The Cancer Journal - Volume 9, Number 2 (March-April 1996)
"Every healthy man is a patient in disguise"
"Tout homme bien portant est un malade qui s'ignore"
These famous words which Jules Romains, in 1923, put into the mouth of Dr. Knock (1), who attributed them mistakenly (?) to Claude Bernard, have never been more topical.
A recent summit actively sponsored by several large pharmaceutical companies has been entirely devoted to the diseases of women in mid-life: breast cancer, osteoporosis, menopause, cardiovascular disease.
We are cast back to a time before Genesis, before God sundered earth and water, day and night, animals according to species, the normal and the pathological; it's Chaos. Menopause and breast cancer are in the same boat.
If one adds that half of the male population above 65 has an incipient prostate cancer - a cancer with a frequency that rises with age and with a prevalence that increases with life expectancy at birth in industrialized countries -, the demarcation line between normal and pathological runs right through the midst of cancers but no longer separates menopause from breast cancer.
Is this good news for men and women, for the ill and the healthy ? I shall refrain from answering but will continue to put the question to doctors and biologists, epidemiologists and those they study. Only a new portrayal of health can qualify menopause as a disease and thus prescribe a replacement for an established hormonal 'deficit'. Old age is like a sinking ship but one that sinks very slowly. The question bears not only upon the turning-point that is menopause in a woman's life. Doesn't one also talk about using pharmaceuticals to prevent or treat the stealthy 'andropause' that awaits men and enhances their risk of osteoporosis also.
It is not only our endogenous production of sex hormones that wanes with age. Our melatonin runs short. Fortunately, we are not left in the dark but are told that our immune reactions, sleep, production of protein x, whose gene has just been cloned, or of protein y, whose gene is just about to be cloned, .. are all about to flag. Thank God (bis repetita), where endogenous production fails, exogenous, i.e., industrial, production is ready to step in.
Henceforth, homeostasis must surrender to the balance of powerful economic forces. The failings of the aging viscera and tissue require pharmaceutical compensation. O holy molecules, do not abandon us. The breach that has been opened engulfs trace elements, inoffensive (hydrosoluble) vitamins but also those that are true drugs, calcium and magnesium, selenium... Even if these do not improve health, they improve trade and spending and, after all, isn't this a form of prevention? It remains to be seen.
Have doctors and biologists good reason to promote or combat these invasive practices ? Can they, by careful selection of preventive medication, reduce morbidity, retard the mean age for dying without yielding anything in exchange ? This is the true question, at least if one admits that the beneficial effects of medication are real, a fact that has not yet been proven, far from it.
Even when convinced of a real benefit, i.e., when the drug risk/no drug risk is clearly <1, one should still hesitate. Should women alone be left with the responsibility of choosing between prevention of osteoporosis by hormone therapy and an hour of brisk walking every day ? Ethics committees could give an opinion on this point but the media, independently of any commercial consideration, could also inform the public. Is not a risk of breast cancer periodically evoked with hormone replacement therapy (HRT) ? But won't the cardiovascular gain shift the balance back toward HRT ?
Menopause or andropause are they diseases in terms of mental representations only, i.e., no longer in terms of a preestablished classification but of an opinion or state of mind ? As we all know, states of mind fluctuate with fashion and the pressures exerted by publicity, whether directly or indirectly through the media and grapevine. I doubt whether even citizens of large towns have a persistently moderate and reasonable attitude. Many of our contemporaries in an undeniably modernistic world refuse these constant exhortations to compensate the deficits of aging. But, the extent to which these diverse deficits are deleterious to health is largely unknown. In how many instances does a decrease in endogenous production just mean an adjustment to a new optimal equilibrium ?
What the new medical order will be is still uncertain. Jules Romains was right to playfully stigmatise the advent of Medicine 73 years ago and it is reassuring to note that, after all this time, the debate is still ongoing. Canghuilhem (2) proposed his thesis just 53 years ago; the medical world is only just beginning to talk about it. Patience !
1. Romains J Knock ou le triomphe de la médecine, 1923.
2. Canguilhem G. Le normal et le pathologique. Translated into English by Fawcett CR, Cohen RS. Zone Books, New York, 1991.