Dr. Howard Kushner: Human Health as a Problem Based Enterprise

By Katherine Lewis

Howard Kushner, the Nat C. Robertson Distinguished Professor of Science and Society Emeritus at Emory, is a highly influential figure in the field of medical humanities. He is currently engaged in teaching and research at San Diego State University’s Graduate School of Public Health and the Laboratory of Comparative Human Cognition in the Communications Department of the University of California, San Diego.

Dr. Kushner believes that humanities are at the heart of our understanding of disease, rather than just a small addendum. Using the examples of suicide, Tourette syndrome, and Kawasaki Disease (KD), Kushner discussed the importance of seeing the social trends behind medical data, analyzing the history of a disease in order to fully understand it, and organizing interventions that are effective with respect to the available treatments.

Kushner discussed the work of Emile Durkheim, a sociologist who argued that social disintegration, specifically egocentrism and social isolation, results in increased suicide rates. Durkheim failed, however, to deeply address suicides due to fatalism and altruism, which are highly prevalent in the modern world.

Fatalism occurs when one over-identifies with the group within which they belong. According to Kushner, this results in an individual blaming himself rather than his group or larger society. When such individuals are faced with a challenge which severely impacts their mental health, they are more likely to direct resulting anger at themselves rather than others. This increases risk for self-harm and suicide.

Altruism, on the other hand, occurs when one gives her life for someone else, which is highly prevalent in suicides committed by members of the armed forces. Kushner argued that the highest rates of suicide occur in the military, but they are vastly under-reported due to the fact that deaths that occur in battle are not recorded as a suicide.

Confusion about who is at risk for suicide is dangerous because without the proper and correct data, it is impossible to know which areas require the most investment in suicide awareness and prevention programs. Kushner developed this example by describing suicide rates among members of the military as well as among women. Traditionally, data has suggested that men are at higher risk for suicide than women. Kushner, in contrast, argued that these data are misleading because for every 4 attempted suicides by men, there are 6 by women. This difference is heightened by social conceptions of masculinity and femininity.

While is most common for men to commit suicide with a firearm, women are more likely to use poison. These deaths contribute to misinformation because a woman who poisons herself may not die until several days later, in which case the death may not be recorded as a suicide. Kushner also argued that the suicide of a man is viewed as an offense against a person, while the suicide of a woman is seen as an offense against her family–a dichotomy which further reflects societal sexism and gender stereotypes. According to the American Foundation for Suicide Prevention, men die by suicide 3.54 times more often as women, but “adult females reported a suicide attempt 1.4 times as often as males.” Only by understanding who is at risk in what has been called the ‘suicide epidemic’ can we address the problem with any hope of success.

Besides using humanities to evaluate the social complexities of data, Kushner also discussed the importance of history as a crucial tool in the medical field using the example of Tourette syndrome. Formerly, doctors believe that Tourette syndrome, which is marked by rapid, non-voluntary movements, was caused by an over-abundance of dopamine in the patient’s brain. In response, psychotics were prescribed to reduce the transmission of dopamine, which effectively reduced symptoms, but became a massive burden for the mental health of the patient. Many patients began to self-medicate with drugs such as tobacco, alcohol, and even opioids. Only by examining the history of the disease over a larger time frame were researchers able to discover an association between movement disorders and rheumatic fever, which may explain some cases of Tourette’s. In this case, extreme psychotics were not necessary, and the resulting damage to the health of the patient could easily be avoided.

In order to design effective social intervention programs, such as those for suicide prevention, it is crucial to understand what the population is actually experiencing, even if the data may conceal this at first.

Research into the relationship between rheumatic fever and Tourette syndrome was extremely difficult to perform given the fact that it directly opposed an established paradigm of understanding. Kushner and others attempting to perform this research struggled to obtain funding for their grants because many granting agencies were convinced by the neuro-transmitter theory of Tourette’s. This difficulty points to a larger issue in research funding and our acceptance of new ideas. Kushner stated: “The competition is not just over ideas. The competition is over money.” By refusing to challenge established paradigms, doctors and researchers will miss crucial opportunities for medical advancements.

Finally, Kushner discussed the importance of effective medical interventions with a case study of Kawasaki Disease (KD), a 5 day fever which occurs at exceptionally high rates among Japanese Americans. When untreated, Kawasaki disease can lead to coronary artery aneurysms (CAA) and can be fatal.

San Diego has high rates of reported KD, which Kushner attributed to the city’s efficiency at diagnosing it rather than an abnormally high presence of the disease itself. Since the doctors in San Diego were highly familiar with the disease, mortalities associated with it dropped significantly because it was diagnosed early and treatment was prescribed rapidly. In contrast, the disease may be equally prevalent in other locations, but goes undiagnosed because doctors are unfamiliar with it. The deaths, then, are misrecorded and the actual prevalence of the disease is understated. Kushner argued that teaching medical professionals how to recognize, diagnose, and treat a disease is a more effective public health strategy than spending millions of dollars to find the molecular cause, if there is still no viable treatment associated with that cause.

Kushner discussed the role of humanities and history within the medical field while critiquing the way that modern medicine is shaped by tradition and economic limits. In order to design effective social intervention programs, such as those for suicide prevention, it is crucial to understand what the population is actually experiencing, even if the data may conceal this at first. This understanding can only come with an understanding of the historical prevalence of the disease as well as the social factors with which it is associated.