The ecology of health

Expenditure on health services throughout the industrial world has got out of hand. In many countries it is increasing so rapidly that, at the current rate, it is a matter of decades rather than centuries before it absorbs the whole of the GNP. Clearly, before this point is reached, drastic action to curb health expenditure is required.

But how is this to be done? It is generally assumed that the problem is one of organisation. Some critics favour the American system of free medical enterprise, others the nationalisation of medical services as in the UK, while others favour some intermediary solution such as that adopted in France.

If one looks into the question a little more deeply, it becomes apparent that the problem is not how our health services should be administered but what sort of services should be provided. Those provided today, based on modern medical science, have failed to deliver the goods.

If they had been successful, levels of health would be rising and we would expect to see a reduction in the number of people consulting a doctor, in the number of working days lost through illness and in the expenditure on medical services. The opposite is of course the case. As Powles writes::

“one of the most striking paradoxes facing the students of modern medical culture lies in the contrast between the enthusiasm associated with current developments and the reality of diminishing returns to health for rapidly increasing efforts.” [1]

It is agreed, of course, that modern medicine has increased longevity, but this has been greatly exaggerated. Dr R. Logan, Director of the UK’s Medical Research Unit, tells us that “a man today can expect to live three years more than his counterpart in 1841″. [2] Most of this improvement however occurred before the introduction of scientific medicine. In the period of rapid increase in expenditure on health improvement, life expectancy has more or less levelled off.

Little has done more to increase the prestige and credibility of modern medical science than its apparent success in eliminating infectious diseases, but this success has proved to be short-lived. We are witnessing today a resurgence of infectious diseases throughout the world, in particular of malaria, gonorrhoea, tuberculosis, pneumonia and cholera, while others such as schistosomiasis and dengue fever are spreading to areas where they were hitherto unknown.

The total impotence of modern medical science to reduce the incidence of the so-called ‘diseases of civilisation’ – cancer, ischaemic heart disease, diabetes, diverticulitis, peptic ulcer,appendicitis, varicose veins and tooth caries – is apparent to all. Their incidence, in spite of all efforts made by the medical profession, continues to increase along with per capita GNP.

The only realistic conclusion to be derived from all this is that medical science is on the wrong track and that a new health policy is urgently required. But what form should it take? It seems clear that, before we can answer this, we have first to rethink basic concepts such as health, disease, medicine and health services.

What are health and disease

Health, in terms of our technological world-view, is seen as the absence of ‘clinical symptoms’ and disease as the presence of such symptoms. But what do we mean by ‘clinical symptoms’? What are they symptoms of? Presumably of disease but this does not get us very far, because many of the diseases we suffer from are classified purely in terms of their symptoms.

This is true for instance of rheumatism, arthritis and many of the ‘diseases of civilisation’. It is also true of psychiatric diseases such aspsychosis, neurosis and schizophrenia. Often too, the ‘symptoms’ are but those of the normal workings of the body’s defence mechanisms rather than of any really pathological state. As Dr Malleson points out,

Over millions of years our bodies and those of our ancestors have perfected defence mechanisms against microbial invasions and noxious chemical substances.These mechanisms are very highly developed. For example, mucus which might be dangerous if it were to accumulate in the trachea is expelled by coughing. Toxic substances in the intestines are eliminated by diarrhoea. Microbial invasion of the body is accompanied by a rise in temperature, which is probably intended to increase the rate at which the defence mechanisms are able to act. To suppress this cough, to prevent this diarrhoea, to reduce this temperature is to counteract essential natural processes. [3]

Yet this is precisely what many medical practices aim at achieving. In this way, they mainly serve to eliminate symptoms and, in doing so, tend to exacerbate the diseases they should be serving to cure.

What is more, if the medicines employed are biologically active, they may also produce side effects and thereby induce diseases where previously there were none. Indeed such ‘iatrogenic’ diseases, as they are referred to, now make up a substantial proportion of the total disease-load of a modern industrial society.

To treat the symptoms is often futile for another reason. They are often those of a disease that has taken such a hold over an enfeebled patient that, regardless of the medical treatment provided, it must prove fatal. In such conditions, the object of treatment is nothing more than to prolong human life, just for the sake of it, and without any regard for the quality of the life prolonged – an absurd and often immoral enterprise, if we take into account the pain that the patient must suffer as a result of the often drastic treatment needed to keep alive from day to day.

Few people realise what proportion of the national health budget ofan industrial country is spent in this way. According to Professor Ross Hume Hall of McMaster University in Canada, 80 percent of the health budget of that country is devoted to prolonging the lives of patients who, whatever treatment they receive, will die in the next ten months, and in this respect Canada does not appear to be exceptional. [4]

To fight the symptoms of disease is insufficient for yet another reason. The absence of ‘clinical symptoms’ in a patient cannot necessarily be taken to denote that they are in good health. Some 75 percent of people visiting doctors’ surgeries today are said to suffer from no recognisable ‘clinical symptoms’. Yet they feel ill and-in some sense of the term-they are ill.

