Social media is agog with warnings about germs.

Nosferatu (1922): vampires killed victims by inoculating germs

Nothing new. Movies from Nosferatu (1922) to Contagion (2011) prey on human loathing and disgust of microbes. OK, there are important nasty strains, pandemic flu, resistant Staph, but here we are talking about a surge in paranoia about everyday exposure to germs. Witness the fetish for using germicidal soaps and sprays in the home.

Remote controls came under scrutiny after a study in a hospital found more germs on the TV remote that the toilet. Yipes! The news spread quicker can a virus in a pre-school, and was immediately extrapolated to remotes in hotel rooms. Dirty, dirty remote controls. Don’t touch them. You could use the controls on the actual set…hang on, the last 50 guests knew this trick. Yuk. Or press the buttons with the end of the ubiquitous pen in the room. Then, whatever you do, don’t touch the end of the pen.

The next headline involved Malls. Yep, there are eight places that are dirty, really dirty, in malls. They are: makeup samples, gadget shops, clothes in fitting rooms (quote “that’s why it’s important to wear underwear” – I knew there must be a reason), toy stores, ATMs, handrails, tables in food courts (I’ll let you in to a secret – you’re more likely to get sick from the food), taps in the bathroom.

No-one has mentioned the buttons in elevators. I reckon they must be filthy! So if you work on the 21st level, do not use the elevator. Go up the stairs. Do not touch the handrail. Warning: you may die of a heart-attack.

It’s not the number of germs, folks, it’s the type. There are 10 times as many germs in the human body as cells. These are normal. The collection is now referred to as the human microbiome, and important for good health and good immunity. When you touch, kiss, or even talk with someone, there is a pleasant exchange of germs. Live with it. Relax.

If you touch people, or food, for a living, there are strict precautions. And the severely immunosuppressed need care. Vaccinations work where available. There are sensible tips when you travel. But for everyday life, just follow these three rules:

• wash your hands after going to the toilet
• wash your hands before a meal
• don’t suck your thumb

Reductionist Medicine is based on a piecemeal scientific dissection of disease to determine the cause of symptoms and the treatment. Lots of people don’t like this approach. Why?

• humans are complex organisms
• complex organisms are not simple
• if you only look for simple causes then you ignore the whole person
• if you ignore the whole person then your treatment is incomplete

Even William Osler, one of the best physicians of the 19th Century, said “It’s more important to know what sort of patient has a disease than what sort of disease a patient has”.

But you know, it really is all about disease. Examples: you’ve got worsening abdominal pain – Reductionist Medicine diagnoses acute appendicitis. You have it removed, you don’t die, easy. Or, you have recurrent infections, chronic sinusitis, asthma, dermatitis, food allergy, hypertension, obesity and depression – Reductionist Medicine determines you have an immunodeficiency, you are allergic (atopic) with sensitivity to egg, house dust mite and cats, your airway disease and infected skin are triggered by both your immune and allergic problem, your hypertension is persistent, your obesity morbid, and your depression severe. You are managed with allergy treatment, immune treatment, drugs and referral to a dietitian for weight loss, you improve but are not cured. In both scenarios, a good doctor will talk to you, maybe not for long, but with empathy.

It’s NOT about normal health. If you are healthy, and you seek constant treatment while you remain healthy, then you are one of the “worried well”. It’s not hard to reduce (not eliminate) your risk of losing your health. You know, normal weight, reasonable exercise, no smoking, alcohol in moderation, varied diet, vaccinations, preventative assessments according to age and gender, and so on. There are very little other evidence-based interventions that are useful. In Australia, there are many good General Practitioners who can sort this out for you. We are a lucky country in that respect.

What is the alternative to Reductionist Medicine. Well, at its most banal, it’s called Holistic Medicine, at its most sophisticated, the term Systems Biology is used. A good summary is provided by a Harvard Group in PLOS medicine, presented as two articles called The Limits Of Reductionism In Medicine and The Clinical Applications Of A Systems Approach. I have read these, and many other similar papers, carefully. I am not impressed by a ‘new’ terminology: pseudoscience at its best, mumbo-jumbo when bad. Here is one example from the PLOS papers: “Circadian rhythms are an example of oscillatory behaviour, and complex heart

Ahn AC et al, PLOS Medicine Open Access, July 2006. My comment? I feel that Systems Science is nothing without a Reductionist Approach

rate variability (an example of) chaotic behaviour”. Does this really add to the armamentarium of a skilled Reductionist doctor? No. And you can view a summary of their ideas in the diagram. The more I look at the diagram, the more I see it as an exercise in semantics.

