Wednesday, September 13, 2006

The Politics of Disease

In the late 1990's some watermen working on the Eastern Shore of Maryland came down with unusual psychiatric symptoms: sudden onset of disorientation, memory loss and inability to retain new information. The rapid emergence of these unusual cases was associated with an algae bloom which also killed off lots of fish. The organism that caused the problem, Pfiesteria piscicida, is an interesting little creature---officially known as a dinoflagellate (which to me sounds like a sexual disorder involving masochistic mastodons)---that goes through multiple different physical forms throughout its lifespan. It secretes a fat and water-soluble neurotoxin that affects humans if exposed in large quantities.

The toxic algae story garnered a lot of media attention and drew in marine biologists, medical researchers and neuropsychologists from Maryland, Virginia and the CDC. Some of the 22 original cases showed demonstrable severe memory deficits on testing that eventually resolved after about seven to ten days. The state of Virginia funded a team of researchers to conduct medical and psychological testing on affected individuals in that state and a special hotline was set up specifically to provide information to the public and to identify potential human exposures. Eventually a name was given to the disorder: possible estuary-associated syndrome (PEAS). Investigators established preliminary criteria to diagose the disorder:

  • Symptoms develop within 2 weeks after confirmed exposure to estuarine water
  • Memory loss or confusion associated with three or more associated symptoms persisting at least three weeks. The associated symptoms are: headache, skin rash at the site of water contact, sensation of burning skin, eye irritation, upper respiratory irritation, muscle cramps, and gastrointestinal symptoms
  • No other identifiable cause for the symptoms
Nearly 2000 people eventually responded to the Pfiesteria hotline. None of those who were examined were found to meet criteria for PEAS.

The algae bloom was attributed to nutrient run-off from shore-based businesses, specifically the large poultry farms that formed the basis of much of the Eastern Shore economy. Environmentalists rallied to the cause, and researchers found themselves caught up in the political cross-fire between environmentalists and the agribusiness industry. As one Pfiesteria expert stated:

"A problem is identified; scientists are asked by policy makers to present their best research on it; but then the policy makers disregard the science if it isn't politically expedient."

Now I come to the point of this post, which is the difficulty of discussing neutral, fact-laden evidence in a politically charged atmosphere. What got me thinking about this was the announcement from the National Institute of Health this week that there was no evidence to support the validity of a Gulf War Syndrome. I am expecting a fair amount of outrage from veteran's groups. I am concerned that politicians will bow to expedience and demand a new medical category where none exists. I have seen the PTSD diagnosis expand ad infinitum until the idea of a 'traumatic event' had no real limits.

The problem here, of course, is that human distress does not require a medical diagnosis to be valid. As Dinah pointed out in her last post "Behind Closed Doors" (conveniently relevant to my topic---we didn't plan this), we don't currently have a good schema for planning treatment for psychotherapy. If tens of millions of dollars are going to be spent to provide services to veterans, there must be a way of providing accountability and preventing abuse. The medical model is standard here. As the Pfiesteria story suggests, many people can believe they are diseased when in fact they are not. And giving someone a medical diagnosis can have huge implications so you better get it right. Dr. Fuller correctly suggested in her comment to Dinah's post that the medical model may not be relevant or applicable to psychotherapy, however it is presently the best---if not the only---form of accountability we have.