Drug History Canada

Musings on the history of drugs in Canada.

Pain and perception

So today in response to an interview I had on CBC and some tweeting that was going around some mysterious person stated “The human body is not meant to be pain free.”  I refuse to engage in troll-y debates, so I figured I’d do what I promised yesterday and begin to dig into some of the stories I have learned since the op ed on pain was released last week.

But first a reflection on language.  You often hear the phrase “meant to be” as in “the human body was not meant to be pain free” or “their love was meant to be.”  It might just be a convenient cliche, but when you talk about something that was “meant to be,” you are implying intention and conscious action by some outside force.  So if someone says “that little boy didn’t mean to hit his friend” or “I meant to take my Christmas tree down yesterday” we are talking about an act of intention.  So to say something was “meant to be” is to say that there is a predetermined outcome, or a predeterminer. In other words, you’re saying God meant this.

The human body was not meant to be pain free is an asinine statement that suggests your god wants you to be in pain.  Now, I’m no religious scholar, but even in religion pain is something to be avoided. Job wasn’t exactly thrilled that he was plagued with injury; Jesus wasn’t singing show tunes hanging from the cross.  The very process of The Crucifixion was in itself an act of pain and degradation, and it is framed in Christianity as the process by which humanity is saved by Jesus taking on the punishment that deeply flawed humans are supposed to have suffered.  He “suffered for us.” It’s a fundamental of Christianity, and so pain avoidance is not a problem.

But perhaps this person is really just saying it is unnatural to be pain free. Fair enough, but pain is not a desired nor a normal state.  Pain is an indicator that there is something wrong.  We have evolved to avoid pain. If we didn’t, we would not have likely evolved, since our ancestors would have kept doing things that caused pain and possibly not procreated, and kept the race going.

Pain is, however, natural.  It is that thing in our brains that says “don’t do that.”  So if one were to say “the human body was not meant not be unable to feel pain” or “it is not natural not to feel pain” I’d be in agreement.  But to suggest that feeling pain is a natural state is just silly .

That aside, usually such statements are made by people who are not in chronic pain, have not faced the debilitating blinding pain of people like my friend Lisa I mention in the op ed, and have a “suck it up” attitude based more on a sense of superiority over weak people, rather than any kind of sophisticated appreciation of the dimensions of pain.

The problem is: our health and the integrity of us as physical beings is more than just about living in fleshy machine that gets our brain through life. It is fundamental to our being.  This is why the field of medical ethics and bioethics is so important. Unlike work on a car, or on your house (both of which have different levels of emotional involvement) work on your body affects fundamentally your sense of self.

I invite such people who shrug off stories of pain to get heart surgery without anaesthetic. Or, less vindictively, I will reproduce some of the stories I’ve received about pain.

Let’s get the less challenging stuff out of the way first. One correspondent thanked me for my “supremely intelligent essay on pain – a problem I share with a great deal of life-destroying intensity.”  Life destroying intensity relates to that sense of self, and the reality that quality of life is filtered through our experience with a body in pain.

Something more heartwrenching came in a few minutes later

Normally I am up @6:00 a.m. But today slept in until 8:30 because of a brutal pain attack which 2 naproxen, 2 tfa, ointment, heat, cold did not alleviate.

My output today will be well below normal but I will find my way to my Chinese doctor for a foot massage.  I will be 80 next Friday but still active… and have endured pain for nearly three decades. My Doctor who doesn’t do pain didn’t prescribe Naproxen until I brought it to her attention five years ago.

As I lay sleepless last nite, some times screaming out (some distance from my wife so I wouldn’t bother) I wondered why can’t I get opioids to ease the pain?

So thank you for your help.

This was a difficult one, a personal story of endurance and the persistence of pain. Screaming out in pain at night, avoiding close contact with his wife so he wouldn’t disturb her, and a gap in medical knowledge.  A doctor who “doesn’t do pain” is a startling concept.  .

The final one will be difficult to anonymize, but I will try.  It is about an individual’s family member. I use the acronym AB for this person.

Fifteen years ago AB was given benzoes and high dose painkillers (Percocet)  for CFS [chronic fatigue syndrome], fibromyalgia and anxiety disorder. AB has lost [his/her job] and is on long term disability.

