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The Trans-Technique Aspects of Disease and Death

This is the century, we are told, in which innovation and scientific
and technological advance - progress in other words - should be
able to produce anything within the limits of what is physically
possible in principle. We have only to want it sufficiently and to
pay the price and we can have it. If rocks from the moon can be
brought to Houston, why should we not be able to apply molecular
biology, cytology, and the rest, to cure what is now incurable?
- Mac Farlane Burnet

The technological triumphs in medicine in the 20th and 21st centuries
outweigh and outclass the aggregate medical achievements of the
entire human past; yet modern man has been denied the elixir, the
cure for his disease and death. An objective survey of medicine's
failures reveals that it is not that the technology per se is ineffective
- it does what it is designed to do - but that what technology solves is
trivial, and what is just cannot touch is crucial, being beyond any
technique - extant, evolving, or envisaged. Most of human diseasing
and death is trans-technique.

What is technique , and what is trans-technique ? Technique in medicine
is whatever a doctor does to a patient, be it diagnosing, treating or
prognosing. It admits of the simplest to the superlatively sophisticated.
Trans-technique aspects of disease and death are those innate,
ordinary, day-to-day features of human diseasing and dying that
technique can in no way modify to a patient's advantage. Before we
detail the principles that underlie the trans-technique-ness, a survey
of the state of the medical art in the new millennium is in order.

'Need Your Doctor be so Useless?'
The above title of a book by the Canadian physician Andrew Malleson
is symptomatic of the current state of modern medicine - confronted
with the insoluble congenital malformations, cancer, coronary artery
disease, peripheral artery disease, stroke, high blood pressure, or
diabetes.

'It is a sobering thought that after several decades of research, a
number of international conferences and many other meetings,
seminars and symposia, the problem of human malformations remains
essentially unchanged.' Having introduced a symposium with these
words, McKeown proceeds to chastise modern medicine further on
human malformations - etiology unknown, rate unchanged, relative
contribution to infant mortality greatly increased.

Breast cancer, as a paradigm, typifies the colossal failure of cancer
research: It is a subcutaneous (under-the-skin, superficial) cancer -
the natural history of which has been studied for the past 200 years at
least, easily amenable to examination by the patient herself, and more
so by the doctor, subjected to varied forms of grading, staging,
radiography, hormonal therapy, minimal to most radical surgery, and
cocktails of chemotherapy–that has stubbornly refused to yield at all,
in any way from the time a group of Scottish physicians published a
memorandum on its nature in 1802. Indeed, Atkins of England pointed
out that the recent studies on breast cancer have made such tremendous
progress that, today, no one knows how to treat it.

Coronary artery disease, generally manifest as heart attack, has been
attacked by doctors through electronic wizardry enshrined in the
ICCUs and through invasive retubing (bypass) and/or arteriolysis-n-
stents (angioplasty). Of no avail. The ICCUs, wryly described as
'pressure cookers' have proved counter-productive, with the patient
having a greater chance of dying there than outside. McIntosh, a past
president of the American College of Cardiology commented on
coronary bypass that 'there is no convincing evidence that the
procedure prevents or postpones premature death.' Datey, a leading
Indian cardiologist stated: 'The five year end results of heart patients
with conservative medical treatment and bypass surgery are the same.'

The widely read and translated CURRENT Medical Diagnosis & Treat-
ment , 48th edition, 2009 concludes that "the excellent outcome of pa-
tients treated medically has made it difficult to show an advantage
with either revascularization (bypass, angioplasty) approach." The
equally eminent Clinical Pharmacology 10th edition, 2008 maintains,
on cardiac failure the refrain that relief of symptoms by drugs, does
not alter the prognosis. The famed Bible of medicine, Harrison's Prin-
ciples of Internal Medicine , 17th edition, 2008 has maintained, since
the 8th edition, 1980, that bypass, most probably, relieves symptoms
by infarcting (killing) the ischemic (complaining) segment of the
heart. Ditto, for angioplasty. The invasion of coronaries by stents, of
whatever type, has made in-stent restenosis the commonest "malig-
nant" disorder today. Invasive coronaryology, like chemotherapy for
cancer, offers to the recipient the poorest therapeutic trade-off.

About peripheral artery diseases, Jaffe has observed: 'Despite an
extraordinary investment in research resources we are still far from
understanding the pathologic mechanisms responsible for peripheral
vascular diseases. As a consequence, all treatment, medical and surgical,
must be directed towards abatement of symptoms and prevention of
complications, rather than against the diseases themselves. It must be
clear, therefore, that our therapeutic armamentarium is limited severely.'
Stroke, medically labelled as cerebrovascular disease, has remained
impervious to all modes of medical and invasive management,
maintaining its pristine behaviour the world-over, exercising closely
comparable 5-year-survival rates and 'funeral-rates', prompting an
epidemiologist to suggest that we had better accept it as but a form of
ageing, being as unsolvable and as irreversible as ageing itself.

