Medical Humanities Blog

On Black Soldiers, Medicine, and the War Between the States

As one might surmise from the tacked post, I have recently begun to take advantage of podcasted/webcasted space as it relates to the medical humanities.  Yes, at this late hour I arrive.

In any case, I'll try to mark down here any lectures or presentations that could interest a medical humanities audience.

The University of Virginia has an outstanding collection of academic podcasts, and I recently listened to a lecture given by Margaret Humphreys in the History of the Health Sciences Lectures series.  The lecture is entitled Intensely Human: The Health of Black Soldiers in the American Civil War (links to mp3 or Flash Player, ~ 56 minutes long).

Humphreys, of course, is one of the world's leading historians of medicine, and is in particular an expert on the history of medicine and public health in the American South.  The lecture is as fascinating and as incisive as any of Humphreys' work.    

Post on the Place of the Medical Humanities in Medical Education

Johanna Shapiro has a wonderful post up at Literature, Arts & Medicine Blog about the place of the medical humanities in medical education:

The institution of medicine is deeply rooted in certain mechanistic, linear, positivist, objectivist, and reductive assumptions that are expressed every day in the ways physicians behave and the system as an entirety works; and which make it difficult to see the humanities as anything other than, at best, a nice but not essential, part of medical education; and at worst, pretty much a waste of time. Even if institutionalized medical education “makes room” for the humanities, it will do so on its own terms. This is not necessarily bad, but it is also not necessarily sufficient.

As they say, go read the whole thing.

7th Global Conference On Making Sense of Health, Illness and Disease

Mansfield College, Oxford, is hosting the 7th Global Conference On Making Sense of Health, Illness and Disease.  The Conference specifically has an interdisciplinary and multidisciplinary approach that

aims to explore the processes by which we attempt to create meaning in health, illness and disease. The project will examine the models and metaphors we use to understand our experiences of health and illness (looking particularly at perceptions of the body), and to evaluate the diversity of ways in which we creatively struggle to make sense of such experiences and express ourselves across a range of media.

This looks to be an excellent forum for those interested in the medical humanities, who, I would argue, would have to work very hard to avoid as a central feature of their work attempting to "make sense of health, illness, and disease."

300 word abstracts are due by February 1, 2008.  Further details are available on the website.

On Podcasting

Pardon the navel-gazing: I (we?) am (are?) toying with the idea of instituting a Medical Humanities Podcast Series.  I'd like to solicit feedback on this, so comments are welcome either on the blog or over email.

__________________

Tacked 12/22

Wonky Links

Abundant guest blogger Frank Pasquale has been issuing some interesting posts over at Concurring Opinions.  I am biased because Frank is kind enough to guest blog here at MH Blog, but I particularly like the way his (subjective) normative preferences are always plainly stated.  Frank and I have had several conversations across blogs and otherwise in which we have discussed the value of subjectivity, and this is further evident in the way he weaves narratives into his analysis of health policy (see this collection for further analysis).

In this regard, Frank also writes consonant with the ethos of the Renaissance and medieval humanists who stressed the importance of the subject in thinking about ethics.  Montaigne, the patron saint of MH Blog, is the paragon of this exemplum, and the reason why is contained in the subheading of this blog: C'est moi que je peins (it is myself that I paint).  Montaigne was acutely aware that his Essais were nothing if not his own subjective views on all manner of social and cultural practices.  The verb essai itself means to attempt, to assay, which is exactly what Montaigne was doing. 

So, whether one agrees with Frank's policy positions (and I freely admit to agreeing with many of them, though often for slightly different reasons), his perspectives are always worth engaging.  We are subjective creatures, and my dissertation on pain will evaluate the merits of limning the Self with the veneer of a constructed and dubious notion of objectivity.

In any case, Frank has several excellent posts, concluding with his most recent post, which references epicycles and market-based health care.  Frank, anyone familiar with Kuhn's The Copernican Revolution would be quite aware of the significance of the metaphor (a personal favorite of mine and an elegant demonstration of the inferential power of Occam's Razor).

On Insurance and Health

We have noted on this blog the relatively weak evidence for the proposition that lack of insurance coverage and access to care has a pronounced effect on health.  For understandable reasons, many assume that a strong relationship exists between the two variables, but the evidence for this assumption is lacking.  What's more, given the Whitehall studies, there is good evidence that pronounced differences in health outcomes persist even when the population in question enjoys coverage to basic care. 

I have argued that the case for increasing access is therefore on sounder footing if made on ethical grounds than on policy grounds that doing so will substantially improve population health.  In addition, I continue to believe that we would do well to direct some of the energy and focus we spend on the access debate to agitating for a reallocation of health care dollars to public health and primary prevention, both of which are on much firmer empirical footing in terms of their likely effects on improving population health.