Recently the B.C. College of Physicians and Surgeons, in a very crude and sledgehammer approach , dictated that no Dr.s shall prescribe OxyContin, something AB was switched to from Percocet. So AB has had to try and go cold turkey. Even finding a Dr. at one of the walk in… clinics is next to impossible. Most have signs stating unequivocally only one problem per patient! Ten minutes at most for any medical advice. How AB will end up is a constant worry for us – and more so for AB.

Pain is pain and cannot be just ignored because of a dictate by the esteemed medical community. The edict by the College ignores thousands of people suffering from real, life changing pain.

There are several elements of this story that reappear elsewhere. Problems with understanding of pain management, access to consistent medical treatment, sweeping directives that leave many people in an untenable position.  I should note that the BC College “edict” is explained by the college as guidelines, although it has some rather punitive fines for doctors who run afoul of the system.

Pain is something we try to avoid. Pain that is persistent is distracting at the least, debilitating at the worst.  You may be able to limp along on a strained ankle, but if there is no way to ease that pain, if you can’t sleep because of it, if your relationships are strained, your work is lost or diminished, your opportunity for advancement curtailed, it is more than an inconvenience.  Pain is a fundamental feature of our life; it is what helps keep us safe, and avoiding it is something we all try to do (even sadomasochists have safe words). But when we can’t avoid it, when the control over the fundamental integrity of our body, the one thing we truly possess is lost, it can strike to the core of our being.

So don’t tell me pain free is an unnatural state.  Having no empathy for people in chronic pain is unnatural.

But before I click “publish” I want to make something clear. My discussion of pain is not intended to justify pain medication.  There are many ways to address pain that do not involve pain medication. However, medication can be part of a pain strategy.  and some types of pain need certain types of medication. Long-term therapy helps, but we should not reject the need for a pharmaceutical intervention due to stigmas of addiction or dependence or at just some kind of ideological rejection of the pharmacomedical industrial complex. Pain management, just like the issues of addiction, is a complex process requiring thoughtful consideration of multiple factors.


Fentanyl crisis and historical perspectives

Over the past month or so I’ve been mulling over the current opioid crisis and what it means, and of course what history can tell us about it.  It culminated in an op ed in the Globe and Mail entitled “Why is everyone talking about painkillers, but not about pain?” I felt that this article in its 700 word format was a decent introduction to the complexity of the current opioid crisis, but of course there is so much to say.

Having written op eds before, on cannabis legalization and liquor control, I don’t think I was prepared for the type of attention this article received.  I guess it was the timeliness and the national scope, but also the emergent nature of the crisis. I will in the next few days try to capture some of the response without betraying any confidences. Suffice it to say when dealing with pain and medical treatment, people have a lot of stories to tell, and they need to tell them.  As the recipient of these stories, I’ve been humbled and saddened but also enlightened. Moreover, it has reinforced my resolve that the current painkiller crisis has much deeper roots and needs more concerted efforts to address its origins.

Cannabis and liquor regulation

If the weather holds I’ll be off to Saskatoon tomorrow for a symposium on cannabis legalization.  I have been asked to do a keynote based on my observations and research on the connections between liquor control and cannabis legalization.  It’s something I have looked at a few times, so it will be fun to bounce these ideas off an audience in a city where cannabis has been an especially hot topic of consideration and debate for a while now.

Here is the poster. If you’re around, come by.

Cannabis Symposium Poster

Cannabis legalization, liquor control, and bias

Just an update on the cannabis file. There has been considerable interest in this topic since, well, the past few years I suppose. But after the Liberals came back to power, with Justin Trudeau making a clear argument for legalization, not just decriminalization, the attention has been ramped up.

I’ve had a chance to speak to the media quite a bit on this, and several articles have come out about the topic.

As a historian, of course I take the long view. I relate current cannabis legalization challenges to the challenge of legalizing liquor after prohibition. These views have come out in several pieces in the past little while

First, I’ll let my ego soar and mention articles that I’ve written or been involved in:

Toronto Star‘s Chris Reynolds 22 Dec 2015

Prohibition: A history lesson 

My Op ed on this topic from 15 Dec 2015 The Globe and Mail

Why should liquor control boards sell cannabis?

My op ed in National Post over a year ago (5 November 2014)

How to legalize pot?

Of course there is more, and some of it does not take a historical focus apart from looking at the last few months or years’ experiences.  These are important perspectives, but a longer view gives us more insight.  After all, both the Colorado and Washington state regimes are still being established.

