actual Oath hasn’t been used for nearly a century no matter what TV shows would have you think.)

“Enough”, when it comes to cars and refrigerators and trips to sunny Spain is only limited by your budget and, presumably, greed and appetite: if you really want thirty six SUV’s, or feel the need to stuff your kitchen with 97 Sub-Zero fridges full of chocolate ice cream and would like to give Imelda Marcos a run for her money when it comes to shoes – well, if you can afford it, it’s your choice. Medicine is not like that.

Too much medicine – too many medical interventions – can kill you.

It’s called iatrogenesis. A term from the Greek, meaning harm caused by medical treatment. One aspirin can take away your headache; popping the whole bottle is a suicide attempt. One operation could save your life (if it goes well) but if you have an appendectomy and for whatever reason things screw up and you end up in ICU with sepsis and need four more operations, well, you could easily end up maimed or dead. In fact the more you get done medically, the lower your chances.

As Peter Davis writes in the Canadian Medical Association Journal (“Health Care as a Risk Factor”, http://www.cmaj.ca/cgi/content/full/170/11/1688), close to 70,000 preventable adverse effects occur each year, some 20% of which result in the person’s death. This, writes Davis, is not because hospitals are inherently dangerous places but because the “unchallenged therapeutic imperative” tends to move people to ever-higher (and more complex) levels of care, levels that they are unable to sustain.

When people proudly proclaim that American health is “the best in the world” therefore, as they are wont to do, what they mean is that they have access to more MRI’s and operating theatres and doctors than anyone else. The model they’re using is that of the market. Except they’re dead wrong (so to speak). By any objective measure American health care is the worst in the developed world. Life expectancy is lower, infant mortality is higher and your odds of surviving healthily after a heart attack are considerably lower than they are anywhere else in the west. Why? Iatrogenesis. Americans do too much. Too many tests, too many surgeries; too many drugs. In short, overtreatment. Because medicine in the US is treated like a commodity, like cars and refrigerators and Prada bags, which it is not.

That’s what Obama’s bill didn’t even begin to address. True, some of the currently uninsured might, if  all goes well, not end up bankrupt if they get sick. More people will have access to health care. The notion that health care might be a basic mark of a civilized society has at least come up and might even be discussed further. It will continue to cost too much (16% of GDP at last count versus an average of 10% in Canada and France and everywhere else); doctors will continue to practice “defensive” medicine and Americans will continue to get sub-standard care. But at least it is a start.

Too bad it was so fitful.

* photo c/o creative commons and newsrealblog.com

When things work out well – contrary to expectation – it is only right and proper that one acknowledge this. And, as it turns out, the Olympics (whatever the long-term consequences might be) appear to have been a stellar experience.  People even less enthused about them than I (whose interest, to quote Edward Lear, would have had to grow to be even cursory) have told me that the energy was positive, the vibe, good and the atmosphere good-natured: in short, the whole experience was simply splendid.  For whatever reason, these 2010 Winter  Olympics brought out the best in people, visitors and residents alike.

So all in all A Good Thing – and now that the 2010 Winter Olympic and ParaOlympic Games are over, closing ceremonies and fireworks finished, one can breathe a sigh of relief and say: Bravo Vancouver!

Inevitably, a handful of people have taken this wonderful memory way, way too far – at least according to what I read. These folk are said to be “grieving” the end of this huge party, this wonderful feeling of liberation, this sense that Vancouver was a real city, united and at one with the universe. Ah, get over it. Parties end, everybody goes home, the mess has to be cleaned up.

I’ll wager the many small businesses who did zero business during the Olympics aren’t that sorry to seen the end of it, no matter how much as individuals they may have liked dancing in the streets. (A merchant at Granville Island, a hub for many pavilions and events, told me that “unless you sold fast food or booze you didn’t sell anything”.) Perhaps that is why, pleased as I am that it all went well, that I am glad (nay, ecstatic) that I left the city and that it’s bloody over.

My impression is that festivities tended towards youthful exuberance and the beer-fuelled; my proclivities tend more towards red wine and quiet jazz. A friend who wrote an Olympic Diary to record the wonderful time she and her husband had relates that they stood in line for nearly three hours to get into some pavilion or t’other – and frankly, I wouldn’t stand in line that long to meet the late JC .

I don’t see the point of wandering the streets, no matter how charming the crowd or super-cool the win – which that Canada-US hockey final turned out to be.

And the crowds go wild when Canada wins hockey gold

Even the massive police presence felt benign, protective, apparently. There were a few hiccups at the start, particularly the second day when some scary looking ski-masked thugs broke windows at the Bay downtown and the police looked really jittery. But things settled down – and the massive crowds felt like a large, happy family.  Another friend, about as enthused as I was at the outset, told me he found himself (much to his own astonishment) high-fiving a large, mildly sossled,  American gent partying downtown and this uncharacteristic gesture actually felt right.  OK, that’s impressive.

Perhaps it was all that international attention, the bulk of it positive.  This I noticed on my travels; people really seemed psyched about Vancouver and not just the gorgeous scenery, although that did garner much attention. The mountains! The water! The forests! Si beau! And wasn’t I lucky to live in such surroundings. I smiled and mumbled something lame. One cannot, after all, take credit for nature. Still, I couldn’t help feeling a little chuffed. (I didn’t mention I live in the heart of the city and not up in the Whistler mountains.)

Most impressive was the fact that more people turned out to watch and cheer the ParaOlympian athletes than ever before, something no host city or country has done. That was elegant.

So now can we say it was all worth it? Too soon to say, really. True,  we did get a metro to the airport from downtown (though having lived a few blocks away from the construction I am still smarting from the dust and noise). And Vancouver did raise its international profile – but will that translate into actual benefits, economic or otherwise? More investment, better and more social housing, fewer homeless people, more opportunities? Possibly, but I doubt it.

In the grand scheme of things, then, did any of it matter? This short event, lasting only a few weeks, no matter how grand everyone says it was? To quote Bertrand Russell: “The fact that an opinion has been widely held is no evidence whatsoever that it is not utterly absurd.”

Well, a spot of absurdity is not the worst of things in a world where so much seems so unrelentingly dreary.  So, ephemeral as it may have been,  to everyone who was here, to the many volunteers and guides and people who worked on the Games, to the athletes and coaches and all the rest: a tip of my fedora and a red-mittened high five.

The Vancouver Olympics may not have changed the world, but they didn’t stink. A curmudgeon can’t say fairer than that.

My friend, web designer Mia Johnson, with her daughter & gallery owner Diane Farris out there after that hockey win.