“A PRAGMATIC MODEL OF HEALTH AND DISEASE UNDER THE INTEGRATIVE PARADIGM

J.C. Meeroff, MD. PhD Clinical Associate Prof of Medicine UM and FAU

“Everything in excess is opposed to nature.” Hippocrates of Cos
"I fear the day that technology will surpass our human interaction, the world will have a generation of idiots." Attributed to Albert Einstein

INTRODUCTION

Life and living are very complicated issues for which we do not have straightforward answers. We know that modern Homo Sapiens have consciousness and with consciousness come uncertainties and anxieties originated by the fact that we still don’t know the purpose and meaning of life (Lanza 2016). We also recognize that the pattern of diseases changes from generation to generation: some diseases disappear while new ones emerge and others occur in a different manner. In general terms, our current situation is that we suffer more from slow accumulation of damage rather than from acute attacks of strong external agents (Sapolsky 1994). We also recognize that when confronting a disease, the body has mechanisms to heal itself and to return to “normality”. This alleged spontaneous healing is assumed to be synchronized via the subconscious mind, while the conscious mind seems to interfere with self-healing mechanisms (Weil 2000).

Different societies and schools of thought have proposed conflicting theories to the vital questions of human life, but in general terms most of the Anglo-Saxon western ones accept the Cartesian dualistic viewpoint that humans are structured in levels or components combined into two main categories: the material aspect of life including body and energy and the immaterial aspects of existence comprising mind, soul and spirit (Hart 1996, Ross 1992, Diley 2004). Moreover, some schools of thought such as

physicalism (Kim 2005) deny the existence of the immaterial aspects of man (Novak 1979). Obviously, this is a very complex philosophical and theological subject for which we cannot offer precise answers yet (Einstein1949; Kostro 1998; Heil 2003, 2012) and a detail discussion of this puzzle is beyond the scope of this presentation. Nevertheless, and for practical purposes, we can set aside those controversies since Medicine is focused on the art and science of using scientific and non-scientific methods to diagnose, prevent and treat diseases of living human beings (Saunders 2000). In recent times, medicine, based on the biomedical model proposed in the early 1900s after the Flexner report (Flexner 1910; Berliner 1975) has been limited mostly to interpreting the damage that disease produces to the different parts of the body and on the treatment of problems affecting the body as a broken mechanical unit (Badash 2017). As such, the biomedical model that follows reductionistic cartesian dualism (Gold 1985, Mehte 2011) has solved many crucial health problems but in recent years it has reached an impasse on the subject of clinical effectiveness. Conventional Biomedicine is now very expensive, too cumbersome , partially inefficient and showing signs of phylosophycal disorientation (Engel 1977; Caplan 2004; Giordano 2007;). It became more materialistic and tends to ignore the mind, implying that the mind may be just a mechanical function of the brain (Taylor 2012). Unfortunately and as consequence, public trust in Biomedicine has deteriorated (Blendon 2014). To the rescue and to partially solve the problem, Integrative Medicine proposes to fill the gap by viewing the material and the immaterial components of humanity as intertwined elements of a complex system, as it is proposed by Eastern and indigenous medical models (Farre 2017, Robbins 2011). Modern Integrative Medicine also takes advantage of scientific discoveries from quantum physics in the direction that observation affects reality. This supports the notion that the mind can modify what happens to the body (Stapp 2007). In the struggle to accomplish wellness, Integrative Medicine is not a new player. It was practiced in the East as well as in the West since ancient times. Unfortunately, and for reasons beyond the scope of this article, it was partially displaced during the 20^th century by flexnerian Biomedicine (Almeida-Filho 2001). Here we want to share what we have shaped up in terms of theory and practice of contemporary Integrative Medicine. Not all the ideas and concepts that we will present here are original or new, but by assembling the experience and knowledge of others and adding our own, we came up with a pragmatic model that explains the way we, biomedically trained physicians, practice contemporary clinical medicine (Orgaz 1950; Meeroff, M. 1992, 2004; Meeroff J.C.2007). The best feature of this open model is the fact that it doesn’t require the total rejection of the conventional biomedical model. It will suffice just to adapt it to the present latitude of knowledge.