So consider the following documents

Centre for Addiction and Mental Health releases its policy framework supporting legalization based upon harm reduction principles

Canadian Medical Association Journal advocates a similar perspective but is much more circumspect.  If you can’t access that material (it may be behind a paywall) then check out the CBC’s coverage here 

My concern with this editorial was this fixation on “big cannabis” which rhetorically links it to other industries presented as conspiratorial and out to mess with the public’s health, such as “big tobacco” and “big pharma.” Let’s leave the rhetoric aside, since it does nothing more than perpetuate myths that may not be valid.

Yet although I advocate cannabis legalization (and note, I have never smoked the stuff and have no interest in consuming it in any way) I should note that there are many voices of caution. I’m not going to post them all, but a quick jump into the newspapers will reveal a range of angles.  As a caution, remember to read through the rhetoric and into the evidence.

Here is a good example of rhetoric trumping content, as presented in the Toronto Star also on 22 December.

More young adults in Ontario would smoke pot if feds legalized drug: Poll

Pretty alarming title, huh?  And given that many people may see this on the front page in large type it could sway opinions.  But read on.

The president of Forum Research, which ran the study, noted that “He noted that overall, it doesn’t appear that legalization would prompt a sharp uptake in marijuana use.” Moreover, he said “When you look at how many are using it now and how many would use it when it’s legal, it’s not that many people at the end of the day.”

Yet the Star’s title, histrionic as it is, suggests something more dire.  It is literally correct, but does not provide anything like the nuance that the study found.

I’m not surprised (and wrote to the Star about this, a letter which appeared 4 January 2016) because the Star is historically a prohibitionist paper.  That angle persists, just manifested in different ways.

While we are talking about rhetoric, I’d like to point out the rhetoric of opponents. This is the problem I find, that people internalize the intense moralism of those who disagree with cannabis legalization. Like the temperance forces a century ago, they write as if the substance itself will bring down Western society.

After my op ed in the Globe, I received the following letter:

I’m totally shocked that you have allowed yourself to be brainwashed by potheads’ lies and propaganda.

Pot is definitely more harmful than pot. While cigarette smoke harms only the lungs, pot smoke harms both lungs and brains (especially young brains). And cigarettes don’t cause impaired driving resulting in injuries and deaths, like pot does.

According to columnist Michael Den Tandt, “Data gathered by the Rocky Mountain High Intensity Drug Trafficking Area (Colorado), established to monitor the effects of legalization, shows a dramatic increase in impaired driving due to marijuana. In 2014, according to a report released in September, the rise in pot-related road deaths was 32 per cent. From 2010 to 2014, the rise in marijuana-related traffic deaths was 92 per cent, compared with an eight per cent increase in all Colorado traffic fatalities over the same period.”

For more news, articles and info about the harms of pot, visit: http://harmsofpot.blogspot.com

And the much-ridiculed old film “Reefer Madness” has been proven to be truthful and correct after all by news and evidence.

I was so excited to have someone engaging in my editorial that it took me a while to write the following response (originally I’d decided not to engage, but how could I resist?):

Thank you for your interesting message.

I’m not sure where you’re writing from or what aspects of my recent discussion on cannabis legalization you’re responding to and choose not to engage you beyond pointing out one thing.

You may wish to look beyond blogs and journalists for your evidence.  I prefer getting my information from respected sources written by researchers whose jobs it is to ask critical questions and then look at the evidence available, like CAMH, or the Lancet, or the CMAJ, all of which come out in favour of legalization due to the way it will reduce associated harms.

I don’t think these peer-reviewed journal article authors are “potheads” nor that their evidence can be called “propaganda.”  I think they are critical scholars who also seek to figure out if a perspective is supported by evidence or not.

I am also not a pothead. I don’t smoke the stuff, never have, and never will. I find people who smoke pot boring, and the smell is disgusting.

I’d rather have a beer.

What I didn’t point out is the fun you can have with stats.  If deaths rise from 2 to 3, that is a 50% increase, but only one additional death (not that any single death should be acceptable, but again, we’re dealing with histrionics). If deaths rise from 1 to 2, that’s a 100% rise.

That said, the RMHIDTA data deals with larger numbers, but the meanings behind those numbers are shaded with caveats about limits to data and the way it’s reported. this, of course, is lost on the correspondent, and also on Den Tandt, the National Post article’s author. (BTW, the RMHIDTA is a passionate anti-drug collective of policing agencies, so don’t expect their stats to be clear or unbiased.

