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Winter 2010

Chestnuts

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Bert Keizer

Wo die begriffe fehlen stellen die Wörter sich ein, said Goethe. Running out of concepts, you can still throw in some words. If you don’t understand it, you can still name it. There is a medical parallel to this: when we run out of therapeutic possibilities, we can always resort to medication. Recently we went through a minor clash in the Dutch media on the subject of the effectiveness of Reminyl (trade name) or galantamine (generic name) as a treatment of Alzheimer’s disease. The pharmaceutical company used the text: Do something before your mother starts muddling everything.

These words had the blessing of a professor of geriatrics who explained: “Every doctor will weigh the clinical relevance of medication differently. As long as there are no other effective anti-Alzheimer’s drugs, doctors must be allowed the freedom to employ this type of medication.”

Which is a roundabout way of saying that anything goes, as long as we haven’t got anything that really works. To my mind, any attempt at selling anti-Alzheimer’s drugs is a cynical move in response to the despair of patients and relatives. There is at present no drug that effectively stops Alzheimer’s or any other form of dementia. There isn’t even a drug in the offing, for the obvious reason that we don’t know what the disease actually is in terms of biochemistry, cell damage, immunological disfunction, inflammatory response, and so on.

This dubious way of dealing with so-called anti-Alzheimer’s medication is scandalous, maybe, but it’s also very ancient and almost certainly ineradicable. William Osler, one of the wisest American physicians of the nineteenth century, spoke the unforgettable words: “The difference between men and animals is the desire to take pills.” And the difference between doctors and the rest of us is the inclination to prescribe them.

I believe medicine to be precisely as old as what is usually described as the oldest profession, and both occupations thrive largely on hope. We don’t know exactly how or when doctoring got going, but as soon as someone asked for the impossible in terms of physical recovery, some other one came rushing in with the assurance: “I might have just the thing for you.” The sufferer looked on the doctor as a hero because he knew, or suggested he knew, how to end the misery. The doctor protested all too feebly against this “hero” idea—didn’t really hate it, though—and left a roasted chestnut as a remedy of sorts, which wouldn’t do any harm. That’s how it started.

But that’s not the situation today.

Some of our medical problems are treatable with medication: diabetes, hypertension, pain, many infections, some psychiatric diseases, certain types of cancer. But nothing avails against Alzheimer’s or any other form of dementia, in which case all we have is that roasted chestnut.

Alzheimer’s is the worthy successor to cancer, once Public Enemy Number One. In the past sixty years we have heard it announced many times that once more there was an immense breakthrough in the titanic struggle against cancer. Nevertheless, we are still stuck with precisely the tools we had in 1950: burning, slashing, and poisoning (or, in more polite terms, radiation, surgery, and chemotherapy). Yes, I know, it all happens in a far subtler fashion than ever before, but still these are the only strategies. There is no causal treatment of cancer in the way that there is, say, of bacterial infection.

Alzheimer’s is gradually ousting cancer as the most dreaded physical threat, now that the baby-boom generation is slowly but unstoppably moving in the direction of that awful mist into which they saw their parents vanish. And the mechanism which caused doctors all over the world to face the camera with triumphant announcements from the frontlines of the war against cancer will inevitably bring about the same development around Alzheimer’s.

So don’t bother to start waltzing around the room when you hear on television that “We’re almost ready to announce what could well turn out to be a major revolution in the further exploration of a medicinal approach toward Alzheimer’s,” etc., etc. Remember that the main risk factor for developing Alzheimer’s is getting old. Aging is a corporeal process that is far too complex as yet for anyone to be capable of unraveling the thousands of strands which together weave or unweave what is known as a healthy body. It’s silly to think that one magic pill is going to intervene fruitfully in such a process. On the other hand, it’s equally naïve to think that doctors are going to maintain a scientifically respectable stance in the face of the increasing pressure to come up with a solution.

There’s the pressure from the sufferers. And there’s that other pressure, from the pharmaceutical companies. They urge their doctors to tell the public that they might have something, with the emphasis on “might.” Galantamine is one such example. What they are selling is hope, which is of course the ultimate merchandise, for which the patient, in William Burroughs’s words, “will crawl backwards through a sewer in order to get at the stuff.”

Meanwhile, back on the ward, the doctor who refuses to prescribe galantamine as a supposed dementia-blocker is the villain of the piece. Says the angry daughter: “Are you saying that you refuse to help fight the onset of my mother’s disease?” Indignation rising to fury. Not much room here for an enlightening disquisition on the desire to take pills, in Osler’s sense.

I don’t know about her mother, but in my case I would gladly waive any dementia-blocker and opt for an enhancer. Anything to speed it up, I’d say.

Aren’t you being cynical?

No, I’m trying to say that it’s a horrible disease.



Bert Keizer is a doctor and philosopher who works with geriatric patients in Amsterdam. The author of Dancing with Mister D, he is currently at work on a philosophically tinged account of neurosurgery.
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