THE suggested FUNDAMENTAL COMPONENTS OF A HUMAN BEING

Following modern non-Cartesian substance dualism (Lowe 2006) but in a very simplistic, tentative and pragmatic way we can separate the two aspects of humanity as follows:

MATERIAL (PHYSICAL PLANE): 1. BODY; 2. ENERGY

· BODY = Atoms, molecules, cells, tissues, organs, systems, circulation

· ENERGY = Electrical fields, vitally, activity, motion

IMMATERIAL (METAPHYSICAL PLANE): 3. MIND; 4. SOUL; 5. SPIRIT

· MIND = Cognitive process, consciousness, sub-consciousness, mental, thoughts, understanding.

· SOUL = Wisdom, behavior, feelings and emotions.

· SPIRIT = Core “I” force that animates and maintain perennial existence, supra-consciousness, supra-mental component controlling, character, personality, premonitions, and intuition

Under the above conceptual scheme, the human being can be viewed as a complex system with numerous interacting components whose aggregate activity is nonlinear, that is not the result of the summation of the functions of the individual components and typically exhibits hierarchical self-organization under cybernetic conditions (Mordacci 2004).

A human being can be considered as the whole integration of the following components (for examples we use the digestive system):

1. Body parts (architecture, structures, units).

· Ex: gastric mucosa containing gastric parietal cells, gastric chief peptic cells, gastric mucus cells, etc.

2. Functional connections among the units (spatial and temporal relations, communications, network).

· Ex: circulating hormones such as gastrin, insulin, glucagon, etc.; released neurotransmitters such as acetylcholine, epinephrine and dopamine.

3. Particular specific functions to act in a certain way (specific functions, tasks, contributions, responsibilities).

· Ex: secretion of gastric juice containing HCl, pepsin, IF, etc.

4. Activities to accomplish an overall systemic process (general actions, purpose).

· Ex: digestion of food

During life the physical components of the person integrate completely with the mind and the soul to form a complex unity which has been called “soma” (Shusterman, 2008, 2012) and is also compatible with John Dewey’s body-mind philosophy of non-dualistic naturalism (Shelton 2013, Gendle 2016).

The opposing view , that is monist, indicates that “body and mind are an essencial unity in which mental life emerges from the body’s more basic physical and psychophysical functions rather than being superimposed on the soma by transcendental powers of reason emanating from a spiritual world beyond nature (Shusterman 2008).

Making it simple we have two different windows to observe the world:

Gnostic or dualist where the person is formed by a material part (body, energy) and the inmaterial part (mind, soul, spirit)

Agnostic or monist where everything is soma and where cognition derives for a specialized function of the brain

Nevertheless and setting aside the philosophical disputes, both position may lead to the same practical conclusion: in life body and mind (cognition) are an integrated unity.

BASIC PRINCIPLES OF INTEGRATIVE MEDICINE

In the Integrative paradigm of Medicine, health and disease are not just the static opposite ends of one continuous linear dimension. On the contrary, they represent relative states of homeostatic dynamic balance strongly influenced by personal values, feelings, structural body composition, genetic influences, and social and spiritual characteristics of the environment where the individual exist (Hungelman, 1992). Theoretically it is impossible neither to reach a state of perfect health nor to be in a state of total disease (Dubos 1959). A human being is a unique combination of health and disease plus abilities and disabilities, both emotional and physical. The body, the mind, the soul and the spirit, since they are strongly interconnected during life, adjust in a constant state of dynamic balance to coexist in a meaningful and almost stable equilibrium. Health and disease refer to variations in the operative network of the individual human being. Finally, it is important to understand that in clinical medicine arithmetic average “normality” not always equates with health as Christopher Boorse proposed (Boorse 2004), therefore what is healthy for one individual may be unhealthy for another (Nordenfelt 1987). For instance, having three bowel movements a day with soft stools may represent diarrhea, constipation or “normal” bowel function according to the different physiologic, psychological and sociologic circumstances surrounding the presentation of such cathartic frequency.

