What's wrong with you? It depends where you live
Jeremy Laurance looks at how different countries treat the same symptoms
Tuesday 28 April 2009
Human beings may belong to the same species, but they experience sickness differently. Each nation has its favoured illnesses and its favoured explanations, which alter over time. A doctor in one country may label an illness as depression, while the identical symptoms may be labelled as low blood pressure in another, or as the effects of dental amalgam in yet another.
These cultural variations throw light on illnesses that are poorly defined but that impose a huge burden of suffering on individuals, and on the workload of doctors and hospitals, who can often do little to help.
It reminds us that while medicine in the modern world has achieved an extraordinary level of sophistication, there is still much it cannot do. We can create babies in a test tube, transplant organs and bring people back from the dead. We are beginning to grow new body parts from stem cells, to defeat diseases by genetic engineering and to help the blind see.
Yet 40 per cent of those attending GPs and hospital out patients departments never receive a conventional medical explanation for their symptoms. These are people who typically complain of headaches, fatigue, inability to concentrate, aches and pains, and feeling unwell. They are suffering from malaise, of unexplained origin, whose expression apparently depends on which country they live and how the culture responds to their condition. Are these different conditions? Or the same condition, just given different names?
Simon Wessely, professor of psychiatry at Kings College, London, who has studied cultural trends in illness, says: "People will always seek explanations when they feel under the weather or not quite right. Much of it depends on what is currently hot in medicine. Each age and each culture has its own answers. Doctors use many different labels to describe patients with unexplained symptoms – somatisation, burn-out, chronic fatigue syndrome, multiple chemical sensitivity, subclinical depression, post traumatic stress disorder, low blood pressure, spasmophilia – despite no evidence that any of these are distinct or separate entities. Our belief is that most of these labels refer to similar clinical problems."
The choice of label has profound implications for how patients deal with their symptoms and the treatment they expect from doctors. "Clearly someone who believes their symptoms are due to spasmophilia or low blood pressure will seek different treatments from someone who believes they have a food allergy or chemical sensitivity. Public health measures will also differ and the resulting controversy and political indecision can cause ill feeling, distrust and suspicion," Professor Wessely says.
In Britain, our obsession with our bowels extends back to the 19th century when a condition called intestinal auto-intoxication – self poisoning from one's own retained wastes – was widely diagnosed, especially in young women.
It was thought that the colon leaked toxic material into the bloodstream, which caused sufferers to feel tired, weak, depressed and wracked by unexplained aches and pains. Constipation was seen as "the disease of diseases" and the public became prey to marketers of anti-constipation remedies and, in extreme cases, surgery to remove a section of the colon was carried out.
Professor Wessely said: "The condition was always diagnosed in young women, surgeons took out their colons and quite a percentage died. You can see the legacy of it today in the fashion for colonic lavage and the interest in detox treatments. Surgeons no longer take out people's bowels and so they go for the detox option instead."
Germany: low blood pressure
Regarded as a sign of excellent health elsewhere, in Germany low blood pressure is seen as a disease responsible for weakness and fatigue and is treated with drugs to boost it. Chronic low blood pressure is said to cause tiredness, giddiness, black-outs, anxiety and sweating. It is known as "constitutional hypotension" in German medical textbooks, but the diagnosis is not well accepted elsewhere.
Britain and France: chronic fatigue and spasmophilia
French doctors do not recognise the condition known as ME (myalgic encephalitis) or Chronic Fatigue Syndrome (CFS), which is widely known and frequently diagnosed in Britain. Often the condition is triggered by a viral illness, such as glandular fever. Most people get over it but some become trapped in monitoring their symptoms, restricting their activities beyond what is necessary and getting demoralised.
Professor Wessely, a specialist in the problem, said: "In Britain, people with chronic fatigue think that if they do too much the virus that caused it is still there and will come back and make them worse. That is catastrophising the illness. They don't think like that in France and they don't have the same outcomes. It is how you respond to symptoms that determines the outcome."
