- Constructing RSI: Belief and Desire by Yolande Lucire
New South Wales, 216 pp, £24.50, September 2002, ISBN 0 86840 778 X
- Meaning, Medicine and the ‘Placebo Effect’ by Daniel Moerman
Cambridge, 172 pp, £14.95, October 2002, ISBN 0 521 00087 4
In The Healer’s Power (1992), Howard Brody imagines an imposing figure known as the Chief of Medicine. Faced with an insubordinate medical student trained in the new, inferior style – humble, egalitarian, emotionally honest – the Chief of Medicine delivers a long monologue on the nature of a doctor’s power. Patients have a deep need to bow down to a doctor’s authority, he says, as he paces the room. If doctors are to heal, they must believe in their own authority and wield it like a scalpel. ‘Do you think I know nothing of the history of medicine?’ the Chief of Medicine asks. ‘Those men of a century ago healed because they believed their incantations; their so-called science provided the ceremonial backdrop and special effects needed to inspire, awe and ultimately heal the multitudes. Did you think I would fail to see that our lasers, scanners and computerised toys are just a finer and richer set of stage props?’ Then he adds, a little sadly: ‘The only difference is that our predecessors may have truly believed. I cannot believe; I know too much.’
This confession gets at a major problem faced by contemporary doctors. The more effective their medical technology, the less faith they have in the power of their office. Doctors have come to believe that it is their tools, not they themselves, that are responsible for what happens in the clinical encounter. What becomes of the doctor’s power when doctors lose faith in their own authority and start believing in technology instead? If the Chief of Medicine is right, then these doctors will be a lot less effective, and may even be dangerous.
This view gets some scholarly backing from two fine new books. The darker side of doctors’ power is on display in Yolande Lucire’s carefully argued Constructing RSI. Lucire writes about the epidemic of repetitive strain injury in Australia in the 1980s, which she believes was a mass psychogenic phenomenon. She argues that doctors played an important (if unknowing) part in transmitting the disorder. Daniel Moerman’s Meaning, Medicine and the ‘Placebo Effect’ is a lucid, accessible look at the power doctors have to restore patients to health with placebos. Both writers recognise the power of doctors themselves, quite apart from their tools, to make us healthy or sick.
Moerman’s real topic is the meaning of the clinical encounter. The placebo effect cannot be understood, he argues, without understanding the broader webs of significance in which the clinical encounter takes place. His book is a finely documented catalogue of surprises and misunderstandings about placebos. He shows, for example, that people who take their placebos diligently do better than those who take them only occasionally; that placebo injections work better than placebo pills; that brand name placebos relieve pain better than generic placebos; and that blue placebos are better sedatives than red ones – except for Italian men, for whom the opposite is true. If phenomena like this puzzle us, he suggests, it is because we have grown too accustomed to the machinery model of medicine, whereby the body is reduced to a complex device and doctors to mechanics. According to the machinery model, placebos should not work at all. As Moerman says, it is as if someone had designed a joke spanner that looks real but won’t turn a nut, and secretly slipped it into a mechanic’s toolbox. But when the mechanic uses it, the joke spanner works just fine.
What could account for such a thing? Psychologically minded clinicians believe that the placebo effect has something to do with what goes on in an individual patient’s head. This view is not entirely wrong, but, Moerman suggests, it is too narrow. The placebo response is highly variable across cultures. Germans with ulcers, for example, respond to placebos at a rate twice that of people in the rest of the world. In fact, the placebo healing rate for ulcers in Germany is almost three times that of the Netherlands or Denmark. Does this mean that there is something about German psychology that makes them extraordinarily responsive to placebos? Not at all, Moerman says. When you look at studies of blood-pressure drugs rather than ulcer drugs, the situation reverses itself. In blood-pressure studies, the Germans have the lowest placebo response rate in the world. Whatever the reason for the contrast, it probably has less to do with individual psychology than with the varying cultural significance of ulcers and high blood pressure.
Many doctors continue to think that some individual patients are simply more susceptible to the placebo effect than others – more gullible, more neurotic or more acquiescent to authority. In clinical studies of new medications, for example, these people are called ‘placebo responders’, and the studies are designed to weed them out. Many studies begin with a ‘placebo washout’ period, during which all patients are given placebos; those who get better are dropped from the trial.
According to Moerman, the notion of ‘placebo responders’ is misguided. Nobody has figured out a reliable way to identify who is likely to be a placebo responder and who is not. People who do not respond to placebos at one point in time may well respond later. Even when so-called placebo responders are dropped from a study, a good proportion of the remaining patients respond to placebos anyway. Whatever the placebo effect is, it isn’t reliably predictable on the basis of the characteristics of individual patients.