Conceptually Integrative Medicine is the response to some of the limitations of the conventional Biomedical Model of Medicine (Baer 2004; Beck 2004; Quirke 2008). In attempting to formulate such medical model, the most important intellectual challenge is not to completely break links with the old model but instead, to incorporate into the model contemporary science based on the systems view of life (Von Bertalanffy 1976; Maturana 1991; Varela 1974), new technology supported by evidence based medicine and medical quality improvement concepts and methodologies (Parker 2007; Varkey 2007), as well as the necessary elements of the human and social aspects of life (Fromm 1955; Fabrega 1975; Fontanarossa 1998; McInervey 2015). It is also important to include lessons learned from the non-cartesian substance dualism theories (Lowe 2006), from the eastern models of Medicine (Tsuei 1978 ), from quantum and space-time models of health (Dossey, 1982, Salata 2004), from modern naturopathic medicine (Zeff 2005), from indigenous native healing traditions (Koithan 2010) and from many other forms of mind-body theories (Elkins 2010) .

Under the Integrative model, Medicine is:

ü Comprehensive, that is including all material and immaterial aspects of the human existence

ü More qualitative than quantitative

ü Wellness oriented and not business oriented

ü Anti-bureaucratic, scientific and progressive

ü Distant from special interest advocacy and not used for preserving social privileges. (M. Meeroff 1996; J.C. Meeroff 2007)

ü Cultural, regional and generational

The Integrative Medical model introduces a pluralist, eclectic, pragmatic, inclusive, and scientific paradigm as follows:

ü The human being is not an unsophisticated simple mechanical device, but a complex biopsychosocial entity integrated in the universal Gaia (Margulis 1998).

ü During life, living individuals are characterized by a complete integration of body, mind, soul and spirit in a way that modifications in one of the components influences the others (Bateson 1980). This symbiosis concludes with death, when body and spirit may take different directions (Parnia 2006)

ü “Medicine is psychosomatic or is not Medicine” (Meeroff M 1992),

ü “Medicine is a biopsychosocial activity” (Engel 1977, Carpenter 2017)

ü The role of the physician is to understand the biopsychosocial disturbances afflicting individuals as well as assisting them in their struggle to reduce suffering and to regain functional dynamic balance.

ü Disease is the result of perturbations that cause imbalance and not just the sole effect of external agents

ü Different social groups require and favor different approaches to their medical problems (Juckett 2005, Meeroff JC. 2007)

· A sick individual is an emergent, that is a unique living organism where the whole is different of what can be assumed by the summation of the activities and properties of the parts (Dacher 1995), and this emergent has a flexible identity (Bell 2002)

ü Patients must actively participate in their health care not just be passive receptors of the treatments prescribed by doctors

ü Physicians must be interested in both, the elucidation of the biological mechanisms of diseases and the quality of life of their patients.

ü Physicians must be divergent and creative in order to understand the patient’s problems.

ü The use of modern technology is not just a tool for scientific advancement, but also an approach to help patients

ü Medicine is not and industry nor a commerce, it is applied science at the service of the individual, the family and the community (Meeroff JC, 2007).

ü “Neither evidence from randomized controlled trials nor observational methods can dictate action circumstances. The practice of modern medicine is the application of science, the ideal of which has the objective of value-neutral truth” (Saunders 2000).

ü Physicians must be technically specialists, clinically generalists and sociologically humanists.

For the Integrative model it is inconsequential if body, mind, soul and spirit have a common origin and/or structure or not, what matters is the assumption that they coexist in an inclusive interconnected system representative of life. The integrative paradigm doesn’t require any postulations about the ultimate composition of matter nor does it need to adhere to the chimerical idea of the theory of everything. Furthermore, the integrative paradigm, by being pluralist, is beyond the material/inmaterial dichotomy. Currently, we still have great difficulties in understanding the immaterial aspects of humanity; it should remain a question for future investigation, discoveries and revelations (Maller 2007, Lanza 2016). Nevertheless, this uncertainty doesn’t interfere with the practice of contemporary clinical medicine under the integrative paradigm.

For the Integrative model, it is not required to accept an exclusive reductionist approach to biology, but it is essential to take advantage of the analytical methods coined by Cartesian-Newtonian objectivism (Wilson 2000). The important concept here is to understand that complex systems such as the human being can be deconstructed to analyze their parts, but the overall activities of the system may not be manifested and/or recognized by the sum of the isolated functions of the parts. Finally, as clinicians we must emphasize that the key role of medical providers is to help our fellow humans to experience life in the best possible circumstances and for the longest period conceivable.

