Comments on: Richard Smith: The end of disease and the beginning of health http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/ Just another blogs.bmj.com weblog Tue, 24 Nov 2009 06:38:41 +0000 http://wordpress.org/?v=2.5.1 By: Artem http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-3336 Artem Sat, 13 Dec 2008 12:41:27 +0000 http://blogs.bmj.com/bmj/?p=412#comment-3336 the capacity to love and work - really great. OR other one similar which I like: "Health is a condition of highest freedom of an individual". the capacity to love and work - really great.
OR other one similar which I like:
“Health is a condition of highest freedom of an individual”.

]]> By: Dr.N.P.Viswanathan http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2647 Dr.N.P.Viswanathan Fri, 25 Jul 2008 11:16:49 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2647 Age is not a criteria. Feel young, be happy.Age grace fully. N.P.Viswanathan Age is not a criteria. Feel young, be happy.Age grace fully.
N.P.Viswanathan

]]> By: Peter Ward http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2645 Peter Ward Fri, 25 Jul 2008 06:05:48 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2645 When seeing patients with multiple prediseases, things that threaten harm but don't make you feel ill (NIDDM, BP, stable angina, high chol. etc), I have wondered what replies I would get if I could ask the patient " Now what would you rather have; simvastatin, aspirin, amlodipine, losartan and regular blood tests, or £40 a week cash and a free bus pass. I wonder which would improve health more? When seeing patients with multiple prediseases, things that threaten harm but don’t make you feel ill (NIDDM, BP, stable angina, high chol. etc), I have wondered what replies I would get if I could ask the patient ” Now what would you rather have; simvastatin, aspirin, amlodipine, losartan and regular blood tests, or £40 a week cash and a free bus pass. I wonder which would improve health more?

]]> By: shaun http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2640 shaun Wed, 23 Jul 2008 12:29:10 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2640 It really nice to read that “Ayurveda” the historical Indian system of medicine explain diseases as “awareness of any part of body” as disease. _____________________________ shaun <a href="http://www.addictionrecovery.net/south-dakota" rel="nofollow">Addiction Recovery South Dakota</a> It really nice to read that “Ayurveda” the historical Indian system of medicine explain diseases as “awareness of any part of body” as disease.
_____________________________
shaun
Addiction Recovery South Dakota

]]> By: Gary Rimmer http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2627 Gary Rimmer Thu, 17 Jul 2008 09:23:17 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2627 What quaint 20th century ideas you still have Richard. Health and Disease? Surely nowadays we all just have 'lifestyles' with differing ranks of clinical facilitators. What quaint 20th century ideas you still have Richard. Health and Disease? Surely nowadays we all just have ‘lifestyles’ with differing ranks of clinical facilitators.

]]> By: Tracey Lynn Perez Koehlmoos http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2624 Tracey Lynn Perez Koehlmoos Wed, 16 Jul 2008 17:57:34 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2624 Excellent posting Richard. Freud v. the WHO definition of health...I think there is a strong relationship between the two. If you consider that the social determinants of health without mentioning them specifically, include concepts from Freud that support Love and Work, which almost universally play a strong role in well-being and self-concept if not necessarily "health." And, yes, we should all exercise more, eat less and make love more often! Excellent posting Richard. Freud v. the WHO definition of health…I think there is a strong relationship between the two. If you consider that the social determinants of health without mentioning them specifically, include concepts from Freud that support Love and Work, which almost universally play a strong role in well-being and self-concept if not necessarily “health.”

And, yes, we should all exercise more, eat less and make love more often!