All of this is context for a study released yesterday in CA: A Cancer Journal of Clinicians (an American Cancer Society journal) entitled Association of Insurance with Cancer Care Utilization and Outcomes.  The study produced statistically significant survival differences based on insurance.  According to the ACS press release, the study found that

About 89% of privately insured white women with breast cancer survived at least 5 years, compared to 76% of white women with Medicaid or no insurance. Among African-American women, 81% of breast cancer patients with private insurance survived 5 years, compared to 65% of those on Medicaid and 63% of those without insurance. A similar pattern emerged in colorectal cancer. Among white patients with private insurance, 66% survived 5 years, compared to 50% of those with no insurance and 46% of those on Medicaid. Among African Americans, 60% with private insurance survived 5 years compared to 41% of the uninsured and Medicaid patients.

This study suggests, of course, that lack of coverage is relevant to health outcomes as to cancer.  Several points are worth noting here: first, given that all manner of primary prevention interventions are in fact contingent on coverage, one should be careful about drawing conclusions from this study as to the overall effect of acute care on population health.  The study notes this, of course, reporting that the uninsured subjects had significantly lower access to cancer prevention programs and education, as well as lower access to early detection and screening programs.

Second, only about 4% of U.S. cancer patients are uninsured.  Accordingly, it is fair to wonder whether, even if insurance status is strongly linked with cancer outcomes, increasing access will have a large impact across the entire cancer population, let alone the U.S. population.  Third, finding a significant positive correlation between insurance status and health outcomes should not be taken as proof that insurance status is a primary factor.  The evidence has generally been lacking that it is a significant factor at all, and this study does not evaluate the relative contribution insurance status makes to outcomes as compared with other factors (i.e., health literacy, relative socioeconomic disparities, early child development, etc.)

None of these cautions detract from the study, which seems to me to have been thorough and well-done, and which certainly provides evidence that there may be a stronger link between insurance and health outcomes than prior work has demonstrated.

The Library of Medicine's Online Collection

Disability studies blogger extraordinaire Penny Richards brings word that the National Library of Medicine has an extensive online collection.  She has a fascinating post on how technical innovations are often developed "first for disability-related applications and only later translated to wider use."

Though I'll hopefully have more substantive commentary on some of the images for a future Imaging the Medical Humanities post, but given my interest in pain, I pulled these images (below the fold) that may be of interest.

Webcast on Link Between Disparities and Social Determinants of Health

Those of you who have been interested in our focus on prevention, public health, and the social determinants of health might consider checking out Kaiser Health's HealthCast on Reducing Health Disparities Faster: Addressing Social Determinants of Health.

Kaiser's HealthCasts are generally indispensable, and are available via web video feed, podcast, and in transcript form.  This one was particularly good, IMO.

Who's Who In the Medical Humanities: Thomas Linacre

"At last," sigh our faithful readers, "a physician appears in the Who's Who."  Heretofore we've featured diplomats, lawyers, mayors, professional scholars, but this is our first physician.

On HDT/ABMT for Patients with Advanced Breast Cancer: The Final Word?

We've previously covered the story of high-dose chemotherapy + autologous bone marrow transplantation ("HDT/ABMT") being used experimentally on patients with advanced breast cancer, and have argued that the narrative is relevant both to the therapeutic misconception and to the ongoing Abigail Alliance litigation, which is currently pending on writ of certiorari at the U.S. Supreme Court.

Todd Ackerman, the fine medical journalist for the Houston Chronicle, reports today on the results of a systematic review of the efficacy -- or lack thereof -- of HDT/ABMT for patients with advanced breast cancer.  Excerpts:

In releasing their report on a review of existing studies, the researchers said women who received high-dose chemotherapy, followed by transplants from their own bone marrow, fared no better than patients on other therapies.

"This shows more is not necessarily better," said Donald Berry, head of quantitative studies at the University of Texas M.D. Anderson Cancer Center and the review's lead investigator. "We're still in the dark ages at recognizing who benefits from which treatment, but we've seemed to reach a plateau delivering chemotherapy."

Berry's quote there is particularly important, as it underscores the uncertainty in the efficacy and benefits of different treatments for breast cancer, which, as Jay Katz documents, is all too often suppressed or diminished, rather than disclosed.

Ackerman continues:

The analysis, presented at the 30th annual San Antonio Breast Cancer Symposium, appears to be the final confirmation that the once cutting-edge therapy shouldn't be an option for women whose breast cancer has spread to their lymph nodes.

The therapy fell out of favor after four randomized studies presented in 1999 showed no benefit, and a fifth that did show a benefit was revealed in 2000 to have been falsified.

Actually, HDT/ABMT was never evidence-based therapy at all, but was an experimental protocol that was hoped to be therapeutic for advanced breast cancer patients (HDT/ABMT is evidence-based therapy for other cancers, particularly certain leukemias, which underscores the importance of understanding that "cancer" is really about 150 different diseases).  The fact that it was never "therapy" at all is itself an apt example of the power and scope of the therapeutic misconception.

Berry said he was surprised that the review did not show even a subset of patients who benefited from the therapy.

Perhaps this review will constitute the final word on this sad story, in which dozens, if not hundreds of women suffered -- the procedure itself has horrifying side effects -- and may have even died prematurely due to the statistically significant mortality risks from the procedure.  The story also reminds, as many commentators have noted, that terminally ill patients can be conceived of as a vulnerable population insofar as the power of hope is enough to prompt many such patients to undertake virtually any experimental protocol that provides even the tiniest glimmer of such hope.