THE CONCEPT OF THE DYNAMIC BALANCE CHARACTERISTIC OF LIFE

Humans are constantly exposed to demands (stressors) imposed upon them (Aldwin 2007). According to the origin, stressors can be external or internal; according to the characteristics they can be physical (such as hypothermia), chemical (such as inhaled carbon monoxide), psychological (such as uncertainties of life and death) and/or social (such as struggle for integration among migrant people). Upon those demands, humans must adapt their operational mechanisms to maintain a healthy balance. Humans respond to imposed demands with allostasis that is the process of insuring viability in the face of challenge (Sterling 2004; Schulkin 2003; Kuzawa 2005; Magnum 1997). Stress is a feature of human life and is neither positive nor negative per se. The result depends on the magnitude of the demands and on the coping abilities of the person to handle those demands. (Aldwin 2007; Sapolsky 1994). What is clear, is that the cumulative magnitude of internal and external stressors is increasing in our post-modern society.

Eustress is the positive response to imposed demands. Here the stressors are given in quantity and quality that can be managed by a coping able individual. Conceived as such, eustress not only help maintaining balance but can also induce enhancements in physiological and psychological functioning. (Dhabhar 2014)

Distress, on the contrary, is the negative response to stressors. Here the demands can’t be handled by the individual: demands are too strong, they are acting for too long periods of time, they come too soon, and/or the coping abilities of the individual are too weak and/or inefficient. In other words, the demands exceed the capacity of the individual to cope, regulatory mechanisms become faulty and the individual eventually get sick or ill (unwellness).

Demands (stressors) can be ignored, avoided and/or controlled (adaptation and transformation). In those circumstances the demands are not harmful, instead they may generate eustress. But if imposed demand(s) produce distress, sooner or later the person will cease to be in a state of wellness and disease will prevail.

EXAMPLES OF DISTRESSORS CAUSING UNWELLNESS

The following are examples of some common situations that produce external and/or internal distress triggering disease:

ü Not enough good sleep: excessive uninterrupted consciousness, too little subconsciousness

ü Unsanitary conditions: excessive exposure to pathogens

ü Poor diet: excessive caloric intake causing metabolic syndromes

ü Exposure to dangerous environmental conditions: excessive exposure to toxic material(s) causing degenerative diseases, cancer

ü Inertia and sedentary life: excessive buildup of insoluble material that can produce cardiovascular diseases

ü Unhandled physiological factors: excessive mood changes causing anxiety, depression, neurosis, psychosis, even early death

ü Physical trauma: injuries causing hard and/or soft tissue lesions

ü Congenital factors: genetically inherited structural and/or functional mistakes causing diseases such as cystic fibrosis, Marfan syndrome, coarctation of the aorta and many others.

ü Potentially addictive substances and behaviors: flooding the brain with disproportionate high levels of dopamine

ü Social lack of integration: unwarranted behavior such as victimization, discrimination, and percussion yielding to psychosomatic disorders such as irritable bowel syndrome, migraine, hypertension and others.

THE INTEGRATIVE CONCEPT OF HEALTH AND DISEASE

The orthodox Biomedical Model follows the Disease/Illness/Sickness trilogy paradigm (DIS). In DIS, everything is defined in a mechanistic fashion as follows: disease is the “objective” body malfunctioning, illness is the “subjective” response of the patient to the malfunctioning and sickness is related to the social role a person with illness or sickness takes or is given by society (Boyd 2000; Twaddle 1973; Taylor 1979; Wilkman 2005). In DIS there is not only a clear separation between organic, mental and social spheres but also a temporal relationship among the DIS components: disease leads to illness and illness leads to sickness (Hoffman 2002).

For the orthodox version of Biomedicine, a disease can be viewed independently from the person who is suffering from it and from his or her social context. Each disease has a specific causal agent, and it is the goal of the physician to discover them and to administer specific remedies aimed at removing the cause or relieving the symptoms. The physician is a detached investigator, and the patient is a passive, grateful recipient of care. (McWhinney 1988; Wilson 2000)

In the integrative proposed model, a different paradigm that is better tuned with today’s experiences in clinical medicine is used. It goes as follows:

Health (Wellness)