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Our view of health and disease

The trouble is that our health policies are the only ones consistent with the world-view that has developed during the course of our industrial age and which colours our thinking on all the basic problems that confront us today. What is more, they are the only ones that lead to the sale of medical hardware and expertise and that are thus ‘economic’. For these reasons, they are the only ones that, at present, we seem capable of entertaining.

The thesis of this chapter is that to understand health and disease we must see them in the light of a very different world-view – one which we can perhaps refer to as the ‘ecological world-view’. This involves, first of all, looking at them in a much wider context.

Modern medical science, we must remember, like all the other disciplines in terms of which knowledge has been divided, has been developed on the basis of the experience of the industrial era – a period of about 150 years – which is negligible in terms of humankind’s total experience on this planet of several million years. It is in terms of this total experience that we must look at the issue of health and disease.

But this is not sufficient. We think of health and disease as it affects humans, but they are not something unique, they are only one particular form of life among very many. General systems theory, over the last 30 years, has shown that living entities (systems, such as molecules, cells, organisms, ecosystems, etc.) which may outwardly appear to be extremely different are, at a certain level of generality, very similar and that, at such a level, their behaviour can be shown to be governed by the same basic laws. It also appears that this principle applies to the method by which living systems are controlled. I shall seek to apply a general systems approach to the problem of health.

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Stability

The tendency today is to see life processes as largely random. Though the notion of randomness is subject to different interpretations, it can be construed as designating a state of disorder as opposed to order and goallessness as opposed to directiveness or purposefulness.

This is very misleading. Order and directiveness, the latter being really nothing more than four-dimensional order, are the most fundamental features of the biosphere. Indeed if the biosphere did not possess these qualities it could not be studied by science whose role must be to establish regularities and patterns whose very presence must imply order and directiveness.

Still less could there be a science of cybernetics, the science of control, since to control a process is to keep it on its course or trajectory i.e., in the direction of its goal, the latter concept being taken to be dynamic rather than purely static.

I shall take the goal of life processes to be the achievement of stability. A living system is stable to the extent that it is capable of maintaining its basic structure in the face of possible disturbances. This is another way of saying that it is capable of maintaining its homeostasis (as the term is used by Cannon [5]) in the face of change. This does not mean that a living entity is static, it must change as a means of adapting to environmental changes. But such changes do not occur for the sake of them but as a means of preventing more disruptive changes.

It is only in the light of such theoretical considerations that one can understand what is health. Health in fact can only be seen as the stability of the organism within its social and physical environment. This means that to show that an organism is healthy must mean that it is capable of maintaining its stability in the face of potentially damaging discontinuities. I think that most students of health, who see their subject matter in anything but the very narrow context within which it is presently studied by modern medical science, would agree with a definition of this sort.

It is, for instance, that of Professor Audy who saw health

“as a continuing property potentially measurable by the individual’s ability to rally from insults, whether chemical, physical, infectious, psychological or social.” [6]

If we define health in this way, then, among other things, our notion of cause-and-effect must be radically modified.

The cause of a disease can no longer be seen to be the immediately antecedent event that triggered it off-the micro-organism for instance that is associated with an infectious disease-but that a constellation of factors has reduced the resistance of the organism to a point at which it falls victim to an insult that would normally induce in it only relatively mild symptoms.

If we see cause and effect in this way, then the criterion for determining whether environmental changes can adversely affect health must also be very different from that which is currently applied. It no longer suffices to determine whether such a change actually gives rise to clinical symptoms but whether it is capable of reducing the overall resistance of living things and hence their stability or health in such a way that they become more vulnerable to other insults.

The object of a health policy must be equally revised. Rather than waging chemical warfare against the vectors of disease i.e. at eliminating symptoms, it should be aimed instead at creating those conditions in which discontinuities are reduced to a minimum and in which people’s ability to deal with such discontinuities is maximised.

On that basis, our notion of what, among other things, constitutes a pollutant must be radically modified. The acceptable level of a pollutant in the air we breathe, the food we eat or the water we drink, is not just that at which clinical symptoms occur, but that which might be considered to have an adverse effect however slight, on our ability to counteract the biological effects of any other insult.

As Professor Samuel Epstein of the Department of Environmental Medicine at the University of Illinois in particular has shown, a very large proportion, perhaps as much as 80-90 percent of cancers are caused by exposure to chemicals and radiation. [7] Exposure by itself however does not seem sufficient to trigger off a cancer.

