The Waiting Room
It is Monday morning in the waiting room of an imaginary general practice on the outskirts of the inner city. The patients include students from the nearby university, factory workers, shift workers, business people. Many ethnic groups are represented. Let us suppose that I work in this busy practice with four or five other doctors. We all get on well together and often discuss difficult cases with each other. All of us have areas of special interest in medicine, and we have a wide range of outside interests. Mine is a hobby farm in a bushland environment a few hours out of the city. These various interests form the subject matter of many of our lunchtime conversations.
In the waiting room on this busy morning are a group of typical patients who could be in any city, any suburb. Some have cuts or sprains from weekend sporting activities or need a routine check, but most have chronic health issues such as high blood pressure, depression, menstrual disorders, headaches.
My colleagues and I have recently been to courses on nutritional and ‘alternative’ medicine. We felt that it was time we learnt about the safety of the things our patients are taking. Lately they have been asking us about treatments such as St John’s wort and glucosamine. One of us has a pregnant wife who is taking vitamin supplements. Does my colleague know that this is safe? She eats well, why would she need them? Is there any scientific evidence?
My first patient of the day is Mary, who is 28 years old. She has come to see me because of chronic, low-grade depression and a feeling of ‘just not being well’. She has a job which she enjoys and good friends. A two-year relationship ended amicably a few months ago, and she currently does not have a partner. She says she wants her own space for a while. She eats reasonably well, although she admits to a sweet tooth and perhaps more coffee than she ought. She drinks a fair bit of tap water because she has heard that this will help to keep her bowels regular. She drinks alcohol within a safe range and is a non-smoker. She gets some exercise, although admits she hasn’t had a lot of energy lately.
Her medical history includes mild asthma with seasonal exacerbations, for which she has a range of puffers. She uses at least one of these most days, but regards her asthma as fairly easy to control. Her bowels are usually okay, but if she’s not careful she can become constipated. She is on the oral contraceptive pill although she has no current need for contraception. She has been on the pill on and off since she was 16 and says she is scared to come off it because she will have heavy cramping periods and her skin will break out. When she first went on the pill she was still at school and did not need contraception. The doctor she was seeing at the time said it would be the best thing for the cramps that were keeping her away from school one or two days a month, and it would also help her troublesome acne. At the time of commencement she had never had a migraine. She has had three or four migraines since, but the doctor thought that it was okay for her to take the low-dose pill.
Her blood pressure went up a bit on the pill, but as it is in the normal range she and I have agreed just to keep an eye on it. We plan to do this regularly, because I am also treating her mother for mild hypertension. Mostly the pill controls Mary’s painful periods but sometimes she has to take an anti-inflammatory. She is totally dependent on these when she is giving the pill a ‘rest’. At those times, she often has to take antibiotics for her skin as well. She gets mood swings around the time of her period, and thinks these are a bit better on the pill, although she suspects that her overall well-being is reduced. She has discussed with me her lack of interest in the things which used to give her pleasure. We have talked about an anti-depressant, but she is not keen to take that path yet.
There is probably a Mary in every doctor’s waiting room every morning of the week, and few doctors would argue with the treatments she is on. After all, one in four Australians now has a lifetime expectancy of asthma, and although this is one of the highest rates in the world, other developed nations are not far behind; in the UK, 5.2 million people are receiving treatment for asthma and that figure is 20 million in America. And it’s known that certain illnesses such as asthma, migraine, depression, dysmenorrhoea and irritable bowel cluster together — in individuals, in families and in cultural groups.
So it’s common for these conditions to occur together, and we’ve also come to accept it as normal. But have we accepted Mary’s symptoms too readily? When we see whole families of asthmatics and migraineurs we think of shared genes, but how can such conditions be shared by whole cultures?
If we look at Mary, and the thousands like her, from the perspective of a hundred years ago, or of a rural dweller from the rapidly vanishing tribal peoples of the world, her diagnoses and treatments are nothing short of astonishing. Here she is, still in her twenties, a healthy individual, and yet she has been, or is, taking:
• a beta adrenergic bronchodilator
• oral or inhaled corticosteroids
• synthetic oestrogen and progesterone
• long-term antibiotics
• a non-steroidal anti-inflammatory pain killer
• a specific anti-prostaglandins medication.
As if this is not enough, an antidepressant could soon be added if things don’t look up. Most of her medications require a prescription, or at least dispensation by a trained pharmacist, in Western countries. A look at the associated list of side effects, precautions, drug interactions and warnings of use in pregnancy soon explains why. These medications are not to be taken lightly.
If we look at the various treatments Mary has had, there is no underlying pharmacological consistency. Each has targeted a specific problem. The bronchodilator she takes for her asthma is unlikely to do much for her mood swings or her tendency to constipation. If these conditions tend to cluster, it seems intuitive to expect that a treatment for one might have a favourable effect on the others — assuming that the relationship between the conditions is at least partly causal, which commonsense seems to dictate.
But Mary’s medications lack logical connection with each other. Some are potentially incompatible. This incompatibility may be pharmacological — that is, the drugs themselves interact in a negative way — or it may be to do with the symptoms. The action of the steroid medication could well worsen the depression. If Mary is among the 20 per cent of asthmatics who are sensitive to aspirin, the medications she takes for her period pain may make her asthma worse. If she were a severe asthmatic this would rapidly become apparent, but as she is usually well controlled the overall deterioration over time may not be connected to her intermittent use of aspirin-like painkillers.
Even a few decades ago, patients like Mary would have had a much narrower range of medications at their disposal. There might have been something for her asthma, and some aspirin or paracetamol for her pain. Under the age of 40 or 50, only an unusually sick patient would have been taking more than a couple of prescription medications on a regular basis.
What is so bad in the human design that one in four now needs drugs in order to breathe normally? What is so maladaptive about a menstrual cycle that it regularly puts a significant number of women to bed once a month? Mary has not got asthma because she has a Ventolin deficiency, and menstrual cramps are not caused by Ponstan deficiency. Why does she — like thousands of others — have such a constellation of medical problems, and such a galaxy of pharmaceutical solutions to them?
These are the questions that we are beginning to debate in our lunchroom at work. To begin to answer them, we have to start a long way back, at the moment when some humans decided that hunting and gathering was too hard.