Health is defined as a state of dynamic balance leading to a stable bio-psycho-social condition of well-being and to a harmonious interconnectedness of the person with the environment, with nature and with the universe. Health is balance and harmonious functioning of both the material and the immaterial aspects of life (Saracci 2011). In Health, the material body (molecules, cells, tissues, organs, systems) and the immaterial constituents (consciousness, subconsciousness, ideas, thoughts, feelings, perceptions, awareness, purpose) are constantly maintaining a stable dynamic interrelation, allowing the person to operate in a meaningful and self-satisfying physical, psychological and spiritual manner. Health means harmonic balance in motion. A healthy individual is one who can adjust her/his operative network to continue functioning in an efficient and self-satisfying manner. “The healthy individual is well-functioning as a whole, in harmony physically and mentally with himself and with his surroundings” (Mordacci 2004)

Disease (Unwellness)

Disease represents a deviation from the somatic, psychic, social, and spiritual dynamic healthy balance. Disease is a multifactorial process that occurs when the individual is incapable of handling demands (distress, overload). Clinically, disease can be acute or chronic. We call “sickness” when it is acute and temporary and “illness” when it is chronic and long-lived

Sickness

Sickness is a situation of sudden and temporary inability to maintain the state of dynamic balance. In sickness the overload is unexpected, intense and/or very aggressive therefore it acutely disrupts normal healthy stability causing symptoms. In sickness disturbances on the architecture, connections, functions and the overall performance of the system are temporary and not developing in progressive phases but overlapped among themselves. In sickness physical signs may or may not be present. For example, a common cold occurs with symptoms such as earache, headache, and malaise as well as signs such as productive cough, nasal discharge and elevated temperature. Contrarily, acute gastritis may present only with symptoms such as abdominal pain, pyrosis and nausea even in the absence of endoscopic signs of gastric inflammation. In Sickness, due to the sudden and temporary characteristics of the process, the patient’s systemic network is not seriously damaged and frequently therapy can be accomplished just by targeting the temporary changes discovered in end organs.

For practical clinical purposes we propose that sickness be split into three overlapping stages:

Offensive stage (incubation period and disease activity). Here the aggressor is winning the contest. In this stage, as a consequence of the intense overload, there is an intensified activity of the sympathetic nervous system (SNS) and the hypothalamic-pituitary-adrenal axis with increased dopamine and adrenaline release. This allostatic response stimulates the glands and organs that will eventually defend the body against attack. The SNS is catabolic, it can destroy the aggressor, but it can also tear down body structures and/or connections if it is over activated (Eyer 1977). Here energy is used to prepare for defense, rather than for nourishment or for elimination of wastes. The offensive stage is characterized by specific symptoms according to the type of sickness involved (localized pain, pyrosis, pruritus, etc.) and non-specific symptoms and signs such as vasoconstriction (cold extremities, hypertension, tachycardia), anxiety, insomnia, anorexia, glossodynia, parageusia, dyspepsia, nausea, flatulence, diarrhea, and mydriasis.

Defensive stage (exudative remedial phase). In this stage the patient is neutralizing the effects of the overloading-imposed demands. The allostatic defensive responses are adequate and enough to withstand distress. Paradoxically here, the symptoms and signs became more evident and notorious, causing concern to the patient and to the family. In this counter-attacking stage there is a dominance of the parasympathetic nervous system ( PNS). The PNS control actions designed for nourishment, tissue restoration, elimination of foreign agents and regeneration of the body. The defensive stage is more anabolic than the offensive one and involved with rebuilding the short-term damages that may have affected the structures and/or connections of the body. The defensive stage is characterized by vasodilatation (warm extremities, bradycardia, hypotension), tiredness, hypersomnia, increased perspiration, fever, constipation, and miosis.

Stabilizing stage (return to balance, adaptation, transformation). In this stage, the person has controlled, eliminated and/or neutralized the stressors, the defensive allostatic response is finished, and she/he is ready to re-establish a new state of homeostatic balance that is characterized by “normotonia” with sympathetic/parasympathetic balance and steadiness. The symptoms and signs disappear, and the patient feels fine.

Clinically, to treat sick persons, practitioners must use a pragmatic combination of deduction and intuition to fit the individual case (Sledge 1997). The objective is to help the patient to return to the state of dynamic balance as soon as possible. This is done by: A. Eliminating the source of the imposed demand, and B. Improving the allostatic defensive responses

A1 Eliminating a direct source of aggression.

o Example 1: treating a bacterial upper respiratory infection (external source of stress) with antibiotics.

o Example 2: treating a ST-Elevation Myocardial Infarction or STEMI (internal source of distress) with percutaneous coronary intervention or PCI.

o Example 3: performing a cholecystectomy to treat a case of acute calculous cholecystitis (internal source of distress).