]]> By: Matt James http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2620 Matt James Wed, 16 Jul 2008 00:32:27 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2620 Dear Richard, I have recently turned 40 ... the same day you turned 56. Thoughts sometimes turn to my impending need for invasive checks that we are told to consider beyond this age. It's refreshing to consider new approaches such as health vs disease, but how would it benefit in practice? Or indeed benefit a practice? Maybe there is some middle ground we can aim to achieve, between accepting both? We once did the London to Brighton together which is great as a one off now and again, but I think that my hilly 1.6 mile ride to the BR station lock up each day is the steady healthy supping of exercise as opposed to the binge of a 60 mile ride once a year, or the addict's 4 sessions a week at the gym doing a spin class. Most things in excess are bad for you. We are designed to do what is required to keep us alive, not sit and eat saturated fats in front of the TV all day nor go for a 5 mile run before work each day. Obese people suffer from more from disease and die young, highly tuned athletes regularly explode in a heap of ruptured muscle, stress fractured bone and shredded tendon. Just look at our decimated Olympic squad! Then there is mental health, possibly our most neglected area of wellbeing. We should find things which amuse us as we get older, I think people laugh less with age and the relentless pressures that life dishes up dampen our moods too often. We all need to have time, again in moderation, to press the reset button and see life for what it is, reflect, take time out with people of our choice then pick up and start again. I guess, in conclusion, I believe a long healthy life is all about moderation, or if you are very lucky, the super-gene. Even this post will be moderated?! Dear Richard,

I have recently turned 40 … the same day you turned 56. Thoughts sometimes turn to my impending need for invasive checks that we are told to consider beyond this age. It’s refreshing to consider new approaches such as health vs disease, but how would it benefit in practice? Or indeed benefit a practice?

Maybe there is some middle ground we can aim to achieve, between accepting both? We once did the London to Brighton together which is great as a one off now and again, but I think that my hilly 1.6 mile ride to the BR station lock up each day is the steady healthy supping of exercise as opposed to the binge of a 60 mile ride once a year, or the addict’s 4 sessions a week at the gym doing a spin class.

Most things in excess are bad for you. We are designed to do what is required to keep us alive, not sit and eat saturated fats in front of the TV all day nor go for a 5 mile run before work each day. Obese people suffer from more from disease and die young, highly tuned athletes regularly explode in a heap of ruptured muscle, stress fractured bone and shredded tendon. Just look at our decimated Olympic squad!

Then there is mental health, possibly our most neglected area of wellbeing. We should find things which amuse us as we get older, I think people laugh less with age and the relentless pressures that life dishes up dampen our moods too often. We all need to have time, again in moderation, to press the reset button and see life for what it is, reflect, take time out with people of our choice then pick up and start again.

I guess, in conclusion, I believe a long healthy life is all about moderation, or if you are very lucky, the super-gene. Even this post will be moderated?!

]]> By: Les Simpson http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2616 Les Simpson Sun, 13 Jul 2008 22:39:07 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2616 Richard Smith's interesting commentary on his concepts of health and disease have drawn several significant responses. But none of those writers got to the real nitty gritty of good health which implies that because all tissues are functioning normally, then bodywide function is normal. Furthermore, normal tissue function implies that the rate of delivery of oxygen, metabolic needs, hormones, etc., are normal. Therefore if good health equates with normal tissue function, then normal rates of blood flow are needed for good health. But it is a strange feature of modern medicine that the very large literature which records changes in the flow properties of blood (blood rheology) in the major causes of morbidity and mortality is simply ignored. I have failed to locate a medical school which teaches blood rheology. Dr.Smiths reference to dementia can be used as an example. According to published reports based upon SPECT scans, the dementing process is accompanied by reductions in regional cerebral blood flow. I was greatly impressed by an early report of a man with myelomatosis. High levels of myeloma protein had greatly increased his blood viscosity. His major presenting symptom was dementia. When the myeloma protein was removed by plasmapheresis, normal blood viscosity was associated with normal brain function. I can only wonder if Dr.Smith is aware that his walking, running and cycling has the beneficial effect of lowering his blood viscosity. Although low level physical activity has ben shown to improve the quality of life in patients with major depression, post-natal depression and multiple sclerosis for example, such studies usually make no comment on the mode of action of the beneficial effects of exercise. In a 1998 review, Ajmani and Rifkind from NIH reported that the aging process was accompanied by an increase in blood viscosity and a reduction in red cell deformability. Such changes will have a detrimental effect on blood flow which will contribute to the functional changes which accompany aging. Because such changes are potentially treatable, it is difficult to imagine what savings in healthcare might result from the treatment of the blood rheology changes of the elderly. Such treatment would sustain the feeling of good health and their quality of life and their independence. But in the absence of treatment,the changes in blood rheology will contribute to tissue dysfunction in various parts of the body which would be conceived as ill health. The patient Lucy, may provide a good example of a situation where blood rheology problems have not been recognised. In 1966, Lancet published the first report of increased blood viscosity in type 1 diabetes. Many other reports have confirmed that finding, but there seems to be no clinical recognition of that information. Similarly, there have been many reports of changed blood rheology (frequently these are cholesterol related) in cardiovascular disease. But the failure to recognise such information meant that Lucy saw both a diabetologist and a cardiologist. In a world,"...where most of medicine is concerned with multiple chronic conditions combined with social and health problems," it is essential to recognise that stress of any kind will amplify the changes in blood rheology and worsen tissue dysfunction and symptom severity. For example, the effects of cancer on the internal environment alter blood rheology and red cell stiffness. The post-radio and chemo-therapy worsening of symptoms are accompanied by an amplification of the blood rheology changes. Such changes reduce in concert with symptom severity. Similar observations could be made about other chronic disorders. Until it is recognised that normal rates of blood flow are an essential component of good health, it is unlikely that treatments aimed at normalising blood flow will be used to increase the quality of life of those who live in chronic ill-health. Richard Smith’s interesting commentary on his concepts of health and disease have drawn several significant responses. But none of those writers got to the real nitty gritty of good health which implies that because all tissues are functioning normally, then bodywide function is normal. Furthermore, normal tissue function implies that the rate of delivery of oxygen, metabolic needs, hormones, etc., are normal. Therefore if good health equates with normal tissue function, then normal rates of blood flow are needed for good health.

