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SUPPLEMENTAL: What do you think is a non-disease? [Full text]

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Rapid Responses published:

Dodgy to say the least

Kieran E Fallon   (15 February 2002)

Peri-menstrual Dysphoric Disorder

Marvin K Malek   (15 February 2002)

Additional non-disease

Hans R. Koelz   (15 February 2002)

Non-diseases

Caroline Richmond   (15 February 2002)

Possible non-diseases

George B. Alcorn   (15 February 2002)

Raised cholesterol levels - a non disease

Malcolm E Kendrick   (15 February 2002)

Bereavement

Om Prakash   (15 February 2002)

non-disease apostasy

Dale Archer   (15 February 2002)

What is a Disease / Complaint?

Lonnie J Perry   (15 February 2002)

Reconsidering Cholesterol and Atherosclerosis

Eric S. Freedland ,MD   (15 February 2002)

Society's stigma spells DISEASE

Dr Rani Pal   (15 February 2002)

Non-disease

Mathai Babu   (15 February 2002)

Non-disease if doctor recognize physiological deterministic chaos.

Stagnaro Sergio   (15 February 2002)

Diastema

Chinelo E Nwokolo   (15 February 2002)

Time warps perception

Susan J Wighton   (16 February 2002)

A non disease

Clare O'Connor   (16 February 2002)

Non-diseases

douglas n salmon   (16 February 2002)

How to use an esteemed medical journal to increase suffering

Margaret Bailey   (16 February 2002)

Non-diseases

Joel M. Kauffman   (16 February 2002)

Lactose intolerance, ignorance, noncompliance

Myrna Y. Munar, Pharm.D.   (16 February 2002)

Re: Raised cholesterol levels - a non disease

Gunnar Lindgren   (16 February 2002)

menopause and pregnancy

Jo A Rosenfeld   (16 February 2002)

Solatic

Jeffrey D Bernhard   (16 February 2002)

Non disease

Sethuraman K Raman   (16 February 2002)

non-disease?

Tom P. Kindlon   (16 February 2002)

Disease Vs. Non-disease: When a non-disease becomes a disease?

Malvinder S. Parmar   (16 February 2002)

Non-Diseases or CO Poisoning?

Albert H Donnay   (16 February 2002)

Arrogance

Anelie J. Walsh   (16 February 2002)

Medicalization.. non-disease.. a view from across the pond

Gary N. Fox   (16 February 2002)

Hypercholesterolaemia - the superior winner

Uffe Ravnskov   (16 February 2002)

Other Non-Diseases??

Patricia S. Blankenship   (16 February 2002)

non disease of the month

John p McCormack   (16 February 2002)

"Non-disease"

Aya Biderman   (16 February 2002)

Non Diseases - A Case of Throwing the Baby Out With The Bath Water?

Dianna Dunbar   (16 February 2002)

Myalgia Encephalitis

Raymond Henry Givan   (17 February 2002)

Dis-ease= Drug-Deficiency

Kenneth M. Jacobie   (17 February 2002)

Who carries the can?

Alexa E McLaughlin   (17 February 2002)

More choices

A Chaudhuri   (17 February 2002)

This exercise is a slippery slope itself

Raymond F Colliton   (17 February 2002)

Domestic violence and Non-disease

seshubabu gosala, Pondicherry   (17 February 2002)

Re: Additional non-disease

Kjell O. Skavdal   (17 February 2002)

Common childhood symptoms

Peter M Jones   (17 February 2002)

Myalgic encephalomyelitis/chronic fatigue syndrome

Domenic A. Tricome   (18 February 2002)

Profit & loss

Raelene J Reeves   (18 February 2002)

here we go again

Paul S Mitchell   (18 February 2002)

Join the queue

Gurli H. Bagnall   (18 February 2002)

Autism as a process of dealing with the world

David N Andrews   (18 February 2002)

Non-Diseases of the Past

Robert D. Tennent   (18 February 2002)

The origin of "Non-Disease"

James A Dickinson   (18 February 2002)

Missing Non disease

Sri S Varman   (18 February 2002)

Re: Common childhood symptoms

zaffar sultan   (18 February 2002)

Age

Dirk Ulbricht   (18 February 2002)

'Wind'

Surinder Singh   (18 February 2002)

Shyness etc

Tim R Anderson   (18 February 2002)

non-diseases

douglas n salmon   (18 February 2002)

Re: Non-diseases

Tim R Anderson   (18 February 2002)

Impacted wisdom teeth

Mahendra Bagur   (18 February 2002)

Stupid Idea Syndrome

Trevor Wainwright   (18 February 2002)

Non-Diseases

Christopher I Stark   (18 February 2002)

non-diseases

Indramani Jena   (18 February 2002)

Bags under eyes

NAEIM ASAAD, Common Road-Langly-SL3 8LB   (18 February 2002)

another non-disease

Mark S CADE   (18 February 2002)

Let's leave dental problems to the dentists!

Sarah David   (18 February 2002)

Non disease or lack of knowledge?

Ann E. Fonfa   (19 February 2002)

Benign Chest Pain and Syndrome X

Colleen McKinnon, Ramsey lk rd. Sudbury, Ontario, Canada. P3E 2C6   (19 February 2002)

Re: Three other responses

Collen Mckinnon, Sudbury, On., Canada. P3E 2C6   (19 February 2002)

Ivan Illich on what is and what isn't a disease

Richard Smith   (19 February 2002)

Re: Two other responses

Colleen McKinnon, Sudbury, Ontario, Canada. P3E 2C6   (19 February 2002)

Chinese restaurant syndrome and penis envy

Caroline Richmond   (19 February 2002)

Miscarriage

Rupak R Roy   (19 February 2002)

Dental signs and symptoms

(Dr) Trevor Watts   (19 February 2002)

another one

Nicola A Cooper   (19 February 2002)

prevalence of non-diseases outside the UK

David W Pitches   (20 February 2002)

Disability

Kevin Reel   (20 February 2002)

...and another

Caroline Richmond   (20 February 2002)

atypical depression

Edward Shorter   (20 February 2002)

Hyperlipidaemia is the champion

Jorgen V Nielsen   (20 February 2002)

Physical-Mental-Social and Spiritual well being

praveen kumar madikonda   (20 February 2002)

non-disease

Phillip I Hodson   (20 February 2002)

Rationing?

Steve Hajioff   (20 February 2002)

Chronic Fatigue Syndrome/M.E. Medical Profession Cops Out

Christopher A. Szabo   (20 February 2002)

The most insideous non-disease

Jeffrey Craig Phillips   (20 February 2002)

Re: Re: Three other responses

Alexa E McLaughlin   (20 February 2002)

Re: Ivan Illich on what is and what isn't a disease

Alexa E McLaughlin   (20 February 2002)

two list additions

Anne Peticolas   (20 February 2002)

CFS vs ME

Jill McLaughlin   (20 February 2002)

ear wax

naeim ASAAD, common road-langley-slough-SL0 0JQ   (20 February 2002)

Criteria for non-disease

Mohan Chawla   (20 February 2002)

Re: Ivan Illich on what is and what isn't a disease

L S Lewis   (20 February 2002)

Laenaac on what is and what isn't a disease

A Chaudhuri   (21 February 2002)

Mitral Valve Prolapse

Hans JM Van Brabandt   (21 February 2002)

sick notes

Antony M Goodwin   (21 February 2002)

Non-disease

Meng-Kin Lim   (21 February 2002)

Re: The most insideous non-disease

Christopher A Weiner   (21 February 2002)

physiological phimosis

Shelton M Kartun   (21 February 2002)

Munchausen syndrome by proxy

Michael D Innis   (21 February 2002)

Non-diseases

Ahmad Reza Rasekhi   (21 February 2002)

Doctor-Thinks-you-have-a-disease syndromes.

Belle Monappa Hegde   (21 February 2002)

old age - a nondisease?

Valmiki Kolmi Nagaraj, Anandhi Nagaraj   (21 February 2002)

Not worthy

Jan Willem de Bruijn   (21 February 2002)

Repetitive Strain Injury

Martin Wilson   (22 February 2002)

A Darwinian concept of non-disease

Kazem Zarrabi, Lund University, 221 84 Lund, Sweden.   (22 February 2002)

Tropical non-diseases

John S. Marr, NA   (22 February 2002)

Everything is a disease?

Alejandro F. Luque-Coqui, Alejandro F. Luque Coqui   (22 February 2002)

Ageing is natural

iona e collins   (22 February 2002)

Re: Re: The most insideous non-disease

David Carvel   (22 February 2002)

low blood pressure

Mónica G Silva   (22 February 2002)

Truth, Justice and our Humanity

Malcolm Hooper   (22 February 2002)

Better to have a 'non-survey' than a 'non-disease survey'

Jeanette L Chapman   (22 February 2002)

Purpose of this exercise

Alexa E McLaughlin   (23 February 2002)

CFS/ME a Non-illness?

Lucy I Dechene   (23 February 2002)

Re: Ivan Illich on what is and what isn't a disease

Gurli Bagnall   (23 February 2002)

The point of this exercise

Richard Smith   (24 February 2002)

Almost none of the above

Peter J Allmark   (24 February 2002)

Smith - Devil's Advocate?

Gurli Bagnall   (24 February 2002)

Labels create legitimacy and produce dependence

Kevin C Murphy   (24 February 2002)

ICD605: Redundant prepuce and phimosis

Hugh P Young   (25 February 2002)

Mythical Malady

Charles Pragnell   (25 February 2002)

What really is the point

Trevor Wainwright   (25 February 2002)

Re: Re: Re: The most insideous non-disease

Christopher A Weiner   (25 February 2002)

Our common sense has atrophied

Julian H Jessop   (26 February 2002)

Elevated Cholesterol Is Not a Disease

Paul J. Rosch   (26 February 2002)

Common Sense

Ian A Miller   (27 February 2002)

Thank you

Dale A. Roose   (27 February 2002)

MIS-DIAGNOSED MSBP

Michael D Innis   (27 February 2002)

The pros and cons of medicalisation

Simon Wessely   (27 February 2002)

In response to Wessely

Gurli Bagnall   (1 March 2002)

Patients' Poll on BMJ Results in Landslide

Jean Linn   (1 March 2002)

Disability is a civil rights issue

Joyce M. Carter, Stephen Marsh, Disability Equality Officer, Liverpool City Council and Liverpool Health Authority, 24 Pall Mall, Liverpool L3 6AL   (2 March 2002)

Disease and non disease in children?

Barbara J Robinson   (3 March 2002)

Is this a useful thing to do?

David J Walland   (8 March 2002)

Re: Is this a useful thing to do?

John P. Heptonstall   (9 March 2002)

The IQOL Indice

Karel A Lyons   (9 April 2002)

what about these others

Alexander Parish   (10 April 2002)

A pathetic attempt at cost-cutting...

Maria Christou   (11 April 2002)

Top 10 Diseases Farce - Why I voted how I did

Trevor Wainwright   (11 April 2002)

What should doctors be doing?

Jon Stone   (11 April 2002)

A Joke, Yes?

Janette A Cobb   (11 April 2002)

One disease should no longer be newly diagnosed, ever

Taimur Shoaib   (11 April 2002)

Non Ilnnesses - another view

Trevor Wainwright   (11 April 2002)

Is this poll supposed to help anyone?

Lynn A Watson   (11 April 2002)

Re: A non disease

Sarah L Davies   (12 April 2002)

it is really a disease!

Elaine s Millard   (15 April 2002)

Shame

Marc G M van Impe   (16 April 2002)

GP's with NON-DISEASE ailments

Vikki Crawford   (17 April 2002)

FIBROMYALGIA

Sylvia M Mills   (25 April 2002)

FURTHER DEFINITION OF A NON-DISEASE

RAJKUMAR K CHETTY   (15 May 2002)

Feel ashamed

Victoria M Whitelaw   (26 November 2003)

BMJ surveys dont speak for the medical profession

John Hopkins, DL5 4SE   (27 November 2003)

