Posts tagged “NEJM”

200 Years of the New England Journal of Medicine

The New England Journal of Medicine - among the most preeminent medical journals¬†- is 200 years old this year. In recognition of that two century milestone, they’ve put together a number of special (and accessible) articles available here.

In “The Burden of Disease and the Changing Task of Medicine,” authors David Jones, Scott Podolsky, and Jeremy Greene outline shifting patterns of disease and their effect on the role of medicine in society.

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The article contains numerous anecdotes, some unbelievable, about diseases and disease states that were common 100 years ago. Some sound familiar; others, not so much. I find the article particularly interesting when it starts to delve into how we define and prioritize diseases, and how that ties into inequities in well-being:

A population’s disease status can also be gauged by lists of common diagnoses at clinics or hospitals, but no single measure definitively characterizes a population’s burden of disease. Choosing among metrics is as much about values and priorities as about science, and it directly affects health policy. Whereas advocates of clinical and research funding for cardiovascular disease might use mortality data to support their claims, mental health advocates can cite morbidity measures in seeking greater resources. Data on causes of childhood mortality would justify certain priorities; analyses of health care spending would justify others. An ideal, sophisticated health policy would integrate all measures to form a holistic map of the burden of disease, but in practice competing interests use different representations of disease burden to recommend particular policies.

And, later in the article:

The persistence of health inequalities challenges our scientific knowledge and political will. Can we explain them and alleviate them? Genetic variations don’t explain why mortality rates double as you cross Boston Harbor from Back Bay to Charlestown or walk up Fifth Avenue from midtown Manhattan into Harlem. Nor do they explain why Asian-American women in Bergen County, New Jersey, live 50% longer than Native American men in South Dakota. Although we know something about the relationships among poverty, stress, allostatic load, and the hypothalamic - pituitary - adrenal axis, doctors and epidemiologists need more precise models that sketch in the steps between social exposure, disease, and death. … Disparities in health and disease are outcomes that are contingent on the ways society structures the lives and risks of individuals.

In many respects, our medical systems are best suited to diseases of the past, not those of the present or future. We must continue to adapt health systems and health policy as the burden of disease evolves. But we must also do more. Diseases can never be reduced to molecular pathways, mere technical problems requiring treatments or cures. Disease is a complex domain of human experience, involving explanation, expectation, and meaning. Doctors must acknowledge this complexity and formulate theories, practices, and systems that fully address the breadth and subtlety of disease.

The article hints at the relationship between public health, health policy, and medicine, but doesn’t delve fully into how those relationships have evolved over the 200 year history of the Journal. It would be interesting to learn more along that vein - how medicine has informed policy and influenced public health measures, etc. Overall, though, an interesting, enlightening read.

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