Deconstructing Modern Illness: Idiopathic or Iatrogenic?

A few weeks ago, I had the great pleasure of delivering a keynote address at the Midwifery Today Conference in Eugene, Oregon. As requested, here are my notes and the presentation deck. Enjoy.

Presentation Notes

Before we begin, I’d like to preface this talk with one of my favorite quotes by Maya Angelou:

“You did then what you knew how to do, and when you knew better, you did better.”

The talk I am giving is depressing. The magnitude of the health crisis we face is enormous. Indeed, from every angle we face threats of new diseases and disorders with a degree of complexity current medical practices are not equipped to deal with.

If I were a less hopeful person, I might bury my head in the sand. But I think, rather than sugar coat the difficulties we face, the only way we can find solutions for these problems to know more and do better. And so, in many ways, the quote above provides hope.

At the end of this talk, over the course of the day and course of your career, as you know more, you will do better. And that’s all anyone can ask of you – to keep learning and applying that learning and knowledge to the problems in front of you.

Today, I am speaking about how we deconstruct modern illness in a toxic world – and yes, the world is pretty toxic. What I’d like you to get out of this talk are three concepts.

Pregnancy is a time where we can break the cycles of bad health in a way not possible at other times of life. It has been my experience, that women trying to conceive and those who are pregnant and their partners are hungry for information about health. They want to learn about ways to improve their health so that they can have healthy babies. This means, as healthcare providers, we have an opportunity to affect change and improve the health of not only the adults but the children.  And so, we must take this opportunity counsel our clients to better health.

This brings me to the second lesson I hope to impart

Reproduction. I think reproduction should be viewed from a much broader and longer perspective. Some of the aspects of reproduction that we often don’t consider but should, include:

Dad’s health. So often when we talk about conception and pregnancy, all responsibility for the health of the pregnancy and child rests on the mom. This is absolutely shortsighted and as we see with the epigenetic, endocrine disrupting, mitochondrial impairing chemicals we face, dad’s health is equally important to the health of the offspring. Forgetting to include Dad in these conversations means opportunities lost.

Longer time frame both before and after pregnancy. I think we ought to consider reproduction across a much longer time frame. Ideally, both partners would begin cleaning up in the months and year before conception. Barring that, however, if we can begin working with couples earlier, maternal and fetal complications might just be reduced.

Similarly, the health of our children and their children depends upon our health. So any changes we make now, for good or for ill, impacts our children’s health and likely their children’s health. Therefore when we look at reproductive health, we must begin earlier and consider the long game – the transgenerational consequences of our actions.

Everything is connected to everything else. In Western medicine and science, we like to separate things, test theories, compounds, and toxicities individually; discuss diseases by morphological or physiological elements, neatly and concisely distinct from other diseases. And while that works in acute and emergent care, with trauma or injury, with basically everything else, this separateness doesn’t work at all. Think about it for a moment, from a logical or probability standpoint, which is more realistic, that we are a people with multiple, completely distinct disease entities, or the myriad of symptoms so many experience, have coordinate, common, connected, underlying causes that simply express in different organ systems. I think it’s the latter.

With modern illness (or maybe all illness), the kind of conditions that are chronic and where more often than not, multiple organs or systems are involved, simply tackling the health of one organ or remediating one symptom or set of symptoms in isolation, while dismissing the others, misses not only research and discovery opportunities but therapeutic opportunities as well.

So when I talk about deconstructing modern illness, a key portion involves understanding the connections between seemingly disparate disease processes.

Let the Deconstruction Begin

As I considered how to put this presentation together, I struggled with where to begin, what to leave in, what to leave out.

There is so much that needs to be understood about modern illness that we could fill a week of lectures and discussions. And we may, because I have way too many slides.

What I kept coming back to, however, is the notion that if I can teach you how to think health and disease, and medical treatments in general, if I can teach you how to question and evaluate the research, how to find the answers that you need; if I can give you a foundation and a framework for understanding the science, the economics and the politics of modern illness, then each of you can find your own answers, and perhaps, if you are so inclined, contribute back to the knowledge base, so that we all have a better understanding of these issues.