High blood pressure, medically called essential hypertension or
essential high blood pressure , has remained as elusive an entity for it
has yet to be defined, satisfactorily for the doctor or rewardingly for
the patient. Pickering, one time Regius professor of medicine at
Oxford, showed that the 'so-called essential hypertension' is incapable
of being defined except arbitrarily, the definition varying from day to
day, doctor to doctor, and place to place. Doctors cannot decide
whether or not what they call high blood pressure or hypertension is
something natural to the patient, being 'a disease in its own right;'
and no wonder, they hold the appellation essential , as essential to
their hypertensive thinking. As is the definition, so too are the
diagnosis, treatment, and prognosis of essential hypertension -
arbitrary, erratic and anxiety-making.

Talking of diabetes, Boyd, an eminent pathologist and author, la-
mented that the more we know about it the less we seem to under-
stand it. This continuing counterproductiveness stems from the fact
that (a) diabetes - more completely called diabetes mellitus - has never
been clearly defined, (b) the disturbance of glucose metabolism that
doctors emphasize and treat represents only the tip of the iceberg of
the disturbed metabolism of the patient, and (c) neither insulin nor
any other 'antidiabetic' agent alters the course of the disease or the
accompanying, inevitable arterial damage. It is chastizing to note that
85 years after the epochal discovery of insulin and its (first) usage on
Leonard Thompson, we know more about the inherent limitations of
insulin therapy than about its presumed ability to 'cure' diabetes.

All told, the most sophisticated medical manoeuvers or machines don't
seem to make a major difference, and 'advances in diagnosis and
treatment do not necessarily translate into increased survival.' Most
of the tools a doctor used twenty-five years ago fitted into a small
black bag; today the technologically-armed physician owns or has
access to $500,000 worth of equipment: whenever one tries to link
the development of new technology with a coincidental improvement
in healing, the answer is always the same: Nil. Medical recourse to
computers has had the GIGO snag: Garbage In, Garbage Out.

Where has medical technology gone wrong? A dispassionate, episte-
mological evaluation of medicine's technological gains reveals them
to be imagery ; accessive , analytic , associative , and amplificatory . The
more the physicistic science and the physicianly art interact, the
greater is the variety of means by which medical imagery can be ob-
tained. Yet, to take but one example, X-rays, xeroradiography and
computerized-tomgraphic (CT) scan, ultrasonography and MRI and
PET-scan imaging have left a cancer where it was - diagnosed a little
too late. The ability to cannulate the pancreatic duct or artery towards
the diagnosis and treatment of pancreatic cancer, or to get into the
skull to treat the brain cancer, is an accessive advance that leaves the
cancer's autonomy untouched. Increasingly refined biochemical tech-
niques allow many a substance to be measured with nano / pico -preci-
sion, thus analytically telling us a lot about heart attack, diabetes
mellitus or rheumatoid arthritis, but without the liberty to predict-
ably and/or favourably alter the course of the disease. Epidemiology
connects the husband's cigar to the wife's cancer, coffee to cardio-
vascular disease, and refined sugar to peptic ulcer - an associative
exercise that makes more anxiety than sense. The electron microscope
amplifies the size of a T-lymphocyte any number of times only to
amplify our ignorance of the cell to the same magnitude. In modern
medicine, technology glitters, but is, often, not gold.

A number of diverse medical men have admitted that ninety per cent
of the bad things that happen to man's body are beyond the ken of
modern medicine. Armed with technical might, the doctor can, with
the healing power of Nature providentially at the patient's beck and
call, revert acute physiological crises to healthy states, set fractures,
fix retinae, deliver babies facing a narrow birth canal, remove lumps
and cataracts, replace a valve or a joint, correct mechanical defects
such as cleft palate or hernia, all this comprising the ten per cent of
man's maladies that medicine can rewardingly, nay , gloriously
manage. The rest is trans-technique. Let us see how, and why.

Four principles account for the trans-technique nature of diseases.
These are cellularity , systemicity , uniqueness and herdity . An
integrated appreciation of these principles will help us understand
medicine's limits, no matter what its technical might.

