The Humpty Dumpty Problem – Part Two

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden S. Lundgren
May 17, 2024

In Part One, I outlined a process whereby the practice of medicine developed from a holistic framework concentrating on health to a reductionist model focused on disease. There is no doubt that the biomedical model, with its concentration on precise diagnoses and disease-specific treatment, has saved countless lives. The problem is not so much as what is there as what has been left out. Humpty has been broken, and much of him lost.

First, there is the severing of mind from body. This is familiar to every patient who has been told her (and it usually is a “her”) symptoms are “all in her head”—as though psychological states are completely unrelated to physical findings. And this is related to a second problem. Without a specific diagnosis ideally confirmed by laboratory or imaging findings, the disease doesn’t exist and cannot therefore be treated. But isn’t the point of the exercise to treat the patient? Symptoms can be alleviated even when their source is not known. Emotional support can be provided. Above all, the patient should not be abandoned because there are no orthodox physical findings. The word patient is derived from the Latin pati meaning to suffer. Suffering requires care with or without a diagnosis.

There is also a communications issue. I cannot count the times patients have come to me to explain what a doctor has just told them. But beyond my personal experience, there is considerable evidence that doctors interrupt their patients in as few as 11 seconds. Physicians speak a different vocabulary, and think largely in the quantitative terms that are the language of the biomedical model. Patients think largely in terms of the quality of their lives. How can there be stellar outcomes if the patients are not heard and the doctors are not understood?   

The constrained biomedical model brings its own problems to clinical practice especially when that practice is directed to chronic rather than acute conditions. But that discussion is for another day.

Today the issue is what happens to public health when the discipline is dominated by physicians who bring the biomedical model with them. Addressing the disease rather than the patient works as well in public health as it does in clinical practice, i.e., it fails at least as much as it succeeds.

In 2020, we heard from a great many doctors. They told us about the virus, about masks, about social distancing, about means of transmission. But what did we not hear? Basically, the same things we don’t hear in our doctors’ offices: appreciation of how we live our lives, the derangement caused by public health measures, how socio-economic status can affect our responses, how to adapt to changed conditions, what resources are available to deal with the situation…and hope. We needed to know about similar situations and how people survived them along with the reassurance that we can survive too.        

We did not need more doctors prattling on and on about the virus. We needed experts in human behavior. We needed communications specialists. We needed to identify trusted individuals and community institutions that could provide information and comfort. We needed not medical scientists, but social scientists.

In Part 1, I mentioned Rudolph Virchow, the father of cellular pathology, a basic building block of the biomedical model. That does not do him justice. He was also one of the fathers of what we call social medicine. In addition to his discoveries on cellular disease, he was an active politician who emphasized social factors (e.g., poverty) as the fundamental cause of disease—a viewpoint shared by Florence Nightingale. The biomedical model promotes itself as a value-neutral scientific process, detached from cultural influences. Of course, it is not. It is a severely reductionist model that disregards any qualitative aspects of patients’ lives.

Social factors count. Three hundred thousand Americans died from COVID after the vaccine was available. The CDC reported that as of mid-2022, the lowest vaccination uptake rates were among Black American. My own vaccination experience backs that up. I received my first two injections in a mass vaccination center set up the Virginia Department of Health in a dying mall set in a Black neighborhood. Between patients and staff, I saw hundreds of people each time I was there—nearly all white. Where were the neighborhood people? Were they disturbed about the staffing? There were no evening hours scheduled. Should there have been? What about transportation? Would they have been more likely to come had the clinics been scheduled in local churches or schools? Did the Department of Health approach Black leaders for assistance?

Before the next epidemic, there will be a great deal of money spent on viral research, and there should be. But how much attention will be paid to the kind of questions I just raised? The behavior of people is every bit as important as the behavior of the virus. What if we could cure death and no one came? By failing to recognize the social factors driving the epidemic, that’s just about what we did.         

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Author: Burden S Lundgren, MPH, PhD, RN practiced as a registered nurse specializing in acute and critical care.  After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk VA.  She has served as a consultant to a number of non-profit groups.  Presently, she divides her time between Virginia and Maryland. She can be reached at [email protected].

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