Thus Professor Bryn Bridges of the MRC Cell Mutation Unit at Sussex University points out that in a healthy body, cells damaged by exposure to chemicals tend to be effectively eliminated, [8] indeed, if we consider the thousands of carcinogenic chemicals to which we are now daily exposed, were this mechanism not operative, there would be very many more cases of cancer than there already are.

If this is so, then the present epidemic of cancer is not only due to the increase in the number of chemicals to which we are exposed but to the effect of those chemicals and other factors in reducing our ability to eliminate crippled cells.

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Learning to live together

It can be shown that as systems develop via the evolutionary process, so do they become increasingly stable. Thus a pioneer ecosystem is subject to all sorts of discontinuities. These are slowly ironed out as the ecosystem evolves, i.e. as pioneering species are slowly replaced by more advanced ones and as a ‘climax’ or adult state is achieved.

Climax forests, for example, are subject to few discontinuities. Thus demographic explosions and diebacks which characterise a pioneer ecosystem do not normally occur in a climax forest. Nor do droughts and floods, erosion and desertification.

The same is true of living systems at all levels of organisation. As evolution proceeds, they become better adjusted to the particular ecosystem in which they live and hence to the various forms of life that inhabit it.

Thus it is possible to obtain some idea of the time during which an animal has lived in a specific environment simply by determining to what extent it has learned to live with the other forms of life, including the parasites and micro-organisms, that inhabit it. If it has lived in it a long time, then the diseases that could be caused by such parasites have become endemic. They are relatively mild and their function is simply to kill off the old and the weak, i.e to apply quantitative and qualitative controls on host populations.

Consider the case of myxomatosis. It was a well-established disease among rabbits in Brazil among whom it is endemic and causes but mild symptoms. It was unknown among European rabbits which are of a different genus. When myxomatosis was introduced into Australia in 1950, the European rabbits introduced there were exposed to a virus of which they had no previous experience.

In the first year it killed 99.8 percent of the rabbit population, in the next year the death rate went down to 90 percent, seven years later it had fallen to 25 percent. The rabbit population is clearly learning to live with the virus, and vice versa. The relationship between the rabbit and the virus has thus become progressively more stable.

The same thing has happened to human populations throughout the world, as they have been exposed to parasites of which they have had no previous experience and with which they have gradually learned to live.

The population of the various islands of Polynesia, for instance, was decimated by the diseases brought there by the European colonists. That of the Maoris of New Zealand fell from approximately 160,000 to 30,000, and at one time it was thought that the Maoris would become extinct. That of Tahiti fell from a similar figure to about 7,000; that of the Marquesas, it is estimated, from 100,000 to no more than about 3,000.

However, the Polynesians have adapted to the introduced micro-organisms that have become a new component of their environment. They have, in fact, learned to live with them and their population has correspondingly grown. In New Zealand it is now two to three times its former size.

All this makes it clear that as living systems evolve they become increasingly adapted to their environment, and increasingly stable which means that the incidence of disruptive discontinuities is correspondingly reduced. From this must follow the essential principle that the environment which most favours the health of a living system must be that to which it has been adapted by its evolution and with which it has co-evolved.

That this must be so is quite clear in the case of non-human animals. Thus most of us will admit that a tiger has been adapted by its evolution to living in the jungle. It is clearly the jungle that provides its optimum environment. It is the activities it is capable of indulging in, in the jungle, that best satisfy its physical and psychological requirements. It is the food that it finds there that it most enjoys eating and that best satisfies its biological requirements and the same must be true of all forms of life, including humans. All must best be adapted to the environment with which they have co-evolved.

The corollary of this principle must also be true. Indeed, as the environment of a living thing is made to diverge from that with which it has co-evolved, and hence, to which it has been adapted, so will it become ever less stable, and hence less capable of dealing with discontinuities, in fact, less healthy.

Stephen Boyden has formulated this principle very clearly. He refers to it as the “principle of phylogenetic maladjustment”. According to that principle:

“if the conditions of life of an animal deviate from those which prevailed in the environment in which the species evolved, the likelihood is that the animal will be less well suited to the new conditions than to those to which it has become genetically adapted through natural selection and consequently some signs of maladjustment may be anticipated.”

Obvious though this principle is, and obvious though its importance, it is seldom referred to in the literature, and consequently its significance seems to have been largely overlooked.

“The term ‘phylogenetic maladjustment’ (the maladjustment is phylogenetic because it represents a characteristic response of the species to the changed environmental circumstances) then, specifically refers to disorders which represent the reactions of organisms to conditions of life which differ from those to which the species has become genetically adapted in evolution through the processes of natural selection. This principle relates not only to environmental changes of a physiochemical or material nature, such as changes in the quality of food or air, but also to various non-material environmental influences, such as certain social pressures which may affect behaviour.” [9]

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