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 Human beings have always been concerned about personal health. Historically, this concern has ranged from mere consciousness amongst the young to overt obsession as we approach old age and senility. At the core of our national quest for ‘happiness’, we would like to see ourselves physically strong, attractive and youthful. After all, what is ‘happiness’ without health?

    I have been in the medical profession since the early 60s. I have watched this ‘healthy’ consciousness blossom into a full-fledged obsession in the late 80s and 90s when a number of socio-cultural factors confluenced to fundamentally alter the way we perceive our physical and mental health. Besides the national anxiety over rising health care costs and diminishing health care accesses, besides the periodic mourning about managed care and malpractice, we are now bombarded with a veritable deluge of medical information about everything from Botox to Viagra, cancer to osteoporosis. One specific factor has been the direct advertisement of prescription medications in television and other public media. Aside from directly responsible for the astronomical price increase of these medications, this daily bombardment of Lipitor, Prilosec,Vioxx, Zyrtec and Allegra in our living rooms have made the ordinary folks suddenly acutely aware of the availability of these wonder drugs and how they can cure all ills from falling hair to diminishing libidos. We are suddenly drug savvy and demanding of the latest and best that medicine can offer regardless of the cost, side effects or restrictive third party payments.

    The second important development to shape our collective health consciousness has been the electronic media. Like everything else in our lives, the Internet has fundamentally changed how we obtain and process our information regarding health. Hundreds upon thousands of websites have sprung up like mushrooms after a rain, touting everything from legitimate treatment options to snake oils. In the true cyber democratic tradition, all are given equal status in the electronic world. Thus ordinary public has no dependable way to sort the wheat from the chaff. In the not so distant past, medical information was limited to professional people only. But that era of ‘paternalism’ is over.  While the easy access and open discussion are certainly desirable for the education of the patient, incomplete or incorrect information without proper perspectives can cause unwarranted anxiety and hypochondria.

    The third factor –closely associated with above two—is the increased—indeed incessant –reporting of the latest medical studies. Most news services now have a full time medical reporter, not unlike a sports reporter or a foreign news reporter.  Every newscast devotes significant time not only on breaking important news like SARS epidemic but also on the latest half baked study reports, not yet published or even peer reviewed data on something like the effect of eating cabbage on incidence of gallstones! Most of these reports are over simplified and made to fit a 60 seconds sound bite without any explanation of methodology, statistical limitations or context. Even reputable medical journals are regularly ‘scooped’ days or weeks before the journal even reaches the physician’s desk. Inevitably incomplete findings are reported, only to be retracted or radically changed next week. Thus, one week we hear that fish is good for our diet and next week we learn that it is loaded with deadly mercury.  One week we learn that hormones are good for bone building after menopause, next week we hear that they also can cause cancers. One report says mammograms save lives; other reports they may not make any difference. Understandably, the lay public is confused and frustrated. A person without scientific background does not understand that this apparent confusion is the normal process of science, that these seemingly random baby steps of progress precede major breakthroughs. The frustration may cause some to tune out completely and others to become overly vigilant in following each new information as the gospel truth.

    I am completely in favor of educating the patient (lately known as ‘healthcare consumer’) and sharing all facts with him and his family. However, sometimes too much information may be as harmful as too little, causing undue anxiety and unreasonable expectations. The constant bombardment of health information makes us believe that drugs are panacea for all that ails humankind. Currently the so-called ‘life style’ drugs are the best sellers of all. There is drug to cure baldness (Minoxydil), a drug to take away your blues (Prozac), a drug to make you feel sexy (Viagra), a drug to make you slim down (Dexatrim), and a drug to cure hot flashes (estrogen), to mention a few.

     One area where American health consciousness has been markedly affected is in the area of preventive screening for diseases like cancers and their pre-diseases. True, early detection by mass screening can make a life or death difference in individual patient’s life, as well as marked decrease in certain common cancers like cervical cancer. However, this has been achieved at a great cost of over diagnosing many benign and insignificant diseases.  In addition to diagnosing true diseases, common cancer screening tests like mammography for breast cancers and serum PSA tests for prostate cancers routinely over diagnose numerous benign, non-lethal conditions that need to be examined further at the cost of high personal anxiety and health care costs.

    Probably the most successful test for early detection and prevention of cancer is the Pap test for uterine cervix cancer. Introduced some 50 years ago, this test has been hugely successful in reducing the rate of cervix cancer, which is still the number one killer of women in those countries where this test is not available. It is inexpensive, easily done and relatively painless, ideal for a mass-screening test. A few cases still seen in this country are mostly due to lack of proper follow up of an abnormal test rather than any deficiency in the test itself. But, thanks to our colleagues in the legal profession, we had to spend enormous resources to update this test. The ‘new and improved’ Pap test costs three times more and delivers only slight overall increase in accuracy. Ironically, the increased cost makes this test unavailable to the uninsured, indigent women who are at a great risk of this cancer and need the test the most.

