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ANOMALY AND PARADIGM JOSEPH HERMAN* Old paradigms never die; they simply fade into special cases of the new. Despite Columbus and his intrepid men, and so long as we stay close enough to home, there is nothing wrong with surveying our property on the assumption that the earth is flat. Plane trigonometry, then, can serve as a good approximation to that which holds true on the surface of a sphere if the numbers involved are sufficiently small. In medicine, on a busy day, even the most loyal proponents of the biopsychosocial model [1] would yield to the temptation to prescribe amoxycillin for a stranger with fever, headache, and a sanguineous nasal discharge . They might well do so without inquiring after his marital status or his wife's health, information that, in other circumstances, could be of critical importance. Thus, the biomedical paradigm can be used to cut corners within a broader, more satisfying framework. Two anomalies have been credited with contributing to the intellectual overthrow of biomedicine: placebo effect and differential morbidity [2]. I shall discuss them briefly and then point out a third anomaly that has not received much attention: differential susceptibility to treatment. Placebo effect has been defined as a response to the form rather than to the substance of therapy [2]. On the one hand, it may be looked upon as making a mockery of medical science, suggesting that people "get well anyway." On the other, it may be regarded as the ultimate tribute to doctors' interactional skills and a primejustification for the long years of training they undergo. The placebo effect is almost certainly a function of expectations, both on the part of the patient and of the doctor. We are inclined to think of it as more pronounced among the unsophisticated , on whose superstitions and suggestibility it preys. But might it not be at its worst there, where people are so oppressed by daily hassles that they cannot put their trust in medicine [3]? It is the affluent and *Department of Family Medicine, Ben-Gurion University of the Negev, Beer-Sheva, Israel. Correspondence: 42 Harav Uzziel Street, Bayit V'gan 96424, Jerusalem, Israel.© 1993 by The University of Chicago. AU rights reserved. 0031-5982/93/3602-0796$01.00 258 Joseph Herman · Anomaly and Paradigm the better educated who have more to live for and who are impelled by the will to believe. The placebo effect requires a modicum of understanding between physician and patient, something that comes more easily of a common social background than of hermeneutic exploration [2]. The very act of compliance—with or without instructions for ingesting active or inert substances—has been shown to be a marker for better outcome [4]. One of the conditions under which placebo effect is maximized is fulfilled when the patient, as a result of the healing intervention, acquires a sense of mastery and control over the illness [2]. This requirement is more likely to be met when the subject is not undergoing undue economic hardship. A second condition, that a group of individuals assuming socially sanctioned caring roles be available to provide support, also has, unfortunately, class overtones [2]. The ubiquity of agents of disease, ranging from defective genes through viruses and bacteria to risk markers associated with lifestyle and environmental pollutants, suggests that pathology should be evenly distributed in exposed populations [5]. This has been shown not to be the case. In one 20-year follow-up of women of the same age and from similar socioeconomic backgrounds, it was found that 52 percent of the illnesses clustered in a quarter of the subjects. Furthermore, the healthiest quartile accounted for only 6 percent of all diagnoses. Among those who fell ill most often, malignant, infectious, metabolic, and degenerative diseases were encountered, with some women having more than one kind of disorder along with a higher frequency of mood, thought, and behavior disturbances [2]. A model which seeks to understand disease on the basis of specific moleuclar derangements cannot explain such differential morbidity. If a 35 percent effectiveness of placebo comprises a challenge to biomedicine [2], then so does the fact that agents with well-defined mechanisms of action benefit only 70 to 80...

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