The story is always the same: dig deeper.  

Be critical.  Always.  Ask where the information is coming from, and whether it makes sense.

That also applies to the information I provide here.

After all, this is just another blog.

(c) 2016 Dan Malleck

Good drugs and their bad tendencies

After several decades of working on this (ok, worked on it in the 90s then took some time away) my book, When Good Drugs Go Bad: Opium, Medicine, and the Origins of Canada’s Drug Laws has been released.

You can order a copy of the hardcover here.

And for reference, here is a picture of the cover.  Below I will tell you more about it.

Malleck - Good drugs - cover image

In this book I look at the origins of Canada’s drug laws, the century or so before the creation of the Opium Act, 1908, and the Opium and Drugs Act, 1911.

My main question was simple: where did the idea come from that some drugs were bad and needed to be regulated. It may seem simplistic, but beneath this question are a bunch of related issues: Why is addiction considered a problem?; what is wrong with recreational drug use? How did the idea that government should be involved in the regulation of drugs come about?

These may seem odd questions, but they really are fundamental to our understanding of current debates over drug laws and drug use.

For example, we seem to have this idea that recreation is an illegitimate application of chemicals.  That is, you can take drugs for pain killing, to heal, to allow children to focus, to reduce coughs, and to get rid of the sniffles, but once you enjoy them purely for the sake of enjoyment, you are misusing drugs.

Here we get this idea of “drug abuse” which is linguistically connected to things like child abuse and spousal abuse, but in this way we’re really considered to be abusing ourselves by using drugs in a way other than one medically acceptable.

Why was medicine the only legitimate use of such substances?  How did physicians get that kind of power?  Why are pharmacists the ones who should be managing the sale of drugs?

The book takes a long view, stretching back to pre confederation, to look at the various uses of drugs, and the different ways that people began to suggest there are legitimate and illegitimate uses of them. It traces the creation of provincial pharmacy laws, which I argue are Canada’s first drug laws.  Here the idea emerged that the trade in certain substances should be governed by small groups of educated men rather than allowing the free market to do its thing.  Once you establish the idea that some things should be controlled by government pronouncement, and you deputize groups of professionals to do the controlling, that scope of control can be broadened. The idea of controlling drugs that could kill you broadens to include controlling drugs that could hurt you. Then the idea of “hurt” expands to include not just maim or debilitate, but perhaps just make you need them all the time (habituation, or addiction).

It’s a complex story, and one that needed to be told for Canada.

I hope you enjoy it. Buy multiple copies.  Christmas is coming, after all!

No need to smoke em if you got em

Smoking is considered a pariah activity. Smokers, driven by “Clean Air” laws, zealous public health advocates and self righteous non smokers do their thing on the edge of activity. Back doors, 9 metres away from doors, unsheltered, cowering, hiding, heads down, grimaced.

This is how health messaging becomes moral shaming. I’m not a smoker, find the habit gross and stay away from smoke, but the overly evangelical approach of the public health advocates to shame into submission the few smokers of the world really bother me.

It is this biopolitical stance, the idea that you internalize the messages of the state related to your body or health in general, that informs other aspects of health messaging and health politics in general. So it is no surprise that when the Supreme Court of Canada agreed (unanimously) that it is unconstitutional for our medical marijuana laws to render illegal all forms of marijuana except in its dried form–marijuana you normally smoke (ie: brownies, marijuana tea, etc still illegal) some people got pissed off.

CBC on Supreme court

You see, smoked marijuana is the most reviled form. It’s kind of gross, and every picture you see on the media of people smoking pot have some unshaven pursed lips sucking from a filthy crumpled spliff. It’s right up there with those gross pictures on cigarette packets: a repellent disincentive to smoke.

The Supreme Court seems to be immune to the aesthetic sensibilities embedded in public health messaging. Indeed, the justices to a person decided that this “dried only” provision unnecessarily hindered the reasonable access to a useful drug.

To be clear, the ruling was about the clause that makes only dried marijuana permissible for medical marijuana, but the main way to consume dried marijuana is by smoking.

And smoking itself, along with its aesthetics, is perpetually connected to the idea of carcinogens or other toxic elements in the product being smoked. So it is an easy leap from something being smoked to believing with little evidence that that item causes cancer.