    At the risk of sounding fatalistic, we need to understand and accept that all these tests may work well in a population, but in individual cases, nothing is guaranteed. Disease may strike in spite of repeated normal checkups.

    We the ‘baby boomers’ are not the first generation facing old age and death. We could learn a thing or two from our parents’ generation. They did not consider any of the above to be a ‘disease’, let alone spending good money for the ‘treatment’. Even now, in many traditional cultures, grey hair, baldness, a paunch, menopause and lack of libido are all considered normal physiologic processes of aging. In many cultures menopause is not mourned as loss of youth but welcomed with relief as freedom from the hassles of monthly bleeding and risk of pregnancy. Lack of sexual desire too is seen as a freedom from earthly desires and ties, indicating purity of the soul, not something to be treated with Viagra!  I remember my mother in India, proudly showing off her very first grey hair, eagerly anticipating that venerable age of wisdom, respect and authority. Old age is to be revered not feared. Wrinkles and grey hair are to be proudly shown off as badges of honor, signatures of maturity and wisdom, worthy of respect, not to be ashamed of. But somehow we have lost that perspective. We not only actively try to postpone the inevitable but also actually look down on others who refuse to do so as being negligent of their own health! Somehow we have come to expect all 70 year olds to be physically and sexually active. Anyone not being so is viewed as ‘abnormal’.

    I wonder why this desire to prolong youth has such a strong hold in our psyche. Our predecessors did not waste their energy trying to postpone death as we do, (or is it that they had no choice in such matters or had other more important problems on their minds?). Perhaps they were strengthened by their faith and spirituality, something that seems to be in short supply nowadays. I remember my grandmother praying the Lord to ‘take her’. It was not because she was suffering physically, was depressed or suicidal, but she just felt that her job was done and she was mentally ready to go. In America, any healthy octogenarian acting this way will be definitely treated for depression if nothing else.

    In this country we go to any extreme to stay alive and look youthful. In spite of the awareness of living wills, and DNRs, 90% of the health care dollars is spent in the last year of one’s life. We will consume expensive medications, undergo costly procedures, and spend weeks and months in hospitals for terminally incurable diseases like cancer, stroke or Alzheimer’s. An entire specialty of Geriatrics has arisen to treat these diseases. We spend much of our research monies looking for cure of these diseases, forgetting that ultimately, one has to die of something. In old days, people died of pneumonia, usually at home, surrounded by relatives and friends. In fact, pneumonia was called the ‘old man’s friend’. Now we admit them in ICUs and treat them with antibiotics. So, now we die of other things like cancers. We can treat cancers too, but then we will die of say Alzheimer’s disease, perhaps in near future we shall have cure for Alzheimer’s too, only to die of some other yet undiscovered malady. Perhaps we have bought a few years at the end of our lives, but at a tremendous cost to society at large. For every bypass surgery on an 80+ year old, we are probably costing hundreds of childhood immunizations or prenatal care for pregnant women.

    No, I’m not advocating pushing all old people off a cliff, or stranding them on a drifting ice floe in the North Pole. But we can perhaps adapt some common sense approach and restrict certain costly procedures and medications for say people over 70 years of age, if that would mean providing better healthcare to younger people. Yes, many card carrying AARP members will be horrified at this suggestion, but some may actually endorse the idea. I personally know of healthy, sane, productive people who absolutely do not want to live a day beyond age 65! Contrary to the popular opinion, most people do not fear death, but dread the pain, suffering, loss of autonomy and personal dignity that usually precede death. A universal terminal palliative care may be achieved at a fraction of the cost we now pay. This must be every old person’s right. But beyond this ‘creature comfort’, we old people should try to be less selfish in giving up our hold on this earth and allow our children more access to the finite resources. Our time is past; we should make room for the next in line and exit gracefull.

    The fairy tale ends with “…and they lived happily ever after”. Perhaps because ours is still a relatively new country with abundant resources, we still have naïve optimism that we can cure anything and all can live happily forever. The two requisites for ‘happiness are health and wealth. We try our best to accumulate as much wealth and want very much to control and hang on to our health by preventing as many illnesses as possible and delaying death as long as possible. The current health obsession is a reflection of this ‘can do’ attitude that has been the source of strength in our society. But, in the matters of health and happiness, more is not always better.  We need to realize that there is no ‘ever after’. We need to bring down our ideas about health and happiness to a more realistic level and realize that it is possible to achieve both without mortgaging the future of the next generation.

AIIMSONIAN/2006