But it is a strange feature of modern medicine that the very large literature which records changes in the flow properties of blood (blood rheology) in the major causes of morbidity and mortality is simply ignored. I have failed to locate a medical school which teaches blood rheology.

Dr.Smiths reference to dementia can be used as an example. According to published reports based upon SPECT scans, the dementing process is accompanied by reductions in regional cerebral blood flow. I was greatly impressed by an early report of a man with myelomatosis. High levels of myeloma protein had greatly increased his blood viscosity. His major presenting symptom was dementia. When the myeloma protein was removed by plasmapheresis, normal blood viscosity was associated with normal brain function.

I can only wonder if Dr.Smith is aware that his walking, running and cycling has the beneficial effect of lowering his blood viscosity. Although low level physical activity has ben shown to improve the quality of life in patients with major depression, post-natal depression and multiple sclerosis for example, such studies usually make no comment on the mode of action of the beneficial effects of exercise.

In a 1998 review, Ajmani and Rifkind from NIH reported that the aging process was accompanied by an increase in blood viscosity and a reduction in red cell deformability. Such changes will have a detrimental effect on blood flow which will contribute to the functional changes which accompany aging. Because such changes are potentially treatable, it is difficult to imagine what savings in healthcare might result from the treatment of the blood rheology changes of the elderly. Such treatment would sustain the feeling of good health and their quality of life and their independence. But in the absence of treatment,the changes in blood rheology will contribute to tissue dysfunction in various parts of the body which would be conceived as ill health.

The patient Lucy, may provide a good example of a situation where blood rheology problems have not been recognised. In 1966, Lancet published the first report of increased blood viscosity in type 1 diabetes. Many other reports have confirmed that finding, but there seems to be no clinical recognition of that information. Similarly, there have been many reports of changed blood rheology (frequently these are cholesterol related) in cardiovascular disease. But the failure to recognise such information meant that Lucy saw both a diabetologist and a cardiologist.

In a world,”…where most of medicine is concerned with multiple chronic conditions combined with social and health problems,” it is essential to recognise that stress of any kind will amplify the changes in blood rheology and worsen tissue dysfunction and symptom severity. For example, the effects of cancer on the internal environment alter blood rheology and red cell stiffness. The post-radio and chemo-therapy worsening of symptoms are accompanied by an amplification of the blood rheology changes. Such changes reduce in concert with symptom severity. Similar observations could be made about other chronic disorders.