He described how a French physician from Lyon who spent a sabbatical in the UK was astonished at the sight of children with chronic fatigue in wheelchairs at Great Ormond Street hospital. "He returned to Paris and wrote an article about how there was just no equivalent in France."
In place of chronic fatigue, the French suffer from spasmophilia – panic attacks characterised by hyperventilation, spasms and convulsions. Young women are again particularly vulnerable and, as with sufferers from chronic fatigue, often dissatisfied with their medical treatment. Spasmophilia is not recognised elsewhere.
Sweden: dental amalgam
In Sweden, the use of dental amalgam in "ordinary dental care" is to be banned from 1 June, and will be subject to a total ban from June 2012, because of the risks posed by mercury, which the Swedish Chemicals Agency describes as a "threat to human health and the environment". The use of dental amalgam has been linked with a range of afflictions including depression, tiredness and malaise and has fallen by 90 per cent since 1997. Tens of thousands of Swedes have had their amalgam fillings replaced with new materials.
In other countries, such as the UK and US, the use of amalgam fillings has not aroused public anxiety in the same way and few patients have had them removed. One US dentist was recently struck off the medical register for removing fillings from a patient. Cultural differences do not come wider than this: that a procedure regarded as normal in Sweden has led to a doctor losing his licence to practice in the US.
Germany and Sweden: electromagnetic radiation
The Swedes and the Germans also share a high level of concern over the harmful of effects of electromagnetic radiation – emitted by mobile phones, electricity pylons and domestic electrical equipment. Most studies of sensitivity to radiation from mobile phones are in German. There have been 46 to date but all have yielded negative findings. When people claiming to suffer electro-sensitivity were tested to see if they could detect the presence of a mobile phone switched to silent mode and hidden from view, they were, on average, unable to do so. (Only those studies that were not "blinded" – where the outcome was not hidden from the researchers – had positive results).
Professor Wessely says the issue was effectively settled. "This is one of the few instances where the UK Department of Health has published a report saying less research is needed." But still, concern about the effects persists in Germany and Sweden.
Britain and France: vaccination
In many countries, there are fears about vaccination – but the vaccines that are the targets differ. In Britain, the suspected link between MMR vaccine and autism has never been proved but has dominated debate for a decade. In most other countries MMR has aroused no concern. The exception is Japan, where the MMR vaccine was withdrawn in 1993 because of concerns about adverse reactions to the mumps component (which is different in the UK vaccine). There have been regular measles outbreaks and deaths in Japan. In France, British concerns about MMR have been ignored, but worries about Hepatitis B vaccine and a supposed link with multiple sclerosis have taken their place.
Eastern Europe: neurasthenia
Neurasthenia, or "exhaustion of the central nervous system", is a diagnosis not used in Britain for a century. It collapsed when neurologists gave up trying to find a physiological explanation for the typical symptoms of sufferers – fatigue, headaches and sleep disturbance – and passed the patients on to psychiatrists, who diagnosed depression and anxiety. But neurasthenia still survives and is widely applied to describe the same symptoms in eastern Europe, Russia, China and Japan. Chinese-Americans living in the US are especially prone, but Americans of other races are not.
Nova Scotia, Canada: perfume
One of the most bizarre national obsessions is the concern about perfume in Nova Scotia. Deodorants, herbal shampoos, perfumes and other scented products are subject to a voluntary ban in most indoor public places including local government offices, libraries, hospitals, classrooms, courts, and on public transport.
The fear is that scented products can trigger asthma attacks and lead to the development of multiple chemical sensitivity. A similar ban has been considered in Ottawa, the capital, and a voluntary ban has been introduced in Marin county, California, in the US.
Brigham and Women's hospital in Boston, US, discourages staff and patients from wearing scent and Shutesbury public library in the city offers a couple of hours' fragrance-free book browsing each week.
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