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As a doctor I see diseases carried into my consulting room by
my patients. I actively try and treat these diseases, and also
the worry and stress that goes along with them. 'Cum scientia
caritas' (knowledge with compassion), as my college motto puts
it. My partner and I spend a fortune of taxpayers’ money
each year on treating these diseases – £300,000 on
drugs for 2850 patients or an average of £105 per patient.
(In mainland Europe or the USA this would be seen as very meagre
prescribing and possibly negligent under prescribing!)
I am treating and actively searching for patients with `chronic
obstructive pulmonary disease (COPD), asthma, diabetes mellitus
(DM), ischaemic heart disease (IHD), stroke, hypertension, high
cholesterol, depression, osteoporosis, and liver cirrhosis. There
are National Service Frameworks (NSFs) in place advising on the
diagnosis and treatment of these illnesses and as a GP I will
be judged on how well I comply with this guidance and how diligent
I am in treating these disorders.
Hurrah, you might say, a defined task and rewards for completing
them. Good management practice. And for the good purpose of making
people healthier, so they live longer and better lives and the
'unacceptable burden of premature mortality' is lifted from our
country. Rousing stuff indeed and to the extent that defined systems
will produce better results, or at least measurable results, I
can see why they are being introduced.
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Like the Irishman giving directions,
we shouldn’t be starting from here
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And yet I cannot wholeheartedly cheer these developments. If
you look at the list of chronic diseases given above you will
see that they are end stage processes. They are all the end result
of lives lived in a way that is unhealthy, and has been unhealthy
for many years. They represent what my colleague Seth Jenkinson
describes as 'end stage social pathology'. In short what we (public
and doctors together) recognize as serious diseases and put loads
of medical and other effort into are in fact epiphenomena, lying
on a much deeper stratum of pathology than we currently choose
to look at.
Like the Irishman giving directions, we shouldn’t be starting
from here. By the time these illnesses are established the underlying
disease causing processes and strategies have been running unchecked
for between 20 and 40 years. Furthermore we can see these processes
going on. In fact doctors and patients know what these processes
are and both sides tacitly chose to stay quiet about them. This
is collusion in silence, and is predicated on fear. It is unhealthy,
and the results of not tackling it are obvious in my surgery.
Risky behaviours
Most of the end stage illnesses doctors see are end results of
risky (threatening to health) behaviours such as smoking (COPD
and IHD), excess alcohol (liver cirrhosis), excess food (obesity,
type 2 DM, IHD), excess sexual activity (sexually transmitted
diseases, some infertility cases), drug misuse (early death, HIV
infection, Hepatitis B and C), excess religion (zealotry, extreme
beliefs), excess gambling (poverty, gambling addiction), excess
work (workaholism). You will notice that all these activities
involve permitted mood alteration strategies in our society. Used
sensibly they can all be used to good effect, at personal and
communal levels, but used to excess they will cause harm. For
example if you smoke 20 cigarettes a day for 20 years or more
you will inevitably have some COPD. Once you have it you have
it and no matter how much treatment you get for it you are still
damaged, functionally impaired and making the best of a bad job.
What then allows some of us to use these mood alteration strategies
safely, pleasurably and effectively whereas others amongst us
are incapable of using them safely? How can one man have enough
food, enjoy eating it and be content whilst another always comes
back for more and keeps on eating even when he has had more than
enough already? What is the second man gaining by overeating?
Or what lack is he compensating for?
How can anyone knowing the long term harms of cigarette smoking
be so keen to afflict their body with such a poisonous mixture
of chemicals? And yet millions of our society do, and many of
them do not even enjoy doing it.
'I'm not worth it'
I think there is a layer beneath these unhealthy behaviours.
I think the layer is to do with self-esteem. I am taking the existence
of risky, unhealthy behaviours with known poor outcomes as evidence
that indicates that people do not value themselves or their health
sufficiently highly. This inability to value yourself, the feelings
that 'I’m not worth it', that 'I don’t deserve this
fuss being made of me, and there’s others worse off than
me' are the hallmark of low self-esteem.
Low self-esteem is Grendel’s mother in all this. The medical
profession (along with its political masters, its pharmaceutical
suppliers and a public that is keener on cures rather than staying
healthy in the first place) is so busy dealing with the visible
tip of the iceberg of disease, with fighting the present day monsters,
that it cannot see the mother of these monsters, the 'hidden evil
upon hidden evil,' that is at the root of the problems. Indeed
many in the medical profession question the concept of self-esteem,
saying that it cannot really be defined so it is not really useful.
God or spiritual power cannot be defined but that does not stop
them existing, does it?
I see low self-esteem as the necessary set of beliefs that people
develop that then enable them to go through excessive risky behaviours
which lead to tissue damage, end stage social pathology and finally
to medically recognizable diseases, which suddenly then get all
the attention of high tech medicine. The classic example of all
this is the fifty year old man who has a heart attack. He thinks
it all happened so fast and is grateful to his doctors and the
ambulance crew for being there, 'just when he needed them'. Although
the dramatic actual process of infarction took only a few minutes
to occur it should be remembered that the event was only possible
on the basis of his risky behaviours of smoking too much, eating
too much and drinking too much which he had been doing for the
preceding 30 years. Viewed over this time frame the event is not
acute at all, simply a needless and preventable disaster waiting
to happen.
Toxic beliefs
Where then does low-self esteem come from? It comes from within
and is a set of beliefs about what we can and cannot do in the
world. It is a set of identity level beliefs that define us in
relationship both to our self and others. These are high-level
beliefs and function as programmes that run our day-by-day thoughts,
feelings, responses and behaviour. As they are high-level beliefs
they are often not exposed to daylight. If they are not effective
for us they will be toxic to us. If your overall belief about
yourself is that you are bad and not really worth bothering about
you will feel rotten and will try to lift your mood in some way
or other. Unfortunately when you are not coming from a position
of self-esteem you will tend to overdo mood altering activities.
Have you ever wondered why the most broken people seek refuge
in the most extreme diversions?
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Doctors and patients know what
these processes are and tacitly chose
to stay quiet about them
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'Shut up and know your place. People from round here don’t
do that kind of thing, do they? No one will be interested anyway.'
Can you see how this kind of toxic language reflects the toxic
belief patterns of the speaker and may well transmit them on to
the listener? The classic in medical school was 'I wouldn’t
say that if I were you' The correct response of course is to say,
'Well then, it’s a good job you are not me,' and say whatever
you want to say anyway.
So, do I think low self-esteem is the mother of all evil, of
all diseases? No I do not and I will give you an example. Imagine
a twenty two year old girl who has meningococcal septicaemia and
dies. I have sadly seen this in my career. Was she a victim of
low self-esteem or just afflicted by a virulent bacterium? In
her case I know it was the latter.
However apart from cases like hers, nearly every event I have
seen in medicine has been predicated on a long, long period of
dangerous risky behaviours, and I believe the substrate that allows
for those behaviours is low self-esteem.
In short one of the best ways of improving the health of the
nation significantly would be an investment to develop us all
to our birthright which is the right to self-esteem as a normal
and natural part of human life. I hope it will be included in
the next health of the nation plan. Because we’re worth it.
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Dr Peter Davies, BSc, MBChB, MRCGP, is
a GP in Mixenden, a deprived and challenging area of Halifax.
He is fascinated by the behaviour of patients and his colleagues
and the beliefs lying behind their behaviour. He uses NLP techniques
to help him in this exploration.
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