What about psychiatry? Is this the bastion of Holistic Medicine? Not in my opinion. Even in psychoanalysis. There may be little scientific evidence for a lot of statements made, but the good psychobiologists are reductionist in approach. There is a wonderful book called Neurosis And Human Growth by Karen Horney. She was a terrific psychoanalyst. The book looks and feels holistic, nearly 400 pages of intense psychiatric analysis of the whole person. But you know, you can summarize her arguments on personality disorder on one page with a few circles and arrows. I suspect she did that before she wrote the book. It is Reductionism at its best. By the way, if you will allow a digression, my favourite quote from the book which I have mentioned elsewhere is from one of Horney’s patients: ‘If it were not for reality, I would be perfectly all right”

So, let’s get back to our opening statements. Reductionist Medicine often diagnoses and treats disease effectively while recognizing complex interactions in humans, and, when treating disease, will treat the whole person, but only as much as required. And William Osler’s quote?  His quote may have been accurate in an era without antibiotics, without effective treatment for gastric ulcers, without good blood pressure drugs, and so on. For 2011 I would paraphrase his quote as: “It is AS important to know what sort of patient has a disease AS what sort of disease a patient has”

Pieter Peach’s post on his blog makes some excellent points, tangential but still relevant to these concepts.

Incidentally, Osler also said: “What is the Student but a Lover courting a Fickle Mistress who ever eludes his Grasp”. Is this a Reductionist or Holistic statement? I’ll leave that to you.

It’s the commonest metaphor I hear at work: ”Doctor, I am sick of band-aid solutions. I want to know the cause of (here insert symptom/disease) and I want to fix it”

Let’s start out with the most famous and useful band-aid in all of medicine. Insulin. Just read the description in Medical News Today: “(In 1922) the scientists went to the other wards with diabetic children, most of them comatose and dying from diabetic keto-acidosis. They went from bed-to-bed and injected them with the new purified extract – insulin. This is known as one of medicine’s most dramatic moments. Before injecting the last comatose children, the first started to awaken from their comas. A joyous moment for family members and hospital staff!!”

Insulin pens. Wiki Commons

Yes, this still brings a tear to my eye. And yet insulin was, and still is, a band-aid. We are close to resolving the immune nature of Type 1 diabetes and with that will come a remedy for the cause, no doubt. But hey, insulin beats the alternative.

And there are band-aids for lots of problems: hypertension, migraine, depression.. And band-aid treatment can improve quality of life and often reduce mortality. People feel better, can function socially and at work, and with some diseases, may live longer. Although some diseases are cured by  finding a cause, in the majority the actual curable origin remains elusive.

Decrease in deaths in people with hypertension. Source: CMAJ 2008

Take hypertension. In about 10% a cause is found and corrected – and  your blood pressure drops. In the rest, well, some factors are modified (you know them – obesity, exercise and so on) but a cure is not possible – yet. And yet treating this hypertension with drugs (the dreaded ‘D’ word) lowers mortality. A band-aid is saving lives!

What about allergic and immune disease? We cannot find the cause of many cases of chronic hives and chronic sinusitis. These conditions lead to a great deal of pain and discomfort and embarrassment. All we offer are band-aids: antihistamines tablets, nasal sprays, sometimes even cortisone or steroids. But used judiciously, these drugs can often (not always) improve your life.

Asthma deaths in Australia. Source AIHW

Finally there is asthma. Trigger factors are important. But the ultimate cause escapes us. So what do regular inhaled corticosteroid preventer sprays do? Less hospital visits. Less time off school or work. Better sport performance. And a contribution to lowered mortality. Not bad for a band-aid. So, stick to your asthma action plans at all times.

The patient, carer and doctor must work together to find a cause for illness. Once examination and tests fail to find a reversible cause, it’s band-aid time. Whether you like to wear a band-aid for your illness depends not only on your perception of it being just a band-aid, and a balancing act between effectiveness and side-effects, but also a realisation that band-aid treatment is not necessarily evil in itself.

Which leaves us with old age. As someone in that group, I know the wonderful advantages of many band-aids. But senility is progressive, live with it, and listen to Woody Allen: “I’m not afraid of death; I just don’t want to be there when it happens”.