Beyond the Patient

Before Hippocrates, health was a supernatural affair. Exorcists and priests charmed money from the dying. Snakes squirmed beneath sickbeds. Sacred dogs licked fatal wounds. Pilgrims dozed within shrines, awaiting divine visitations, and dreamed of magical cures at places like the temple hill at Cos, where the mastermind of Western medicine — born on the island around 460 BC — rooted his revolution in ecology. Though few who now benefit from modern medicine remember, its creator overthrew the order of the gods with one simple mandate: that the physician seek truth only in the natural world, in the study of air, water, soil, and climate — in the study of the body within its ecosystem.

“From these things,” Hippocrates commanded in his treatise On Airs, Waters, and Places, “he must proceed to investigate everything else.”

Hippocrates taught that nature was the doctor, the doctor its aide. Studying the interchange of the internal and the external, a Hippocratic healer paid careful attention to food, exercise, and the ways the waters and the climates acted on the four humors — blood, phlegm, and yellow and black biles, each associated with a particular temperament. By trusting and helping nature, the great healer, to maintain health, Hippocrates’ students sought to provide preventive care over a lifetime. Only after nature had begun to fail would the doctor prescribe treatments that would, in Hippocrates’ words, “help, or at least do no harm.”

For the first time in millennia, however, nature itself is so unwell that doctors cannot fulfill their ancient duties. Twenty-six centuries of medical innovations cannot now protect the patient from the wider world, with its modern stresses and toxicity. And even if they could, modern doctors are focused elsewhere. “We shouldn’t pretend that clinical medicine is really doing primary prevention,” says Ted Schettler, science director of the non-profit Science and Environmental Health Network, “because it’s not — and it’s not particularly interested in it.”

Recognizing these shortcomings, a network of doctors, nurses, and other health practitioners, loosely affiliated in an “ecological medicine” movement, have begun not only to re-emphasize prevention but also to adopt a broader definition of preventive care.

“Our focus has always been on taking care of the immediate patient in front of us,” says Calista Hunter, an internist in Lafayette, California. “That’s all we really focus on. My hope is that physicians, as they become more environmentally aware, will realize that they can help a lot more people by addressing environmental issues that influence their patients.”

Hunter serves on the board of the Berkeley-based Teleosis Institute, one of a half-dozen U.S. nonprofits devoted to ecological medicine. Teleosis has two main goals: preventing the environmental causes of harm and stopping health care itself from contributing to them. Founded in 2004, Teleosis has about 250 members, roughly one-third of them doctors, according to its executive director, Joel Kreisberg. The institute publishes a journal and offers discussion groups, online resources, and a range of classes and lectures. Through a series of “green health care” seminars launched in mid-2006, Teleosis has trained thirty health-care professionals in everything from reducing medical waste to grassroots environmental action.

“We’re doing continuing medical education lectures at a lot of local hospitals,” says Hunter. “And I have found that every time I talk to a physician about environmental issues related to their specialty, people are responsive.” Each specialist knows of some discrete environmental source of illness, Hunter says — an ear, nose, and throat
doctor may bring up concerns about noise pollution; an oncologist may talk about
disposal of medications in hospice care.

Casual disposal of medication is a major target for proponents of ecological medicine. When a hospice patient dies, weeks’ worth of medicines are often flushed down the toilet and into the watershed, joining various other toxic health-care byproducts and excreted pharmaceuticals. A 2006 study in the journal Environmental Science and Technology found that a mixture of thirteen such substances inhibits the growth of human embryonic cells at environmental-exposure levels. Studies have also linked estrogen-related pharmaceutical waste to endocrine disruption in animals, including feminization of male fish. In 2001, the U.S. Geological Survey reported finding medicines in every one of eighty waterways tested nationwide.

“Medications have to go somewhere after people take them and excrete them,” explains Sue Stone, a family physician based in Fresno, California. “The chemical byproducts seep back into the environment and it just adds to the chemical load.”

Those byproducts are clear testaments to the fact that there is no “away” — that the external is the internal and that interconnectedness is a profound biological truth. It is the idea upon which medicine itself is founded; not even the most innovative or preventive treatments can shield the body from its ecosystem. Indeed, the most common waterborne medications are testaments to an unhealthy habitat: acetaminophen and codeine bespeak the strains of modern life and its reliance on palliatives. And diltiazem, a blood-pressure medication, bears witness to epidemic psychosocial stress, the sedentary and solitary nature of a sprawl-divided society, a sick food system, even noise pollution.

If it is to meet its ethical obligations, says nurse Anna Gilmore Hall, executive director of the nonprofit Health Care Without Harm, the medical sector must be “a driver of change, not only modifying our practices and activities but helping other sectors in society to identify how they can change.” Gilmore’s organization, another proponent of ecological medicine, has led a successful campaign against the incineration of medical waste, including the polyvinyl chloride products whose burning emits cancer-causing dioxins.

Much as Hippocratic doctrine rooted medicine in duty to the whole patient, the nascent ecological medicine movement seeks to treat the whole of society as its patient. New York City integrative oncologist and environmental activist Mitch Gaynor says that the ancient mandate “first, do no harm” should require health-care practitioners to educate industry and demand that all chemical manufacturers prove product safety. The larger goal should be “changing consciousness in individuals and institutions.”

That shift in consciousness has begun to manifest in medical institutions like Oakland-based Kaiser Permanente, the nation’s largest nonprofit health care system. In an August 2006 pilot project, Kaiser began working with about a dozen low-income California farmers who do not spray pesticides; they now supply fruits and vegetables for patient meal-trays in nineteen Kaiser facilities in northern California. According to Kaiser’s environmental stewardship manager, Lynn Garske, the project is opening markets to farmers and workers who themselves often can’t afford high-quality food and health coverage — people who would “end up presenting at our facilities or even our sister facilities and other hospitals in the area,” she says. And in supporting the farmers, the project also supports conscientious agriculture, nourishing nature so nature will nourish patients.

This collaboration is an example of what Schettler calls a “new ecology of institutions.” But it will be hard-pressed to make much headway as long as the economy is propelled by a pre-Hippocratic assumption: that the primary purpose of medicine is to cure diseases. The medical sector currently accounts for more than 16 percent of the gross domestic product and is expected to grow to 20 percent in the next decade. And there are those, says Schettler, who want to see it grow further still. But the fundamental twenty-first-century choice, as he sees it — between health care and disease care — will hinge on acceptance of an ethical mandate as old and vital as medicine itself: “As we decide how to live in the world, what to do, and how to make changes, first — do no harm.”

Lee Thirer is a freelance writer living in the San Francisco Bay Area.