Dodgy to say the least 15 February 2002
Kieran E Fallon, Head, Sports Medicine Australian Institute of Sport, Canberra2616 Send response to journal: Re: Dodgy to say the least	Sir, May I add two diagnoses so popular with alternative practitioners - chronic glandular fever and chronic candida infection. Best wishes Kieran Fallon
Peri-menstrual Dysphoric Disorder 15 February 2002
Marvin K Malek, none Barre, VT, USA Send response to journal: Re: Peri-menstrual Dysphoric Disorder	A disease entity created by the manufacturer of Prozac, desiring to find a new market niche for fluoxetine before it went generic. So they invented Peri-menstrual Dysphoric Disorder, and created a new name-- Sarafem--for fluoxetine. Quite a marketing coup! Thanks for the fun exercise!
Additional non-disease 15 February 2002
Hans R. Koelz, Head, Division of Gastroenterology Triemli Hospital, CH-Zurich, Switzerland Send response to journal: Re: Additional non-disease	Chronic fatigue syndrome
Non-diseases 15 February 2002
Caroline Richmond, Freelance journalist Home. SW3 5AQ Send response to journal: Re: Non-diseases	Hyperactivity Seasonal affective disorder Raiding the fridge in the night Oedipus complex Complexes generally
Possible non-diseases 15 February 2002
George B. Alcorn, Rural GP Riverton, S.Australia 5412 Send response to journal: Re: Possible non-diseases	I'm not sure if "candida syndrome" and "burn out" could be considered non-diseases as they seem to have become highly unfashionable diseases at present, but years ago they consumed an inordinate amount of my time. I had difficulty persuading patients that the symptoms they complained of were identical to so many other conditions and that none of them really responded to the "appropriate" treatment recommended by their advocates. Is "allergy to the Twentieth Century" in the same class or is it still a common complaint? I also wonder if low back pain should be a non-disease. The number of treatable causes for this condition is so small as to make it a description of a complaint and not a diagnosis of a disease.
Raised cholesterol levels - a non disease 15 February 2002
Malcolm E Kendrick, Medical director Lifelong Learning Partnership Send response to journal: Re: Raised cholesterol levels - a non disease	It is now widely accepted that a raised cholesterol level must be lowered, and the definition of 'raised' has fallen over the years. It is being proposed that 4.5mmol/l is ideal, on the basis that rural populations e.g. rural Chineses have this choelsterol level, and a very low rate of CHD. Yet from 1980 to 1989, the average cholesterol level in Japan went up, from 4.5 to 5.2, and during this time, the rate of CHD dropped. The cholesterol level in France has risen for the last twenty years, now standing at 6.1, yet the rate of CHD in France has fallen during this time period, and it is a quarter of that in the UK (age-matched), despite identical cholesterol levels. Russia has undergone an epidemic of CHD in the last ten years. This is associated with hypocholesterolaemia and raised HDL levels. In Framingham, a falling cholesterol level was associated with an increasing rate of death from CHD over a fifteen year time period. The average cholesterol level of native, or aboriginal Canadians is 5.1, compared to 6.1 in France yet their rate of CHD is five times as high (age-matched). Emigrant Asian Indians in the USA have lower cholesterol levels than the surrounding Caucasian population, yet three times the rate of CHD. This is despite a 50% rate of vegetarianism, a 1% smoking rate, lower average BP, and significantly less obesity. It is impossible to find any consistent correlation between cholesterol levels and CHD (other than in the extreme condition of FH). I would call a raised cholesterol level a non-disease. Your truly Dr Malcolm Kendrick
Bereavement 15 February 2002
Om Prakash, Head of Dept of Medicine, St MArtha's Hospital, Bangalore India St Martha's Hospital, Bangalore 560009, India Send response to journal: Re: Bereavement	Bereavement is a normal human condition. It is often medicalised and overdiagnosed and treated. What is needed is the social support and understanding to allow the person to cope rather than be treated.
non-disease apostasy 15 February 2002
Dale Archer, Occupational Health Physician Shropshire County Council Send response to journal: Re: non-disease apostasy	chronic fatigue syndrome fibromyalgia neurasthenia adjustment reaction
What is a Disease / Complaint? 15 February 2002
Lonnie J Perry, N/A Warrenton, VA 20187 Send response to journal: Re: What is a Disease / Complaint?	Disease: a condition of the living animal or plant body or one of its parts that impairs normal functioning : SICKNESS, MALADY Complaint: 1 : expression of grief, pain or dissatisfaction 2 a : something that is the cause or subject of protest or outcry b : a bodily ailment or disease 3 : a formal allegation against a party Perhaps we need a more restrictive definition of disease to restrict some of the complaint elements for medical purposes. See: Merriam Webster's Collegiate Dictionary, Tenth Edition
Reconsidering Cholesterol and Atherosclerosis 15 February 2002
Eric S. Freedland ,MD, Medical Director Platinum Fitness Lifestyle LTD; 5 Bessom Street, No. 318, Marblehead, MA 01945 Send response to journal: Re: Reconsidering Cholesterol and Atherosclerosis	Consider the following facts. More than half of all MIs occur in people with normal plasma lipid levels and 40 percent have no warning symptoms1 In fact, angiographic studies indicate that the average stenosis of lesions leading to acute MI is less than 50 percent, with infarction occurring due to rupture of non-occlusive plaques triggering acute thrombosis.2 The beneficial effects of statin agents may be independent of serum lipid levels and can occur before lipid lowering.3-6 In the CARE trial, the risk of an MI was reduced to the same degree whether the cholesterol level was lowered by a large or small amount, i.e., “lack of exposure response.”7 While a number of factors can damage the endothelium and accelerate atherosclerosis, oxidants and free radicals are major initiators of vessel wall damage. Statins have been shown to prevent the activation of monocytes into macrophages, inhibit the production of pro-inflammatory cytokines, C- reactive protein, and cellular adhesion molecules, and decrease the adhesion of monocyte to endothelial cells.8 The benefit of statins may be their anti-inflammatory effect, and the lowering of cholesterol may be an interesting side effect. LDLs appear to be harmful when they are oxidized. Without a pro-oxidant or pro-inflammatory environment perhaps elevated lipids are significantly less of a threat, and perhaps we should be emphasizing the type of plaque, inflammatory milieu, and endothelial dysfunction rather than circulating lipids per se. 1. Braunwald E. Shattuck lecture--cardiovascular medicine at the turn of the millennium: triumphs, concerns, and opportunities. N Engl J Med 1997; 337:1360-9. 2. Ambrose JA, Tannenbaum MA, Alexopoulos D, et al. Angiographic progression of coronary artery disease and the development of myocardial infarction. J Am Coll Cardiol 1988; 12:56-62. 3. Aengevaeren WR. Beyond lipids - the role of the endothelium in coronary artery disease. Atherosclerosis 1999; 147 Suppl 1:S11-6. 4. Ridker PM, Rifai N, Pfeffer MA, Sacks F, Braunwald E. Long-term effects of pravastatin on plasma concentration of C-reactive protein. The Cholesterol and Recurrent Events (CARE) Investigators [see comments]. Circulation 1999; 100:230-5. 5. Nielsen JV. Serum lipid lowering and risk reduction--where is the connection? BMJ 2001; 323 Electronic response to Kmietowicz, Z:1145- BMJ.com. 6. Kendrick M. Finally, proof that statins don't work by lowering LDL. BMJ 2001; 323:1145 (electronic response to Kmietowicz, Z. BMJ.com). 7. Ravnskov U. The Cholesterol Myths: Exposing the fallacy that cholesterol and saturated fat cause heart disease. Washington, DC: New Trends Publishing, Inc., 2000. 8. Koh KK. Effects of statins on vascular wall: vasomotor function, inflammation, and plaque stability [In Process Citation]. Cardiovasc Res 2000; 47:648-57.
Society's stigma spells DISEASE 15 February 2002
Dr Rani Pal, Consultant Neonatal Paediatrician (locum) UK Send response to journal: Re: Society's stigma spells DISEASE	Is Disability a Disease in our society? Discriminate, disqualify, detriment and dispose Illness, Insult, Intimidate and Isolation Sickness, sighs, slighted and slaughtered Eugenics, Equation, Evolution and Exterminate Annoyance, Attitude, Alienate and Axed Sinful, Scorned, Segregate and Slander Excuses, Eye-sore, Evaluate and End
Non-disease 15 February 2002
Mathai Babu, Staff Grade Paediatrician Powys SY18 6EF Send response to journal: Re: Non-disease	Chronic fatigue Syndrome Constipation(non organic) Irritable Bowel syndrome Anxiety disorders Phobias Conduct disorders in children Specific Learning Difficulties
Non-disease if doctor recognize physiological deterministic chaos. 15 February 2002
Stagnaro Sergio, Specialist in Blood, Gastrointestinal and Metabolic Diseases Send response to journal: Re: Non-disease if doctor recognize physiological deterministic chaos.	Sirs, I am very delighted, once again, with BMJ for discussing in April 13 Number the topic "Non-Disease". Really, if doctors around the world would be skilled in Biophysical Semeiotics (http://digilander.iol.it/semeioticabiofisica), it would be senseless to edit such a number by our famous review. Unfortunately, theories nowadays are very different, as regards this original semeiotics, in total disagreement with Claude Bernard et alii. In fact, all biological systems, including the microcirculatory one, are "open" systems, continuously supplied with blood, i.e., material-energy-information, by the related microvessels, and consequently they fluctuate around their equilibrium point in accordance with a deterministic chaotic behaviour. When we are speaking of "Disease" we refer to a defined biological system, involved by whatever disease, which, therefore, loses its physiological degree of deterministic chaos (fractal dimension). In conclusion, a physician experienced in Biophysical Semeiotics, to the question: "What do you think is a non-disease", answers promptly:"A non-disease is the presence of "physiological" deterministic chaos, or normal fractal dimension (3,81), in all biological systems" OF COURSE, I add.
Diastema 15 February 2002
Chinelo E Nwokolo, Staff Grade Forensic psychiatry Chase Farm Hospital Enfield EN2 8JL Send response to journal: Re: Diastema	Diastema, gap teeth.....some think it is a disease... that should be treated....,not everybody! The Ibos of Nigeria see it as a mark of BEAUTY. ( What do you think of Madonna's? Sweet?!)
Time warps perception 16 February 2002
Susan J Wighton, communicable disease nurse Dorset Health Authority BH22 9JR Send response to journal: Re: Time warps perception	Whilst considering the medicalisation of life/health/stigma,perhaps we could consider that disease is inherent in life? As birth and death - perhaps so disease. This could evolve into conception,birth,disease,death becoming normative values instead of anxiety factors. Extrapolating into cancer diagnoses becoming rites of passage - as many potentially life threatening experiences are interpreted within the historical/cultural/magical settings in medical anthropolgy.
A non disease 16 February 2002
Clare O'Connor, gp registrar Kirbymoorside surgery, Tinley Garth, Kirbymoorside, York, YO6 6AR Send response to journal: Re: A non disease	Loss of libido in a post menopausal lady in her sixties, who 'wants something done'. Is this not a normal physiological state?
Non-diseases 16 February 2002
douglas n salmon, gp b20 3he Send response to journal: Re: Non-diseases	impotence erectile failure
How to use an esteemed medical journal to increase suffering 16 February 2002
Margaret Bailey, retired 07871 Send response to journal: Re: How to use an esteemed medical journal to increase suffering	People look to your journal to publish scientifically worthy research, not public opinion polls which show the prejudices and ignorance of your readership and contributors. This is the type of article I'd expect to see in a tell-all rag newspaper - unless, of course, you intend to use the poll results to show just how ill-informed, undignified, and easily swayed by personal bias the medical world can be. Your trite apology ("We are not suggesting that the suffering of people with these 'non-diseases' is not genuine") carelessly increases the harm because it shows that you know exactly how the article will be read. This is certainly a new low for medical journalism.
Non-diseases 16 February 2002
Joel M. Kauffman, Research Professor of Chemistry University of the Sciences in Philadelphia 19104 Send response to journal: Re: Non-diseases	hyperlipidaemia
Lactose intolerance, ignorance, noncompliance 16 February 2002
Myrna Y. Munar, Pharm.D., Associate Professor Oregon State University College of Pharmacy Send response to journal: Re: Lactose intolerance, ignorance, noncompliance	Lactose intolerance, ignorance, noncompliance
Re: Raised cholesterol levels - a non disease 16 February 2002
Gunnar Lindgren, Teacher Gothenburg University Send response to journal: Re: Re: Raised cholesterol levels - a non disease	I think the cholesterol issue together with the money from margarine industry is one of the strongest marketing success ever. The industry has got its advertisments in white gowns in a situation when patients fear for death. I am convinced that the focus as fast as possible should be moved from intake of fat to intake of carbohydrates with high glycemic index instead.
menopause and pregnancy 16 February 2002
Jo A Rosenfeld, Asst Prof Johns Hopkins Baltimore MD 21113 USA Send response to journal: Re: menopause and pregnancy	There are women's conditions that have been medicalized and considered a disease. Thus if the woman after obtaining a consultation does not agree she is non-compliant. Three of these are pregnancy, menopause and contraceptive needs. They require a physician's involvement, prescription, and the woman can be "non-compliant."
Solatic 16 February 2002
Jeffrey D Bernhard, Professor 01655 Send response to journal: Re: Solatic	The term "solatic" is used to describe a person who has a delusional belief that sunlight is causing a rash or an abnormal cutaneous sensation. In some cases there may be a genuine rash or abnormal sensation that can be attributed to a different (non-solar) cause; in some cases there is no detectable rash or physiologically logical sensory disturbance. Bernhard JD, Parrish JA. Nonrashes. II. Solatics. Cutis 29:253, 1982. The term has appeared in the glossary of the last few editions of the Rook/Wilkinson/Ebling Textbook of Dermatology. Champion RH, Burton JL, Burns DA, Breathnach SM. Rook/Wilkinson/Ebling Textbook of Dermatology, 6th ed. Oxford: Blackwell, 1998, p3676.
Non disease 16 February 2002
Sethuraman K Raman, Professor of Medicine Jawaharlal Institute of PG medical education & research, Pondicherry, India. Send response to journal: Re: Non disease	Please add "Worried Well" person.
non-disease? 16 February 2002
Tom P. Kindlon Dublin 15, Ireland Send response to journal: Re: non-disease?	impulsive-desire-to-indulge-in-psychological-speculation syndrome
Disease Vs. Non-disease: When a non-disease becomes a disease? 16 February 2002
Malvinder S. Parmar, Consultant Physician, Director of Dialysis Timmins & District Hospital, Timmins, ON. P4N 8R1. Canada. Send response to journal: Re: Disease Vs. Non-disease: When a non-disease becomes a disease?	Disease: “a condition that impairs normal physiological functioning.” Health: “state of optimal functioning with freedom from disease or abnormality.” Non-disease is a state somewhere between health and disease. Its definition varies depending on the individual and society. An individual might feel that he/she is normal but if his/her behavior is affecting the society’s moral values then that would be considered abnormal by the society. Although it may not be classified as ‘disease’ but it definitely would not be considered ‘healthy’ and would likely be classified as ‘un-healthy’ or ‘non-disease.’ Similarly an individual afflicted with an abnormality that impairs his/her normal functioning would consider himself/herself as ‘having a disease’ but society may not consider him as such because that ailment has not been recognized by the society as a disease for various reasons (no consensus on definition, ambiguous symptomatology, lack of recognition etc.). It is interesting to note that a so-called ‘(ab)normal or sub-normal state’ remains a non-disease until a modality or treatment becomes available. When a drug or therapy for a ‘non-disease’ becomes available then that ailment becomes not only a disease, but an epidemic. Obesity and osteoporosis have been embedded in human culture for centuries and in fact about a century ago, obesity was a sign of good health and prosperity. In the past decade these conditions have become epidemics. Why? Is this really an effort to improve the overall health of the population or has some ulterior motives (financial gains for the ‘interest group(s)’).
Non-Diseases or CO Poisoning? 16 February 2002
Albert H Donnay, President, MCS Referral & Resources, www.mcsrr.org 508 Westgate Rd, Baltimore MD USA 21229 Send response to journal: Re: Non-Diseases or CO Poisoning?	I think it is very telling that more than half the disorders on your list of "non-diseases" are characterized by common--but also commonly overlooked--symptoms of carbon monoxide poisoning, including: Air rage, Anorgasmia, Attention deficit disorder, Brain death, Diabetes, False memory syndrome, Fibromyalgia, Fibrositis, Food intolerance, Gulf war syndrome, Hypoglycaemia, Hypotension, Hysteria, Insomnia, Iron deficiency, Irritable bowel syndrome, Jet lag, Migraine, Multiple chemical sensitivities, Myalgic encephalomyelitis/chronic fatigue syndrome, Obesity, Pain, Personality disorder, Post-traumatic stress disorder, Premenstrual syndrome, Recurrent miscarriage, Restless legs syndrome, Road rage, Seasonal affective disorder, Short stature, Sick building syndrome, Social phobia, Somatisation disorders, Stress, Tension headache, Total allergy syndrome, and Unhappiness. It is for this list and more that CO poisoning has long been known in medicine as a Great Imitator (1). I wonder if any of the physicians who are so quick to dismiss these conditions as non-diseases have ever read any of the literature linking them with CO or ever tested anyone who suffers them for this possibility. Listed below in chronological order by date of their first appearance are 50 more disorders consistent with CO poisoning that have been reported in English medical literature since the seminal discovery of neurasthenia in 1869, which I have shown was most likely caused by CO from gas lighting (2). You may as well add all 50 to your list of "non-diseases" since that unfortunately is still how most of them are regarded by physicians and medical historians (3). 1871 Irritable Heart, aka Da Costa's Syndrome 1892 Hyperaesthesia 1895 Anxiety Neurosis 1904 Phrenasthenia 1906 Psychasthenia 1914 Shell Shock Syndrome 1916 Battle Fatigue, aka Soldier's Heart 1918 War Neurosis 1930 Heat, Cold and Effort Sensitiveness 1930 Allergic Toxemia 1936 Morbid Industrial Fatigue 1938 Neurocirculatory Asthenia, aka Effort Syndrome 1945 Allergic Fatigue 1950 Epidemic Neuromyasthenia, aka Icelandic Disease or Akureyri Fever 1952 Allergy of the Nervous System 1954 Cerebral Allergy 1955 Encephalomyelitis simulating poliomyelitis, aka Royal Free Hospital Disease 1956 Specific Adaptation Syndrome 1956 Benign Myalgic Encephalomyelitis 1957 Epidemic Postinfectious Neuromyasthenia 1965 Familial Dysautonomia, aka Riley-Day Syndrome 1965 Asthenic Neurosis 1966 Psycho-Vegetative Syndrome 1968 Pseudoneurasthenic Syndrome 1969 Idiopathic Hypogeusia 1973 Ecologic Mental Illness 1974 Epidemic Mass Hysteria 1975 Autonomic Dystonia 1976 Neurasthenic Musculoskeletal Pain Syndrome 1978 Mass Psychogenic Illness 1978 Psychic Possession 1978 Chemical Hypersusceptibility 1980 Neurasthenic Neurosis 1982 Familial Chronic Mononucleosis Syndrome 1984 Chronic Active Epstein Barr Virus Syndrome 1984 Chronic Mononucleosis 1985 20th Century Syndrome 1986 Sporadic Postinfectious Neuromyesthenia 1986 Hypersensitivity Syndrome 1987 Darkroom Disease 1988 Chronic Fatigue and Immune Dysfunction Syndrome 1990 Chronic Habitual Hyperventilation Syndrome 1996 Iatrogenic Hypochondriasis 1996 Multi-Organ Dysesthesia 1996 Idiopathic Environmental Intolerances 1997 Chronic Pain and Fatigue Syndrome 1997 Autoimmune Fatigue Syndrome 1998 Toxicant Induced Loss of Tolerance 1998 Chronic Multisymptom Illness 1999 Multi-Sensory Sensitivity, aka MUSES Syndrome in honor of Edgar Allan Poe --Albert Donnay, MHS, Environmental Health Engineer and Certified CO Analyst References (1) Grace TW, Platt FW. Subacute carbon monoxide poisoning. Another great imitator. JAMA 1981;246(15):1698-700 (2) Donnay A. Carbon Monoxide as an Unrecognized Cause of Neurasthenia: A History. In: Penney, D. ed. Carbon Monoxide Toxicity. 2000. Boca Raton FL : CRC Press. (3) Wessely S, Hotopf M, Sharpe M. Chronic fatigue and its syndromes. Oxford: Oxford University Press, 1998.
Arrogance 16 February 2002
Anelie J. Walsh, student Send response to journal: Re: Arrogance	The arrogance of this concept is breathtaking. Had this list been compiled fifty years ago, which illnesses would have been listed? Multiple sclerosis, Crohn's Disease, hypothyroidism...? The medical community's inability to learn from past mistakes - namely, to acknowledge that the vast majority of patients are honestly relating their symptoms and sincerely wish to recover - will doom generations of innocent people to the kind of humiliation and insult this article encapsulates. Unable to perceive their own ignorance, these commentators will enjoy a brief moment in the spotlight sneering at the 'proponents' of 'non-diseases', and utterly fail to advance medical science. And you wonder why the benighted sufferers of their non-diseases resort to 'alternative practitioners'.
Medicalization.. non-disease.. a view from across the pond 16 February 2002
Gary N. Fox, Teaching Faculty St. Vincent Medical Center, Toledo, OH 43608-2691 Send response to journal: Re: Medicalization.. non-disease.. a view from across the pond	At least from the other side of the Atlantic . . . 1. SPORTS PHYSICALS -- required by most school districts for middle school and high school athletes in the U.S. Annually, in the U.S., there are about 20 reported sudden cardiac deaths per year among 2.1 million athletes competing in high school sports. That's a pretest probability of 1/100,000. The author uses a sensitivity for H&P of 6% and specificity 97.8%. For ECG, he uses sensitivity of 70% and specificity of 84.3%. Let's take a sample size of 2.1 million (the number of athletes at risk) and apply a pretest probability of 1:100,000 using the ECG numbers - - 70% sensitivity and 84.3% specificity. Of the 21 folks who are going to die, we'll accurately find 14.7 and miss 6.3 of them. However, we'll have 329,696.7 false-positive tests (compared with the 14.7 true-positives) for a predictive value of a positive test of 0.0045% (that's 0.000045). We'd have to work up 329,696.7 + 14.7 athletes to find the 14.7 who are going to die, while missing 6.3 anyway. Observations: (1) We've got much better uses of the resources, like preventing the slaughter of teens in motor vehicles. (2) You might contend that the screening has eliminated a lot of athletes bound to die, so the numbers would be much higher, say a couple hundred per year if they weren't being eliminated. H&P using the above assumptions identifies 1.26 of the 21 individuals who are going to die, while identifying an additional 46,199.5 individuals with false- positive tests, for a predictive value of a positive test for disease of 0.002727% (or 0.00002727, mostly a reflection of the very meager pre-test probability). Fuller CM. Cost effectiveness analysis of screening of high school athletes for risk of sudden cardiac death. Med & Science in Sports & Exercise 2000;32:887. Overall, the approx costs per year of life saved: CV-specific H&P $84,000; 12-lead ECG, $44,000; 2D- echocardiogram, $200,000. The 12-lead ECG is the most cost effective preparticipation cv modality of the 3. 2. Work excuses -- off work, return to work. Holleman WL. School and work release evaluations. JAMA 1988;260:3629. Major ethical issues with a confusion about the professional boundaries of medicine, education, and industry. Other issues include confidentiality and truth telling. "Casual absenteeism" -- for minor illnesses -- threatens productivity, morale, and even viability of industry and schools. In the traditional medical relationship, a patient seeking help has no incentive to lie. With the advent of physicians-as-investigators, the rules of the game are changing, and the physician-*employee* relationship threatens to damage the physician-*patient* relationship. Casual absenteeism is an economic problem, not a medical one. Physicians practice bad medicine when they offer slips when the problem is a dishonest employee, an employee with family problems, a poorly structured sickness benefits policy, an unjust pay scale, unpleasant working conditions, or bad employer-employee relations. In most instances, physicians cannot confirm or deny or even determine the extent to which work ability is impaired. 3. Some have listed such things as dyslipidemia/hyperlipidemia as "nondiseases." That is true in that, like hypertension, they are *RISK factors* rather than diseases. Some have listed such things as constipation, which is a *symptom* that may be a matter of lifestyle but can also be a harbinger of underlying disease(s). For "non-disease," I think mostly of the "medicalization" of things that physicians really should play no role. Granted, there are probably some gray areas between risk factors, symptoms, and medicalized non-diseases. But I, for one, want to know about my patients' risk factors and symptoms.... but don't want to waste my time with non-disease. Based on recent articles, we might also talk about medical NON-sense, which might go so far as to bring mammography and PSA measurement into the fray.
