Is it the underlying philosophy of medicine that is responsible for a tide of “sickness”? Are the words of medicine worsening public health?

Life is often painful. Everybody knows that. People we love die or have terrible accidents. We know we will die. People we love desert us. We are fired, fail exams. Rising costs mean we struggle to feed our children. We are lonely. We often have aches in our heads, our stomachs, our joints, and our minds. We fall over. People bully us. How do we make sense of all of this? We feel a need to do so.

For most of history and for most people still, religion, the invention of gods, provides an answer. It’s god’s will. It’s fate, karma. We have offended the gods, and they punish us. The gods may be benign or malignant. If we pray to them they may listen, help us.

Failing a god, we may turn to a guru. There are many available. Philosophers are gurus, but most are more interested in method than advice on how to make sense of the world and they seem unable to agree on anything. The most “effective” gurus are charlatans, mini and mortal gods.

But most people in Britain don’t believe in gods, can’t understand philosophers, and are sceptical of gurus. Where can we turn for meaning? Science is the choice of many, and particularly medicine, the ancient art of healing that now wears the many-coloured cloak of science. Medicine with its classification of diseases, diagnostic methods, and wide array of treatments will provide not only practical help—perhaps a drug or an operation—but also meaning. I have this pain in my head because of an infection, a hormonal imbalance, or a faulty gene. I need medicine not only to take away my pain but also to provide meaning to my pain.

May this line of thinking explain why the number of people with long-terms sickness in Britain has increased from 1.8 million in 1993 to 2.8 million now, 1.9 million people have long Covid, 2.6 million have attention deficit hyperactivity disorder, and 172 000 adults and children are on a waiting list for an autism assessment, a 400% increase since 2019? May it explain why antidepressant prescriptions in England have increased from 47.3 million in 2011 to 85.6 million in 2022-23? Almost 9 million adults in England are now prescribed them annually (around a fifth of adults).

Henrik Vogt and Paul Garner have written an important paper in which they argue that medicine is not only providing a meaning to people’s pain but also making it worse. https://onlinelibrary.wiley.com/doi/10.1111/jep.13934  They quote the scientist and psychiatrist Arthur Barsky who has warned about “The iatrogenic potential of the physician’s words…health professionals can inadvertently amplify and prolong symptoms through the information they convey to patients.” They can do this not only for individual patients but also for populations, creating a public health problem.

Vogt and Garner write their paper in the dangerous context of long Covid. Garner, a friend of mine, became famous when he was one of the first—perhaps the first—to describe his symptoms of long Covid. His blog in the BMJ became the most accessed ever. He became a hero of what might be called “the long Covid movement.” But he then became an anti-hero by recovering. Both Garner and Vogt are doctors, and Vogt is “the former leader of Recovery Norway, an organisation consisting of people who have experienced recovery from post-viral syndromes and other illness commonly labelled “medically unexplained”.”

They are not suggesting and nor am I that people’s pain, discomfort, or misery is not real. Rather they may have opted for a medical meaning when that may not be the best meaning. I use the word opt, but I don’t mean that people have actively chosen a medical meaning. They may have attached a medical meaning to the pain, discomfort, or misery because that is the favoured source of meaning in our society just as it was once religion.

Vogt and Garner identify three ways in which people come to have to attach the medical label of long Covid to their symptoms. “The first is the biomedical community, which provides the philosophical and empirical contents of the narrative.” Medicine saw long Covid as a medical problem and set about identifying symptoms and testing treatments. That’s what doctors do. There were soon dozens of symptoms and a range of ineffective treatments. A label of long Covid could provide meaning for people searching for meaning for their dysfunction.

A similar process may explain the increases in long term sickness and attention deficit disorder. A medical label, a diagnosis, is the default explanation or meaning for dysfunction just as once it might have been angering the gods. The label activates the sick role, meaning that people are not lazy, immoral, or in some other way deficient, and also opens up the possibility of treatments, a fix. Much more important, I think, is that there is now meaning attached to what people are feeling. The problem is that the medical label may divert people from a deeper, more real meaning for what is wrong. (I’m conscious that every word here is potentially wrong and harmful to somebody. I’m like a medieval heretic, doubting the favoured meaning for life’s ills.)

Vogt and Garner identify the mass media as the second driver, although this driver could not exist with the philosophical underpinning from doctors. The media may spread the idea that the condition may be life-long and that recovery is uncertain. Always keen on individual stories, the media chose dramatic stories of people incapacitated and ignore “dull” stories of people recovering.

The third driver are patients themselves, sharing stories, often through social media, of symptoms and fears. Nature has recently reported on a group of patient who frustrated by what they see as an inadequate response from health systems have started their own research programme. https://www.nature.com/articles/d41586-024-00901-3?utm_source=Live+Audience&utm_campaign=cedc5d5936-briefing-dy-20240402&utm_medium=email&utm_term=0_b27a691814-cedc5d5936-51976720 The Patient-Led Research Collaborative has identified over 200 symptoms linked with long Covid. Another patient researcher has identified more than 150 medications and supplements that people have tried for treating myalgic encephalomyelitis (or chronic fatigue syndrome), a condition with strong advocates that, as Vogt and Garner observe, has merged with long Covid. The advocates state that the conditions are “a ‘biomedical disease’, nothing “psychological” is causing it, activity is dangerous, many will never recover. These groups crack down on any mention of a biopsychosocial approach, portraying this narrative as ‘gaslighting’ patients.”

As I read about a conditions with over 200 symptoms and possibly 150 treatments, I think of the writings of the neurologist Suzanne O’Sullivan’s, who specialises in treating what medicine currently labels as “functional disorders.” Acutely aware of the limitations of her medical craft, O’Sullivan describes how these patients undergo many tests and pick up diagnoses. They may become permanent patients and find themselves in battles with the medical establishment, the very people who have provided a way to give meaning to their problems.

I can’t conclude much with confidence from all this, but I think that I can conclude that responding to the increasing numbers of people with long-term sickness, long Covid, attention deficit and hyperactivity disorder, and other conditions with more diagnostic labels, tests, and treatments is unlikely to be the best response.