"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, ..." Charles Dickens, A Tale of Two Cities
Dickens' words, written in 1859, could aptly describe contemporary society's experience of modern medicine, miraculous or mistaken, death defying or dubious. We worry more than ever before about our health.
Health care cost, access and quality are very real concerns. But I wish to address the somewhat different day-to-day anxiety we Americans experience about our health. This is a curious state of affairs when one considers the remarkable medical advances since the Second World War. A timeline of medicine's greatest hits reflects this golden age:
- Penicillin 1941
- Smoking identified as cause of lung cancer and
- Tuberculosis cured with streptomycin and PAS 1950
- Chlorpromazine for schizophrenia and the first intensive care unit 1952
- Open-heart surgery and polio vaccine 1955
- Cardiopulmonary resuscitation 1956
- Endoscopy 1959
- Oral contraception 1960
- Levodopa for Parkinson's disease and hip replacement surgery 1961
- Kidney transplantation 1963
- Stroke prevention programs and coronary bypass grafting 1964
- Heart transplantation 1967
- Neonatal intensive care 1970
- Cure of many childhood cancers 1971
- CAT scanner 1973
- First test-tube baby 1978
- Coronary angioplasty 1979
- Thrombolysis for heart attacks 1987
- Triple therapy for AIDS rendering it a nonfatal illness 1996
- Viagra therapy for impotence 1998
The previous 2,000 years had seen no significant therapeutic discoveries for the scourges of infant mortality, infectious disease, surgical death, cancer, heart disease or mental illness.
In 1900, 30 percent of all deaths occurred among children aged less than five years. By the end of the century, that percentage was only 1.4 percent.
In 1900, the leading cause of death was infectious disease. At century's end these diseases were largely controlled with infectious disease causing only 4.5 percent of deaths.
The 20th century witnessed a 30 year increase in life expectancy.
And yet, despite these unprecedented advances, more people feel uneasy about their health today than in 1900 or 1940.
I believe there are three reasons. Two relate to events on the hit parade of 20th century medical accomplishment and can explain much of the paradoxical loss of confidence in our health; the discovery that smoking causes lung cancer and the realization that high blood pressure causes stroke and cardiovascular disease.
The third and perhaps most powerful cause of our anxiety concerns modern medicine's impact on the way we die.
Let's take them one at a time:
1. The revelation that smoking, a nearly universal post World War II habit, caused a fatal illness introduced the idea that health was tied to lifestyle. A habit that seemed to cause no harm in the short term could kill you. From that time forward, people had to wonder what other behaviors might prove lethal.
2. The impact of connecting high blood pressure to stroke and cardiovascular disease was more insidious. Hypertension, a remarkably common ailment affecting about 30 percent of the population, is usually silent, causing no symptoms. You go about your business feeling fine. Prior to the connection of hypertension and fatal disease, it was fair to assume that if you felt well, you were well. Suddenly how you felt was no guarantee. You no longer had to feel sick to visit a doctor. In fact, annual visits became the norm.
And death is not what it used to be.
As late as 1910, less than 15 percent of Americans died away from home. To die at home was to die in a familiar place with people who knew you.
National polls indicate that approximately 80 percent of Americans wish to die at home. However, only 20 percent succeed. About 60 percent die in acute care hospitals and 20 percent die in nursing homes or hospices.
The cause of death has also changed. Prior to the invention of antibiotics, most people died of infectious diseases. Doctors had little to offer in terms of cure and focused on easing suffering.
The length of illness also differed. While infectious diseases usually ran a short course before killing, the major contemporary killers (cardiovascular disease, cancer, stroke, diabetes) are usually chronic conditions that inflict a long deteriorating experience before death. This lengthens the period of dependence.
As medicine racked up the achievements I listed above, its ethos changed. Easing suffering and managing the inevitable gave way to medical heroism, rescue and an all-encompassing battle against death.
Fantasies of defeating death are not hard to promote. Removing death from view helps. This has taken many forms.
Less than a century ago most homes had a room called the "parlor" where important social events took place. One of the most important occasions often was a viewing of the dead and a religious service before burial. In a linguistic demonstration of distancing death from our lives, the parlor became the "living room". The function (and name) once served by the parlor moved outside the home, hence "funeral parlor."
The relocation of death from home to hospital, nursing home and funeral parlor has made it less familiar and consequently more frightening. Attempts to mask aging, while nothing new, have grown increasingly extreme and speak to a more intense reluctance to acknowledge the inevitable.
Older people now represent a larger part of our population than any time in our history. This happens to coincide with a medical era when incurable chronic diseases define a long deteriorating final chapter marked by significant dependence. Non-medical societal changes have contributed to this picture. In 1950, one-person households represented 1-in-10 households. By 2000, they comprised 1-in-4.
The priorities of the ill as they approach death are to be with family, have the touch of others, control pain and not be a burden. Many now fear end-of-life medical treatment more than death. Eye-opening investigations of advanced directives such as "Do Not Resuscitate" indicate that patients' wishes are routinely not honored.
Hospices and palliative care have begun to address these needs. But we have a long way to go. No one wants to die alone, in pain, plugged into a machine, away from home. And far too many do.
Death is inevitable. The way we die is not.
For more by Paul Spector, M.D., click here.
For more on death and dying, click here.
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