Hypercholesterolaemia - the superior winner 16 February 2002
Uffe Ravnskov, Independent researcher Magle Stora Kyrkogata 9, S-22350, Lund, Sweden Send response to journal: Re: Hypercholesterolaemia - the superior winner	In a competition for being the commonest non-disease in the world, no one can stand comparison with hypercholesterolaemia. Together with its many cousins in the lipid family, it includes at least a third of the Western population, if not more (1). Non-disease is rarely met by non-treatment. Unfortunately so, because not a single life has been saved by the boring diets and the toxic drugs that have been used since many years in millions of people (2). The new cholesterol lowering drugs, the statins have saved some, but the number is small in comparison with the number of treated non-patients. That the statins do benefit is taken as proof that hypercholesterolaemia is a disease although all evidence has shown that the statins do not operate through cholesterol lowering. Indeed, statins may benefit, not because of, but in spite of their cholesterol lowering, because high cholesterol may protect against disease. This was the conclusion from the finding of a lower than normal coronary and total mortality seen in several pedigrees of individuals with familial hypercholesterolaemia (3). The sad paradox is that by treating non-diseases we may create real ones. 1. Executive Summary of the third report of the National Cholesterol Education Program (NCEP)expert panel on detection,evaluation, and treatment of high blood cholesterol in adults (adult treatment panel III). JAMA 2001; 285: 2486-97. 2. Ravnskov U. The cholesterol myths. Washington DC: New Trends Publishing; 2000. 3. Sijbrands EJG, Westendorp J, Defesche JC, de Meier PHEM, Smelt AHM, Kastelein JP. Mortality over two centuries in large pedigree with familial hypercholesterolaemia: family tree mortality study. BMJ 2001; 322: 1019- 23.
Other Non-Diseases?? 16 February 2002
Patricia S. Blankenship, retired USA, 36854 Send response to journal: Re: Other Non-Diseases??	You have really opened a can of worms. This topic will evoke angry responses from non-medicos who read your journal on-line. What about these in your list: Diabetes? Easy to prove if one has this malady. Hypotension? Ask people who faint easily. Warts? Can one not believe one's own eyes? Varicose veins? These hurt and can cause long term circulatory problems. Stress -- Measure the cortisol pre and post stress. Pet scans. Give us a break here. Stretch mark, Polycystic ovary syndrome, and Positive cervical smear, Premenstrual syndrome, Recurrent miscarriage, Fibrocystic disease of the breast, Calcium deficiency -- These must have been submitted by a man. Restless legs syndrome -- Anyone who ever underwent anesthesia or has a brain disorder may develop nocturnal myoclonus. Or are brain disorders also non-diseases? Obesity -- See current gene studies. Where in the world did this list come from? Migraine -- NOT A DISEASE? Please! Halitosis -- while not usually treated, this is frequently caused by bacterial infestations in the upper pharynx. A bacterial infection is not a disease? Astigmatism -- Can be measured and treated. I see you have included Chronic Fatigue Syndrome / ME / BME and Fibromyalgia as non-diseases. At least a million people in the US suffer from these diseases. Peer reviewed publications from NIH and CDC support these conditions as diseases. Maybe you should define disease instead of non-disease - this exercise at your web site is ludicrous without definitions. You must be defining disease in a very different way than most primary care doctors and patients. I think you should add Arrogance and Chronic Ego-Centrism to your list of true diseases, if this is your best effort. I could go on, but won't. Not worth the effort. Patricia S. Blankenship
non disease of the month 16 February 2002
John p McCormack, GP registrar Westport, Co. Mayo. Ireland Send response to journal: Re: non disease of the month	Autistic Enterocolitis. A makey uppey diseasey namey attempting to give scientific kudos to a postulate based on fewer cases than I have changes of underpants.
"Non-disease" 16 February 2002
Aya Biderman, Deputy Head of Department Dept of Family Medicine, Ben-Gurion University, Beer-Sheva, Israel Send response to journal: Re: "Non-disease"	Domestic violence is another "non-disease" with important implications on health
Non Diseases - A Case of Throwing the Baby Out With The Bath Water? 16 February 2002
Dianna Dunbar, none (have a BSc (hons) Health and Community Studies also personal interest. Home code: (UK) BA21 3SB 20 Send response to journal: Re: Non Diseases - A Case of Throwing the Baby Out With The Bath Water?	Having read the list of 'non-diseases' I'm not at all sure I fully understand the rationale behind it. However - as a person who experiences chronic fatigue syndrome, fibromyalgia, obesity and several other 'conditions' included on the list - I do have a vested interest in the outcome. I fully accept that the 'medicalisation' of certain diseases, illnesses, and conditions has impacted negatively on those who experience them. Moreover, I also accept that there are certain situations whereby it might be better not to treat certain conditions. However, I would argue this to be true of both diseases and 'non-diseases' and can comprehend no automatic correlation between disease = treatment and 'non-disease' = no treatment. A cursory glance at the list would appear to highlight this. The condition of having 'Big ears' is listed and I guess very few people would argue that having 'big ears' is a disease. Therefore, its inclusion as a 'non-disease would seem to pose few problems. However, this does not mean that one can automatically assume that the condition requires no treatment. That decision would surely depend on various factors including the extent to which the condition impinges on the life of the person experiencing it. Conversely, cancer is (arguably) a disease that often benefits from highly aggressive treatment though there are also many situations where, for a variety of reasons, it might be better to treat less aggressively or even withhold treatment altogether. Moreover, despite the best efforts of certain egotistical members of the medical profession to convince us that they have all the answers, there are many conditions where too little is known about them to be able to label them as either disease or 'non-disease. It might be argued therefore, that it would be better to label a condition a 'non-disease' rather than to erroneously label it a disease. Conversely, I would argue that any rush to label a condition of unknown origin a 'non-disease' could have negative effects. Historically, conditions that have no known origin have attracted 'labels' such as 'psychosomatic' and 'psychological'. This in turn has stigmatised those experiencing such conditions as; at best, lacking and/or weak in some way and; at worst, mad, and this has defined the treatment given or withheld. For example, prior to the discovery that Multiple Sclerosis (MS) has an organic origin those who experienced MS were often labelled psychosomatic or as having psychological difficulties and treated in an inappropriate manner. This is still the case with conditions such as for example chronic fatigue syndrome and myalgic encephalitis. Labelling certain conditions as 'non-diseases' could also have more far reaching consequences. In the UK (and I would imagine in many other countries) a person's entitlement to receive certain State and other benefits when one is unable to work due to ill health is largely dependent on the recognition of a pre-existing condition. It seems clear that having the label of 'non-disease' attached to that condition might well serve to negatively affect either the level of benefit or even whether a benefit is paid. It is my contention that the classification of certain conditions as 'non-diseases', in an attempt avoid the perils of 'medicalisation,' would seem to be a case of throwing the baby out with the bath-water. I feel it would be far better to take a holistic 'social' approach to illness and disability, treating each person individually rather than seeking a 'cover all' solution. That appears to do little more than replace one label with another with many possible negative concequences.
Myalgia Encephalitis 17 February 2002
Raymond Henry Givan, General Practitioner BT45 7QX Send response to journal: Re: Myalgia Encephalitis	Myalgia Encephalitis or POst-viral Fatigue Syndromeis a comlex modern disease which to a large extent does not exist and is simply used to hide behind a diagnosis. Often such people should be diagnosed with depression.
Dis-ease= Drug-Deficiency 17 February 2002
Kenneth M. Jacobie, Licensed Massage Therapist Private Practice Send response to journal: Re: Dis-ease= Drug-Deficiency	"Thinking within a fixed circle of ideas tends to restrict the questions to a limited field. And, if one's questions stay in that limited field, so also do the answers" -- David Bohm, Physicist. If one consults the Encyclopedia Britannica "Disease is considered to be a harmful deviation from the normal structural or functional state of an organism." This definition continues: "A diseased organism commonly exhibits signs or symptoms indicative of its abnormal state." And most poignantly "Thus, the normal condition of an organism must be understood in order to recognize the hallmarks of disease." It is here that the continued perversion of the medical establishment comes into focus and why I applaud the BMJ for this very unique dialogue. Can a doctor who has not ever studied contemporary nutritional sciences, in particular nutritional biochemistry, create an accurate base line for normal function of the human condition? Be assured that drug companies are major sponsors of this type of research. This also brings into question as to why modern nutritional standards are still completely devoid of the modifying effects of forensic anthropology, evolutionary biology, primatology and other pertinent fields of study. Consider closely that the medical profession specifically treats the symptoms of the bodies cellular 'dis-regulations'. This is done most typically with drugs. However would you bring you car to a mechanic that has never studied it's fuel system? He would have a framework to diagnose it's problem but would he be accurate? Not if the problem was in fact with the fuel system. If doctors haven't been exposed to large areas of valid scientific pursuit, it is actually impossible for them to continue to "test" the hypothesis of allopathic medicine. Perhaps 'deficiency states' are a key to the disease process, and perhaps this applies to some of ten of thousands of compounds in a multitude of chemical classes that have only recently characterized(last 50 years) by modern analytical chemistry and that doctors have ZERO educational exposure to. As such I nominate as 'situations' where people may have better outcomes if the problem limited to the modern concept of disease(drug- deficiency): ADD/ADHD Depression Many Cancers/Childhood Cancer Most Idiopathic Diseases Obesity Heart Disease Diabetes Stroke Hypertension AIDS Asthma Allergies Mental Disorders Any disease studied more than 30 years is a possible candidate. Be Well, Kenneth M. Jacobie, LMT
Who carries the can? 17 February 2002
Alexa E McLaughlin, Writer and editor Red Hill, ACT, Australia Send response to journal: Re: Who carries the can?	This exercise is very woolly. My best guess is that your concept of non-disease is meant to portray those "life experiences" which do not have a physical basis, so are instead of psychological origin. While acknowledging that the suffering may be real, your view is that no medical treatment should be provided. Let me put this another way. Many items on this list are conditions in which no physical basis has yet been shown to universally apply. That is NOT the same thing as saying it has no physical basis, just that it hasn't yet been identified. This contrasts with multiple sclerosis, which was earlier also seen as having no physical basis, until the physical basis was identified. Certainly, at this time, the best treatment may in some cases be psychological support to cope with the disease, while better treatments are developed, but that doesn't make such treatment curative of the underlying condition. So there may be some value to looking for non- physical ways to manage these conditions, but that doesn't mean they are non-diseases. I suggest that your explanations need to spell out clearly if you are claiming that the "non-diseases" are psychological rather than physical in basis, and that non-medical treatment is considered appropriate, rather than the only thing available. As a writer, I wondered if the article was a joke, a tongue in cheek April Fools type joke. If so, it is in incredibly poor taste in a serious publication. Even if it were intended ironically, the reality is that the issue of physicians dismissing genuine physical suffering as psychological, and not seeking treatment or understanding, is a lived reality for large numbers in the community. It impacts on all aspects of their lives, harming them and the wider community. It is not a laughing matter. It is not something they can put aside when "work" finishes, to be taken up another time. I am very concerned at the number of physicians who have responded enthusiastically to belittle patients and conditions. This is likely to encourage and extend the number of practitioners who dismiss genuine concerns and experiences of patients. I expect that many of the conditions on your list will turn out to have a physical basis. Where is the responsibility of practitioners, researchers and the BMJ, who have belittled sufferers and not sought or identified treatments. Surely this abrogates "duty of care", "first do no harm" and scientific integrity. What will you do to compensate sufferers for the needless suffering caused by your article?
More choices 17 February 2002
A Chaudhuri, Senior Clinical Lecturer University of Glasgow Send response to journal: Re: More choices	Sir, A selection of additional “non-diseases” as defined by the BMJ for consideration: Acne Aging Anorexia Anxiety Borborygmi Cataract Cough Dementia Depression Diarrhoea Dizziness/vertigo Endometriosis Fainting (syncope) Fever Food poisoning Haemorrhoids Hallucination Hunger Ingrowing toe nail Malnutrition Mania Motion sickness Pediculosis Phantom limb Phobia Pruritus Pre-menstrual syndrome Sinusitis Skin rash Sickness(nausea and vomiting) Substance abuse Sweating Tics ( habit spasms) Tinnitus Tonsillitis Vegetative state and, of course, Myopia (editorial or otherwise!) Finally, at the risk of invoking harsh editorial censorship, I would cautiously propose the important topic of human sexual experience to be included in the proposed theme issue. Not only sex is the usual pre- requisite for pregnancy (listed as a non-disease) but medical imaging of sexual arousal has also been a topic of serious scientific interest. I believe that the BMJ readers are adults and selection of this topic will make the BMJ ever more popular than the Cosmopolitan. I am left with no doubt that the cumulative list of “non-diseases” would be more impressive and important than some of the known “diseases”. It is worthwhile to debate the medicalisation of the human experience of head lice rather than worry about Pogosta disease because one may use a behavioural approach for human pediculosis (avoid social head contacts) but not for the Sindbis virus in Finland!
This exercise is a slippery slope itself 17 February 2002
Raymond F Colliton, retired retired Send response to journal: Re: This exercise is a slippery slope itself	Sir: You define non-disease as a "a human process or problem that some have defined as a medical condition but where people may have better outcomes if the problem or process was not defined in that way." This begs the question of how people with the problems contained in the rather long list of proposed "non-diseases" would be better handled if they were not defined as a medical condition. Surely one would suspect that diabetes both requires medical intervention and is best served as being considered a medical condition. In fact, while a limited number of the conditions listed appear to be simply the experience of the human condition, most do benefit from medical intervention and treatment. Is there some reason to portray these conditions as unworthy of medical attention? The purpose of medicine is to reduce human suffering. To the extent that medical intervention can reduce the suffering of people with the conditions on your ever-growing list, it serves no purpose to classify them as "non-diseases," given your definition of non-disease. And to cap this exercise, we will be given the opportunity to vote on the top ten "non-diseases," as if the discernment of truth is best done by majority vote. This is perhaps a novel approach, but it is, nonetheless, extremely problematic. Raymond F. Colliton Bensalem, PA, USA
Domestic violence and Non-disease 17 February 2002
seshubabu gosala, chief medical officer JIPMER, Pondicherry Send response to journal: Re: Domestic violence and Non-disease	Many sequelae of one or many repeated episodes of domestic violence presenting as organic diseases must also be included as non-diseases as the main problem is the stress of violence than any bodily injury. For example chronic headache without any evidence of treatable causes etc. following repeated domestic violence. The list may vary from the socio- economic background, literacy and the availability of medical services. seshu
Re: Additional non-disease 17 February 2002
Kjell O. Skavdal, rheumatologist N-3260 Larvik,Norway Send response to journal: Re: Re: Additional non-disease	ME/chronic fatigue syndrome
Common childhood symptoms 17 February 2002
Peter M Jones, Consultant Paediatrician Bishop Auckland DL14 6AD Send response to journal: Re: Common childhood symptoms	A number of behaviours and physical findings in children present as symptoms and signs but our inability or insufficient time or our own need to medicalise and hence maintain control (and power, prestige, and sometimes income) elevates them to diseases Prime examples are wind in infants colic postnasal drip for a cough minor variations of skeletal development which become pes planus, genu valgum, low tone, hyperextensibility tongue tie tight foreskin
Myalgic encephalomyelitis/chronic fatigue syndrome 18 February 2002
Domenic A. Tricome, disabled King of Prussia, PA 19406-3568 Send response to journal: Re: Myalgic encephalomyelitis/chronic fatigue syndrome	I think that this disease should be in the top ten.
Profit & loss 18 February 2002
Raelene J Reeves, Unemployed Metford NSW, Australia Send response to journal: Re: Profit & loss	Definition of Non-Disease - One you can't get in and out of the office inside 10 minutes and still make a profit on the consult (e.g. recurrent stomach ulcers, circa 1985).
here we go again 18 February 2002
Paul S Mitchell Edinburgh EH4 Send response to journal: Re: here we go again	Cancer Broken Legs The common cold For goodness sake, what is this, backlash week? I dare say the majority of upset caused to people with chronic back pain is due to their gradual loss of social contact, general stigma at work, and loss of mobility, but it doesn't mean it's particularly useful to not treat the central causative issue here: back pain. People with M.E./CFS are constantly berated for treating their condition "simplistically" by separating body and mind and just thinking about the body problem, while they know full well that all conditions affect body and mind as part of the whole organism. As it does with cancer. And now you're suggesting we forget about the "body" bit? If the body's wrong, it's a disease, and declassifying it as such has only one effect: to remove funding. Are you saying we should de-medicalise cancer too? Would that help? If so I'm all for it: there's nothing more disabling than being treated as simply "a patient". I'm not sure so much research would get done though. There's plenty of evidence of organic disorder in ME/CFS patients too. On the face of it, yes, you aren't quite denigrating the "suffering" of people with these "conditions" - thanks. But the very fact that attempts like this exist to redefine conditions where valuable in-roads into the organic disease process are being made elsewhere simply serves to put back research years and make the UK a laughing stock. This forum smacks of conversations in a pub where everyone throws in their favourite minority group for denigration. I'm not surprised you have so many responses: you've given people an opportunity to grind axes.
Join the queue 18 February 2002
Gurli H. Bagnall, Patients' Rights Campaigner Lawrence, Otago, New Zealand Send response to journal: Re: Join the queue	The medical profession expects patient compliance, but who if not they, promoted the idea that most of the listed conditions need treatment? The tacit suggestion is that “non-diseases” are the result of patient inadequacy, but like it or not, discomfort indicates that something is wrong. Explaining to the elderly person that, at his age, he does not need more than a couple of hours sleep at night, is not helpful when he is experiencing the effects of sleep deprivation. It is much better to be truthful and say that the only treatment available is highly addictive, and could cause a great many more problems than he already has - few people demand miracles, but they do expect honesty. The fact that most of the listed discomforts/conditions are not alleviated (and are often made worse) by drug treatments, is not due to the patient’s shortcomings, but rather the shortcomings of medical science, and therefore the medical profession. Richard Smith, editor of the BMJ, put it this way in the TV documentary “Why doctors make mistakes” which was screened last year: “All doctors in some ways are bogus doctors because [they] are very aware of the extreme limitations of what [they] can do.We have very limited ways of dealing with disease.” Creating a spurious difference between illness, disease and now, non -disease seems to be a deliberate exercise in manufacturing confusion in an attempt to maintain medical mystique. Judging by the responses, the article on “medicalisation of human experience” which is to appear on 13 April, promises to be a wonderful “talkfest” of medical self-justification. It might, however, be as well to remember that the listed conditions account for most visits to the doctor, and if they are barred as non-medical, there may well be a dramatic increase in the dole queues.
Autism as a process of dealing with the world 18 February 2002
David N Andrews, occasional lecturer it varies, but includes universityies Send response to journal: Re: Autism as a process of dealing with the world	In my work, I tend to leave the medical model as far out of the process as possible, since it has very little - if any - value. I am a social psychologist currently training to become a professional psychologist in order to work on autism in Finland. My special area is mental health issues in Asperger Syndrome, and I have a diagnosis of this condition. This does not, however, mean that it is a disease or disorder of the person: it may well be a disorder of the system surrounding the person. I have published (not peer review) on this topic, and am investigating a model which draws on the vast research base in social psychology and in constructionist psychology. It has become clear to me that - in the absence of any clear compelling evidence of real brain pathology - we can no longer see any form of autism as a personal disorder. I use the comparison between autism and haemorrhoids as the basis for this. I should be happy to submit a paper on this for publication if the BMJ so desired. I do not like the medicalisation of autistic states: there is no justification, and it does no good. Kanner saw it as a medical (psychiatric) problem, and none of his patients improved in functioning while in therapy. Asperger on the other hand saw it as being a personality thing (not exactly spot on, but somewhat closer to the mark than Kanner's ideas), and saw the value of re-thinking how we educate children, rather than how we try to make them "normal", whatever that is! David N. Andrews sosiaalipsykologi, EPiT
Non-Diseases of the Past 18 February 2002
Robert D. Tennent, Queen's University Kingston, Canada K7L 3N6 Send response to journal: Re: Non-Diseases of the Past	I suggest that non-diseases of the past be included in the list, such as asthma, lupus, multiple sclerosis, and so on. At one time, these were considered by medical science to be non-diseases. Wouldn't it be wonderful if all of these conditions could now be cured by simply declaring them again to be non-diseases?
The origin of "Non-Disease" 18 February 2002
James A Dickinson, Professor of Family Medicine Chinese University of HongKong Send response to journal: Re: The origin of "Non-Disease"	I hope that your articles about non-disease will pay appropriate tribute to the originator of the term: Clifton Meador, who wrote about non -disease in the New England Journal in about 1965. I do not have ready access to this paper so cannot check, but if I remember rightly, he used this to describe people with minor abnormalities, in whom pathological lesions were excluded (as far as possible) but nonetheless resulted in fear and sickness behaviour. An example was "cardiac non-disease", where a minor heart murmur of no significance in a child led to restriction of activity and unnecessary coddling. This type of use is far better than the broader approach taken by some list-makers, since it places the onus on doctors, and our difficulties in interacting and explaining what is happening to patients. Doing this better is an important goal for our education and training.