A much better predictor is the characteristics and qualities of individual doctors. The more convinced a doctor is that a drug or a placebo will work, the more likely that it really will. The pioneering study here was conducted almost forty years ago. Physicians were treating anxious outpatients with meprobamate, or Miltown, a popular tranquilliser of the 1950s and 1960s. In two clinics, patients given Miltown became no less anxious than patients given placebos. But in the third, patients on Miltown became much less anxious. The difference was that doctors in this clinic had self-consciously adopted an enthusiastic, confident attitude towards the drug’s effectiveness. When they switched to a more neutral, experimental attitude, Miltown was no better than a placebo.
A more elegant study to the same effect was published by Richard Gracely and his colleagues in 1985. Gracely purported to be studying a pain reliever called fentanyl in patients recovering after having their wisdom teeth removed. But he was more interested in whether a clinician’s attitude relieved pain. So he recruited unknowing clinicians to administer the treatment. Gracely and his colleagues told half the doctors that they would be administering one of three possible treatments: fentanyl (a pain reliever), naloxone (a drug that blocked opiate receptors and could make the pain even worse) or a placebo. But he told the other half of the clinicians that there had been an administrative problem, and none of their patients would be getting fentanyl.
The results were striking. All the patients got placebos, and all were told the same thing about their chances of getting placebos. But their pain response differed tremendously. How it differed depended on what their clinicians thought they were administering. If a doctor thought there was a one-in-three possibility that he was giving the patient fentanyl, the patient was likely to feel a lot better after an hour. But if a doctor thought there was no chance he was giving the patient fentanyl – that he was giving either placebo or naloxone – then the patient’s pain was likely to get worse. Somehow, the clinicians were unknowingly transmitting their attitudes towards the medication to their patients.
A similar phenomenon may account for the strange career of Tagamet, or cimetidine, an ulcer drug which blocks the production of acid in the gut. Twenty-five years ago, it was the best treatment available for gastric ulcers. Before 1981, clinical studies showed that 72 per cent of gastric ulcer patients treated with Tagamet were healed. In many of those studies the number was over 90 per cent; in one, every single patient given Tagamet was healed. But then the drug started to lose its effectiveness. In studies after 1981, only 64 per cent of patients treated with Tagamet were healed. In one study in the late 1980s, the number was as low as 37 per cent. What had happened?
What had happened was Zantac, or ranitidine. Like Tagamet, Zantac is an ulcer drug, and it began appearing in published clinical studies in 1981. This was bad news for Tagamet: the better Zantac performed in these studies, the worse Tagamet did. As the years passed, Tagamet’s performance gradually declined, like that of an ageing athlete faced with a younger, fresher competitor. The reason had nothing to do with the active ingredients of the drug. As long as doctors believed in Tagamet, it performed well. But as the evidence mounted in favour of Zantac, doctors began to lose confidence in Tagamet, and they unconsciously transmitted that attitude to their patients. If you had a gastric ulcer, you were much better off seeing a true believer than a doctor who had lost his faith.
But what if the problem was in your arms instead of your gut? In the early 1980s, an alarming number of Australians began to find themselves in pain: often in their forearms or wrists, but sometimes in their neck, shoulders or back. It could feel like an ache, or fatigue, or pinpricks, or a cramp. Sometimes it was more like numbness or paralysis, or even problems with co-ordination. Most of the sufferers did repetitive work with their hands: clerical workers, keyboard operators, computer programmers. Soon a name describing this constellation of symptoms appeared in the medical literature: repetitive strain injury, or RSI. The ‘injury’ part of the name was important, because RSI was initially seen as an occupational disorder resulting from excessive keyboard use.
RSI steadily made its way into public consciousness. Newspapers began to report it, the Government began to investigate it, lawyers began to bring suits about it, doctors began to treat it, unions protested against the conditions causing it and compensation schemes began to pay for it. The number of reported cases of RSI rose dramatically. At the peak of the epidemic, in 1984, the Australian Public Service Association launched an awareness campaign with rallies, marches, posters and RSI handbooks. By the mid-1980s, virtually everyone in Australia had heard of RSI and almost as many had an opinion about it: that it was an occupational injury caused by inhumane working conditions, or that it was a fake disorder manufactured by whingers set on collecting compensation, or that it was the result of mass hysteria and moral panic. Case reports of RSI began to appear in New Zealand, Europe, Canada and the United States. Doctors treated it with surgery, cortisone injections, splints, slings, pain relievers, anti-inflammatory drugs, exercise, acupuncture, physiotherapy, ultrasound and vitamin B12, none of which seemed to work very well. Some doctors in Europe even tried brain surgery.
