Where Medicine Went Wrong: Rediscovering The Path To Complexity

Rediscovering the Path to Complexity

Bruce J West

• Publisher: WSPC
• Year: 2006
• Print ISBN: 9789812568830
• eBook ISBN: 9789814338219
• Topic: Sciences biologiques
• Subtopic: Science générale

Where Medicine Went Wrong explores how the idea of an average value has been misapplied to medical phenomena, distorted understanding and lead to flawed medical decisions. Through new insights into the science of complexity, traditional physiology is replaced with fractal physiology, in which variability is more indicative of health than is an average. The capricious nature of physiological systems is made conceptually manageable by smoothing over fluctuations and thinking in terms of averages. But these variations in such aspects as heart rate, breathing and walking are much more susceptible to the early influence of disease than are averages.

It may be useful to quote from the late Stephen Jay Gould's book Full House on the errant nature of averages: “… our culture encodes a strong bias either to neglect or ignore variation. We tend to focus instead on measures of central tendency, and as a result we make some terrible mistakes, often with considerable practical import.” Dr West has quantified this observation and make it useful for the diagnosis of disease.

Contents:

• Chance and Variation
• The Expectation of Health
• Even Uncertainty Has Laws
• The Uncertainty of Health
• Fractal Physiology
• Complexity
• Disease as Loss of Complexity

Readership: Healthcare professionals, pre-med students and general readers. May be used as a supplementary text for advanced undergraduate or graduate course in complexity science.

Chance and Variation

This book is a tour through the technical developments that lead to the modern theory of medicine, or at least one version of such a theory. Being on a tour I do not spend much time in any one place, or give too much detail on technical issues, but attempt to paint in broad strokes, laying out what I consider to be the important background. I do, however, consider some concepts to be central to the discussion, concepts that are so obvious that they are rarely, if ever, questioned. Such concepts are like the water in which fish swim; the fish does not see the water because that is the very basis of its existence. The examination of such concepts in physiology, by a relatively small number of scientists, has produced a revolutionary view of medicine over the past two decades that has gained more than a foothold in medical research. This new view has been collected under the rubiric of fractal physiology. The application of nonlinear dynamics and fractal statistics to physiologic phenomena has enabled physicians to uncover and interpret a new richness in physiologic time series, but I am getting ahead of my story.

It is generally prudent for me to consult a map before starting out on a journey, particularly if I am traveling to somewhere I have not been before. But even if I have made the trip previously, I find that it does not hurt to refresh my memory about unmarked turns and possible areas of congestion. For this reason I begin each chapter with an intellectual map of what is to be discussed, because many of the places I visit, if not new to the reader, will be approached from a unique perspective. Thus, there are many readers who have driven into New York City, but few have parachuted into Times Square from an airplane. My experience of the city would be quite different in the two cases and the conclusions I might draw regarding what is, or is not, important about the city would also be very different.

In this first chapter I argue that the history of western civilization has formed the way in which we, its progeny, view the world. This mundane observation, made in every history class on every college campus, often fails to make the case for specific ideas. The big concepts like democracy, capatalism, socialism and the like, are more than adequately discussed, even if I might take issue with the relative emphasis. In the present analysis I am more concerned with a handful of little ideas rather than big ones. Little ideas like whether the world is a fundamentally fair place and the origin of the idea of fairness. It will surprise many that fairness developed at the intersection of law and gambling. From this nexus of ideas, other notions took shape, such as ambiguity, averages and eventually certainty about the future. These are the things with which I will be concerned, because the little ideas, like equality and coin tossing, have done more to influence how most individuals within our society think about the world than have the big ideas.

Equality is a well defined mathematical concept, but it loses precision when applied in a social context, since no two people are exactly alike. To trace the myth of social equality requires that I develop some elementary statistical concepts and examine how these arcane ideas crept into the dicussion of social well being. In particular I am interested in how medicine was affected by such pubic health decisions as inoculating a population against smallpox in the 17th century. This background is useful in order to appreciate how a predominantly agrarian society molded some of the less obvious concepts supporting our present day view of medicine. Furthermore, I argue that by rejecting these fundamental assumptions many of today's questions concerning certain diseases can be answered, at least in part.

I outline how to reason about luck and chance, because it was through such reasoning that society determined to adopt average measures as the way to think about complex systems like the human body. These arguments can become very convoluted and formal, so I also introduce the idea of information as a simplier way of characterizing complex phenomena. The discussion regarding information and even probability is elementary and will be taken up repeatedly in subsequent chapters as the need arises, but we avoid introducing equations and attempt to communicate the content without the formalism. The emphasis is on ideas.