Missing Non disease 18 February 2002
Sri S Varman, Director of Surgery Cleveland, Queensland, Australia 4163 Send response to journal: Re: Missing Non disease	Sir, In your long list of non diseases, one that is missing is, teenage pregnancy. Many developed countries and societies worry about this and spend a lot of time, money and effort to control it. Yet in many developing countries and primitive (for want of a better word) societies, teenage pregnancy is the norm.
Re: Common childhood symptoms 18 February 2002
zaffar sultan, Consultant Paediatrician Ahmadi Hospital,Kuwait Send response to journal: Re: Re: Common childhood symptoms	I do not agree with the honourable authors about the signs or symptoms mentioned.When a parent comes with such complaints;they are genuinly concerned about the child & his future.Sometimes the parents are at the height of anxiety & near to collapse especially with colicky babies.It takes my 30-45 minutes to explain about natural variation of the human body,physiological response of the body to feeds & reassurance.It is only repeated reassurance which calms down the parents & they stop looking for help or "Doctor Shopping".Who else in our present day society can take this role except for the Doctors! I always give such children a second & sometimes even a third appointment to give parents a chance to ask different questions,show up their fears & talk about their bad experiences or heard stories.I find it very helpful when they bring out their hidden fears & then I can easily reassure them.It is time consuming but I find it more rewarding to explain the process rather than prescribing the medicines most of which are of little use in these conditions.
Age 18 February 2002
Dirk Ulbricht, Centre Hospitalier de Luxembourg 4, rue Barblé, L-1210 Luxembourg Send response to journal: Re: Age	Age is just happening and most of the so-called age-realted diseases are just simple aging. Age should be accepted as such and not be medicalised to create lots of ???
'Wind' 18 February 2002
Surinder Singh, Clinical Lecturer in GP/GP Waldron HC, STANLEY STREET, LONDON SE84BG Send response to journal: Re: 'Wind'	PLEASE ADD 'WIND' TO YOU LIST OF NON-DISEASES. Thank you.
Shyness etc 18 February 2002
Tim R Anderson, Clinical Pharmacist Hellesdon Hospital NR6 5BE Send response to journal: Re: Shyness etc	Just to add another one or two to the list. Please consider shyness, fear of public speaking and quite possibly the inability to speak coherently to the girl/boy of your dreams! Tim Anderson Hellesdon Hospital
non-diseases 18 February 2002
douglas n salmon, gp b20 3he Send response to journal: Re: non-diseases	other non-diseases; erectile dysfunction/impotence infertility menopause domestic violence ageing personality disorder
Re: Non-diseases 18 February 2002
Tim R Anderson, Clinical Psychiatric Pharmacist Hellesdon Hospital NR6 5BE Send response to journal: Re: Re: Non-diseases	Dear Sir, I suffer from Seasonal Affective Disorder and when proper diagnostic criteria are applied then it is by no means a non-disease but a very real, albeit atypical, presentation of depression, which is a very real illness. SAD proper is not getting a bit low and demotivated because it is cold and wet outside, which is universal.
Impacted wisdom teeth 18 February 2002
Mahendra Bagur, SHO 3 Falkirk Royal infirmary, FK1 5QE Send response to journal: Re: Impacted wisdom teeth	Impacted teeth, if not associated with major pathology (like cysts, tumors) needs no treatment. How about Temporomandibular dysfunction syndrome, Bruxism, Atypical facial pain? can we include them? Thank you
Stupid Idea Syndrome 18 February 2002
Trevor Wainwright, Administrator Castleford Aid for ME (CAME) Send response to journal: Re: Stupid Idea Syndrome	An adequate title for a non disease which is conversant with stupid ideas for nominating non diseases, particularly when the idea come from a so called respected Journal. But given some of its contributors this is hardly surprising. Perhaps they should be called non medical persons and we could vote on a top 10 of them.
Non-Diseases 18 February 2002
Christopher I Stark, PRoject Manager BUPA Wellness, WC1X 8DU Send response to journal: Re: Non-Diseases	Hangovers
non-diseases 18 February 2002
Indramani Jena, Consultant Physician The Clinic, 271, Sahidnagar, Bhubaneswar, Orissa, India. PIN- 751007 Send response to journal: Re: non-diseases	1. Cataract (senile) 2. Osteoarthritis (senile)
Bags under eyes 18 February 2002
NAEIM ASAAD, General Practitioner Langly Health Centre-Common Road, Common Road-Langly-SL3 8LB Send response to journal: Re: Bags under eyes	Some patients come C/O bags under their eyes-It is not in itself a disease,but It could be a sign of lack of sleep/tiredness.
another non-disease 18 February 2002
Mark S CADE, staff urologist Burnley General Hospital Send response to journal: Re: another non-disease	small penis
Let's leave dental problems to the dentists! 18 February 2002
Sarah David, Psychotherapist (Retired) TW11 9NU Send response to journal: Re: Let's leave dental problems to the dentists!	Any doctor who thinks bruxism is a non-disease (as defined by the editor) deserves to have a root canal treatment without anaesthetic. I speak as someone whose bruxism led to a cracked tooth and abscess just before Christmas. Bruxism damages teeth so why not send patients to a knowledgeable dentist for exercises and a splint? The same goes for TMD: another disorder often trivialised by those who know little about it. Yours, dentally challenged,
Non disease or lack of knowledge? 19 February 2002
Ann E. Fonfa, Founder, The Annie Appleseed Project www.annieappleseedproject.org Send response to journal: Re: Non disease or lack of knowledge?	I found your list insulting and extremely short-sighted. As others have pointed out, the curent knowledge base is limited. Things change over time as more information is generated, sometimes by studies, sometimes in other ways. If/when we really look at the dis-eases that our polluted environment is creating, we may have a better picture of some of the problems you chose to call non diseases. As a person who has suffered from multiple chemical sensitivity since the late 1980's, I can certainly testify that this is not an imaginery illness. Will you really dismiss Gulf War Syndrome even after it has been shown to be a result of exposures? We simply do not know the cause (who has been looking for it?), nor do pharmaceutically-trained doctors have the answers. If your prescription drugs cannot cover up the problem, as is the usual method, do not feel compelled to dismiss our reality. None of this is enough reason to dismiss these health issues.
Benign Chest Pain and Syndrome X 19 February 2002
Colleen McKinnon, Anthropology Student Laurentian University, Ramsey lk rd. Sudbury, Ontario, Canada. P3E 2C6 Send response to journal: Re: Benign Chest Pain and Syndrome X	Having recently become well aquianted with the phenomenon of "Syndrome X", I would have to say it is perhaps the most important non- disease being currently diagnosed. After 30 years of attempting to find the cause of Syndrome X, a standard definition of the term has yet to be agreed upon. Patients with otherwise benign chest pain are undergoing an array of invasive tests and being led to feel as though they have heart disease. Unfortunately, when their angiograms show normal coronary arteries (which occurs in approximately 30% of all angiograms), they are branded with "Syndrome X" which not only prevents them from feeling healthy, but imprints them with an overall sense of illness and fear of death. I feel that rather than being an "underexplored" disease that has yet to be defined, Syndrome X is a "cultural" phenomenon and its use should be re-evaluated in clinical practice.
Re: Three other responses 19 February 2002
Collen Mckinnon, Anthropology Major Laurentian University, Sudbury, On., Canada. P3E 2C6 Send response to journal: Re: Re: Three other responses	Re: Who carries the can? I believe the intentions of the editors have been misunderstood. If we consider the definition of "medicalization" by anthropological terms, then it means a natural human process or suffering (such as giving birth), which does not need medical intervention. In fact in some instances, intervention produces a worse outcome than non-intervention. This concept is central to medical anthropology right now and is worth considering for the betterment of Western biomedicine on the whole. Re: How to use an esteemed medical journal to increase suffering I think that an important point has been missed by many reading this journal. The key word "medicalized". This is a clarification of the intent of the editors in itself. "medicalization" is the process by which something natural (such as giving birth) is turned over to the medical institution and does not necessarily improve the outcome for the patient. No one is being belittled and I think that we should all understand that the examination of the process of medicalization as such, is a good thing. It can only lead to a re-evaluation of the Western biomedical approach to patients and thier outcomes in general. Re: Time warps perception I would have to agree. Perception is half the battle. I'm sure things are seen much more clearly by people experiencing illness as a phase of life rather than a fear-inducing abnormality. If the medical institution could alter its approach to patients, many of them would be less likely to suffer from the 'nocebo' phenomenon (which dictates that if patients are told they are going to die-out of fear, they die quickly). I am happy to see that some in the medical profession are begining to view illness from a cultural point of view. This can only improve patient treatment and outcomes.
Ivan Illich on what is and what isn't a disease 19 February 2002
Richard Smith, Editor BMJ Send response to journal: Re: Ivan Illich on what is and what isn't a disease	Ivan Illich, author of Limits to Medicine, (1) had some interesting thoughts on defining what is and what is not a disease: "Medicine is a moral enterprise and therefore gives content to good and evil. In every society medicine, like law and religion, defines what is normal, proper, or desirable. Medicine has the authority to label one man's complaint as a legitimate illness, to declare a second man sick though he himself does not complain, and to refuse a third social recognition of his pain, his disability, and even his death. It is medicine which stamps some pain as "merely subjective," some impairment as malingering, and some deaths--though not others--as suicide. The judge determines what is legal and who is guilty. The priest declares what is holy and who has broken a taboo. The physician decides what is a symptom and who is sick. He is a moral entrepreneur, charged with inquisitorial powers to rediscover certain wrongs to be righted. Medicine, like all crusades, creates a new group of outsiders each time it makes a new diagnosis stick. Morality is as implicit in sickness as it is in crime or in sin." 1 Illich I. Limits to medicine. London: Marion Boyars, 1976. Richard Smith, Editor, BMJ
Re: Two other responses 19 February 2002
Colleen McKinnon, Anthropology Major Laurentian University, Sudbury, Ontario, Canada. P3E 2C6 Send response to journal: Re: Re: Two other responses	Re: Stupid Idea Syndrome First point - Perhaps people who do not understand the basis for the concepts under review should do a little research first rather than discuss the stupidity of others. "medicalization" is a current concern (or should be) of most educated physicians. I am shocked at the number of ignorant replies that have come in discussing how invalid the topic is. This topic is currently a major concern in the mangement of patients and thier outcomes. Anyone not concerned with the medicalization of otherwise normal behaviours obviously posseses little or no intellect. Lastly - If you can't say anything nice don't say anything at all! At least if you can't say anything constructive you should keep you opinions to yourself. Re: Arrogance I believe what you need to do is define the term "medicalization". Then you may possible understand that this cultural 'abnormalizing' of what is to other cultures a 'normal' condition (i.e. giving birth) is detrimental to patient recovery. If a patient with atypical chest pain is told they do not have heart disease, they more often than not, fail to be reassured. This is because Western biomedicine has told everyone that chest pain = heart disease until proven otherwise. It is the proven otherwise part that patients do not hear. This means that what a person would normally call indigestion, they now rush to the emergency room for and begin a life of dissability (which I have sudied in depth from the patient point of view). Perhaps you should read up on the medicalization process currently being studied in medical anthropology to obtain a better understanding of what you are discussing.
Chinese restaurant syndrome and penis envy 19 February 2002
Caroline Richmond, Freelance journalist London Send response to journal: Re: Chinese restaurant syndrome and penis envy	Dear Non Diseases Supremo, If you'd like a piece on Chinese Restaurant Syndrome, I'm your woman. In 1985 I got interested in Chinese restaurant syndrome and traced it back to its source - and wrote an article for New Scientist about it. I'll try to dig it out. The syndrome started with a facetious letter in the NEJM from a New York neurologist saying that he often got a funny feeling after eating in his favourite Chinese restaurant. He went on to say that it couldn't be due to MSG as he often cooked with it at home, but added that he would love to get an NIH grant, with travel funds, as he loved Chinese food. A year or so later he published the first and allegedly definitive paper on Chinese Restaurant Syndrome, attributing it to monosodium glutamate. The amazing thing was - he had got himself an NIH grant with a travel bursary! I traced the story in my New Scientist piece, which I don't have to hand. I do remember that MSG doesn't cause problems in rats, even in mega doses; it doesn't cause problems in double-blind trials to people who are convinced they have the syndrome; most people who claimed to have the syndrome refused to take part in a blinded trial - and anyway, glutamate is a physiological substance, so we all have it in us anyway. - And - glutamate is naturally present in virtually all meats and vegetables - the difference between a bland mushroom and a tasty mushroom is the amount of natural glutamate. Of true love it's a certain sign, When kisses taste like vintage wine, For all you will get from a casual date Is monosodium glutamate. from c@roline.demon.co.uk PS. I'd also like to suggest penis envy as a non-disease.
Miscarriage 19 February 2002
Rupak R Roy, Consultant obstetrician and gynaecologist Peerless Hospital, Kolkata, India 700095 Send response to journal: Re: Miscarriage	May I add "First miscarriage". Drug companies in our country spare no effort to promote drugs that are supposed to "prevent" abortion. Such is their campaign that a large number of doctors in our city nowadays routinely prescribe progestogens and/or uterine relaxants in completely normal pregnancies. These companies and doctors have successfully made miscarriage an "easily treatable disease".
Dental signs and symptoms 19 February 2002
(Dr) Trevor Watts, Senior Lecturer & Consultant in Periodontology Guy's Kings' and St Thomas' Dental Institute Send response to journal: Re: Dental signs and symptoms	To be more exact, bruxism is not a disease, but a sign and symptom of psychological stress. The dentist can sometimes do a little to help alleviate this when there are triggers in the disharmony of the occlusion, but as a dentist I think it is better to pay attention to the cause. I advise patients to seek counselling to help them resolve or cope with their stress.
another one 19 February 2002
Nicola A Cooper, SpR Medicine LS2 9JT Send response to journal: Re: another one	drug addiction
prevalence of non-diseases outside the UK 20 February 2002
David W Pitches, Specialist Registrar, Public Health B16 9RG Send response to journal: Re: prevalence of non-diseases outside the UK	Sir, I presume that you are seeking "non-diseases" that are encountered by British doctors in the main. It is a considerable diagnostic challenge to be presented with an apparent "non-disease" in other environs. A short period of clinical practice in one of the former Soviet Central Asian republics recently introduced me to the debilitating condition of "raised intracranial pressure", which was not infrequently diagnosed in children. Such children were considered delicate, fragile, banned from playing sports and games at school and had regular injections of vitamins (arguably vitamin supplements were no bad thing in areas of profound nutritional deficiency - but why administer by injection?). Clinically they had no indication of what in the UK would be considered raised ICP and I suspect the label was being given to what in the UK might be considered "difficult" or "clumsy" children. Those who asked me how I would treat them in the UK I could only reassure that they had a benign condition out of which they would grow and be completely healed once they hit their teens. In the main this was accepted, although one of my translators refused to say this to a patient, testifying that she had been having painful vitamin injections for raised ICP for many years and knew just how debilitating the condition was! In saying the above I am anxious not to trivialise something which for the patients was a clearly distressing and genuine problem, and I wonder whether other clinicians have had similar experiences? Yours faithfully, Dr. David Pitches Specialist Registrar in Public Health, Birmingham, UK
Disability 20 February 2002
Kevin Reel, Senior Lecturer, Occupational Therapy Oxford Brookes University, School of Health Care, 58 London Road, Oxford OX3 7PE Send response to journal: Re: Disability	While not precisely defined as a 'medical condition', disability carries such a strong association with the notion of disease it may be indistinguishable from it in the minds of many, including some health care professionals. The changes recently made to the International Classification of Functioning, Disability and Health (ICF, previously the ICIDH-2)have shifted the perspective from the consequences of disease to the components of health. This aims to limit the 'medicalisation' of disability regardless of the cause, and focus on the individual's own experience in terms of function and roles. This, in and of itself, is quite likely to lead to a more positive client-centred outcome.
...and another 20 February 2002
Caroline Richmond, Freelance journalist SW3 5AQ Send response to journal: Re: ...and another	Reflex sympathetic dystrophy penis envy
atypical depression 20 February 2002
Edward Shorter, professor of medical history University of Toronto Send response to journal: Re: atypical depression	Although the mood disorders represent real illnesses, this version is just a relabeling of unhappiness in young women. Consider the DSM-style criteria: not necessarily sad (and brightens if someone pays a compliment), BUT hyperreactive about romantic rejection, overeats, oversleeps, and is tired all the time . . . This is supposed to be a psychiatric disease, like manic-depressive illness? Oh, and one more thing: responds preferentially to MAOIs. Gimme a break.
Hyperlipidaemia is the champion 20 February 2002
Jorgen V Nielsen, Consultant physician Dept. Med. Blekingesjukhuset, 37480 Karlshamn, Sweden Send response to journal: Re: Hyperlipidaemia is the champion	Hypercholesterolaemia is the champion. The winner in this contest is without doubt hypercholesterolaemia, meaning blood cholesterol in the upper half of the normal range. The building -- also in medicine -- of a scientific hypothesis goes through several steps. 1 Observation. 2 Hypothesis. 3 Testable predictions (explanation of the phenomena in the world). 4 Experiments, clinical studies and fine-tuning of the theory. The third stage is crucial. If the hypothesis is unable to explain the world, it is not true. Testable predictions can be done internationally and they fail hopelessly. The latest failure, as seen in the authoritative largest international MONICA study that since its start in 1982 was supposed, once and for all, to confirm the role of the ‘classical’ risk factors, is very clear, if one cares to read the tables in the article. [1] The contribution of blood cholesterol to the risk of cardiovascular disease for women is zero percent. In short, the correlation between cholesterol levels and the risk is zero (correlation coefficient = 0,04 (95% CI: - 0,39, 0,47)). It is impossible to predict anything in women from a cholesterol concentrations, because there is no correlation. And if there is no correlation it follows that there is no causation. So, the hypothesis fails 100 percent in women. Blood levels of cholesterol do not contribute to cardiovascular disease in women. So simple is that. In men the contribution of cholesterol to the variation is about 20 % (r = 0,22 ( 95% CI: -0,04, 0,48)). Also here the predictions from cholesterol fail in 80% of cases. The correlation is poor. And naturally, the whole idea that cholesterol above 5 mmol/l is dangerous in men, but not in women, is absurd. It is of course no wonder that meta-analyses without fail show increased total mortality in lipid lowering studies in healthy people (except for statins) [2,3], and if the statins work for example in women it cannot be because of the lipid lowering effect, but must per definition be owing to something else. For the hypothesis is still not true. We have therefore – especially for women – a factor that cannot predict risk, that cannot cause risk. The risk factor is called disease and millions are worried about their cholesterol and getting treatment. That, I declare, is the most eminent and widespread case of non-disease, besides being the greatest scam in the history of modern medicine. 1 Kuulasmaa K, Tunstall-Pedoe H, Dobson A, et al. Estimation of contribution of changes the classical risk factors to trends in coronary- event rates across the WHO MONICA Project Populations. The Lancet 2000;355:675--87 2 Law MR, Thompson SG, Wald NJ. Assessing possible hazards of reducing serum cholesterol. BMJ 1994;308;373-379 3 Muldoon MF, Manuck SB, Mendelsohn AB, Kaplan JR, Belle SH. Cholesterol reduction and non-illness mortality: meta-analysis of randomised trials. BMJ 2001;322:11-15
Physical-Mental-Social and Spiritual well being 20 February 2002
praveen kumar madikonda, senoir resident Faculty of ayurveda, Institute of Medical sciences:Banaras Hindu University Varanasi; INDIA 221005 Send response to journal: Re: Physical-Mental-Social and Spiritual well being	Unfortunately most of the conditions listed in the nondisease category cannot fulfil the holistic Ayurvedic definition of health. "Health" according to Ayurveda denotes a state of "physical, mental,social and spiritual wellbeing".The contempory modern medicine has failed to focus on the broader aspect of health. It is evenmore unfortunate to note that the healthcare system in general has been totally unaware of the preventive and curative aspect of Ayurveda, which has been a living tradition of medicine oparating in india since ages. Untill and unless man learns to maintain a balance and harmony between himself and nature he cannot be healthy. The science of ayurveda has valuble answers for many of the problems of present day health care system.
non-disease 20 February 2002
Phillip I Hodson, Fellow, British Association for Counselling & Psychotherapy s/employed therapist - 58 The Pryors East Heath Road, London NW3 1BP Send response to journal: Re: non-disease	Procrastination
Rationing? 20 February 2002
Steve Hajioff, public health physician London Send response to journal: Re: Rationing?	Sir, I am singularly unimpressed by the nature of this enquiry and the content of most of your responses. I note that many of the suggested non-diseases are conditions for which we have little in the way of effective treatment. Perhaps this says more about some doctors than it does about diseases or patients. There is an old joke about the four major diagnoses in psychiatry: Phenothiazine deficiency SSRI deficiency Lithium deficiency Electricity deficiency This caricatures the 'need to do' which is a personality trait of some clinicians and which leads to a rejection of conditions where there is uncertainly or where nothing can be done at this time. This has been the case for many conditions through history where aetiology was poorly understood and effective treatments were lacking. Crohn's disease, MS and coeliac disease are good examples. Healthcare is a service industry, it's function is to provide care, cure and relief to those who seek it. Resources (including clinician time) are limited and some activities need to be prioritised over others. Simply because a condition is afforded low priority because scarce resources can be more efficiently deployed elsewhere does not make it any less real. Indeed many of our technically advanced treatments give far less health gain per unit cost than simple treatments for non-diseases. Thus if the 'making a difference' argument is the crucial one, there perhaps a better case for diverting resoures from our hospitals to more social sector based activities, than for denying care for those with 'non-diseases'. Neither course of action is appropriate, nor is the stigmatisation that people may suffer by being branded sufferers from a non-disease.
Chronic Fatigue Syndrome/M.E. Medical Profession Cops Out 20 February 2002