And so it is from that perspective that I have decided to approach this discussion. I want to give you a foundation and a framework from which to build your own house of knowledge. Sounds a little corny, doesn’t it, but bear with me, learning how to think critically about medical science might just save your life or the life of a loved one.

A Framework of Knowledge

I have a background and a natural inclination towards philosophy.

One of the questions that plagues my thinking is ‘how we know what we think we know’. I find that more often not, pondering from where and from whom the knowledge, the science, the politics, even the historical interpretations come from, tells us a lot about what it is we know exactly and what we really have no business claiming knowledge of.

With maternal health and in fact, the entirety of women’s health, when we deconstruct what is known and detach it from how we know it, or at least how we think we know it, it becomes very clear, very quickly, that our knowledge is severely limited.

In the title, I mention deconstruction. It means what it sounds like, a taking apart of things in order to understand the larger picture. The concept is a philosophical one, originating from a French philosopher Jacques Derrida. It was used primarily in literature to separate the text from the cultural associations in order to find a supposedly truer meaning. Ironically, his writing was all but completely indecipherable – so deconstruction of Derrida’s work was prohibitive, at least for me.

Nevertheless, the notion that we should look at a text, in this case medical diagnostics, what we consider illness versus health and the markers that reflect health versus illness, apart from their cultural context and what we assume their meaning to be, to see if they still prove valid, is a useful one. Often when deconstructed, the meaning, the validity of a particular definition of disease, is bundled with so many assumptions that its validity crumbles under its own weight. We’ll see this in many areas of women’s health.

Idiopathic or Iatrogenic?

The second part of the title reflects both the notion of deconstruction and the cultural context that influences the naming of things, but also hints a structural problem in medicine that comes from those assumptions. And if I am honest, it reflects my understanding, my biases towards modern medical care.

Idiopathic and iatrogenic are two terms routinely used in modern medicine.

Idiopathic, in particular is catchall for all of the disease for which we have no earthly notion about causation. A good percentage of the conditions affecting women are considered idiopathic.

When I was in graduate school, I read a report that suggested some absurdly high percentage of pregnancy complications were considered idiopathic – something like 60%. I have long since lost the report and have no idea if I am recalling the number correctly, but it was sufficiently high that I dug a little deeper.

How could it be that in the 21^st century we did not know what was going on with pregnancy? After all, women have been having babies since the beginning of time. It turns out, no one was looking, and if they were, that knowledge did not make into mainstream medicine.

At the time, pregnancy and maternal health funding was less than 2% of the total NIH budget, of which most was allocated towards pregnancy prevention. I would venture that there is wealth of knowledge in this room that if it were to make into mainstream ‘medicine’ might redefine many conditions considered idiopathic, but I digress. Virtually no money went to basic research, understanding pregnancy complications like pre-eclampsia for example, and so, complications that many women suffer from were, and yet are, considered idiopathic.

While the connection between idiopathic and much of women’s health is easy to attribute to a lack of money, the notion of idiopathy is much more complicated than simply funding priorities. After all, cancer is considered idiopathic – and as we all know cancer is an industry, receiving billions of governmental and private research dollars.

Implications of Idiopathy

Claiming something is idiopathic absolves us of personal responsibility and accountability – it means that it does it not matter what we put into our bodies or into the into the environment – a boon for industry and for all of us who want to have our cake and eat it too, but from a medical standpoint, it absolves of an our own willful ignorance.

It means we don’t have to ask any more questions, study anything else. It implies that what we do not know is not our fault – it is random.

It allows us to say cancer is random and that our behavior matters not.

It allows us to ignore research like this, that attributes 80% of cardiovascular disease to lifestyle – to what we put into our bodies.

Or research that says glyphosate is actually dangerous.

Or research that says perhaps we shouldn’t put chemicals of unknown effects into pregnant women.

It allows us to live a bubble, and presume no matter what we put into our bodies, whatever we expose ourselves to will somehow magically dissipate and not affect our health.

It allows us to effectively write-off the differences between women and men in things like drug metabolism. And for our purposes, it allows us to narrowly limit what is considered iatrogenic – to only a few readily acknowledged illnesses. It’s a position that is more akin to magical thinking than what we consider medical science should be.

How does this affect medicine and women’s health in particular?