The Tories are not happy. Health Minister Rona Ambrose is “outraged.” Of course she is. Their mission with respect to drugs has been to return marijuana to its illegal status, so a ruling that makes it more accessible is outrageous in their eyes. Don’t be swayed by her arguments that her outrage comes from perspective that only Health Canada can decide if something is acceptable as a medicine. The court is not changing the medicine; only the mode of ingestion. Indeed, it’s about access.

Smoking is gross, and possibly the thing that keeps a lot of people from taking pot. I’d never smoke it, but once in Amsterdam I did have these less than delicious but oddly satisfying cakes. (Ultimately I wasn’t happy with the experience, but it made it literally palatable.)

But, I get it. The concern is that marijuana is a gateway drug, and that restricting medical marijuana to its smoked form makes it a narrow and rather unappealing gateway. Well, not to be concerned. The legalization of marijuana has shown that the gateway theory is bunk. So there’s no gate to make ugly.

Today is good news for those of us who think the drug laws are overly restrictive and not very useful. And the fact that it’s another decision that shows the Tories are out of step with the basic elements of our constitution is just icing on the space cake.

Media II: the morning after the referenda

Two more states voted for various forms of cannabis legalization. The District of Columbia also voted to permit marijuana possession. Several municipalities in New England passed similar initiatives.

These are big deals. How they will play out in Canada (if at all) is a good topic of debate.

I spoke to Yahoo News about this, and they published an article reflecting on the potential impact.

It is available here

As noted in the article, I think that the most interesting part of these outcomes is in Oregon, where the existing Liquor Commission will take on the role of regulation. (In Alaska a similar situation would be temporary, with a Marijuana Control Board possibly taking over). Since we have liquor commissions or liquor boards in all provinces, it makes for a good template for a legalization framework.

I should note, with due diligence, that I mis-remembered the Washington State law. It also puts the regulation of cannabis in the hands of the state liquor control board. Don’t ask me how I misremembered it, ok? These things happen on busy days when you’re asked to respond quickly.

Other links

Some of the answers to questions bout Oregon’s marijuana laws

Oregon’s Measure 91 – Cannabis legalization framework

Information on Alaska’s measure

Colorado’s Marijuana Amendment 64

Washington State’s marijuana initiative

Cannabis legalization in the media

There is a lot of attention to the issue of legalization of marijuana. So I wrote a little op-ed. It was published today. I have to say the editors came up with a much better title than I had given it. It was so forgettable, I forget my title.

How to legalize pot? We figured this one out a century ago.

Reflections on a “road” trip

I visited the United Kingdom in February, as I often do, to attend conferences and talks. There is always a lot going on in the medical history and booze and drug policy/history area, so I am always finding myself quite stimulated intellectually by these trips.

This time I added the title of “unofficial university ambassador” to my credentials, since I met the director of internationa student exchanges at University of Kent and paved the way for what looks like adding another university for our students to visit on exchange. And this one in Canterbury, so they’ll get lots of our students there.

But more properly for the topic of this blog, I spoke at three universities, delivering three very different papers to three unique groups and also got to participate in an undergraduate class.

The first was at University of Leicester. There I explored, in more detail than I have on this blog, the connections between post-prohibition liquor control and the advocacy for and advent of marijuan licensing in the United States and (possibly in the future) Canada.  I’ll do a new blog post on that at some point in the future.

Also while at Leicester, I got to sit in on a class on liquor control in North America (mostly in the USA) run by my friend and colleague Deb Toner.  We did a session on the origins of prohibition in the USA, and she had students read the intro to my book Try to Control Yourself as a primer on theoretical framing of this topic.

After class, I was confronted by a student afterwards, who had a pointed question about what I wrote in my preface to that book. The preface was a reflection on my personal intersection with liquor and liquor control. In that reflection I noted that I benefitted from my parents modeling a “healthy relationship” with alcohol. This student asked: “Do you really think an academic can have a healthy relationship with alcohol?” Her stern face took me aback until she assured me she was kidding.

Two days later, at the School of Geography at University College, London, I presented a revised paper on the spatial rationalities of liquor control in Ontario.  This drew somewhat from my chapter on the organzation of the public drinking space, which looked at community layout and internal layout of beverage rooms.  But in the presentation I also used powerpoint to consider the geography of liquor control. I mapped the location of hotel spaces on a Toronto street, and looked at how the nature of those businesses shaped and was shaped by liquor control board decisions. I’m going to work this into a proper academic paper, but suffice it to say that my simple thesis was “you can’t make simple conclusions about a process as complex as liquor control in a diverse province,” which is also a general theme in the book.