Christopher A. Szabo, N/a 405 Capitol Hill, 345 Walker Street, Muckleneuk, Pretoria 0002 South Africa Send response to journal: Re: Chronic Fatigue Syndrome/M.E. Medical Profession Cops Out	I must say I am deeply shocked at the lack of humanity used by those who pooh-pooh CFS/M.E. Unfortunately, I know all too much about this illness, and in the light of the recent CMO's report underlining its reality, I cannot fathom what lack of basic human understanding STILL exists among the ignorant. What is truly tragic is that the patient is misdiagnosed, told - incorrectly - that he/she will get better, and when that fails, is told he/she is crazy, or lazy! I first had exhaustion symptoms in 1992, I was diagnosed with everything from Hypogammaglobulinaemia to Crohn's Disease, but no-one could help. As a result, I became impoverished, lost my home, and finally, in 1998, here in Pretoria, I was diagnosed as having CFS by a doctor with a concern for a patient, not a dogmatic viewpoint. I have followed his guidelines - which are similar to the CMO's ones - and can work about half a day from home. As to how I manage to own a computer, well, my wife hasn't left me, otherwise I would really be a goner. My only hope is that they contract the "non-existent" CFS/M.E. I would love to shove their letters in their faces in say, 10 years. YOurs in Shock, Christopher Szabo
The most insideous non-disease 20 February 2002
Jeffrey Craig Phillips, Clinical Research Assistant Professor Florida Inernational University, Miami, FL 33199, USA Send response to journal: Re: The most insideous non-disease	WORK
Re: Re: Three other responses 20 February 2002
Alexa E McLaughlin, Writer and editor Red Hill, ACT, 2603 Australia Send response to journal: Re: Re: Re: Three other responses	With regard to my earlier posting "Who carries the can", I do understand the term "medicalisation" as, as you say, "a natural human process or suffering (such as giving birth), which does not need medical intervention. In fact in some instances, intervention produces a worse outcome than non-intervention." I suggest there are many such conditions but that many of the items on the list (eg ME/CFS) do not fall into this category. They may indeed have a worse outcome from some interventions than non-intervention, because the state of our knowledge is not yet adequate. That doesn't prove they are medicalised non-diseases. I support un-medicalising genuine non-diseases (eg normal childbirth). However, I don't support un-medicalising genuine diseases and am greatly concerned when genuine diseases are dismissed, as this exercise proposes. A common thread I have observed in recent years is that many proposed non-diseases are considered by some (the "somaticisers") to have a psychological origin, or to be psychological outcomes. The sub-text may be that this is a question of personality or choice, a non-medical matter. This is rather curious, since other psychological diseases, like schizophrenia, have physical markers as well as psychological effects, and are nevertheless considered diseases. I suggest that what's missing for many so-called "non-diseases" are approved physical markers. So far. The certainty of the "somaticisers" seems to me to be tunnel vision. In the mean time, defining such conditions as non-diseases would mean that sufferers of these conditions would be denied research and treatment. That could constitute negligence.
Re: Ivan Illich on what is and what isn't a disease 20 February 2002
Alexa E McLaughlin, Writer and editor Red Hill, ACT, 2603 Australia Send response to journal: Re: Re: Ivan Illich on what is and what isn't a disease	I am not clear how the Illich quote by Richard Smith, editor of the BMJ, meshes with this discussion. I agree that medicine is a moral enterprise, in the sense that it should be done in a moral fashion. I don't understand how it could give "content to good and evil". If Richard Smith is suggesting that medicine is the arbiter of good and evil, then he should say so. I think that would be an interesting debate, especially if the proponents or suffering of the so-called "non-diseases" are considered evil. As for medicine's capacity, even authority, to define what is or is not disease, that is the central question here - medically and morally. I agree that medicine can and does define what is or is not disease. I suggest that practitioners and researchers have a scientific and ethical responsibility to get that right. The quote seems to be encouraging a move to un-medicalising conditions. If that is Richard Smith's point, it would be useful for him to spell that out. My point is that un-medicalising many conditions discussed would actually fail Illich's approach, "to rediscover certain wrongs to be righted". The move to un-medicalise many conditions is already afoot, including by the "somaticisers". I believe that that is a "wrong to be righted". I remain concerned that we have to guess the intentions of the BMJ in pursuing this discussion. If the intention is to identify a list of conditions to be viewed as non-medical, rather than just managed as non- medical, then that should be explained. Since many proposed items are conditions for which physical markers have not yet been identified and are treated by the "somaticisers" as non- medical, then that controversy should be addressed directly, rather than being implicit. I doubt the intention was to uncover the hostility and disdain of some practitioners towards these conditions and their sufferers, as has occurred, by encouraging such disdainful submissions. It would have been more responsible to write an editorial drawing attention to the dangers of being dismissive, certain in uncertainty and lacking respect. I would appreciate Richard Smith elaborating the BMJ's concerns and positions in this dialogue, rather than waiting for the journal article.
two list additions 20 February 2002
Anne Peticolas, Senior Systems Programmer Austin Automation Center, Austin, Texas 78772 Send response to journal: Re: two list additions	rosacea sleep apnea
CFS vs ME 20 February 2002
Jill McLaughlin, Executive Director National CFIDS Foundation, Inc., Needham, MA 02492 Send response to journal: Re: CFS vs ME	What could have been the impetus for providing more productive and informative discussion fell short and was undermined by the lack of better clarification or even an attempt to reach a consensus on the meaning and interpretation of what is meant by terms such as "medicalization" and "disease." Would the existence of treatment or lack therof in any way determine or validate any condition as a disease? Lack of treatment first and foremost should bring to mind the inadequacies and shortcomings of medical science. Nor should the existence of treatment equate with disease. High cholesterol alone produces no symptoms and thus does not "impair normal physiological functioning" yet there is effective treatment. High cholesterol is not generally considered a disease but there would seem to be universal agreement that it should be treated and that it can in fact cause disease if it is not. "By "non-disease" we mean "a human process or problem that some have defined as a medical condition but where people may have better outcomes if the problem or process was not defined in that way. By these standards CFS would be considered a non-disease. It is universally understood that CFS represents a heterogeneous population of fatigue states. Fatigue is not a disease, it is a symptom of many diseases, both physical and psychiatric, as well as a normal physiological state. It is a major symptom of many mental illnesses as well as many serious neurological, infectious and autoimmune diseases. A definition should never be based on one symptom, especially one so vague, non-specific and immeasurable. When CFS was first defined in 1988 it was similar to what had been known as Myalgic Encephalomyelitis (ME), but with the redefinition in 1994 there were many patients who could fulfill the new criteria for CFS who did not have ME. The continued broadening of the CFS definition has failed in both its intended use for identification of a population for research purposes and in its unintended use as a clinical definition. The ambiguities in this definition have lead to widespread discrepencies in epidemiological studies and in diagnostic and theraputic outcomes. ME should be considered a disease. ME is not the same as CFS and the two should not be linked and used interchangably. ME has been well documented in the medical literature (before CFS was "invented") and characterized as an organic, not psychological, illness. Many outbreaks (as well as endemic cases) share strikingly similar clinical and epidemiological features and ME thus has historically been considered as distinct clinical entity. ME has been formally classified by the WHO as a neurological disease in the ICD since 1969. It has been the amalgamation of ME into CFS, mainly by psychiatrists and in particular those from the "Wessely school," that has caused the problems, confusion and controversy. Fortunately, the U.S. DHHS has convened a name change committee of researchers, clinicians and advocates, which, after considerable deliberation, has proposed that indeed the best approach is to separate out ME and other specific readily distinguishable subgroups from CFS. This substratification of patients is absolutely essential for further etiological and treatment research. ME needs to be recognized as originally identified through clinical investigations - without being associated with CFS - in order to insure that patients will be properly and accurately diagnosed and treated. [There is also a petition which calls for the recognition of ME located at: http://www.petitiononline.com/MEitis] Jill McLaughlin Executive Director National CFIDS Foundation, Inc. Needham, MA 02492
ear wax 20 February 2002
naeim ASAAD, General Practitioner langley health centre, common road-langley-slough-SL0 0JQ Send response to journal: Re: ear wax	many patients attend for ear wax syringing as a habit, they believe that ear syringing needs to be done on a regular basis!!!!
Criteria for non-disease 20 February 2002
Mohan Chawla, Consultant Psychiatrist Kettering Geneeral Hospital, NN15 7EU Send response to journal: Re: Criteria for non-disease	Mental health is desparately in need of well informed people to have a discussion as to what is or not a disease? It appears that as British society is progressively Americanised for good reasons, we want to medicalised all matters of day to day life. We seem to be forgetting basic difference between private and public health care. In private health care, anything and everything becomes disease so long as there is insurance company to pay for the services and we seem to be happily accepting that model in free health care in UK with it's non-positive implication with increasing demands on our NHS with infinite expectations. I believe that we should be prepared to pay much higher taxes if we want to have free health care based on 'private health care' definition of disease especially in mental health. Dr.M.Chawla
Re: Ivan Illich on what is and what isn't a disease 20 February 2002
L S Lewis, GP Newport Surgery Send response to journal: Re: Re: Ivan Illich on what is and what isn't a disease	A masterful statement of the ideology of disease ! R D Laing presented a more populist version in the 1960's.. To him, Disease was merely 'dis - ease', and varied greatly in its acceptability to those on whom it impinged - with special reference to 'mental illness' and psychosis in particular... In 2002 I would say that 'Sadness' has all the necessary features of the problem - but how on earth did SAD get to be a disease ? To me, 'Seasonal Affective Disorder' has all the hallmarks of a 'group-think' invention in pursuit of a catchy acronym !
Laenaac on what is and what isn't a disease 21 February 2002
A Chaudhuri, Clinical Senior Lecturer Send response to journal: Re: Laenaac on what is and what isn't a disease	"Listen to your patients, they are telling you the diagnosis" , so said Laenaac long before Illich wrote his social theory of medicine. It may be useful here for the beginners to point out that medicine developed as a science by listening to patients and not by enforcing moral disciplines of social life as in a church or in a court. As the youngest science, medicine has sought to understand and explain symptoms by astute observations, development of testable hypotheses and novel experiments. History of medicine teaches us not to discriminate between so-called "disease" or "non-disease". Epilepsy has been one of the finest examples in the past century; history of epilepsy also tells how social stigmatisation for people with epilepsy was influenced by lack of knowledge and psychobabbles. If we were to follow Illich's view, then as physicians we ought to use our own moral standards to decide who has real pain, illusory pain or malingering pain. Smith and Illich's followers will probably agree that in the 19th century, offering analgesia to ease birth pain was immoral because birth is a natural process (a non-disease; use of analgesia and anaesthesia has medicalised this experience). Thus, washing hands in the labour room was not what a physician wanted to do once upon a time and the resulting maternal death from iatrogenic puerperal sepsis must be a mere "non-disease" or "non-event" by the Smith-Illich doctrine. Physician's morality in Ivan Illich's terms is very relative because it changes at the same speed as science makes new discoveries.It is the quality of science that changes the standards of physicians' practice, not morality, opinion polls or psychological questionnaire-surveys. We have witnessed time and again how dangerous the combination of little knowledge and arrogance might become. Breaking down the trust between physicians and patients is the single most irresponsible act, especially when such an act is not based on definitive knowledge. Physicians who seek to discriminate between disabilities due to "disease" and "non-disease" in terms of their management may do well to return to their medical schools.
Mitral Valve Prolapse 21 February 2002
Hans JM Van Brabandt, cardiologist B2800 Mechelen Belgium Send response to journal: Re: Mitral Valve Prolapse	Mitral Valve Prolapse. Although I have never been able to trace the paper, I remember a AHA meeting where a lecturer stated that people with MVP have a better life expectancy than a control population. Nevertheless, numerous people undergo follow-up exams and echocardiograms, holtermonitorings and lifelong endocarditis prophylaxis for this non-disease.
sick notes 21 February 2002
Antony M Goodwin, GP Undercliffe Surgery WF17 8DQ Send response to journal: Re: sick notes	It seems ludicrous to still be providing sick notes to patients, as they are basically given on demand. Working in a deprived area, any patient who has ANY illness and is unemployed, is asked by the benefits agency to get a sick note from their GP. This devalues our role and helps the government to massage the unemployment figures downwards. I also believe that it absolves employers from the responsibility of providing adequate occupational health services for their employees. (this is also allowed by lack of legislation).finally, it can lead to areas where our loyalties are divided, and can adversely affect the doctor-patient relationship
Non-disease 21 February 2002
Meng-Kin Lim, Associate Professor Department of Community, Occupational & Family Medicine, National University of Singapore 117597 Send response to journal: Re: Non-disease	Non-disease - itself, the latest non-disease.
Re: The most insideous non-disease 21 February 2002
Christopher A Weiner, SpR Public Health West Midlands Send response to journal: Re: Re: The most insideous non-disease	It may have been Oscar Wilde who said that work was for the idle classes. If work is a disease then it displays that most unusual of features; a disease without the socio-economic gradient seen with virtually every other disease known in the modern world. If it is a non-disease, then I suppose it could be viewed as a measure of health. Interestingly enough, it would then display the socio- economic gradient that one would expect of most other indices of good health. Is this proof that health and disease are not opposite sides of the same coin, but are really entirely separate currencies?
physiological phimosis 21 February 2002
Shelton M Kartun, consultant Cockfosters EN4 9BX Send response to journal: Re: physiological phimosis	the unacceptably high rate of circumcision is in part due to the mis- diagnosis of normal physiological phimosis ie a non fully rectractile foreskin which can be the case until the age of 17 years in some boys. This is a non-disease state! Circumcision is certainly not the appropriate intervention for this non-diseased state of developing male genitalia. Preputioplasty and even better, conservative apporaches such as the use of steroidal creams usually solves the situation.
Munchausen syndrome by proxy 21 February 2002
Michael D Innis, Director Medisets International Home Send response to journal: Re: Munchausen syndrome by proxy	Munchausen syndrome by proxy (MSBP) if not a Non Disease at least a Disease of Last Resort The advocates of Munchausen syndrome by proxy (MSBP) should take the trouble to exclude the coagulopathies or bleeding disorders encountered in children before concluding MSBP to be the cause of the bruises, petechial and frank haemorrhages they observe on and in a child. If they are unable to think of any coagulopathy, as was the case in one recent murder trial, let me remind them of a few. 1. Haemorrhagic Disease of the Newborn (HDN), that is possibly, better called Vitamin K Deficiency Bleeding (VKDB) because a bleeding tendency may manifest itself up to six months after birth. It should be remembered that it is not sufficient to exclude VKDB on the grounds that a single injection of 1mg of Vitamin K was administered at birth. There is ample evidence to show that this practice, which is common in the U.K., is not necessarily protective [1]. It should also be realized that each and every lesion found in the “shaken baby syndrome” could be seen in VKDB. [2]. The simple procedures of getting the laboratory to do a Prothrombin Time (PT), Platelet count and Fibrinogen estimation would prevent innocent mothers being imprisoned for murder or their children taken from them by the state. Another point MSBP accusers should be aware of is VKDB may be hereditary and hence two deaths in the same household does not necessarily have sinister implications 2. Hereditary Factors 1,V,VII, VIII, IX and X have all been described as causes of bleeding and bruising in children and all could be mistaken for child abuse by those looking out for MSBP. [3] 3. There is evidence that an adverse vaccine reaction has been mistaken for the “shaken baby syndrome”. [4] In response to the accusations of MSBP perhaps a counter charge of MOPF (Misinterpretation of Post-mortem Findings) should be entertained by the defence. By branding a concept with a name it can no longer be ignored. MOPF. Michael Innis FRCPath; FRCPA Honorary Consultant Haematologist Princess Alexandra Hospital REFRENCES 1. Routine administration of vitamin K to newborns. Fetus and Newborn Committee. Canadian Paediatric Society Paediatrics and Child Health 1997:2(6):429-31 2. Using the Search Engine “Google” and the terms ‘shaken baby syndrome and Vitamin K deficiency’ 96 records are retrieved in which mistaken diagnoses are abundant. 3. Williams W. Beutler E. Erslev AJ. Lichtman MA, Hematology Fourth edition p 1453 – 1509 McGraw Hill Publishing Company New York 4. Using the Search Engine “Google” and the terms ‘shaken baby syndrome and DPT Vaccine’ 92 records are retrieved in which mistaken diagnoses are recorded.. No conflict of interest.
Non-diseases 21 February 2002
Ahmad Reza Rasekhi Nemazee Hospital, 71934, Shiraz, Iran Send response to journal: Re: Non-diseases	Irritable Bowel Syndrom, Fibromyalgia, Hysteria
Doctor-Thinks-you-have-a-disease syndromes. 21 February 2002
Belle Monappa Hegde, Vice Chancellor Manipal-576 119. India Send response to journal: Re: Doctor-Thinks-you-have-a-disease syndromes.	Dear Sir, In a sizeable section of the patient population in scoiety, the hapless victim is apparently very healthy and asymptomatic. His doctor, on routine screening, in my opinion a dangerous pastime, finds out some minor bio- chemical or other abnormalities. This becomes a label. Labelling has made more people miserable in this world than all the diseases put together. Many a time the victims even become targets for interventions. Some of the latter, on retrospective audits, have been shown to be useless, if not dangerous! This syndrome is better called doctor-thinks-you-have-a-disease. Most of these patients are better off with change of mode of living-and some of them with "unrest cure". Interventions using drugs and technology might sooner than later make them real patients. Routine screening to predict the future onset of diseases, per force, has to go wrong. Time evolution in any dynamic system, like the human body, does not depend on some bits of information of the body. Future prediction needs the total intial knowledge of the organism(man). Doctors, therefore, have been predicting the unpredictable. Earlier we realise this the better for the public. Doctors must realise that patients could live without our help but doctors can not live without patients. Are we manufacturing more patients by some of our methods in hi -tech medical world? Defining non-disease is an urgent need. bmhegde.
old age - a nondisease? 21 February 2002
Valmiki Kolmi Nagaraj, SP.Registrar in Public Health SWDHA, Dartington, Anandhi Nagaraj Send response to journal: Re: old age - a nondisease?	Old age with its own physiological and pathological changes will, may well fit into the definition of nondisease. But the consequences of old age may not.
Not worthy 21 February 2002
Jan Willem de Bruijn, physiotherapist, student Health Science University Maastricht The Netherlands Gaertner Ergonomic Furniture, 6525 SE 165 Send response to journal: Re: Not worthy	This kind of NON-SENSE journalism is unworthy for an international journal like BMJ. As for NON-DISEASE, it would suit the cynics in the medical profession to study the origins of the complaints patients have. Non-diseases might very well be mind-problems but are these problems interfering less with the WHO's definition of Health then e.g. a broken leg? There is the compassionate scientific way to deal with all the unclearness of "functional disorders". That is what I would like to see in the BMJ. Jan Willem de Bruijn
Repetitive Strain Injury 22 February 2002
Martin Wilson, retired through ill-health Glasgow G12 Send response to journal: Re: Repetitive Strain Injury	I would very much like to know why, when there is a wealth of independent, internationally accredited research clearly supporting the existence of RSI - and in particular it's relevance to spinal injuries - which has been sufficient to persuade Government appointed experts in the USA/ Scandinavia/the EC/Australia/the International Labour Organisation in Geneva/not to mention the UK's own Health & Safety Executive - our own Government, regardless of it's political persuasion, strenously denies any such possibility. Surely, it has nothing to do with money?
A Darwinian concept of non-disease 22 February 2002
Kazem Zarrabi, postdoc researcher Dept. of Physiological Sciences, BMC,, Lund University, 221 84 Lund, Sweden. Send response to journal: Re: A Darwinian concept of non-disease	A Darwinian Concept of Non-disease I have a serious problem with what you have included as non-disease. In order to provide a list of what we may call as the so-called non- disease we have to refer to a widely accepted view, perspective or simply a definition of the non-disease. For example, perhaps, we can say that an “interruption, cessation, or disorder of body functions, systems, or organs (Stedman’s Medical Dictionary 1997),” is a good starting point in our search for an inclusive definition of disease. Or we can briefly define it as “impairment of health and well-being (Mascie-Taylor 1995:1).” Although, these descriptions can help us to compare and relate different concepts, we need a more integrative definition that can include bio-cultural diversity of different individuals within and among their respective populations. Nevertheless, we should recall that even such an attempt, as an anthropocentric approach to disease, may hardly embrace all that we should know on the never-ending evolution of the struggle between a disease causing agent and its host. Therefore, all definitions of disease are relative in their scope and content, especially as long as our integrative approach will suffer from our bio-cultural biases. With all these in mind, perhaps, a Darwinian approach can be more helpful. Even though, our social evolution has been a coevolutionary product of our biology and culture (Lumsedn and Wilson 1981, 1983), by all means, we belong to animal kingdom (Wilson 1980). Therefore, as a biological life-form, i.e. in contrast to artificial life- forms such as rapidly evolving computers and robots, we are comprised of structural units (SU) and their related functions (F). Mental and emotional functions are also included in F. The purpose of our SU and their respective F are to keep us alive, i.e. operational, in the struggle for both natural and cultural resources. Thus, any agent or condition that can undermine our SU and F which are, respectively, evolved and developed by phylogeny and ontogeny programs, for our continued individual and reproductive survival can be defined as a disease causing agent or condition. Consequently, a non- disease, caused by an agent or condition, is the one that will not compromise our individual and reproductive survival. Therefore, many of the conditions that you have listed as non-disease will, and should certainly, qualify as disease because they compromise our inclusive fitness (Hamilton 1964). For example, let us take a mild case such as baldness that you have wrongly listed as non-disease. Hair has double functions of protecting the scalp from extreme cold and warm temperatures and also aiding both sexes in mate selection. Apparently, different hair styles will change our appearances to the opposite sex. Therefore, lack of it is a disadvantage. However, as our concepts of health and disease are in fact statistically based concepts as well, as baldness is a widespread condition, we can rightly call it as a common disease. This is also true with herpes simplex or common cold sore. But, no matter how common, they should be classified as diseases. Therefore, many of your non-disease conditions do indeed qualify for nothing less than diseases. For example, alcohol dependency, attention deficit disorder, baldness, diabetes, ejaculatory disorders, food intolerance, hypertension, irritable bowel syndrome, migraine, obesity, tension headache, and gulf war syndrome are diseases even if we happen to be uncertain of their exact etiology. Kazem Zarrabi Department of Physiological Sciences, Lund University, Sweden www.lu.se References: Hamilton, W.D.1964. The genetical evolution of social behavior. I and II. J. Theoretical Biology 7:1-52. Lumsden, C.J. and E.O. Wilson. (1981). Genes, Mind, and Culture: The Coevolutionary Process. Cambridge, Mass.: Harvard University Press. Lumsden, C.J. and E.O. Wilson. (1983). Genes, Promethean Fire: Reflections on the Origin of Mind. Cambridge, Mass.: Harvard University Press. Mascie-Taylor, C.G.N. 1995. The Anthropology of Disease. Oxford: Oxford University Press. Stedman’s Concise Medical Dictionary: Third Edition. 1997. Philadelphia: Williams & Wilkins: A Waverly Company. Wilson, E.O. 1980. Sociobiology. Cambridge, Mass.: The Belknap Press of Harvard University Press.