Until it is recognised that normal rates of blood flow are an essential component of good health, it is unlikely that treatments aimed at normalising blood flow will be used to increase the quality of life of those who live in chronic ill-health.

]]> By: Bob Leckridge http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2609 Bob Leckridge Fri, 11 Jul 2008 19:58:27 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2609 Excellent post, Richard. I'm with you in the 50-something untested so still feeling healthy group! I think this is SUCH an important issue. I frequently ask groups of health care professionals to give me a definition of health WITH NO reference to disease or illness. Pretty much they are stumped. Sometimes someone suggests something like Aristotle's "eudaimonia" (often translated as "happiness" or the "good life" but better translated as "flourishing" - onto something there methinks!) The book I read which progressed my thinking about this was a collection of essays by the philosopher, Hans Georg Gadamer, "The Enigma of Health". Interestingly, Dr Atheya, he says quite a lot about this concept of disease being awareness of part of the body. Personally I've found the newish concept of "complex adaptive systems" ("CAS") to be helpful. A healthy CAS adapts ie it copes with change; it develops new behaviours and solutions to problems ie it is creative; and it is engaged ie it is in active interaction with its multiple environments. So that's my definition - ACE - Adaptive/Creative/Engaged. That's what I look for in patient outcomes. Someone who copes better, becomes more creative and more actively engaged with the world. http://heroesnotzombies.wordpress.com/2007/05/13/3-ways-to-know-if-you-are-healthy/ Excellent post, Richard. I’m with you in the 50-something untested so still feeling healthy group! I think this is SUCH an important issue. I frequently ask groups of health care professionals to give me a definition of health WITH NO reference to disease or illness. Pretty much they are stumped. Sometimes someone suggests something like Aristotle’s “eudaimonia” (often translated as “happiness” or the “good life” but better translated as “flourishing” - onto something there methinks!)
The book I read which progressed my thinking about this was a collection of essays by the philosopher, Hans Georg Gadamer, “The Enigma of Health”. Interestingly, Dr Atheya, he says quite a lot about this concept of disease being awareness of part of the body.
Personally I’ve found the newish concept of “complex adaptive systems” (”CAS”) to be helpful. A healthy CAS adapts ie it copes with change; it develops new behaviours and solutions to problems ie it is creative; and it is engaged ie it is in active interaction with its multiple environments.
So that’s my definition - ACE - Adaptive/Creative/Engaged. That’s what I look for in patient outcomes. Someone who copes better, becomes more creative and more actively engaged with the world.
http://heroesnotzombies.wordpress.com/2007/05/13/3-ways-to-know-if-you-are-healthy/

]]> By: Paolo Magrassi MD http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2607 Paolo Magrassi MD Fri, 11 Jul 2008 10:37:11 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2607 Uno splendido, brillante,e così veritiero " pezzo " di Mr. Smith ! I would be so glad if he would write another " piece " on the anti-ageing craze .... Uno splendido, brillante,e così veritiero ” pezzo ” di Mr. Smith ! I would be so glad if he would write another ” piece ” on the anti-ageing craze ….

]]> By: Robert Long http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2606 Robert Long Fri, 11 Jul 2008 07:25:27 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2606 I read your blog because I misread the title. I thought it was 'the end of disease and the beginning of death'. Maybe because I work in aged care and I have such trouble drawing the line. Perhaps its not up to me to draw the line anyway- it worries me. And then we often seem to have folk who die an expected death with endstage cardiac disease or other organ failure and who have 10 or so medications on their chart on the day they die, including the usual mix of statins, ACE inhibitor, aspirin, biphosphonate, and sundry puffers and most fruitless of all the obligatory warfarin. I read your blog because I misread the title. I thought it was ‘the end of disease and the beginning of death’. Maybe because I work in aged care and I have such trouble drawing the line. Perhaps its not up to me to draw the line anyway- it worries me. And then we often seem to have folk who die an expected death with endstage cardiac disease or other organ failure and who have 10 or so medications on their chart on the day they die, including the usual mix of statins, ACE inhibitor, aspirin, biphosphonate, and sundry puffers and most fruitless of all the obligatory warfarin.