Yolande Lucire, a forensic psychiatrist, was a controversial figure in these early debates. She argued that the origins of RSI were not in excessive keyboard use but in the psyche of the sufferers. In Constructing RSI she backs up her arguments with a wealth of data, including her own interviews with RSI patients. In blunt, no-nonsense language, Lucire argues that RSI is a mass psychogenic illness without a physical cause. RSI, she claims, was not the result of repetitive work, static strain, ergonomics or poor posture. It was caused by the belief that these things may harm the body. One important source of this belief was the medical profession. Some of these doctors were moral entrepreneurs: public crusaders on behalf of workplace reform. But others were simply well-intentioned practitioners. ‘The kindest, most sympathetic physicians,’ Lucire writes, ‘became vectors of a disabling illness, one caused by the ideas inherent in its name.’
She believes that RSI is the type of condition that in earlier times might have been called hysteria or, later on, a psychosomatic disorder, but is now more often called somatisation: the experience of anxiety, depression or stress as symptoms in the body. The symptoms of somatisation are usually inconsistent with physical and laboratory tests, inexplicable by known pathophysiological mechanisms, and do not correspond to the symptoms of known medical disorders. Yet somatising patients are not fakers. They really do experience paralysis, blindness or, as Lucire argues in the case of RSI, symptoms of pain and weakness, which can also manifest themselves as redness and swelling.
Anyone who argues that RSI is psychogenic is asking for trouble, from doctors, patients and unions. The most receptive audience will probably be the employers whose faulty workplace conditions are alleged to be causing RSI. In Australia, they received some very large financial penalties. According to Lucire, New South Wales saw an eleven-fold increase in disability claims for arm problems between 1970 and 1985. Between 1980 and 1982, absenteeism from work because of arm problems tripled. One small manufacturing company saw its insurance premiums triple to $150,000 in a single year when three RSI claims were filed against it. The epidemic cost Telecom Australia an estimated $15 million over five years, even though the work of its keyboard telephonists involved only about four hundred keystrokes an hour – the equivalent of typing a couple of words a minute.
Whether or not Lucire is right, she presents a case that must be taken seriously. The benefits of getting an RSI diagnosis are plain enough: a medical excuse from the obligation to work (often at jobs that were repetitive, boring and poorly paid) and financial compensation for a workplace injury. Not that this made life rosy for RSI sufferers in Australia. The diagnosis was hotly contested, and its sufferers often stigmatised. As with many other contested disorders (such as fibromyalgia, chronic fatigue syndrome or multiple chemical sensitivity) RSI eventually became part of a social movement in which sufferers banded together in solidarity. When a conference on RSI called ‘Medical Mythology’ was organised in Sydney in 1985, it was picketed by women in arm splints carrying protest banners.
Lucire does not provide a straightforward rebuttal of the various physical explanations of RSI that have been offered in the medical literature, which is a pity, but in one of the most illuminating sections of the book she does discuss case reports (20 are included in an appendix). At the request of a third party, Lucire interviewed 319 patients in litigation over arm pain. She found little evidence that their symptoms were caused by workplace injuries, but a lot of evidence that the litigants were working under extraordinary levels of personal stress. They were undergoing divorce proceedings, financial trouble, family crisis, pregnancy, miscarriage or the threat of job loss. About a third had other significant health problems. Many were responsible for children or sick relatives. According to Lucire, 60 per cent could not possibly have continued to work given their other responsibilities. Almost all were women.
Advocates of the occupational injury theory of RSI attribute it to the rise of the computerised workplace, but Lucire suggests that the only really new aspect of RSI is the name. In 19th-century England, people suffered from ‘scrivener’s palsy’ and ‘writer’s cramp’. In the early 20th century, telegraphists in the UK began experiencing ‘telegraphist’s cramp’, a condition thought to be caused by the rapid, repetitive movements required to send Morse code. The condition affected up to 18 per cent of British telegraphists. Similar cramp-like syndromes were reported in the United States. One common element was the suspicion of a psychogenic component: poor constitution, neurosis, weak nerves, neurasthenic temperament. Samuel Solly, the surgeon who first described ‘scrivener’s palsy’, warned his fellow surgeons to be very careful in their diagnosis. Make a mistake, he warned, and ‘you may destroy the happiness of your patient and bring on the very disease you have erroneously diagnosed.’
Perhaps the most interesting thing about placebos and conditions such as RSI is just how embarrassing we find them. The embarrassment stems partly from the seeming inexplicability of the phenomena, partly from the implication that what has happened to your body is not real, and that you could make yourself healthy through an act of will if only you would try. Critics of mainstream biomedicine sometimes say that we should just accept the idea that the mind can work on the body. But as Moerman points out, our current model is of the body as a machine. Asked how the mind works in it, the best we can do is to imagine a ghost turning the levers. Given the mechanical model, a placebo might as well be a magic wand, or an amulet to ward off spirits. We do not yet have the conceptual tools to describe how the mind works on the body, and without those tools, placebos and psychogenic illnesses look like magic. What do you say to the witch doctor who can reliably make it rain?