Sunday, March 11, 2007

A hypothetical question

Let's say you were suddenly granted the magical power to wipe one human disease off the face of the earth, as if it had never existed. Which disease would you choose and why?

Before I give my answer, let me explain why the question interests me. I’ve noticed that there seems to be a lack of thought and communication in medicine regarding the implications of disease. As physicians we hand out diagnoses left and right without really explaining what those diagnoses are going to mean to our patients. What does it mean, for example, to live with diabetes, or coronary artery disease, or rheumatoid arthritis? How devastated should you feel if you are given one of those diagnoses, and how will the diagnosis change your life? To the extent that we do answer these questions, we tend to downplay the impact to our patients. “It could be worse,” we might say, or we may neglect to tell them some of the more depressing details of their new condition. How likely, for example, would we be to tell a 50 year-old woman newly diagnosed with rheumatoid arthritis that she is now much more likely to have a heart attack and that her life expectancy has just dropped by 4 years? In the semi-dispassionate setting of this blog, I’d like to open a more frank discussion about which of mankind's diseases are its worst enemies.

The question also comes to mind in part because of the controversy surrounding the HPV vaccine. Many conservatives, apparently, are against universal vaccination because they feel that it would encourage sexual promiscuity. Presumably, if they had the power to eliminate the virus simply by pushing a button, they would pass on the opportunity. Never mind the thousands of women who die from cervical cancer every year around the world; their fate apparently is a necessary reminder that sex should be reserved for marriage. I wonder, would these people also decline the chance to remove the world of HIV? It’s a mystery to me how with such attitudes the religious right can still be considered to hold the moral high ground in this country.

But let’s talk diseases. Here are some considerations:

Scope – how many people does the disease affect, and how many does it kill?
Demographic – does it affect young or old people?
Preventability/treatability – can it be prevented and/or treated?
Potential for cure – does a cure seem to be just around the corner anyway?
Sin factor – does it strike indiscriminately or is it related to drinking, smoking, drug use, over-eating, and/or philandering?
Personal – has the disease affected my family or people that I care about?
Chill effect – does the disease have any particularly terrifying aspects?

My answer:

Stroke kills an extraordinary amount of people (second worldwide) from early middle age to old age. It has taken down some of the world’s foremost leaders including Woodrow Wilson, Franklin Roosevelt, Winston Churchill, and Ariel Sharon. We know how to reduce its incidence by treating blood pressure, cholesterol, and aneurysms before they rupture, but it’s a disease that we are unlikely to be able to control to any great extent in the near future. It strikes indiscriminately but with a predilection for certain families; if you belong to such a family, your life is lived in fear, and if you don’t, well, you shouldn’t make the mistake of thinking that you’re safe.

What’s really frightening about stroke, though, is its debilitating morbidity, which comes swiftly and without warning. A listless limb isn’t such a huge loss, but when you lose cognitive function – the ability to think and speak, your memories, your personality even, then you’ve lost something sacred. The feeble thoughts that enter your brain can no longer be trusted, and the you that people used to know and love is no longer you. What could be more damaging to a person’s dignity than having his or her very identity destroyed by disease? In an instant, one can go from an intelligent, articulate, fully self-sufficient individual to a lifelong invalid, unable to care even for one’s own most basic needs. With all of the uncertainty and potential for suffering in life, if just the mind could be protected, I think that would be of the most added benefit and comfort.

Any other takers?