DOMINATION BY THEORY AND
BACTERIOLOGICAL REDUCTIONISM?
“Domination by Theory and Bacteriological
Reductionism?”
[July 2001]
“In attempting to reduce the use of antibiotics
for respiratory infections it is profitable to look at the incidence of
several of these problems. Ear infections in the US have increased from
9.9 million in 1975 to 24.7 million in 1990 (1). Though there are no
comparable large scale studies, sinus disease appears to be increasing as
well. All respiratory disease are primarily caused by bacteria colonizing
the nasopharynx.” [1]
9.9 million to 24.7 million in 25 years, being 149%
increase over 25 years, is a 6% annual rise in these conditions. Given the
veritable blitz on the bacterial world with antibiotics, sustained in rich
countries like the US over this very same period, how can bacteria be the
cause of these infections – which are so steeply rising? The one datum
supplied simply
does not seem to warrant the conclusion drawn. Can Lon Jones please give
us the total US consumption of antibiotics in 1975 compared to 1990, so we
might evaluate his theory that bacteria CAUSE “all respiratory
disease“?
“Antibiotic use (and misuse) has soared since
the first commercial versions were introduced and now includes many
non-medicinal applications. In 1954 two million pounds were produced in
the U.S.; today the figure exceeds 50 million pounds.” [2]
1954 to 1998 is 44 years; a shift from 2 million pounds
to 50 million pounds is 48 million; an increase of 48 million over 44
years is 1.091 million per year and that represents an annual increase of
54.5%. It is hard to interpret such figures against those of respiratory
infections
given above, as these are global figures for all antibiotics in the USA.
However, some might say that a 6% rise in such infections would be much
higher without antibiotics. Others might say such a war waged against the
microbial world is fundamentally unwinnable and therefore futile. Perhaps
Dr Jones could comment upon this aspect?
Let me open an historical window for him to gaze out
of.
“Lest in the eager hunt for specifics against
the bacillus, we lose sight of that most important factor, the
predisposition, the soil upon which the bacilli seem to flourish…let the
bacilli take care of themselves, let us take care of our patients.”
[3]
“Physicians who criticized the proposal to ground
therapeutics in bacteriology especially feared that domination by theory
would oversimplify practice…the complexity of clinical phenomena and the
exercise of judgment could not be bypassed by bacteriological
reductionism.” [4]
Has much progress in this view been made in 120 years?
“The flaws in nineteenth century bacteriology were
evident to everyone. Why did diphtheria bacilli cause disease in one
person and not another whose throat cultures showed the presence of
virulent bacilli? How did bacilli actually cause disease? All physicians
were ignorant of the answers to these and many other fundamental
questions.” [5]
And patently still are.
“Physicians were less concerned with how and why a
therapy worked then with the demonstrable fact that a therapy was
medically valid, demonstrable, and consistent.” [6]
Does not ‘bacteriological reductionism’ ignore, exclude
and downgrade the importance of previous medical history [of the patient],
general level of health, hygiene, psycho-social factors, diet and
lifestyle factors in the development of infectious disease? Factors which,
in fact, create the very susceptibility to infection, which distinguish
‘the infected’ as a category from ‘the non-infected’, not only in the same
town, but in the same house or family.
Therefore, we might conclude that bacteria, viruses,
and other bugs are not ‘primarily the cause of all infectious respiratory
disease’, but secondary, tertiary or even merely associative causes.
Finally, Professor Warner gives another clue that might
explain both why physicians in the 1890s despised the Germ Theory, and why
physicians today give antibiotics by reflex:
“Therapeutic conformity, or at least avoidance
of criticism, was important to the young practitioner trying to gain
approval…regular physicians’ attitudes towards therapeutic change were
molded by a dialectic between their commitment to progress and their
loyalty to tradition.” [7]
Perhaps the force of conformity in medicine is far more
powerful than the desire to answer those ‘fundamental questions’ that
Rothstein lists above or to make progress in the use of antibiotics that
Dr Jones suggests in his e-letter.
Sources
[1] BMJ letter, Re: Reducing antibiotics for
respiratory infections, 6 July, Jones, Lon, Family Practice, Hale Center,
Texas, USA
http://www.bmj.com/cgi/eletters/322/7292/939#EL7
[2] The Challenge of Antibiotic
Resistance, Stuart B. Levy, Scientific American 1998
http://www.sciam.com/1998/0398issue/0398levy.html#link4
[3] Eric E Sattler, The Present Status
of the Tubercle Bacillus, Cincinnati Lancet and Clinic, 12, 1884, 415;
quoted in John H Warner, 1986, The Therapeutic Perspective – Medical
Practice, Knowledge and Identity in America 1820-1885, Harvard Univ.
Press, USA, 280
[4] Warner, 281
[5] William G Rothstein, 1972, American
Physicians in the Nineteenth Century, From Sects to Science, Johns Hopkins
Univ. Press, Baltimore, 281
[6] Rothstein, 281
[7] Warner, 183