1.1. The myth of equality

Today society has the telephone, the Internet, the FAX machine, email, and any of a number of other technologies by which its members can remain in contact with one another. It is not an exageration to say that communication in the 21st century is instantaneous throughout most of the industrialized world. Like communication, when I am faced with a problem, my response for obtaining a solution tends to be either immediate or never. Modern day problem solving methods often reject solutions that have intermedicate time scales, forcing those solutions that can be immediately executed over those that require maturation times for their implementation. It is almost impossible to trace today's archetypes back to their non-industrialized beginnings, but that is what I need to do, at least in part, in order to clarify the limitations of understanding in modern medicine due to complexity.

In the 16th century 90% of Europe's population lived on farms or in small towns and their view of the world was very different from what ours is today. This difference is due, in part, to how people interacted with the physical world. The foundation of an agrarian society was land, animals, people and tools, all motivated by the creation and storage of food. The typical latrine was a small wooden structure tens of meters from the house, with one, two or three holes, each the size of a pie plate, cut into a board spanning a ditch half filled with biowaste, with no partitions to separate the often multiple simultaneous users of the facilities. Water was obtained from a well, using either a wynch to lower and raise a bucket at the end of a rope, or using a pump that invariably needed to be primed. The bread on the table was baked in the farmer's kitchen in a wood burning stove, using flour that was locally milled. The meat was butchered in the fall and preserved by smoking, salting or canning in grease for the long winter. Fresh fruit and vegetables were determined by what could be picked from the trees or pulled from the farmer's garden and stored in a root cellar.

One example of a relatively stable agrarian society was the Hälsingland farms in Sweden^1,:

A Hälsingland farm is a unit of production, and for it to function there had to be a balance between land and animals, people and tools, and buildings. If something is missing, the equilibrium is disturbed and the whole system falls apart.

These farms actually began around the beginings of the Iron Age and continued to grow throughout the Middle Ages, retaining a constant level in the 250-year period from 1500 to 1750. In such a successful society one would expect the population to grow, which it did, but the labor excess did not become farmers, but rather they became fishermen, tradesmen and craftsmen. The migration from the land was an adaptation made by the people to the constraints of the society into which they were born, such as the amount of land available for farming.

However, Europe was not homogeneous, and the ideal of the Hälsingland farms was only partially realized elsewhere. Regardless of the degree of success of the social system, the farm and its demands moulded the world view of the rural and urban populations alike. A farmer would get up before sunrise to work the farm: milk cows, gather eggs, feed the stock; and then s/he would come in for breakfast. Whenever possible the morning meal would be large, consisting of meat, usually pork or beef, fried in a heavy grease, and eggs, bread lathered with cream rich butter and containers of milk. Potatoes would later be added to the farmer's diet, often replacing the more expensive and harder to obtain meat. Breakfast would provide the energy required for the day's work in the field. The time of year determined whether one plowed, planted or harvested—but it was always physical and occupied most of the farmer's time. When it was too hot to work in the field, often after the mid-day meal, there were always machines to be fixed, buildings to be repaired and animals to be tended. A farmer's work was never done.

The social interactions during the week were with one's family. The children always had to be taught, by both the mother and the father. Farming was hard manual work for both sexes, and contrary to common belief, the work was an intellectual challenge to those who were successful at it. Filling a barn with hay and a silo with grain, so the farm animals could eat through the winter, was not a simple task, recalling that only animals were available to carry or pull loads, and only the farmer's imagination determined the machines that could be used to leverage that horse power or human power. Farmers understood levers and simple machines, they also knew the work that running water can do, such as turning a paddle wheel to mill flour, and the wind driving a windmill blade to pump water from deep underground. These things had to be taught to one's children at the earliest age possible, because life was brief and uncertain, and one had to be able to make one's way in the world.

Walking along a country road every few minutes in Europe and somewhat longer in the colonies, a person encountered another farm. These neighbors were the second circle of socialization known to farmers and were the people one met in church on Sunday and in town on Saturday, when one went shopping for staples. These neighbors shared a common perspective on the weather, the price of crops, the marrying ages of various children and the successes and failures of both last year's and next year's harvest.

The individuals that survived childhood were generally strong, independently minded and confident in their ability to control the small world around them. In the 20 year period 1603–1624 in the city of London, 36% of all deaths occurred before the age of six. In Paris in the middle of the 18th century, approximately 20% of all children were left in Foundling Hospitals and of those dying, 30% were in such hospitals. This practice of abandoning children continued well into the 19th century (see Montroll and Badger² for a more complete discussion).

For many, the farm became too small a universe and they would strike out for the nearest big city, whether it was London, Paris, Rome or New York. The city was a dramatically different place from the 17th century farm. The farmer entered the city with a wagon of fruits and vegatables to sell, and the buyers were those that cooked for the city dwellers. This was the third and final level of socialization for the farmer. They talked, joked and argued with the wives of the merchants and artisans, servants from the wealthy families, and cooks from restaurants and taverns. All these buyers would compete with one another for the best and cheapest staples. The farmers were at the bottom of the food chain necessary to sustain the life of the city.