Tropical non-diseases 22 February 2002
John S. Marr, Senior Lecturer Americhoice 7 Hanover Square, New York, NY 10004, NA Send response to journal: Re: Tropical non-diseases	Manson-Bahr still lists these curiosities; the last at least has somatic findings, the first three appear to be Asian non-diseases. Koro Latah Amok Ainhum
Everything is a disease? 22 February 2002
Alejandro F. Luque-Coqui, Cardiologist Centro de Diagnostico 38000, Alejandro F. Luque Coqui Send response to journal: Re: Everything is a disease?	Cardiological syndrome X
Ageing is natural 22 February 2002
iona e collins, SpR Trauma John Radcliffe, Oxford 0X3 9DU Send response to journal: Re: Ageing is natural	Many ageing patients attending for review of their Colles- type fractures ask about osteoporosis and what can be done to treat this disease. I don't see the menopause as a disease and likewise, I believe that osteoporosis is a physiological part of the ageing process.
Re: Re: The most insideous non-disease 22 February 2002
David Carvel, GP principal Biggar ML12 6BD Send response to journal: Re: Re: Re: The most insideous non-disease	I'd be disappointed if Oscar Wilde said that "work is for the idle classes". It just is not in his typical pithy style. He did however say that "Work is the curse of the drinking classes". But perhaps even more memorably: "We live in the age of the overworked, and the under-educated; the age in which people are so industrious that they become absolutely stupid". THE CRITIC AS AN ARTIST (1890) So perhaps work is a disease after all!
low blood pressure 22 February 2002
Mónica G Silva, general practioner Centro de Saúde da Senhora da Hora - R. Lagoa - 4460-000 Sra. Hora - Matosinhos Send response to journal: Re: low blood pressure	patients (specially young ones) often complain of low blood pressure when in fact their BP is absolutely normal and could even be considered as an excellent blood pressure (eg: 100/60)
Truth, Justice and our Humanity 22 February 2002
Malcolm Hooper, Emeritus Professor of Medicinal Chemistry University of Sunderland Sunderland SR2 7EE Send response to journal: Re: Truth, Justice and our Humanity	I trust that you will give equal space for those who would make the case against the non-diseases identified in your survey. There is much evidence to support the organic nature of many of the diseases mentioned particularly, ME-CFS, fibromyalgia, multiple chemical sensitivity, and the occurrence of the shared symptoms found in these and other medically puzzling and taxing disorders, such as Gulf War Syndrome/Illness, irritable bowel syndrome. We have recently produced a 36-page booklet entitled, "What is ME? What is CFS?" and a copy has been sent to the editor of the BMJ. Further copies are available, price £3-00 (including postage and packaging) to anyone contacting me. "All diseases have a molecular basis", Linus Pauling. The validity of this statement is substantiated by many who advocate the existence of non- diseases yet, by their actions in prescribing various antidepressants, antiepileptic drugs, agonists and antagonists of the major biogenic amines and neurotransmitters, make clear that they are changing the underlying physico-chemical, and physiological properties of organs and body systems, particularly the brain. Ivan Illich has written perceptively about the medicalisation of life and its origins and consequences, see Limits to Medicine. Medical Nemesis: the Expropriation of Health. His insights need to be attended to. Medical ignorance and arrogance dominated by rationalism seeks explanations of puzzling signs and symptoms and ends up creating spurious diseases/disorders that put the blame on the patient or his/her caring family and friends. The spurious Munschausen-by-proxy provides a prime and damaging example of such a condition. There are numerous examples of, and articles about, non-diseases in the medical peer-reviewed literature by eminent people of their day. They were wrong. The advancement of scientific and medical knowledge has now identified the underlying biochemical and physiological disorders, eg diabetes, Parkinsonism and multiple sclerosis. The sufferings of patients imposed by these arrogant, rigid and Olympian attitudes demeans both patients and doctors and creates mistrust. The consequence of the triumph of such attitudes is now seen in the abandonment of any responsibility for one's own health. Life style however destructive is pursued in the belief that medicine will somehow provide an answer. The drug industry and much of modern medicine seek new agents to modify or offset the consequences of our excesses, for example the search for new anti-obesity agents in the face of the modern endemic of obesity and maturity onset diabetes, now even found in the young. The modern food industry also contributes to modern health problems with the widespread use of pesticides, plant and animal hormones, and gene- modified crops. In consequence even eating a healthy diet leads to an increasing burden of novel man-made toxins, many of which have not been toxicologically assessed. Diet, lifestyle, exercise, spirituality, and the search for meaning are all parts of our human condition. We ignore them at our peril. What is required is a change of heart and mind leading to a change of practice that embraces human values of mutual respect ( the patient as expert is a welcome development), careful listening, (this takes time that is not available to the GP for most patients), wise patient management that uses modern drugs effectively and not in a random fashion (many patients need to learn a new appreciation of modern drug use), recognises the possible benefits of alternative therapies in a constructive and critical ways, perceptively examines diet and nutrition, allows patients to make crucial judgements about how they live and die with their illness. Let's return to being fully human.
Better to have a 'non-survey' than a 'non-disease survey' 22 February 2002
Jeanette L Chapman, retired J's Enterprises, Morro Bay, CA, 93442 Send response to journal: Re: Better to have a 'non-survey' than a 'non-disease survey'	Your survey or poll of what people classify as “non-diseases” invites the respondents to show their prejudice and ignorance. It may lead to stigmatization for people diagnosed with medical conditions that are on your long original list and especially for those in the final ‘top ten’. Among the early responses (Feb. 15 & 16), several medical professionals suggested ‘adding’ Chronic Fatigue Syndrome (CFS), thus showing their ignorance that CFS is known as Myalgic Encephalomyelitis (ME) in Britain as well as the rest of the world outside the USA. Other responses showed that this is an exercise in semantics: what is a disease, syndrome, disorder, symptom or complaint? The allopathic system has a propensity for showing bias against disease processes that are hard to diagnose and are not easily or successfully treated. Witness Dr. George B. Alcom who responded Feb. 15th. He desired to add Candidiasis (Candida Syndrome) to the list of non -diseases because he wasn't able to have success treating his patients that had this medical condition. Lumping new-age ‘diseases’, like Air Rage and Road Rage which are really expressions of personality traits, together on your list with real disease processes, like Diabetes, CFS and Hypertension is insulting and trivializes the people living with these diseases. I am aware that people do get physical consequences from living non-healthy lifestyles and choosing non-healthy attitudes (such as choosing anger and rage instead of self-control and peace). Paul said it best at Galatians 6:7, “whatever a man is sowing, this he will also reap” and at 2 Timothy 3:1-5, “critical times hard to deal with will be here. For men will be lovers of themselves, lovers of money, self-assuming, haughty, blasphemers, disobedient to parents, unthankful, disloyal, having no natural affection, not open to any agreement, slanderers, without self-control, fierce, without love of goodness, betrayers, headstrong, puffed up [with pride], lovers of pleasures rather than lovers of God, having a form of godly devotion but proving false to its power; and from these turn away.” The words of David at Psalms 37:8 “Let anger alone and leave rage; Do not show yourself heated up only to do evil” and Solomon at Proverbs 29:22 “A man given to anger stirs up contention, and anyone disposed to rage has many a transgression” also apply. These scriptures express truths that modern day doctors and researchers have been able to quantify. Quoting from a 1982 issue of American Health, “In the routine of our lives, the anger we waste upon trivia, in traffic jams and ticket lines, and the ‘urge to kill’ that boils up so commonly and inanely, are most likely to act upon the victims we least intend—ourselves.”1 “And in harmony with that, a study of emotions by medical doctors and psychiatrists reveals that jealousy, anxiety and anger or rage contribute to, aggravate, or even cause, such ailments as asthma, skin diseases, hives, ulcers and dental and digestive troubles, and can trigger heart failure.”2 These medical conditions are the end result of the negative emotions. They are the recognized “disease”, thus the emotion or action could properly be titled a “non- disease”. 1 Watchtower, Sept 1, 1982, p 27, published by the Watchtower Bible and Tract Society; 2 Watchtower, April 1, 1972, p 196
Purpose of this exercise 23 February 2002
Alexa E McLaughlin, Writer and editorR Red Hill, ACT, 2603 Australia Send response to journal: Re: Purpose of this exercise	In the absence of the clarification I sought from the editor of the BMJ and in the presence of so many votes against ME/CFS, many of which were hostile, I sadly conclude that the underlying purpose of this exercise is to specifically denigrate ME/CFS as a non-disease. For any readers unfamiliar with the recent history of controversies surrounding ME/CFS (or whatever it is named), the UK Chief Medical Officer recently issued a report acknowledging it's seriousness and including some material (particularly recommended treatments) consistent with these "non- disease" theories. I understand that some proponents had resigned from the working group because the report did not go far enough to pursue their perspectives. On the other hand, some of those who don't accept their views, especially who were not on the working group, feel the report still errs on the side of the "non-disease" theories. The consequences of perceiving ME/CFS as a "non-disease" are to stop researching physical bases of the conditions and offer only psychologically based therapies (cognitive behavioural therapy and graded exercise) on the assumption that wrong beliefs are leading to the physical symptoms. Should their proponents be wrong, as I believe they are, these would wastefully fail to cure and denigrate sufferers. This is therefore a very serious issue and merits active debate. However, ambushing and hidden beliefs are not the way to go about such a debate. This now looks like the BMJ may be inciting the electronic community to "bash CFS". It also looks as if the discussion about "what is a non-disease" may be a red herring, wasting our energies on a "done deed" - the real intention being to identify "which are the non-diseases". I would welcome a debate on the origins and treatments of ME/CFS in the BMJ and it should be done openly and clearly.
CFS/ME a Non-illness? 23 February 2002
Lucy I Dechene, Professor of Mathematics Fitchburg State College USA 01420 Send response to journal: Re: CFS/ME a Non-illness?	I do not understand how anyone who is really conversant with true chronic fatigue syndrome can think of it as a condition in which the sufferer is better off without a diagnosis or treatment. I came down with CFS/ME in August 1957, a month before starting first grade. I was diagnosed with the Post-viral fatigue syndrome in 1987 and with CFS in 1988. I was definitely NOT better off the 29 years I had no diagnosis nor treatment. How could anyone think I would be? I still had no treatment after 1987 except for treatments I thought of myself until 1996 when I was diagnosed with some sort of "acquired mitochondrial myopathy." Then I actually got some treatment which was helpful. 40 years is a very large chunk of a person's life to wait for assistance from the medical profession for a very serious condition. In spite of being very ill all this time, I have managed to complete a Ph.D. in mathematics and have a career as a professor for 23 years. But I am declining neurologically so much that my career is nearly at an end. No amount of cognitive behavioral therapy will help postpone this result. This is NOT a psychological illness nor a "non-illness". It is a very real, serious physical illness which demands more research.
Re: Ivan Illich on what is and what isn't a disease 23 February 2002
Gurli Bagnall, Patients' Rights Campaigner Send response to journal: Re: Re: Ivan Illich on what is and what isn't a disease	The purpose of this exercise is certainly being kept a mystery. Dr. Richard Smith, editor of the BMJ, quoted Ivan Illich’s philosophy which seems strangely at odds with his own statement in the TV documentary, “Why doctors make mistakes”. (Quote) “All doctors in some ways are bogus doctors because [they] are very, very aware of the extreme limitations of what [they] can do…We have very limited ways of dealing with diseases.” (I presume he was referring to "non-diseases"?) A few years ago, Dr. M.N.C Dukes also had a few words to say about "non-diseases" in the BMJ: “Plenty of people are still dying of diseases which other people do not believe,” he said. Napoleon Bonaparte put it this way, “You medical people will have more lives to answer for in the other world than even we generals.” George Bernard Shaw, who was always at his best when cutting people down to size, looked at the situation from a different perspective. He said: “Let no one suppose that the words ‘doctor’ and ‘patient’ can disguise from the parties the fact they are employer and employee.” Perhaps Judge David Saunders had the right answer when, in the Dunedin District Court (New Zealand), he offered this advice to a defendant: “A closed mouth gathers no feet.” Gurli Bagnall, Patient’s Rights Campaigner, Lawrence, New Zealand.
The point of this exercise 24 February 2002
Richard Smith, Editor BMJ Send response to journal: Re: The point of this exercise	This point of exercise of identifying non-diseases is to prompt debate on the following questions. What is and what is not a disease? What is implied by the concept of disease? When is the concept useful and when is it counterproductive? Are we medicalising an increasing proportion of human experience, and if so does it matter? The debate is a prelude to our theme issue on the limits of medicine. We are compiling this theme issue because readers asked us to do so. We have deliberately been non-prescriptive with the exercise. We developed a list of non-diseases by consulting our editorial board. We were surprised that we came up with so many candidates. Readers were then invited to make further suggestions, and we have included every suggestion in the list. Now we are voting, but we have not specified any criteria for the vote. Our hope is that the debate will roam to wherever readers want it to. The exercise is certainly not designed to "bash" the concept of myalgic encephalomyelitis/chronic fatigue syndrome, and there is at the moment nothing on this condition in our theme issue. If it is voted one of the top 10 non-diseases, then we will write a short "biography" of the condition. At the moment it doesn't look as if it will be in the top 10. Our aim in writing the biographies of the top 10 non-diseases will probably be to be descriptive, objective, and non-judgemental. (I write "probably," as we haven't yet decided on the final form for these biographies.) Richard Smith, Editor, BMJ
Almost none of the above 24 February 2002
Peter J Allmark, Nursing Lecturer Sheffield University S5 7AU Send response to journal: Re: Almost none of the above	In the first place, it is a mistake to declare something not to be a disease when what one really means is that it is not reasonable to spend state money on its alleviation (as in Richard Smith's baldness example). As well as this, it is an error to think that the term "disease" (and related terms, such as "health") admit of any precise formulation. A disease is not a fact, it is a judgment on the facts; it is, roughly, a disvalued state that may now, or plausibly at some time in the future, be alleviated through some form of medical manipulation of the human organism. Baldness, ageing, phobias, infertility, and many others on your list, strike me as reasonable examples. As such, I am inclined to think that most of the "non-diseases" submitted by your correspondents could reasonably be declared diseases. The sneering tone of many of your correspondents offends me (the father of an autistic child, autism being one of the non-diseases) and will surely offend others.
Smith - Devil's Advocate? 24 February 2002
Gurli Bagnall, Patients' Rights Campaigner Send response to journal: Re: Smith - Devil's Advocate?	I have not read the Ivan Illich book referred to by Dr. Richard Smith, but was sufficiently perplexed to refer to the opinions of other authors - unfortunately after my response. Dr. Smith’s quotation raised the question: Was Illich saying, ‘This is how it is’, or was he saying, ‘This is how it is, and should be’? The following from “The Greatest Benefit to Mankind - A medical history of humanity from antiquity to the present” by Roy Porter, offers the answer. Illich “…..maintained that ‘the medical establishment has become a major threat to health’…..Critics in the Illichian mould saw medicine out of control; it was driven not by concern for the patient’s health needs but by collective professional ambition, corporate financial pressures, and deluded imperatives - not least an itch to intervene. The ‘can-do, will-do’ technological imperative came under mounting criticism. It has was (sic) shown that many procedures benefit doctors and other medical professionals and technocrats more than patients, while others are positively harmful.” Even the BMJ recognizes this scenario at times, but it is unfortunate that no differentiation is made between practitioners of this ilk, and those who conduct themselves ethically. In setting this “non-disease” exercise, was Dr. Smith playing devil’s advocate? If so, he has done it most successfully. Gurli Bagnall, Patients’ Rights Campaigner, Lawrence, New Zealand
Labels create legitimacy and produce dependence 24 February 2002
Kevin C Murphy, Medical Oncologist BC Cancer Agency/Fraser Valley Send response to journal: Re: Labels create legitimacy and produce dependence	The last decade has observed an ever increasing role of the patient as the primary decision maker in the management of illness. This approach has been enouraged by the development of advocacy groups, the popular news media and physicians who cater to the non-critical thinking population. For those not trained to reign in their innate "belief engines", the association of "symptoms" with a disease is only encouraged by the production of labels. A symptom complex described by physicians as "fibromyalgia", which is nothing more than a descriptive term for "pain in muscles and fibrous tissue" now has the legitimacy of a disease as opposed to a panoply of symptoms. The near mass hysteria displayed by like-minded believers when these labels are challenged adds to the dependency on the labels as being legitimate. Having evolved a mind which is designed for pattern recognition, resists changng beliefs in the face of new information and encourages the production of cause and effect relationships in the presence of associative phenomena, some humans will always need labels to support their continued suffering in an unfair world. These "non-diseases" clearly contribute to the development of co-dependent suffering.
ICD605: Redundant prepuce and phimosis 25 February 2002
Hugh P Young Pukerua Bay 6010, New Zealand Send response to journal: Re: ICD605: Redundant prepuce and phimosis	The International Code of Diagnosis 605 "Redundant prepuce and phimosis" is actually two contradictory "diagnoses". Redundant prepuce: if he doesn't actually trip over it.... The diagnosis of "redundant prepuce" is made for the parents' or doctor's peace of mind, not the prepuce's owner's health. The infant's adherent foreskin is perfectly normal and by no means phimotic. After it has separated from the glans, many adults are perfectly happy to have a foreskin that does not retract to expose the glans. Surgery to expose the glans, whether permanently or ad lib., should be classified as elective and cosmetic, and ethically that election should ONLY be made by the person to whom the prepuce is attached.
Mythical Malady 25 February 2002
Charles Pragnell, Expert Defence Witness - Child Protection Cleveland TS10 2JN Send response to journal: Re: Mythical Malady	There is no scientific evidence whatsoever of the existence of Munchausen Syndrome By Proxy. Its creation owes more to vivid imagination and clairvoyancy than to evidence-based medicine. In your list of non-diseases it should more correctly have been placed under IGNORANCE. MSBP - the Doctor's escape..... MSBP has been widely used by doctors to avoid the blame for their own ignorance, incompetence, or negligence. Its ready-made and easy to use. If you (the doctor) don't know whats wrong with the child or if you have made a medical error that has harmed the child, just `Blame the Mother'. End of problem. It is especially useful if the parents are threatening to report you to the GMC or to take legal action for medical negligence or error. Doctor's motto Honi soit qui mal y pense.
What really is the point 25 February 2002
Trevor Wainwright, Administrator Castleforsd Aid for ME 92 Lower Oxford Street, Castleford, West Yorkshire, WF10 4AG Send response to journal: Re: What really is the point	Has all this achieved anything, will the medical world be better informed? Will the public be better informed? I think not. Will people take notice of the Top 10 non-diseases and what is written about them, I doubt it. I notice some prominent BMJ contributors have kept their heads down over this issue. Are they waiting and hoping that they will be able to crawl out of he woodwork and say for certain diseases "I told you so". So again the question what is the point of it all?
Re: Re: Re: The most insideous non-disease 25 February 2002
Christopher A Weiner, SpR Public Health West Midlands Send response to journal: Re: Re: Re: Re: The most insideous non-disease	It is a sorry world that disappoints, and so I bow to the greater knowledge of my friend on the subject of all that is Wilde. The Critic is an Artist was written at a time of great industrial development in the UK. That which is defined as a disease or non-disease varies with time. It is unlikely that the passage of time itself is causal of changes of definition. It is possible that changes in definition are due to little more than random variation over time; or alternatively time may be a confounder in an ill-understood system. If time is the confounder, what is the cause? Let us suppose that the cause is socio-economic in character. Socio-economic circumstances in the UK have changed much since the 19th century. Schools and education are now relatively well promoted. The cotton mills of Manchester, the coal mines of South Wales and the Ship Building yards have all declined. To work in this day and age demands high levels of education. Education is taken up more often by those within social class 1 and 2 (student class aside). Work becomes concentrated in the higher social classes, and unemployment and poverty in the lower social classes. So is it perhaps, what may have been a disease in the 1890's is no longer a disease? Or work has always been a disease, but the epidemiology of the disease has changed? Or potentially this is a case of what is one mans' poison, is another mans' cure. The answer to such a sticky question could be determined by an expert panel, but will they take on board the opinion's of the expert worker? Only time time, the confounder, will tell.
