Editor's Note
Root Causes
I remember the first time I encountered the word “etiology.” During my first year of medical school in microbiology class, I learned that the beta hemolytic streptococcus bacterium was the etiology of scarlet fever and strep throat. Derived from a Greek root meaning “giving a reason for,” etiology seemed like such a neat, tidy concept, especially when applied to infectious disease. You got infected with strep bacteria and, bingo, you got strep throat—simple causation like pushing over a domino.
But I soon found out that etiology is complex. For infectious disease, it is an intricate weave of infectious agent and infected person. Whether a streptococcus is successful in its nefarious schemes depends not only on what throat it encounters but also on who the victim is and where he or she lives. A strep throat turns out to be the result of a perfect storm of factors, scientific and social.
The traditional medical school study of etiologies focuses on the microbiological, the biochemical, and the physiological. Yet lurking behind most disease, infectious and otherwise, is a raft of causes as potent as strep. They are stacked in a causative chain, a line of dominos one ready to fall against the next, triggering a deadly concatenation. Worldwide, poverty underlies them, and the force that knocks over the poverty domino is power. In a recent report, the World Health Organization explains it this way:
The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of people’s lives—their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities—and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a “natural” phenomenon but is the result of a toxic combination of poor social policies and programmes, unfair economic arrangements, and bad politics.
The etiology of disease eclipses cell receptors and antibodies; it includes politics, economics, and sociology. Finding ways to treat patients when these are the root causes of their disease is like being in a Minoan labyrinth with doctors, health care workers, politicians, and economists all wandering the aisles of the maze looking for solutions. It makes one yearn for a simple, clean penicillin prescription that will make it all better.
Looking for a way through that maze, Minnesota Medicine gave a virtual check ($64 million) to many of this month’s contributors and asked them how they would use it to solve these etiological puzzles. They spent the money on education, on children, on technological infrastructure, on neighborhood design, and on homelessness. Nobody mentioned MRI machines or cardiac cath labs. Their solutions are very unglitzy but very important.
The days of most physicians are packed with the search for etiologies so they can prescribe treatments, some of us reaching for prescription pads, others for scalpels. But the patient with strep will only respond to treatment if she can find a doctor, if she can get to a doctor, if her parent cares if she’s sick, if she can afford any of the treatment, if…. We need to not only pick the right antibiotic for the right bacteria but also address the giant “ifs” that can foil the best of treatments.
Charles R. Meyer, M.D., editor in chief
Dr. Meyer can be reached at cmeyer1@fairview.org