Finally, I attended and was a guest speaker at a conference in Bristol on public drinking in the Victorian period.  This brought together historians, geographers, literature folks, art history scholars, and political science types.  They looked at the various ways of viewing and managing the pub in Victorian Britain.

I finished the conference with a paper that was, really, sort of out of place in that conference. My paper, entitled “The half-life of the Victorian saloon” looked at how the gradual transformation of liquor laws in Victorian Ontario was the foundation upon which post-prohibition liquor control was built. So instead of completely reconstructing a new system, the post-prohibtion liquor regulatory system imposed a new bureaucracy upon an older structure. Moreover, I argue that the post-prohibition liquor regulation system was more flexible and designed to be more responsive to the needs of individual communities than the system immediately before prohibition, which had grown increasingly restrictive over half a century.

That is all I’m going to write at this point. I love these visits; I have some good and brilliant colleagues and friends in the UK, and their engagement with liquor and drug regulation is different enough from what we have in Ontario (and Canada more generally) that it always stimulates interesting and thought-provoking discussion.

(And usually this happens at a pub.  It may seem cliched, but it is entirely accurate.)

(c) 2014, Dan Malleck

Wherefore medical history

Before I begin, a little Shakespeare tutorial. When Juliet says “Wherefore art thou Romeo?” she’s not asking “where are you?” but “why are you?” In other words, “why are you a Montague?” Her concern was, of course, that he was the child of her family’s arch enemies.

I say that because I’m being snooty humanities guy, and using clever word structures to suggest a depth of understanding. It may be a ruse to seem deep.  Although I do think I stopped trying sometime in second year undergrad, since, contrary to the messages of 1980s high school films, depth was not getting me a girlfriend.

Ok, that’s way more information than I intended to give here.  Let’s move on.

The question of the day is: what use is medical history.

I was talking about this recently with some colleagues who were asking me  what value can medical history provide to health professions.  I was a little preoccupied at the time, and gave a rushed answer.  The even more rushed answer is “plenty.”  But time did not permit me to get into it in more depth.

There has been a big push for medical humanities to be added to medical training recently. The Canadian Medical Association Journal (CMAJ) had an article a few years ago asking why Canadian med schools lag behind the US in this innovation.  The CMJ (which sounds deceptively like the CMAJ but is actually the Croatian Medical Journal) had a great issue on the implementation of medical humanities, mostly focused on initiatives in Eastern Europe. Indeed, there is actually a Journal of Medical Humanities, too.

The evidence generally points to the development of what are often (inappropriately, to me) called “soft skills”: interpersonal interaction, sensitivity to patient needs, awareness of the broader social and cultural issues affecting a patient, etc.  This all goes under the “quality of care” or “professional acumen” or “professional competencies” label. It’s important, affects patients directly, and is certainly not “soft” in its outcome.

I did not talk about that stuff.  I had read a lot of that material, and could have gone on at length, but I wanted to talk about something else, something closer to my research and experience.

Medical history, as medical historian and hematologist Jacalyn Duffin has noted, has the potential to teach health practitioners the value of life-long learning and healthy skepticism. That is, history shows us that we exist on a continuum between the past and future, and that all of our knowledge, techniques, innovations, and assumptions about health are driven by our social and cultural values, economics, politics, and processes that have gone before.  Rather than see what we do as “true” and what people did in the past as “wrong,” rather than looking at the past and saying “how could they have been so stupid?”, medical history encourages us to see that what we believe is a product of our current reality, and that this may change. No, this will change.

The example I often provide to students is the double-blind, placebo-controlled trial (DBPCT). This is considered the “gold standard” of health research. Basically, it emerged from pharmaceutical assays.  You get a bunch of people.  Give half of them a new drug, and half of them a sugar pill. That is the “placebo control.” But it gets better. You make sure the people who are administering the drug, and the people receiving the drug, do not know whether they’re giving/getting the real pharmaceutical or the placebo. that is the double blinded.

The results are considered to be air tight proof of a substance’s effectiveness.

This seems perfectly reasonable, and is to us. as long as you believe the assumptions behind this process.