Our common sense has atrophied 26 February 2002
Julian H Jessop, Consultant Orthopaedic Surgeon Watford WD8 OHB Send response to journal: Re: Our common sense has atrophied	There are a number of orthopaedic problems which qualify as non diseases. They are so common as to rank as normal variants at one or other end of the bell curve, but patients often present to their GPs and request referral. For example, In children: Anterior knee pain of adolescence Intoe gait Curly digits Ganglion In adults: Almost any condition where the patient in question ought to know better eg the 50 year old marathon runner whose heels ache etc etc It may be wishful thinking , but I like to think that in the past most of these conditions would have been recognised by a benign granny figure living in the home as part of life or in the children "growing pains". These days with the explosion of the nuclear family that sort of common sense has all but disappeared and instead these normal people go on to "waiting lists" to see "specialists".
Elevated Cholesterol Is Not a Disease 26 February 2002
Paul J. Rosch, President The American Institute of Stress, Yonkers, NY 10703 USA Send response to journal: Re: Elevated Cholesterol Is Not a Disease	Hypercholesterolemia is a risk "marker" for coronary heart disease rather than a risk "factor" that implies causation. Like a deep earlobe crease, abdominal obesity, premature vertex baldness and some 300 other items it is merely a statistical association whose correction does not correlate with a decreased incidence of coronary events. Cholesterol lowering statins reduce risk of coronary events by reducing inflammation, not by any lipid lowering activities since they are equally effective in patients with normal cholesterol and LDL. As George Mann noted, the diet- cholesterol-heart attack hypothesis is one of the worst scams ever perpetrated on the public. Paul J. Rosch, MD
Common Sense 27 February 2002
Ian A Miller, member of public GUILDFORD Surrey GU1 2SD Send response to journal: Re: Common Sense	I have assumed a disease is an ill-health condition due to a virus or bacteria. Concise Oxford Dictionary says "an unhealthy condition of the body (or a part of it) or the mind; illness, sickness." I understand the people may consult doctors about things that bother them in life, but that does not classify the problem as a disease. Road rage is not a disease but it is a sign that someone is not coping with life or their emotions. Perhaps it is time that emotions were talked about more often rather than being suppressed only to surface later in a more harmful way - harmful to both the person suffering inside and the person to whom anger is directed. One example of suppression is society's attitude that it is not the done thing to cry in public, boys do not cry, and attitude that crying is someone "breaking down", rather than a natural release of pressure.
Thank you 27 February 2002
Dale A. Roose, patient Tucson, AZ 85749, USA Send response to journal: Re: Thank you	This experiment will certainly be of great interest to future historians attempting to understand the mindsets of our times. Imagine their confusion by the way the term "non-disease" carries a definition that has nothing to do with the term "disease." The deprecation of the scientific-method in favor of the truth-by- popular-vote method will help to explain why medical research of many diseases progressed so unnecessarily slow during this period. Regarding "Chronic Fatigue Syndrome/M.E." I have mixed feelings. Although most of the physicians treating me for Chronic Fatigue Syndrome have done more damage than good, one physician has offered very helpful treatment. One physician's non-disease is another's disease. It will be interesting to see how many/few physicians notice that Chronic Fatigue Syndrome and M.E. have been grouped together although they are as different as fever and malaria. The vote totals will of course have little meaning, but then I guess that wasn't really the point. Is this to be published on April 1st ?
MIS-DIAGNOSED MSBP 27 February 2002
Michael D Innis, Director Medisets International Home Send response to journal: Re: MIS-DIAGNOSED MSBP	Editor, Why I voted for Munchausen Syndrome by Proxy as a Non-disease is because the consequences of a mis-diagnosis are devastating for the accused and the family of the accused. For example there was the relatively recent example of an eleven week old child who bled from the nose and not one of the expert medical witnesses could name a single natural cause of such a bleed when they could have looked up the books and found at least a dozen. Here are a few: 1.Late onset Haemorrhagic Disease of the Newborn (HDN) also called Vitamin K Deficiency Bleeding (VKDB) 2.Hereditary Factors I, II, V, VII, VIII, IX, X deficiency. 3.Idiopathic Thrombocytopenia 4.Non-thrombocytopenic Purpura 5.Alloimmune thrombocytopenia 6.Disseminated Intravascular Coagulation 7.Hereditary Haemorrhagic Telangiectasia. Unfortunately for the Mother the child’s nose bleed was not recognized as what to any Haematologist would be significant evidence for considering the possibility of HDN and proceeding with the investigation of the Prothrombin time, Platelet count and Fibrinogen. The child died later from bleeding into other sites and the Mother now languishes in Her Majesty’s Prison having been found guilty of Murder by the evidence of Medical Experts pinning their faith on MSBP. “The Law is an Ass” The Victim Cried “Why Insult me?” The Ass Replied. Michael Innis FRCPath;FRCPA
The pros and cons of medicalisation 27 February 2002
Simon Wessely, Professor Psychological Medicine, GKT School of Mediicne, denmark Hill, London SE11 6BY Send response to journal: Re: The pros and cons of medicalisation	The BMJ’s decision to extend participatory democracy to the question of disease - legitimate or otherwise, is important not so much for the results, but because it happened at all. To a previous generation the idea of asking consumers to decide on these matters would have seemed incomprehensible. The task of deciding which conditions were legitimate, and thus admitted to the Pantheon of respectable "real" diseases, and which should be consigned to the outer darkness was straightforward - doctors took the decision. In the debate about the nature of neurasthenia which occurred at the end of the 19th century, the protagonists, for and against, were all in the medical profession, and the arguments ran too and fro in the pages of the journals. We can infer the views of a small number of patients, invariably the well educated and well heeled, from diaries and fiction, but their voices were largely unheard and unheeded. Now of course medical authority is in retreat everywhere, and we are moving towards an age in which the final arbiter of "non disease" is the patient themself. Illich himself never envisaged this. He saw medicalisation from a very 1960s perspective - a medical establishment seeking to extend its hegemony, and along with many other social commentators viewed this from the position of how professions control and define their authority. I doubt he anticipated what we now see, in which there are numerous examples, Attention deficit Disorder being one, in which doctors are acting to try and limit the usages of the diagnosis to a narrowly defined group, whilst parents and teachers seek to extend it. All this is well and good, so why the outrage exhibited by so many of the correspondents? I suspect it comes from a failure to recognise the different concepts of illness and disease, so ably outlined by Arthur Kleinman. Let us take the example of chronic fatigue syndrome (CFS), largely because so many others have, and because it was perhaps not surprising that would become the eye of the storm. Few now could question that CFS is indeed an illness. It has a nosological status, and is clearly associated with suffering, ill health and disability. And here the patients' voice must be paramount, as indeed it is. But is it a disease? In other words, has a specific pathological process been identified to account for the above? This is, and should remain, a technical question to be answered not by opinion, but by evidence and scientific data. Is CFS a disease? Not yet. No unambiguous evidence has yet been presented that has commanded widespread acceptance by the scientific community, which remains the arbiter on this question. Of course, it is entirely plausible that CFS will make the transition from illness to disease. Many other illnesses have done just that. On the other hand, it may not. The traffic is not, as some correspondents imply, entirely one way, in which illness entities inevitably receive the stamp of scientific approval, usually after a period in of being falsely labelled as psychological. The opposite happens as well - previously apparently sound entities lose their disease status under the cold light of scientific scrutiny. There is also a second reason why CFS , and indeed the entire discussion, has generated so much heat. Ivan Illich and his colleagues, who mounted such a trenchant attack on the process of medicalisation, also (and the name Goffman of course comes to mind) wrote critiques of the concept of labelling as well. People behave according to the labels that are ascribed to them, a process seen as largely negative. Some of your correspondents echo this, citing examples in which the act of labelling distress as something medical, ie pathological, carries with it a host of adverse consequences 1 2 3 4 5 6 7 8. And they are right to do so. In my now more than ten years of clinical practice running a clinic for sufferers from CFS, i have seen numerous examples of just that, in which the label of CFS, given in the context of a chronic, persistent viral infection of muscles for which there is no treatment, and the only management strategy is to rest until symptoms go away, is indeed harmful. But far more often I have also seen the opposite. More common is the experience that so many people relate, and which is well attested in the literature. here the act of giving a name to symptoms and disability brings relief 9 10 11 12 13 14 15. The acknowledgement by the medical profession that their condition does indeed have a name, and is a legitimate illness, is immensely reassuring and enabling. It also provides an end to the so called "battle of diagnosis" - as Nortin Hadler put it - "if you have to prove you are ill you can't get well" 16. It is impossible to begin to plan a collaborative programme of rehabilitation without an explicit and repeated affirmation of the substance and legitimacy of the condition. It is for that reason that so many of your correspondents reacted angrily to those who have pointed out the dangers of labelling, since they are acutely aware of its benefits. Giving a condition a name is an intervention in itself. Like all interventions it has costs and benefits 17. Crudely handled, medicalisation can perpetuate disability and exclusion. But used constructively and appropriately it is the first step towards recovery. Professor Simon Wessely Department of Psychological Medicine, GKT School of Medicine and Institute of Psychiatry, 103 Denmark Hill, London, SE5 8AF 1. Meador C. The art and science of nondisease. New England Journal of Medicine 1965;272:92-95. 2. Bergman A, Stamm S. The morbidity of cardiac nondisease in schoolchildren. New England Journal of Medicine 1967;276:1008-1013. 3. Quill T, Lipkin M, Greenland P. The medicalisation of normal variants: the case of mitral valve prolapse. Journal of General Internal Medicine 1988;3:267-276. 4. Palmlund J. The marketing of estrogens for menopausal and postmenopausal women. Journal of Psychosomatic Obstetrics and Gynecology 1997;18:158-164. 5. Barsky A, Borus J. Somatization and medicalization in the era of managed care. Journal of the American Medical Association 1995;274:1931- 1934. 6. Hadler N. The dangers of the diagnostic process. Iatrogenic labelling as in the fibrositis paralogism. In: Hadler N, ed. Occupational Musculoskeletal Disorders. New York: Raven Press, 1993: 16-33. 7. Plioplys A. Chronic fatigue syndrome should not be diagnosed in children. Pediatrics 1997;100:270-271. 8. Thorn A. Emergence and preservation of a chronically sick building. Journal of Epidemiology and Community Health 2000;54:552-556. 9. Ware N. Suffering and the social construction of illness: the delegitimisation of illness experience in chronic fatigue syndrome. Medical Anthropology Quarterly 1992;6:347-361. 10. Broom D, Woodward R. Medicalisation reconsidered- toward a collaborative approach to care. Sociology of Health and Illness 1996;18:367-378. 11. Reid J, Ewan C, Lowy E. Pilgrimage of pain: the illness experiences of women with repetition strain injury and the search for credibility. Social Science and Medicine 1991;32:601-612. 12. Soderberg S, Lundman B, Norberg A. Struggling for Dignity: The Meaning of Women's Experiences of Living With Fibromyalgia. Qualitative Health Research 1999;9:575 -. 13. Green J, Romei, J and Natelson, BH. Stigma and chronic fatigue syndrome. Journal of Chronic Fatigue Syndrome 1999;5:63-75. 14. Asbring P NA. Women's experiences of stigma in relation to chronic fatigue syndrome and fibromyalgia. Qualitative Health Research 2002;12:148 -160. 15. Deale A, Wessely S. Medical interactions and symptom persistence in chronic fatigue syndrome. Social Science and Medicine 2001;52:1859-1864. 16. Hadler NM. If you have to prove you are ill, you can't get well. The object lesson of fibromyalgia. Spine 1996;21:2397-400. 17. Finestone AJ. A doctor's dilemma. Is a diagnosis disabling or enabling? Archives of Internal Medicine 1997;157:491-2.
In response to Wessely 1 March 2002
Gurli Bagnall, Patients' Rights Campaigner Send response to journal: Re: In response to Wessely	It was hard to take this exercise of determining non-diseases seriously considering some of the conditions in the original list - e.g. big ears. It became even more bizarre when other “non-diseases” such as raiding the fridge at night, and gap teeth, were suggested. Clearly some saw the exercise as a joke, while others regarded it as a backlash after the release of the ME/CFS report to the CMO. But there were also those who took it seriously. In compiling a list of non-diseases, one need go no further than the DSM in which can be found such “maladies” as Caffeine-related Disorders, Mathematics Disorders, Conduct Disorder, Disorder of Written Expression, and one that was actually raised by someone in this exercise, Noncompliance with Treatment Disorder. Medical fads have come and gone, and latterly we have had psychiatry promoting itself, if not touting for business. In this part of the world, a prominent Australian psychiatrist made the “startling discovering” that “Sixty percent of people who visit general practitioners have a mental disorder…” (Sydney Morning Herald, 16 July, 2001) This was based on a questionnaire along the following lines: “In the last few weeks, have you suffered (a) a headache (b) muscle or joint pain etc.” It could have applied to every lay person and doctor in the community. In New Zealand, we are currently favoured with a TV advertisement in which a variety of well known personalities tell us that they are mentally ill. The message is that mental illness is nothing to be ashamed of, and if you are feeling a little blue or worried, rush along to your nearest friendly psychiatrist to be cured. We have seen similar promotions for ADD and it’s treatment, Ritalin. Given these facts, it was interesting to read Professor Simon Wessley’s contribution to the non-disease debate, and I would like to make the following points in the order in which they appear in his letter. FIRST POINT: According to Professor Wessely, this non-disease exercise is a sign that the medical profession has become more democratic. “To a previous generation the idea of asking consumers to decide on these matters, would have seemed incomprehensible,” he said. In fact, Richard Smith’s letter of explanation (24/02/02), did not specify any particular group, and having gone through the responses, I found only 28% came from consumers - by which I mean, in this instance, readers who are not medically trained. SECOND POINT: Public concern about the drugging of our children with mind altering and addictive substances, has been voiced for many years. Hilary Clinton, while first lady in the White House, made her feelings very clear on this issue. The protests were and are world wide, but they were and continue to be, ignored by the medical profession. Parents who refuse psychiatric treatment for a child suffering ME, are likely to be labelled with the MSbP “diagnosis” and have the child removed from their custody. The same applies to ADD. Children who have been diagnosed thus, have been taken from parents if treatment such as Ritalin, is refused. According to the police in New Zealand, parents of some children on Ritalin, are selling the tablets on the streets to augment their income. When asked on national television if this was a sign of over prescribing, one specialist responded, that if anything, it was under prescribed. This lack of concern, never mind logic, raised the wrath of many in the public sector. Given the above, Professor Wessely’s comments on ADD came as quite a surprise. His contention that the profession is trying to limit this diagnosis “to a narrow defined group….” is a moot point. His further claim that at the same time, “parents and teachers seek to extend it”, indicates that brain washing is not eliminated overnight. THIRD POINT: The argument as to whether or not CFS is a disease, has been repeatedly expressed in one way or another, by Wessely in his prolific writing. That he still chooses not to differentiate between ME and what he calls CFS, is par for the course. My response is that the major medical journals (including the BMJ), have shown that medical treatments fall into three categories. 1. A third of medical treatments are either (a) successful or (b) ineffective, but leave patients unscathed. 2. Medical treatment creates a third of all diseases. 3. Medical treatment is the third leading cause of death. Given the statistics, and the continued insistence in many medical quarters that ME is a psychiatric disorder, it does not seem to be an unreasonable proposition for ME patients to ask their practitioners to sign a “To Whom It May Concern” letter in which they take full responsibility for such a diagnosis, and all adverse consequences arising from it. Gurli Bagnall, Lawrence, New Zealand
Patients' Poll on BMJ Results in Landslide 1 March 2002
Jean Linn, Retired chemical engineer PO Box 926223, Houston, TX 77292, USA Send response to journal: Re: Patients' Poll on BMJ Results in Landslide	The British Medical Journal proposed to "cure" disease by defining it out of existence. In the spirit of democracy, patients were invited to vote on how best to recognize the BMJ's innovative proposal for conquering diseases. [Ref.: http://listserv.nodak.edu/scripts/wa.exe?A2=ind0202c&L=co-cure&F=&S=&P=2016 ]. The patients' poll has now closed. There were two questions on the patients' ballot, and the poll was conducted over a period of 10 days. Sixty-eight ballots were cast, with the following results: In a landslide, patients agreed that the BMJ should be nominated for the Nobel Prize in Medicine only if they include "cancer" in their "top 10." On the question of whether patients should nominate a top ten list of "non-physicians," 100% of voters supported the creation of such a list. A combined total of 83% of voters were split by a ratio of about 7:10 between a simple "yes" and the more selective nomination of only those physicians who fail to distinguish between WHO ICD-10 F48.0 and G93.3. POLL RESULTS 1. Should the BMJ be nominated for the Nobel Prize in Medicine for curing, by oligarchic fiat, 10 diseases to be named at a later date? 76% Only if they include "cancer" in the top 10. 13% No 11% Yes 2. Should a list of the top ten "non-physicians" be voted upon by patients? 48% Maybe: If they cannot distinguish between WHO ICD-10 F48.0 and G93.3. 35% Yes 8% Maybe: If they have published "uncontrolled" research in the BMJ. 7% Maybe: If they have published in the BMJ. 0% No.
Disability is a civil rights issue 2 March 2002
Joyce M. Carter, Consultant in Public Health Medicine Liverpool Health Authority, 24 Pall Mall, Liverpool L3 6AL, Stephen Marsh, Disability Equality Officer, Liverpool City Council and Liverpool Health Authority, 24 Pall Mall, Liverpool L3 6AL Send response to journal: Re: Disability is a civil rights issue	We`ve voted for `disability` as a `non-disease` (1) because we, and many disabled people, identify disability as a civil rights issue. Around 30 years ago disabled people in Britain began to self-organise to address the systematic oppression and exclusion that they faced in society (2). Defining ‘disability’ as a medical condition to be cured was identified as a major reason for that exclusion. In 1976, the Union of Physically Impaired Against Segregation developed the social model of disability to reflect accurately disabled people`s experiences, defining disability as “the disadvantage or restriction caused by a contemporary social organisation which takes no or little account of people who have physical impairments…” (3). Subsequently this definition changed to include all impairments, and is different from the concept of impairment, disability, and handicap, developed by non- disabled people and used by World Health Organisation (WHO). But the WHO has now recognised the effect of environmental barriers, which is more in line with the social model (4). Adopting the social model profoundly effects the lives of disabled people, because disability is then viewed as society`s fault not the individual`s. So if a wheelchair user is unable to get into a building with steps, the problem is with building design, not the individual. If a Deaf person is unable to access health services because of communication problems, the problems are due to the inadequacies of the service (including health professionals not having the necessary communication skills), not the patient. Racism and sexism are addressed through changing society to afford full civil rights to oppressed people; disability also must be addressed as a civil rights issue, not a disease. Currently, disabled people are not fully protected by law: arguably the Disability Discrimination Act 1995 is not an anti-discrimination act because it describes situations where it is legal to discriminate against disabled people. The General Medical Council used this as a defence for not approving modifications to an undergraduate course necessary for a prospective disabled medical student to take up a place at medical school (5). The social model is still not fully accepted within statutory agencies and society in general, but Liverpool Health Authority and Liverpool City Council have adopted it and have jointly established the post of Disability Equality Officer to promote it. Many agencies in the city support this approach, although there is still a lot to be done to work this out in practice. References. 1.British Medical Journal website extra. What is a non-disease? http:/bmj.com/cgi/content/full/324/7334/DC1 (accessed 1 March 2002) 2. Oliver M. Understanding disability. From theory to practice. Macmillan. Basingstoke 1996 3. Union of physically impaired against segregation. Fundamental principles of disability. UPIAS 1976 4.http://www3.who.int/icf/icftemplate.cfm (Accessed 1 March 2002) 5. Carter JM, Markham N. Disability discrimination. British Medical Journal 2001;323:178-9
Disease and non disease in children? 3 March 2002
Barbara J Robinson, specialist teacher Suffolk Send response to journal: Re: Disease and non disease in children?	The week before the BMJ Poll on "Non-diseases", I was given a copy of the folowing article article published in NASEN's "Support for Learning", Volume 17, February 2002. "An Exploration of Secondary Teacher's belief's and attitudes about adolescent children with chronic fatigue syndrome." As a secondary teacher with 10 years specialist experience of adolesent children with complex emotional and health related problems including CFS/ME and fibromyalgia,I thought I ought to check this article out and think carefully before replying to your poll. The NASEN article concerned me a great deal.It seemed to reinforce some of the outdated and entrenched views, misconceptions and confusion which characterised some of the responses to the BMJ poll, which equally worried me. This is my response to your poll. At present when children with CFS/ME needs are so great and provision so poor, I am not really interested in semantics. I wish that as much time energy,effort and energy expended on this poll had gone into proper research for children and adolescents and appropriate support services. Only by listening to the young people and by responding in a holistic manner will we eventually moveforward.-Disease, syndrome or non-disease. I have seen the suffering of a significant number of these childen first hand. This debate is of little use or interest to them. I am glad I don't live and work in Oxford.(Where the NASEN article originated) I am glad too that I don't live in the following areas. Shropshire County Council (Dale Archer, Occupational Health Physician) BT45 7QX (Raymond Henry Givan, General practioner) Powys SY18 6EF (Mathai Babu, Staff Grade Paediatrician) So are my students.
Is this a useful thing to do? 8 March 2002
