Wired Magazine: Why Medicine Should Care Less About 'Sick,' More About 'Normal'

Have you ever known an elderly person who fell ill and decided to live out their final days without treatment? The idea behind refusing treatment by the elderly would seem to be that no intervention, particularly costly and uncomfortable invention, is necessary where the final outcome is predetermined by normal parameters, such as life-expectancy. How much pain and discomfort, not to mention inconvenience, are "worth it" to gain an extra year or two of life?

Similar questions are starting to be asked in younger people. A seemingly classic example might be UTIs in infants. For example, instead of asking whether a UTI in the first year of life is cause for long term concern, doctors tend to think in terms of pre-emptive treatment to reduce the risk - at least in the case of neonatal circumcision. But is the prevention of a single UTI in one child out of a 100 + children worth 100 circumcisions if one UTI in a 100 is within normal parameters? Most would say no, especially given easy treatment with a weak antibiotic.

Similar questions should be asked of HIV infection. How many new infections can be expected with a normal level of fully deployed proven prevention efforts? This number may be hard to come by and even more controversial to assert, given the level of funding at stake. Unlike UTIs, HIV occupies a center-of-gravity in the funding universe.

This very state of affairs may explain the irrational rush to promote circumcision in sub-Saharan Africa. Wherever there are doubt and confusion about what is normal and expected given the circumstances, there will be those who rush in to fill the void with whatever they can. However, what would be different if we knew the expected rate of infection with clean water? Better neonatal care? Regular STD screening? Regular HIV testing? Adequate nutrition? Full employment? Greater empowerment of women? The list is really endless.

In the absence of all these things, I suspect the circumcisionists would say their solution is the best stop-gap. But is it? I rather believe that stop-gaps are excuses to fail in the provision of these other important improvements whose benefits extend much further beyond merely reducing HIV infection.

And with that, the following article talks about the idea behind "distinguishing between a condition within normal parameters — which doesn't require intervention — and an anomaly, which demands it."

Link: Why Medicine Should Care Less About 'Sick,' More About 'Normal'.

Comments

[Jen]

One of the things that jumped out at me when I read the Orange Farm study was the failure to report an expected rate of infection in the sample. The authors reported the infection rate for pregnant women in that region, which I thought was odd, but nothing for men in the sample range. You would think that a careful examination of how HIV rates for intact vs. circumcised males differ would be valuable information, especially if you're going to claim vaccine-level efficacy for MC. As it is, the best I could glean from the data was a 4.5% infection rate in the sample based on the 146 men infected at the start of the trial. That means that, according the numbers the authors reported, the infection rate for the control group was 3.1% and, for the intervention group, it was 1.3%. Just being in the trial produced a significant reduction in the HIV infection rate! This was not even acknowledged, let alone explained. Was it the counseling? Did participating in the trial cause some men to become more conscientious about condom use? Did greater access to health care reduce other factors that make infection more likely? There's no way to tell from the report.