Assumption 1:  All bodies function basically the same.  This is the foundation upon which modern “western” medicine is based. It underpins the way medicine operates.  If all bodies were not essentially the same, we would need to find unique treatments for each person.  That is time-consuming, and undermines a particular way of doing science.  It introduces subjectivity into a system that strives for evidence-based objectivity.  It is also both a relatively new idea (since subjective interpretation of individual patient conditions was a hallmark of medicine until the early nineteenth century) and also based upon seventeenth century mechanistic physics that has been mostly overturned by modern quantum and string theory physics.

The problem with this assumption is that it is pretty easy to contradict.  The very existence of the idea of a placebo, some kind of unexplainable effect that means sometimes people who think they’re getting a drug actually get better even if they’re not getting the drug, undermines the “all bodies work the same” assumption. All bodies do not work the same.

In fact, the limits to this assumption has driven additional medical knowledge gathering, and spawned my second favourite word in the english language: psychoneuroimmunology. It is the science of understanding the placebo. Like the DBPCT, it assumes all bodies function the same, but we need to understand more discretely the way they function, and the inputs that affect the output (health or illness). This is normal.  We usually surround a problem with a wall and try to contain it.  This is the very reason for the placebo control  And for psychoneuroimmunology. (I love to say it; hate to type it)

Assumption 2.  Sickness is standardized.  Along with all bodies function the same, there is this assumption that all bodies get sick the same way.  You can see the falseness of this assumption when you ask a group of friends what makes them feel better when they have a cold. Some feel better in warm rooms, some in open air, some in the morning, some at night.  If one illness entity, “the common cold” has so many different manifestations (and we’re talking almost all the time in almost all cases) then how can we conclude that a) all bodies are the same and b) all illness manifests itself the same way.

So medical history helps us to explore these ideas. It shows us how our assumptions are rooted in our culture, just as the explanation about blood letting or leeching or using mercury to treat syphilis was also rooted in a complex physiological understanding of the place of the body in society.  BTW, recent research has shown that mercury does have some effect on the syphilis bacillus, further suggesting that they weren’t idiots.  But also suggesting that we need recent research done properly through condoned scientific methods to convince us of this fact.

Moreover, medical history does give perspective. It permits physicians to understand their social role along with their medical role.  A number of important books underscore this, none less impressive than Susan Sontag’s Illness as Metaphor.  A critical literary scholar, Sontag was diagnosed with cancer in the early 1970s. She was surprised and offended by the way physicians and the general public layered metaphors on cancer patients, and argued that the metaphorical construction of cancer as an embarrassing illness that was probably the fault of the individual, caused way more damage and impediment to treatment than just the straight facts.  She compared the metaphors of cancer to the very different metaphors of consumption/phthysis/tuberculosis/TB of the past.  It’s a great read, and a detailed humanist view of medical history informing today. Well, informing the 1970s.  Ten years later she published AIDS and its Metaphors and explored the topic in more detail, and from a less angry perspective. It was no less influential.

I teach using such texts, and it allows health science students to understand the cultural forms we place on top of biological processes.  As an historian, it is tremendously satisfying to see lights go on when students begin to understand how our ideas are a reflection of a moment in time.

The other thing I like to note is how the stuff I study specifically can inform medical practice. Here is that argument.

People often look to health practitioners, especially physicians, as “experts in life.”  That is, we look to them for a range of answers far beyond the biological and physiological function or dysfunction of our bodies.  Health policy, public health intervention, broader issues of population health, these are the sorts of things that policy makers, media, and everyday people look to physicians (and increasingly nurses and pharmacists, but still usually physicians) to help to address.

Understanding policy, its formation, the politics and economics that underpinned the change, is important.  If we look at a current issue of allowing pharmacists and nurses and nurse practitioners to prescribe controled drugs, we can see the way the idea of drugs as bad came about, and how it was as much a political as a biomedical issue. Indeed, as I’ve argued elsewhere on this blog, it was mostly political and economic.  This understanding can help us question the assumptions behind both resistance to the change, and the advocacy for the change.

Terms like of “danger” “poison” “control” “knowledge” “experience” and “authority” abound.

So wherefore medical history?  Because it helps to excavate the foundation of our current knowledge, gives context to what health practitioners do, and can answer many questions about today that some may not even think to ask.

(c) 2014 Dan Malleck