Cellularity
There are features of a mammalian cell that make disease and death
trans-technique in more ways than one. It is a fitting paradox that what
advanced cytological techniques have revealed about the cell has driven
home the truth that a cell's behaviour, in health or disease, can hardly
be trifled with. The microsize of human body cells accounts for the
fact that before a scan discovers a cancerous lump measuring one cubic
millimeter and weighing one milligram - the smallest tumor mass that
one could ever hope to detect clinically - the cancer is already a million
cells strong and several years old. Early diagnosis of cancer is, thus,
only a myth. The same considerations apply to the disease of coronary
(or any other) arteries, the underlying atheromatous process being held
by some as cancerous in origin. Any attempt at flooding the body with
anti-abnormal cell-agents (radiation, chemicals) fails because of the
selfsameness of all body cells, rendering selective destruction of
undesired cells impossible. Supposing that a highly specific drug is
developed and administered, the target cell can easily recall its microbial
past to readjust its genetic machinery - that is, mutate - to knock out
the drug, since the mutative repertoire of a human cell borders on 256
followed by 2.4 billion zeros.

In no two human beings, twins not excluded, do the cells of one see
eye-to-eye with those of the other person. Each cell, then, in a human
being, has an irrepressible individuality that brooks no foreign cell
around nor is it likely to be tolerated as friend in an alien body. This
is an age of transplants, performed because they are technically easy,
although biologically baseless. Following any organ/cell transplant,
the donor cells and guest cells wage a relentless war for which the
patient (the recipient) pays a great price. There is nothing on the
medical horizon that can mitigate the biological impotence of organ
transplantation, albeit "successful" through lifelong immunosuppres-
sion of the recipient, now experienceally linked with the precipita-
tion of cancer/s in the transplant-recipient.

Systemicity
The human body is an integrated whole that starts as a single cell,
and builds up a cytogalaxy that behaves as a single, concerted unit
whose seemingly disparate parts form, grow, and decay in unison.
Systemicity of a disease implies its presence in wide areas of the body.
Cancer, for example, has been correctly declared a disease of the whole
organism. Arteriosclerosis or the hardening-and-blocking of the body's
arteries involves all the areas of the body. Diabetes (mellitus) affects
all blood vessels and all parts of the metabolic machinery of the
individual. All diseases of ageing involve the whole body; they thus
exhibit systemicity.

The systemicity of a disease rules out its being either diagnosed early
or removed or destroyed completely. A cancer thus does not lend itself
to complete destruction by surgery, radiation, chemotherapy, or
immunotherapy. Even if we were to nab the last cancer cell, the next
normal cell would foil attempts by turning cancerous, through a
process named neocanceration or recruitment . The sole curative
triumph against gestational choriocarcinoma (a cancer arising from
fetal tissue during pregnancy) is entirely due to the fact that such an
eventuality of neocanceration is ruled out by the absence of the normal
progenitor cells that comprise the discarded fetal part of the placenta.
An arterial bypass takes care of the block that the operator sees or
has access to, but what of the arteries beyond, or before, or elsewhere?
This explains why a patient with heart disease fails to benefit from
the much-vaunted invasive coronaryology. As for diabetes,
antidiabetic agents touch the proverbial tip of the metabolic iceberg,
affecting in no way the overall, arterial disease and fat and protein
metabolic disorders, that are now accepted as integral parts of the
diabetic process.

Uniqueness
Variability, it is said, is the only invariable law of biology, a natural
propensity that unfailingly varies one cancer from another, one heart
attack from another. If the uniqueness of every individual is an
unsolved problem of biology, then the uniqueness of every disease is
the unsolved and unsolvable problem of medicine. There are as many
different diseases as patients. Even 'identical' twins differ in their
individual disease patterns. The presumed (but, in reality, absent)
identicality of the genotype in such twins is unable to circumvent
this code of individuality.

Cancer, indisputably traceable to precisely pinpointable and culturable
cancer cells, provides a remarkable example of the unprecedented,
unparalled and unrepeatable nature of a disease. Naturally occurring
cancers are extremely diverse even when they carry the same diag-
nostic label. No two cases of coronary artery disease, stroke, cancer,
diabetes, arthritis, or auto-immune disease are identical either in their
presentation or in their progress. The behavioral uniqueness of a dis-
ease, with its unpredictability, forms the basis for unexpected suc-
cesses and equally unexpected failures, given the same treatment.
Cancers have been classified into 'good' and 'bad', the good ones
curable by any treatment, the bad ones by none - a retrospective judg-
ment applicable to any other disease and fully justifying the Chinese
proverb that a therapy works in a patient destined to survive.