]]> By: dr ps http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2604 dr ps Fri, 11 Jul 2008 04:19:06 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2604 hello This reminds me of what i read in text book of pathology by Robbins when I was an undergraduatemedical student..." if you look at the tree too much you miss the beauty of the forest". Today the specilisation and superspecialisation of "Modern Medicine" is busy looking at the tree too much and has missed the beauty of the forest called - health.. Dr P S Reddy hello
This reminds me of what i read in text book of pathology by Robbins when I was an undergraduatemedical student…” if you look at the tree too much you miss the beauty of the forest”. Today the specilisation and superspecialisation of “Modern Medicine” is busy looking at the tree too much and has missed the beauty of the forest called - health..
Dr P S Reddy

]]> By: Dr.Viveck Atheya http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2598 Dr.Viveck Atheya Wed, 09 Jul 2008 13:29:18 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2598 Indeed, the concept of health and disease need a revisiting.The 'disease' has been analysed and broken down to such minute levels-body,cell,gene and molecule that it has confused us.We need to rethink about diseases at each level and then reintegrate it and workback to the macro level to redefine the definitions. It will be interesting to note that "Ayurveda" the Indian system of medicine has defined disease as "awareness of any part of body" as disease.We need commonsense to help us out. Viveck Atheya Indeed, the concept of health and disease need a revisiting.The ‘disease’ has been analysed and broken down to such minute levels-body,cell,gene and molecule that it has confused us.We need to rethink about diseases at each level and then reintegrate it and workback to the macro level to redefine the definitions.
It will be interesting to note that “Ayurveda” the Indian system of medicine has defined disease as “awareness of any part of body” as disease.We need commonsense to help us out.

Viveck Atheya

]]> By: Danilo di Diodoro http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2595 Danilo di Diodoro Wed, 09 Jul 2008 09:52:17 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2595 I read and enjoyed it. I find very reassuring being in good company as a non sigmoidoscoped and non prostate specific antigen measured fifty-year-old-man. You know, I have a definition of health of my own: you are really healthy and you can completely enjoy your life when you can forget the existence of doctors and hospitals. Someone can do it, but I can't. As a doctor and a psychiatrist, and as a fifty-year-old-man, I know that I should screen my bowel and my prostate, etc., and I can't really forget it. Probably, I should drink more red wine to reach Richard's equilibrium... I read and enjoyed it. I find very reassuring being in good company as a non sigmoidoscoped and non prostate specific antigen measured fifty-year-old-man. You know, I have a definition of health of my own: you are really healthy and you can completely enjoy your life when you can forget the existence of doctors and hospitals. Someone can do it, but I can’t. As a doctor and a psychiatrist, and as a fifty-year-old-man, I know that I should screen my bowel and my prostate, etc., and I can’t really forget it. Probably, I should drink more red wine to reach Richard’s equilibrium…

]]> By: Christopher Buttery http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2592 Christopher Buttery Tue, 08 Jul 2008 17:46:08 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2592 Thank you for this blog. As a teacher of preventive medicine I am concerned that we do too much to provide technical perfection. 40 years ago Ivan Illich said much the same as you in his 'Limits to Medicine' which is one of the first readings I require of my students. Part of the problem is that the media have trained their readers/viewers to expect instant cures for everything. Thank you for this blog. As a teacher of preventive medicine I am concerned that we do too much to provide technical perfection. 40 years ago Ivan Illich said much the same as you in his ‘Limits to Medicine’ which is one of the first readings I require of my students. Part of the problem is that the media have trained their readers/viewers to expect instant cures for everything.

]]> By: Liz Wager http://blogs.bmj.com/bmj/2008/07/08/richard-smith-the-end-of-disease-and-the-beginning-of-health/#comment-2591 Liz Wager Tue, 08 Jul 2008 17:02:28 +0000 http://blogs.bmj.com/bmj/?p=412#comment-2591 At least one person read it ... but maybe bloggers reading each other's blogs is a new disease (but slightly less pathological than reading one's own) At least one person read it … but maybe bloggers reading each other’s blogs is a new disease (but slightly less pathological than reading one’s own)

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