At this point in history the city was, as it is today, a more complex interactive structure than was the farm. The cities, by and large, grew without plan or design to satisfy the needs and inclinations of its occupants or those of the city fathers. No one knows what the precise mix of food delivered to the city and food eaten by the various strata of the city was; what the proper balance in the number of restaurants versus the number of garbage collectors was; how many hotels, hostels and private homes there were; what the number and kind of streets there were, what the various modes of transportation were, or what the size of the merchant class was. It was understood that the city needed various things to survive: food, housing, power, and water. Individuals identified what things were necessary and how they could profit by supplying them to the city for a price. Those seeking their own profit performed a function that insured the survival of the city. The city in turn combined the contributions of the many and provided an environment that no one person could have realized on his/her own. This environment attracted other individuals that could provide additional goods and services needed by the expanding city.

The time interval between strangers in the city was fractions of second, rather than the minutes that separated even good friends in the country. Letters could be delivered by courier on the same day they were written, for those that could read. Newspapers documented rumors, developments, politics and the price of cotton, so that individuals could receive information on a daily rather than weekly basis. In the city the son no longer learned from the father, or the daughter from the mother; instead, the child was apprenticed at the age of eight or so to a master, to learn a trade or craft, and for most people this craft determined their life's path. Few individuals, once apprenticed, had the strength of purpose to abandon their apprenticeship, and go into a future in which their means of earning a living was not secure. In one sense the city replaced the family and this replacement has become almost complete with the blending of the 19th century industrial revolution with the 20th century information revolution.

The city and the farm made each other possible. The farm supplied the excess food necessary to feed the city, and the city provided opportunities for the empolyment of the extra labor generated by the large families on the farm. Montroll and Badger² argue that the potato, which was extremely nutritious, could be grown on poor land and had a yield per acre in nutritional value that was two to four times higher than grain; this then contributed to earlier marriages and higher birth rates. They go on to say that an acre of poor soil planted with potatoes could support a family of between six or eight. In part this explains the continuing population explosion that occurred in Europe, but which did not disrupt the more traditional Hälsingland farms of Sweden.

The excess labor from the farms, in each generation, that could not adapt to the system by becoming tradesmen or craftsmen, went to the city in search of fortune and adventure. The city was the market for the farmer's excess produce and it was also the ladder for each generation's ambition. The farmers were thought to be uncouth, ignorant and superstitious by the city folk, who in their turn were perceived as dandies, cynics and ungodly by their country cousins. Each was seen through the lens of what the viewer could do best, and was rarely acknowledged for their complementary abilities.

It may seem a bit odd, but it was out of this very strange looking world that the contemporary view of being human developed. In large part, it was the conflict between the remnants of the fuedal system and the notion of ownership in the post-Renaissance period that forced the examination of what it meant to be human. Philosophers struggled with the meaning of life, man's place in society, what property meant, whether slavery was acceptable and what constituted fairness. It is interesting that the concept of fairness came out of the synthesis of two very different arenas: law and games of chance.

In the 17th and 18th centuries, law was a very different social phenomenon from what it is today. The way law is accepted by the members of an agraian society is not how it is experienced by those in an urban society. On the farm, law, any law, was seen to be the imposition of the will of the strong on the weak; the domination of the minority by the majority; the disregard of the wants and needs of the individual by the caprice of the group. This perspective on the law was perhaps a consequence of the farmer's ability to stand alone, outside society for the most part, and support his family. The farmer's subsociety was sufficient to insure survival, pretty much independently of what happened in the larger society, probably with the exception of war. Since the farmer accepted little from society, s/he was unwilling to give up anything substantial to society. In the city the view of law was closer to today's perception, since a city, any city, could not survive without codes of conduct and methods of punishment. In the city laws came to be seen as protecting the poor and weak; the social contract that enabled the individual to profit from the abilities of the group; the protection of property ownership from revolution or government usurpage and finally the preservation of the state and therefore the city. Laws produced stability.

One of the fundamental concepts that developed out of law in this period was the notion of fairness. From one perspective, law is man's attempt to impose order on the interactions among individuals and thus make social discourse rational. In England, in part due to the backlash against the church and the aristocracy, the law assumed symmetry between contesting parties, that is, absent any evidence to the contrary two individuals in dispute were viewed as equivalent. It developed that no person's position under the law was seen as different from any other person's, until evidence to the contrary was introduced. Equivalence was an integral part of the notion of fairness, interchangeability of individuals under the law. Fairness is why everyone is innocent until proven guilty; it would be unfair to treat certain people differently from the majority. Thus, the very characteristics that made individuals distinguishable from one another was considered to be irrelevant to the law. So fairness became a doctrine of equivale...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Prologue
• Acknowledgments
• 1 - Chance and Variation
• 2 - The Expectation of Health
• 3 - Even Uncertainty has Laws
• 4 - The Uncertainty of Health
• 5 - Fractal Physiology
• 6 - Complexity
• 7 - Disease as Loss of Complexity
• Epilogue
• References
• Index
• Back Cover