This proverb smacks of irreverence for the celebrated and seemingly
learned art of prognosing, now backed up by technology. Among
diagnosis, prognosis and treatment, prognosis is the most difficult to
evaluate. The accurate prediction of things to come is baffling,
perplexing, and problematic. The reason is two-fold: (a) In most
diseases, what the doctors can prognosticate about is based on group
statistics that obviously have no bearing on an individual case.
(b) Even when, at an individual level, the doctor has fully at hand the
reports of some test, ECG (EKG), X-ray. or scan, and thus 'justifiably'
bases his prognosis on the evident benignity or otherwise of the lesion,
such a correlation has not proved trustworthy or fruitful. Patients with
reassuring investigations and prognosis have died, and those with a
prognosis of doom have survived. All technological marvels, computers
not excluded, deal with the appearances and assumed correlations of a
human being's disease; none, as yet, knows or can know of the
behavioral uniqueness of such a biological entity. Of diagnosis,
treatment, and prognosis, the last is the most trans-technique.

The unique reality of medical practice is that, be it Paul Dudley White
(Cardiologist to American Presidents) and his 103 year old patient
Charles Thierry, or James Herriot and the dog Jock, it is a one-to-one
encounter where the uniqueness of the individual, his disease, his very
biological trajectory is unpredictable, unalterable, and overwhelmingly
important. For modern medicine, the most chastizing part of an
individual's biological trajectory is its refusal to provide any quantita-
tive correlationship between the earliness or lateness of a disease on
the one hand, and the probability of the disease and/or death on the
other. The healthy do not necessarily survive; the diseased do not nec-
essarily die. Norman Cousins' dig at medical experts who 'don't really
know enough' in his Anatomy of an Illness must be viewed from the
standpoint that the experts never know anywhere near enough, not be-
cause they do not want to, but because what they wish to know and
what patients expect them to be knowledgeable about truly lies in the
realm of the unknown, or, more accurately, unknowable.

Herdity could well be described, at the very outset, as a corporate
programme subserved by individual performance. Cellularity,
systemicity and uniqueness are features innate to an individual; herdity
is a force that the human herd exerts on the individual. The relationship
between the individual and the herd is a remarkable biological feature
that more than vindicates John Donne's statement that 'no man is an
island of itself: every man is a part of the main.'

Mankind was, and is, a single inclusive population and is endowed
with a single corporate genotype, a single gene pcol. Appropriate to
this is the concept of an individual as one who extends, in time as in
space, beyond the frontiers of his body, and who is linked to the past
and to the future, regardless of the ephemerality of his present. Add
to this the conceptual framework of quantum physics that reveals a
basic oneness of the universe in which, at a deep and fundamental
level, the seemingly separate parts of the universe are connected in
an intimate and immediate way, in a complicated web of relations
between the various parts of the whole. We are now poised to view an
individual's body, his disease, his cancer - each unfailingly unique -
as a spatiotemporal manifestation of a cosmic order. I am what I am,
and allowed to be so, for I know who all others were, are, and will be
so as not to duplicate them, and they in turn know of me so as not to
make a duplicate of me or of my disease at any time.

Climbing down from cosmic considerations to the clinical, bedside
realities allows us to appreciate the role of herdity in distribution of
disease in any given group. As general statistics go, the incidence of,
say, acute lymphatic leukemia is 1 in 33,000, of cleft palate or neural
tube defect is 1 in less than 1,000, of cancer 1 in 5, of blood vessel
disease 1 in 2, at random, country after country, year after year. A
surveyor of the statistical figures on the occurrence of cancer is struck
by their unexpected constancy, for a given region, year after year,
decade after decade. A high incidence of cancer in one part of the
body is consistently balanced for a given country or a population, by
a low incidence of cancer at another site, to permit the reassuring
generalization that cancer occurs everywhere in the world, in excess
nowhere. The age-specific mortality rates from cardiovascular dis-
ease, year after year, decade after decade, and in country after coun-
try fit quite closely the same line. There is a fundamental natural be-
nevolence in the global impartiality with which disease and death treat
mankind. The prevalence of diabetes mellitus is more or less con-
stant for all countries. Cancer, stroke, diabetes, hypertension, heart
attack and so on are an integral part of humanity, of human herdity.
This remarkable herd-certainty and individual probability of patho-
logical events is a function of a corporate herd program that finds
expression at the level of an individual who has crossed a critical
genetic threshold. Herdity, thus, is a reciprocal relationship between
an individual and his herd, what geneticists have been describing as
polygenic inheritance.