David J Walland, Radiation Protection Adviser University of Bristol, BS2 8BB Send response to journal: Re: Is this a useful thing to do?	I am concerned by the very simplistic word use in this "study". By labelling such things as "Non-diseases" the BMJ is encouraging the position "The BMJ says they don't exist" WHATEVER correction of this position you take. Had the BMJ decided to take the position of stating rather that these are labels which describe many diseases/syndromes, this would have prevented the simplistic attitudes which will now plague medicine for the next century or more. Just as in my profession there are too many Physicists who "don't believe in" the Social Sciences and leave people like myself to try and sort out the mess, just so, you Medics have now so betrayed your purpose of healing and preventing pain and suffering and left enormous numbers curretnly in need to suffer alone and unhelped. Hippocratic oath? No a differnet sort of oath is valid here.
Re: Is this a useful thing to do? 9 March 2002
John P. Heptonstall, Director of The Morley Acupuncture Clinic and Complementary Therapy Centre Leeds LS27 8EG Send response to journal: Re: Re: Is this a useful thing to do?	Sir Although I appreciate the point David makes I hope the BMJ's initiative turns out to be useful inasmuch as it wakes interested parties out of their narrow-minded slumber. I prefer the play on the word 'disease' we use in Traditional Chinese Medicine (TCM) 'DIS-EASE'; this reminds us that anyone who suffers dis- ease of anykind, and asks for assistance, should be respected and helped whenever possible. TCM defines disease in terms of physical, emotional, mental, and spiritual patterns of 'disharmony' -it expects any individual to be able to withstand reasonable assaults on the harmony of these interlinked systems and remain relatively at-ease. However, a prolonged or significant assault on any aspect can render the individual dis-eased. Remedial intervention can be made to restore 'ease' through various modalities common to TCM, from acupuncture & moxibustion through herbs to physical manipulations such as Tui Na and Qi Gong. TCM does not criticise or deny the reality of any patient, it merely seeks to assist one to recover the 'ease' which one requires. The popular Western Medical (WM) term 'somatisation' illustrates how WM has lost it's focus; to WM 'somatisers' are people who believe they have disease but the doctor can find nothing wrong - it's all in the mind. To TCM the same people are dis-eased, and from its holistic standpoint it recognises known patterns of disharmony from their descriptions, from physical and mental to emotional and spiritual, of signs and symptoms; the degree to which the person is afflicted in any of these areas will reflect the kind of prescription each receives. To TCM a 'somatiser' is a dis- eased person; fortunately the disharmonies present will tend to be less entrenched and TCM is capable of correcting the disharmony before it develops into a more invasive disease, the kind WM then finds it is able to diagnose clinically. TCM practises true preventive medicine. Sadly I see the 'non-disease' lists contain items such as ADHD, ME, hyperactivity, 'complexes' and other serious 'dis-eases' - I am surprised that WM fails to recognise these significant disorders such that people still cite them as non-diseases and pity any patient whose physician is so out of touch. This continues to reflect badly on our healthcare system and its limited scientific paradigm, and prolongs the suffering of many hundreds thousands of persons who deserve more care, support and respect. Regards John H.
The IQOL Indice 9 April 2002
Karel A Lyons, Patient-Safety Advocate Medical Error Survivor Support http://communities.ninemsn.com.au/messup Send response to journal: Re: The IQOL Indice	Caution BMJ : It seems that philosophical trials , along with clinical trials , frequently contradict themselves in parallel. Your current study ," What is a non-disease ?" , conflicts closely with the BMJ Study of May 2001 entitled " Why are doctors so unhappy ? " The Top Ten responses for the earlier study surfaced as stress , depression , boredom , work , ageing , sleep deprivation , unhappiness , loneliness , burnout , and adjustment reactions . All of which are listed as non-diseases in the current debate , and all of which contribute to the sad statistics for physician suicide and impairment.(Doctors are patients ,too.) Pertinent to the above list of non-diseases , brain death may be the singular exclusion for current medical practitioners . 99% of the remaining,listed non-diseases being an intrinsic and often genetic dimension to the human condition. Perhaps , a more constructive topic of debate might have been , 'Establishing the indice for IQOL .' i.e. Individual Quality Of Life. A concern for anyone patient or practitioner , who suffers any of the ( disputed )'non-diseases ' categorised in this study. Medical intervention , in disease , may cure , treat , mask or relieve unpleasant symptoms in those afflicted. Therefore none of the above listed conditions qualifies as 'non-disease'. However , many may be minimised by prescribing the three C's ; communication , counselling and compassion. Refs : " Why are doctors so unhappy?" BMJ May 2001 http://bmj.com/cgi/content/full/322/7294/DC2 Yours Karel Lyons Patient-Safety Advocate < br> Medical Error Survivor Support ( Australia ) http://communities.ninemsn.com.au/messup
what about these others 10 April 2002
Alexander Parish, Self-Employed 10956 Send response to journal: Re: what about these others	What about all these other "cripplers of youth", especially in the United States (forgive my limited perspective): Homosexuality Serial Murder Serial Rape Low I.Q. Poverty Draft Dodging and (believe it or not) littering While the journal feels it has a legitimate reason to poll opinion regarding what is obviously a "hot-button" issue, presumably trained medical professionals will continue to adhere to sound scientific practice when treating the patient. The issue of moral responsibility, abdicated by use of terms like "disease", presumably will be left to lawyers and God.
A pathetic attempt at cost-cutting... 11 April 2002
Maria Christou 205, Naish Court, Bemerton Street, London N1 0DB Send response to journal: Re: A pathetic attempt at cost-cutting...	I find your "survey" insulting and condescending. I have both Endometriosis and PCOS and to have them labelled as anything other than a disease would be a further insult. These conditions/diseases are hormonal and, many believe, genetic. Whatever a person suffers from, whether it be an emotional or physical condition, playing semantics is a waste of precious time and resources better placed to finding cures and/or medication which can assist the sufferer. If the "survey" is the result of doctors' views or members of the medical profession as a whole, then it is of little surprise that diagnosis for so many conditions (or whatever you wish to label them as) is missed on a regular basis. I would love one person who dares consider that endometriosis (as well as any other disease) is not a serious matter - your suggestion from this survey is that all symptoms are psychosomatic and that is unacceptable. The BMJ ought to be more careful before we end up with a generation of doctors who become less inclined to listen to their patients and more to a magazine. Do not play semantics with these conditions – find cures for them.
Top 10 Diseases Farce - Why I voted how I did 11 April 2002
Trevor Wainwright, Administrator Castleford Aid for ME. 92 Lower Oxfford Street, Castleford, West Yorkshire, WF10 4AG Send response to journal: Re: Top 10 Diseases Farce - Why I voted how I did	I voted how I because I found out it was possible to vote more than once, simply by clicking the back button and re-voting. This was passed on to other organiasitions aho did the same, one person voting on behalf of his dog. One person who did not wish to vote multiple, said he did notice a sudden increase in the votes for dandruff and other such conditions. I used this technique often until I got bored with it and went on to more important issues, but whilst doing so on more than one occasion voted 10 times or more for the same 10 non illnesses. With this in mind I am forced to ask, how can we and why should we take other such BMJ projects seriously. It is perhaps interesting that the main UK Groups and their members did not bother to vote, perhaps they already had an idea of the farce it would be.
What should doctors be doing? 11 April 2002
Jon Stone, Research Fellow in Neurology Dept Clinical Neurosciences, Western General Hospital, Crewe Road, Edinburgh EH4 2XU Send response to journal: Re: What should doctors be doing?	The list of non-diseases raises the question of what the job of a doctor really is. Is our role to treat disease or treat symptoms? Are we trying to prevent death or prevent morbidity? For those doctors that thought medicine was all about curing disease - wake up - one third of your patients don't have it (1). In fact the relationship between symptoms/illness/morbidity and disease/pathology/death is a pretty loose one. By the time a patient has come to see you they have already medicalised their symptoms. You have several choices. You can: a) despair of the way society is going and give up medicine, b) decide you are only interested in disease and spend the rest of your working life becoming increasingly frustrated by all the 'timewasters' and the 'worried well' who you have little idea how to manage, or c) take on the intellectual challenge of trying to understand symptoms (whether or not the patient has a conventional disease, a label that annoys you or no label), understand why this person has come to see you and have a go at making them better. Smith defines a non-disease as "a human process or problem that some have defined as a medical condition but where people may have better outcomes if the problem or process was not defined in that way". Would he include someone with multiple sclerosis who on learning they have a disease that may or may not cause progressive brain damage, turns their face to the wall when they could have gone on working for another 10 years? The issue isn't whether there are diseases or non-diseases but whether there are doctors who can create good instead of bad outcomes in patients with symptoms - regardless of the label they go under. 1. Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms: an epidemiological study in seven specialities. J.Psychosom.Res. 2001;51 :361-7.
A Joke, Yes? 11 April 2002
Janette A Cobb, Advisor CAB; IP1 3BE Send response to journal: Re: A Joke, Yes?	I find the number and diversity of responses to your article somewhat alarming, especially as so many of them think that you wanted to be taken seriously. I, for one, feel that the exercise should be considered a waste of time and effort and should not be given space in any reputable publication. For that reason, I do not expect to see my brief letter published!
One disease should no longer be newly diagnosed, ever 11 April 2002
Taimur Shoaib, Specialist Registrar in Plastic Surgery Canniesburn Hospital, Glasgow. G61 1QL Send response to journal: Re: One disease should no longer be newly diagnosed, ever	Sir Having read the list of "non diseases", I do hope that at least one will never be newly diagnosed again: "allergy to the Twentieth century"! Sincerely Taimur Shoaib Specialist Registrar in Plastic Surgery Canniesburn Hospital, Glasgow tshoaib@canniesburn.org
Non Ilnnesses - another view 11 April 2002
Trevor Wainwright, Administrator 92 Lower Oxford Street, Castleford, West Yorkshire, WF10 4AG Send response to journal: Re: Non Ilnnesses - another view	Ref my last and recurring voting, it has been said that any duplicate votes have been deleted from the survey, so much for me and voting 10 times for the same 10 illnesses. Well I went one better, I kept returning to the voting scene and changing the illnesses again continued to vote more than once, again proving the BMJ plan nothing more than a sham. Trevor Wainwright CAME
Is this poll supposed to help anyone? 11 April 2002
Lynn A Watson, Special Needs Assistant Edinburgh EH87BA Send response to journal: Re: Is this poll supposed to help anyone?	I did not realise that the BMJ had a silly season..... Just to explain, I am not a Medic - just a Zoology graduate & teacher - or I was until I acquired one of the mentioned "non-diseases." I'm afraid I find your definition of disease very ambiguous. I have Fibromyalgia, which has been given a bad enough press without being added to by this poll, which has already been seized by the media. Before any doubters jump on to the fact that I was a stressed-out, jaded teacher: I was not. I loved my job and hope some day to return to it. Sorry to all those doctors who cant do a simple test to prove it, but Fibromyalgia really does exist. The best way I can describe it is a cross between two days after you've been hit by a car and vivax malaria ( done both in past!) Medications, a good doctor and a pain clinic have helped a lot. I just hope that some of the contributors who have dismissed conditions can sleep well at night. The only thing that would change their mind is to get something like this - and I really wouldn't wish it on anyone. For everyone who is going to feel even more put down by this poll, best wishes, Lynn Watson
Re: A non disease 12 April 2002
Sarah L Davies, Senior medical information officer Manchester, M15 5FP Send response to journal: Re: Re: A non disease	Clare O'Connor considers that loss of libido in a 60yr old post- menopausal women is not a disease as it is a normal physiological state. Apoptosis dictates that our bodies only function as they should for around 60 years. I would imagine that without medical intervention, a significant number of people in the Western World would normally be expected to develop tumours, diabetes, heart disease and other ailments as cells naturally die and bodies naturally wither through age. Doesn't this make age-related illnesses 'normal physiological states'? So on these grounds, should doctors be treating any age-related illnesses? Changes in society and an increasing cultural tempo mean that nowadays more people are presenting with stress-related illnesses and lifestyle issues rather than farmers' lung or pneumoconioses. All that this list has demonstrated is medical practice has not moved with the times. The focus of primary care should dictated by the needs of the patients, not what doctor's feel they can confidently treat.
it is really a disease! 15 April 2002
Elaine s Millard, none at present (was clerical officer and also nurserywomen) Northampton NN5 7RJ Send response to journal: Re: it is really a disease!	As someone who in the past believed conditions like ME/CFS/FMS etc where just a poor excuse for getting out of work etc. I would have said I agree with those listing one or more of them, but Until I had two accidents at work (due to health and safety faults of the compnay I worked for)I now see things in a different light. while trying alsorts of treatments and getting no were fast and infact getting much worse, more and more pain and symptoms, I could not understand why, I didn't what to feel worse, I wanted to get back to work and a normal life, as promised by many a doctor/nurse. I have found out after about 9 years I have Fibromyalgia, after years of basically having this test and that, this treatment and that, some in fact causing more pain and problems, more flares, adding new problems each time, to add to the distress of it all, basically being told, 'its all in my head' etc... I get depressed due to the intense extreme pains I suffer and the never knowing when or where and how bad these flares will come, I can suddenly 'crash out' shaking, shivering and having to lay down, that I have also been told Morphine will not touch the pains I suffer! I am not depressed when the pains are less intense and I've had a short break of extreme ups and downs of symptoms, only a naturally response to anyone with any painful condition that lasts a long, long time. I would like to say to those Doctors that have added ME/CFS/FMS to their lists, I just hope you or a close member of your family never suffers, from any of these Diseases, maybe if they learn't more about these illnesses, they could save so many people suffering unnessary distress of being told 'to get a life' or 'its in your head' I'm not a person that likes taking meds of any sort, I would much prefer my old, healthy, fit life back any day than to take a cocktail of medication daily. Fibromyalgia sufferers have a wide range of problems (check site http://www.fibrohugs.com/html/list_common_symptoms.html if you are not sure what most of us sufferers have to put up with) and each time a flare erupts, new symptoms can appear, a flare can erupt, due to stress, that could mean a doctors/nurses hurtful words of 'get a life' 'it's in your head' and not believing a sufferer etc might actually be making the patient worse. I'm sure this is not what the medical profession is about, its making people better or more comfortable, where a cure is not available We don't want loads of sympathy, just to be treated in a respectable way and not ignored. I'm glad to see many Doctors/nurses are in this group, lets hope FMS Awareness Day will add more to this growing band of medical persons that believe and treat us with some of the list of helpful medications and other treatments, to improve our lives. I have always been lead to believe, disease is something that impairs normal function of the human body. My Cassell Concise Dictionary has this about the meaning of disease: any alteration of the normal vital process of humans.... under the influence of some unnatural or hurtful condition. I rest my case! I doubt very much this letter will be published, but I've written it in the hope, that it will and that those that have a difficuitly in believing this is a disease, can hear it from the horses mouth. Thanks Elaine Millard
Shame 16 April 2002
Marc G M van Impe, senior editor B3071 Erps-Kwerps Send response to journal: Re: Shame	Sir, shame on you. I always considered the British medical press as one off the few reference points in the rude world of scientific publishing. Now I must admit, that after 34 years as a professional journalist, I made a fool off myself. Since a couple of years I had some considerations, now I realise my European colleagues are right: the UK medical profession is in the hands of quacks, preposterous fools and nitwits. It is not for nothing that British patients, who can afford, choose to travel to Belgian hospitals for treatment and due professional care. Reading the responses on your poll I have the strong impression that medical science in the UK became the “business” of psychoanalysts, piss watchers and pendulum readers. More, an editor who indiscriminatingly publishes the results of such a poll is unworthy to call himself a journalist. Excuse my English, but I do read, speak and understand English very well. I wonder if you Sir, and your colleagues ever read something that is not written in the Queens language? We do and know better. If so, you would not dare do act this way. Sincerely yours, Marc G. M. van Impe Senior contributing editor to Het Nieuwsblad, de Financieel Economische Tijd, Solvay Business Magazine, former chief editor of De Huisarts (General Practioner) , and editor to Artsenkrant. Past member of the Belgian National Press Council. N797 National Press registry.
GP's with NON-DISEASE ailments 17 April 2002
Vikki Crawford, Fibromites with additional chronic back pain and scoliosis. Home Ayrshire,Scotland. KA29 0BB Send response to journal: Re: GP's with NON-DISEASE ailments	As a sufferer of Fibromyalgia, I see that 8% of GPs think it is a non -disease. I'd suggest that 99% of fibromites see GP's as suffering from a few non-diseases themselves. Ignorance for one-and how about laziness for number two? Why investigate new illnesses when its SO much easier to treat coughs and colds with the standard response "It's a virus,theres nothing I can do for you". Why put yourself out when you can claim your £60,00 p/a plus expenses by letting a standard response trip off your tongue? And really,to class fibromyalgia/endometriosis etc with the like of baldness shows the ignorance to a greater degree I'm afraid. I know of no-one with fibro who would rather have this than live a full life,who would rather live on the pittance benefits bring in, compared with the wages of £25,000 and upwards that they could earn ? The fact that so many people with this and similar ilnesses have said that they wouldn't wish this on their worst enemy, not even the ignoramuses who filled in the poll, should show how bad it is. If it wasn't that bad,we'd be wishing it on people left right and centre. But maybe I'm a malingerer-the way they're trying to imply I am. I suffer low back pain, fibromyalgia, anxiety and depression-hey,maybe they should shoot me,then I'd be less of a burden to the NHS and the DHS- is that what a report like this is supposed to do? MAke the Govenment look good by being able to say that there's a drain on the economy by people like me who need the essential services,yet who don't even suffer real diseases? This report angers me and I'm quite sure the BMJ can count on a barrage of e-mails and a back lash in terms of the various support groups getting up in arms. Maybe the BMJ will be decent enough to do a FULL report on these illnesses named in its Poll and re-class them in a way that will not OFFEND as many people as I'm sure they have done but this article. It may take a decent decade to become a qualified doctor,but it only takes one pig headed brain cell to make you ignorant. Vikki Crawford
FIBROMYALGIA 25 April 2002
Sylvia M Mills, Disabled 27,westway,Luton,Lu28Dz Send response to journal: Re: FIBROMYALGIA	Let those with compassion prevail. One day it might be you!.
FURTHER DEFINITION OF A NON-DISEASE 15 May 2002
RAJKUMAR K CHETTY, Specialist Registrar, Dept.of Clinical Biochemistry Russells Hall Hospital, Dudley, West Midlands DY1 2HQ Send response to journal: Re: FURTHER DEFINITION OF A NON-DISEASE	I am surprised that obesity, alcoholism and smoking do not figure in your list of top 10 'non-diseases'(1). In my view, the definition of a 'non-disease' should include any self-induced disruption to body function the treatment of which lies in the hands of the individual concerned rather than the medical establishment. Tobacco is responsible for one-third of cancer deaths in the western world and ,since 1971, more than $46 billion has been spent by the U.S on cancer research and the scientific community has come to realise that prevention may be the best approach to this problem!(2)Europe's public sector spends about 1 billion euros each year on cancer research while, incredibly, the european union subsidises tobacco farmers by an equivalent amount! The recent report 'Investing in Health for economic development' produced by the Commission on Macroeconomics and Health set up by WHO, says that a sum as small as $34 per capita in developing nations would be sufficient to improve health care to such an extent that 8 million lives could be saved by 2010 through treatment of malaria, TB, childhood infectious diseases, AIDS and tobacco-related illnesses. It is estimated that economic benefits of this investment will be $360 billions per year by 2015-2020 (3). In reality, we are more inclined to develop expensive treatments and drugs for 'non-diseases' as indicated by the fact that only 13 out of 1200 drugs developed in the world between 1975-1997 were aimed at tropical infectious diseases! (4). In the animal kingdom, the less fit struggle to survive. We humans, on the contrary, mount an organised effort through medical establishments to work against this evolutionary principle of renewal of a system (in this case the human society) by spending an enormous amount of resources and manpower to tackle the mortality and morbidity associated with 'non- diseases' such as obesity, alcoholism, ageing, smoking, depression etc. Stress, depression and boredom, which figure in your list of non-diseases, are direct consequences of two important man-made factors; one, meaningless prolongation of life span, and two, information overload. I feel information overload is a non-disease by its own right. We are being overwhelmed by information from all over the globe and I do not for a moment think our brains are evolutionarily designed to take on this amount of information. No wonder global sales of anti-depressants is mounting year by year! Reference: 1. Smith R. BMJ 2002; 324:883-885. 2. Editorial in Nature 2002; 416:461. 3. Editorial in Nature Medicine Feb 2002;8(2) 4. 10/90 Report on Health Research 2001-2002, www.globalforumhealth.org
Feel ashamed 26 November 2003
Victoria M Whitelaw, Accountant A Hospital EH Send response to journal: Re: Feel ashamed	Having been ill now for the past 2 years and still not knowing why, it is very reassuring to find out that doctors spend quality time slagging off their ill patients. I think its sick that you waste your time doing such a thing, Im sure if your patients found out you wouldnt be left with a job. So instead of wasting your time why not actually try treating your patients for a change. As for the "non illnesses" Im quite sure a few of you have diagnosed patients with these Competing interests: None declared
BMJ surveys dont speak for the medical profession 27 November 2003
John Hopkins, GP Newton Aycliffe, DL5 4SE Send response to journal: Re: BMJ surveys dont speak for the medical profession	Dear Dr Smith, I am sorry to read that Ms Whitelaw is unwell. It would be a shame if her distress were added to by BMJ reader's surveys which dont speak for the medical profession. Getting on for half of those who post rapid responses are not doctors and it's therefore reasonable to assume the same of readers surveys. Doctors spend no more time slagging off their patients than accountants spend slagging off their clients, which I am sure is not much. And for the same reason. If you spend all day getting annoyed at people you go home exhausted. Better just to get on with the matter in hand and leave the tub thumping to politicians. Yours sincerely, John Hopkins Competing interests: None declared