The Curse of Algorithm-Based Medicine

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21st-century medicine is gradually getting smothered in guidelines and flowcharts that aren’t loosening their grip anytime soon. It has become worse over the decades, impoverishing the medical profession of critical thinking and making it devoid of common sense.

Modern-day psychiatry is an excellent example of trying to understand the problem as it appears to have irrecoverably lost its way. The DSM (Diagnostic and Statistical Manual of Mental Disorders) is considered to be the ‘holy bible’ of psychiatrists and is an excellent place to start the discussion. DSM reflects a set of criteria that, when applied to a person’s history, mental health symptoms, and presentation, helps the treating physician arrive at a diagnosis that can direct appropriate treatment options. Curiously, at no point in the formation has the DSM relied on physical examination of patients, targeted blood tests, performing scans of particular body parts or measurement of body biometrics to arrive at the diagnosis. The guidelines were and continue to be formulated by the consensus of a few authoritative psychiatrists in top-tier academic institutions and medical societies. The signs, symptoms and associated factors used are entirely subjective, and the diagnostic criteria involve tick boxes about those mental health symptoms and related social, genetic and environmental factors. That would be the best-case scenario. Here is a recent example of the problem cited.

DSM I was published in 1952 with 106 disorders that were formed from theories of abnormal psychology and psychopathology. DSM II in 1968 saw a leap of 76 additional disorders, totalling 182, and from there, we saw DSM III in 1980 with a total of 265 mental health diagnoses, 292 in DSM III-R (revised) and 297 in DSM IV. Things appear to have come to a slow standstill, with the most current DSM V sitting at 298 mental health illnesses (Journal of Behavioural Sciences -The Evolution of the Classification of Psychiatric Disorders). The increasing number of mental health diagnoses (not disorders) is either a worrying sign of genuine societal mental health decline over the years or, in my opinion, maybe the truth that hordes of psychiatrists, perhaps with broad-ranging conflicts of interest, should not be allowed to put their heads together to become creative with mental health. 

Interestingly, the paper states that “The classification of psychiatric disorders in the 1952 DSM was etiologically based; the nomenclature of the mental disorders as “reactions” to stressors (e.g., “depressive reaction” and “schizophrenic reaction”) implied assumptions of psychodynamic causality.” The critical question, therefore, would be if this explosion in mental health illnesses aided by the splendid buffet of diagnoses is flawed at its core by the medicalisation of normal human behaviours, responses and reactions such as grief, feeling overwhelmed, flatness of mood, difficulty concentrating, being fidgety, etc. As research and science advance, the tricky question is if we need to stop at some point and take recourse and redress.

Most importantly, the paper highlights the pressing issue of how many hands are involved in making the pudding: “In recent years, insurance companies, managed care organisations, pharmaceutical companies, and the government (emphasis on the unholy alliance of industry and government) have increasingly utilised systematic diagnostic criteria for the reimbursement and financial aspects of clinical practice.” In the quest for the causes of mental health disorders, that sums it up nicely.

Based on my understanding of the matter, it is my view that, by definition, DSM diagnoses lack validity, and it’s therefore not surprising that, clinically, they also lack reliability. The credibility of these criteria and the dictating guidelines stand to be questioned. Further, any questioning should look at the end motives and the benefactors. It used to be that doctors saw diseases and patterns in diseases and sought drugs to help treat them. We are at a perplexing time in research and drug development, where this approach has now been flipped on its head, and drugs are manufactured to find diseases that doctors can then use to treat. The trend is especially true in the field of Psychiatry, with psychiatric medications like antidepressants, antipsychotics, and psychostimulants actively used for all kinds of other medical problems, from migraines to irritable bowel and pain management.

Let’s now explore how guidelines-based medicine can impact public health and patient outcomes in acute clinical settings such as global crises and pandemics. The case for discussion is one unfolding in South Africa involving Dr Shankara Chetty, a General Practitioner in remote Port Edward, a small, poorly serviced resort town of approximately 4500 people (catchment of 15000 or more), 165 km south of Durban, the closest city with tertiary medical centres. 

Having a research background, Dr Chetty dived head first into researching the viral genome and its characteristics when he heard of the virus outbreak in Wuhan in 2020 in order to prepare for its arrival in South Africa. Day and night, he scoured the medical literature and online resources, preparing himself. When it finally arrived, he treated everyone who came through the door with older, safe, repurposed drugs (drugs that have come off pharmaceutical patents) and vitamins and managed to keep entire communities safe. He threw the kitchen sink at it as his only other option was to give up, save himself, and flee with the family. 

As PCR test availability was limited, he resorted to using his clinical acumen and experience based on the patients consulting him. Quickly realising that COVID-afflicted patients typically lost their sense of smell and taste to sweetness and saltiness but not to bitterness, he had jars of salt, sugar and lemon as proxy PCR tests and he was intuitively able to identify people who had the novel virus vs other common viruses and recommended treatments accordingly. At the peak of the pandemic in 2020-2023, Dr Chetty treated approximately 14,000+ patients who streamed across to him from all around the provinces, hearing of his knowledge and skills in treating people affected by the SARS-Cov-2 virus. Young, old and infirm, irrespective of race and gender, flocked to his medical clinic from nearby towns and villages and all around the country. 