The evolution of the concept of polygenic inheritance has brought a
shift in genetic thinking, from heredity to herdity, for polygenic
inheritance is necessarily a statistical concept that concerns not the
individual but population aggregates. Polygenic inheritance has been
invoked to explain a wide variety of diseases, ranging from congenital
malformations to cancer, porphyria to peptic ulcer. This means that
most diseases do not have a cause. Causeless diseases cannot be
prevented; they are an integral part of man's growth; in terms of both
cause and course they are trans-technique. Herdity is trans-technique.
The idea of herdity governs all the phenomena in relation to disease
and death in a herd. The herd determines who will get what and when,
in whom the disease will be slow, in whom fast, and so on. This would
explain why the commonness of prostatic cancer beyond the age of
50 is paradoxically matched by the uncommonness of its malignant
behaviour and how persons with bad coronary angiograms survive
those with good ones.

The most compelling evidence in favor of herdity is, in general, the
programmed herd mortality that, as a physiological function, is seen
in man, in animals, and in drosophila. Gompertz saw this as a constant
increment in mortality beyond the third quinquennium of human life,
doubling every 8 years, a phenomenon no medical advance has been
able to stem. John Knowles, as president of the Rockefeller
Foundation, wrote in 1977 on 'The responsibility of an individual '
charging the latter's 'personal misbehaviour and environmental
conditions' for over ninety-nine percent of illnesses. Knowles' faith
in reasoned behaviour did not prevent the pancreatic cancer that killed
him in 1979. He was but one of the 19,000 that develop pancreatic
cancer and die from it in the United States every year. Knowles died
at 52, some do at an earlier age, others at a later age, all a part of herd
distribution, of herdity.

Summing Up
Lester Brown, of the Worldwatch Institute, has divided recent history
into two distinct technological periods - the period 1940 to 1970 of
unrestrained optimism, the second, thereafter, of utter disillusionment,
of the crumbling of a seemingly shatter-proof faith in technology. It
is time that medical men understand the reason behind this stalemate,
and turn the situation to the benefit of their patients and to their own
enlightenment.

Cellularity, Systemicity, Uniqueness and Herdity can be realized as
the SUCHness, of diseasing and dying. The evolution of the trans-
technique concept explains technology's failures and limits, exercises
restraints on this age of inflated expectations, encourages us to be
radical enough to abjure straight-line solutions and many a
technological trap - to wit, the tyranny of mass-screening, debilitating
therapies, or kill-joy preventionism.

An editorial in The New England Journal of Medicine entitled 'The
toss-up' bears eloquent testimony to the rationale of the above. It is
common experience that, on a given case, the proposed diagnostic or
therapeutic thrust ranges from extreme conservatism to surgical ultra-
radicalism. After attributing such divergence in medical thinking to
the idiosyncracies of the physicians, the authors propose: 'Perhaps
all these factors are involved in clinical controversies, but we propose
that one explanation has not been sufficiently recognized: that it
simply makes no difference which choice is made. We suggest that
some dramatic controversies represent "toss-ups" - clinical situations
in which the consequences of divergent choices are, on the average,
virtually identical.' The identicality of the consequences, no matter
what the investigations and what the therapy, is a result of the basic
fact that the problem being tackled is beyond the limits of technology.

Scientis est potentia : knowledge is power so aphorized Francis Bacon.
Some expansion thereof is warranted. Scientia est potentia negativa
et positiva. Science empowers you not to do, as much as it empowers
you to do.

The knowledge that a lot in medical practice is beyond medical
technique can, as a concept, propel us towards discerning inaction in
medicine. Munsif, an eminent Mumbai surgeon, was fond of stating
that 'a good surgeon is one who knows when not to operate.' What a
medical man needs to learn, in today's technicalized scene is when
not to act, an intellectual and a therapeutic revolution that can safely
rest on the concept of trans-technique.

The well-informed physician and patient of tomorrow will accept
'doing nothing' as an integral part of the relevant investigations,
diagnosis, and treatment. No treatment can often be the right treatment,
a proposition that is consistent with a revised connotation of 'cure',
the most cherished word in medicine. The word 'cure' comes from
curatio 'I take care'. Jackson, Oliver Wendell Holmes' teacher, never
talked of curing a patient except in the true sense of 'taking care'.
Jackson felt that doctors, by the misuse of the word 'cure; arrogated
to themselves greater powers than were their due. Modern medicine
is in need of humility, and must restore 'cure' to its pristine and most
pertinent meaning: with a concerned physician around, no disease,
no death, is incurable. A drug to ease, a procedure to palliate, a word
of cheer, the graceful stoicism to hold the dying patient's hand - all
this and more falls within the curative competence of a compassionate
clinician. Regardless of the trans-science and the trans-technique
aspects of disease and death, the art of medicine and the Dear and
Glorious Physician , will be there forever.

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