Using his newfound knowledge, Dr. Chetty used off-label medications, many of them actively used by doctors and nurses in the country to treat various infectious diseases that regularly affect the African population. A sizeable makeshift tent was erected and divided into three large areas for consulting, treating, and observations. As for himself, he isolated from his family, staying in town in a rented apartment for the four months of the peak period of the pandemic. With everything he did, he reported no need for oxygenation, no vaccines and all in all, there were five hospitalisations and deaths.

Moving forward, in 2023, The Health Professionals Council of South Africa (HPCSA) caught up to him, taking offence to his analysis of the pathophysiology of COVID-19 illness and the treatments he used that were off the national guidelines. To layer it all on, he was also accused of questioning the COVID-19 vaccine’s need, safety, and efficacy. The HPCSA guidelines at the time had no specific recommendation for GPs on how to treat the illness apart from using paracetamol and wearing masks, gloves, and hazmat suits. As with most guidelines, they looked pretty on paper with top-down flow-down charts, fancy statements and artistic diagrams, proving little to no benefit for patients who were advised to stay home and to only go to the hospital when they were feeling unwell and turned blue. The success of this compassionate frontline doctor who worked tirelessly saving lives in a crisis in a remote setting is being pitted against the heavy hand of bureaucracy that feels belittled for not being consulted and for neglecting their arty guidelines. 

Like the elephant in the room that one cannot ignore, the failures in public health over the last four years have reached epic proportions. It showcases how ideology and faith blended into propaganda can be antithetical to science. 

Professor Martin Kulldorf, ex- Professor of Medicine at Harvard University, is the most recent victim of the system. The university has recently dismissed him from his role for holding alternate views on managing the foregone pandemic. Professor Kuldorf is a biostatistician and public health expert who worked at Harvard University for 21 years as well as being a member of the US Food and Drug Administration’s Drug Safety and Risk Management Advisory Committee and a former member of the Vaccine Safety Subgroup of the Advisory Committee on Immunization Practices at the US Centers for Disease Control and Prevention.

In 2020, Kulldorf was a co-author of the Great Barrington Declaration alongside world-leading infectious disease epidemiologist and public health expert Professor Sunetra Gupta of Oxford University and Professor Jayatha Bhattacharya, a Professor of medicine, economics and health research policy at Stanford University in the US. Using their combined knowledge and experience in the fields of infectious diseases, health economics, and public health management, they created the document that advocated for protecting the elderly, immunocompromised and vulnerable and lifting COVID-19 restrictions on lower-risk groups to allow them to develop herd immunity through exposure and infection. 

The advice formulated for the world through the document reflected hundreds of years of collective knowledge combined with available data at the time on SARS-Cov-2 disease trends and outcomes. The WHO promptly criticised it as unethical and infeasible and was uniformly rejected by the medical community. Dr Kulldorf and team advocated for focused protection to minimise unnecessary collateral damage from public health interventions (lockdowns, masks, contact tracing and vaccinating children), all of which have since been proven to have delayed but not affected the spread of the virus. Instead, they appear to have caused untold misery and harm to the public. His decision to speak out of line against the WHO and public health guidelines ended up in his dismissal, even though all of his statements and guidance on the issue proved to be correct and are now well accepted. Even the alma maters of education have fallen from grace and, sadly, irrecoverably.

With hindsight, would our health system have dealt with this issue differently if they had held an open view with discourse and incorporated common sense, empathy, curiosity and intuition into the guidelines and protocols? Is the public being harmed by religious adherence to medical guidelines and processes that have infested our health systems without due consideration for debate on these matters? Once again, age-old wisdom comes to haunt us through a quote from the German-Swiss physician Paracelsus in circa 1500: “Medicine is not only a science; it is also an art. It does not consist of compounding pills and plasters; it deals with the very processes of life, which must be understood before they may be guided.”

Automated medicine and machine learning are never a substitute for ingrained and adapted human skills. Unfortunately, with the current drift of artificial intelligence and profit-driven health care steered by guidelines, public health is poised for some challenging times. Unless gears are changed and we shift our thinking and approach to human illness, disease burdens will continue to rise and plague society in ever-increasing numbers with considerable harm and loss of lives, regrettably.

The medical profession is going through a pandemic of sad apathy and devoid of any curiosity as to why and what the contributory elements are that have led to the gross public health failures and the shame on public health and modern medicine. Could it be from the involution in medical knowledge (contrary to popular belief), sheer ignorance vs a mass-attributed glory for ‘the experts’ thought to possess the super intellect and high IQs but who lacks intrigue and scepticism? Or is it the flaw of the guidelines in creating disease compartmentalisation syndromes where humans and diseases are herded into slots and treated based on the group they belong to? Could it be the occult disorder of “credentialism” where respect is credited to individuals in the medical profession based on their intellectual prowess regardless of their inadequacies with common sense and critical thinking skills? Most medical guidelines today are influenced by a cocktail of the above variables and varying degrees. The pandemic years have shone a spotlight on many such issues and sadly, we may need to dig further if we are seeking the truth for the betterment of lives.

As doctors, we have to ask what medical practices are all about and what they have to do with health. Are we becoming minions of a system of guidelines that works in an orchestrated manner to maintain the diseased and help sustain industries that have profits, not health, at their core? Or, like Dr. Chetty, are we doctors who want to rejoice and celebrate with our patients when they regain their health and journey into wellness? If so, together, let’s pause this ‘disease care’ conveyor belt now. 

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