B1 Increasing the defensive ability of the organism to withstand stressing overloads.

o Example: prescribing Echinacea-goldenseal, bed rest with good sleeping hours and supplementing with vitamins to improve cellular immunity while simultaneously combating a viral upper respiratory infection with oseltamivir.

B2 Using safe sympatholytic and vagotonic pharmaceutical agents such as beta blockers, diazepam, clonidine, gabapentin, zolpidem (Gao 2010) and /or phytopharmaceuticals such as lemon balm, kava-kava, valerian root, avena sativa, passionflower, wormwood, angelica, lobelia, lavender, all agents that can help keeping the SNS under control.

o Example: Using diazepam or other muscle relaxants to treat lower back pain.

B3 Using acupuncture, acupressure, reiki and other similar therapies to modulate and restore the SNS/PNS equilibrium.

o Example: Applying acupressure to point 6 to relief dyspepsia in a case of gastroesophageal reflux

B4 Setting in motion compensatory mechanisms to return to a healthy state of dynamic balance.

o Example: increasing fluid intake to replace lost water and electrolytes that are responsible for the hemodynamic imbalance caused by an episode of acute bacterial or viral diarrhea.

B5 Assisting the patient in dealing with the anxiety and frustration that accompanies sickness using all forms of psychotherapy, behavioral therapy and moderate physical exercise.

o Example: Engage in moderate aerobic routines to deal with the anxiety associated with chronic, active hepatitis C.

While dealing with sickness it is not necessary to totally obliterate symptoms and signs, no matter how intense they may be perceived by the patient. Most of those symptoms and signs are signals of healing since the body repairs tissue damage through the universal inflammatory response that is accompanied with edema, fever and pain (Frangogiannis 2014). Therefore, it will suffice to reduce those symptoms and signs with the appropriate doses of pharmacological and/or botanical remedies, physical therapy, etc.

It may also be valuable to use probiotics to improve the ecological community of guest and symbiotic microorganisms that colonize the body of people. The human microbiota is essential in nutrition, immunity and the function and behavior of multiple organs and systems. It is estimated that the human body hosts as many microbes as human cells or more (Sender 2016). At the moment, definitive data is still missing related to microbiota’s role in medical treatment, but it makes sense to consider replacing it when is altered (Hall 2014).

Illness

Illness represents a state in which there is prolonged or permanent imbalance of the normal healthy status. Illness is not just the subjective manifestation of disease; instead it means chronic imbalance. In illness, the coping mechanism and the simple methods used to assist the patient have failed and distress remains present for longer periods of time, collapsing the defensive mechanisms of the patient. Clinically, illness comes with psychosomatic symptoms and signs as well as social responses some of which can be measured. Clinical and para-clinical studies (laboratory tests, imaging, endoscopy, etc.) are designed to document changes in structure, connections and/or functions. Moreover, those measurements are not entirely objective as we comprehend objectivity under a mechanistic discourse: “real”, always reproducible, quantitatively verifiable, something that presumably exists independently of the subject’s perception of it. Contrarily, illness is largely affected by the perceptions and the expectations of the patient, by the intuition and the analytical reasoning of the doctor and by the significance given by the community (Robles 2005). In illness specific symptoms and signs may not be present at all, such as in some cases of early skin cancer or hypertension or they may be very obvious such as in advanced cases of chronic obstructive pulmonary disease or cirrhosis of the liver. Illness evolves through several non-linear stages that overlap among themselves. What is characteristic of illness is the persistent state of dominance of the SNS with a full array of non-specific symptoms and signs such as vasoconstriction (cold extremities, hypertension, and tachycardia), insomnia, anorexia, dysgeusia, dyspepsia, nausea, flatulence, anxiety and mydriasis. The patient is anxious and occupies most of her/his time worried with the illness and the conflicts surrounding the illness.

Compared to the healthy steady state of the normobiotic stage, where theoretically all parameters are preserved, illness progresses from simple to complex through the following stages (refer to Table 1):

Parasymbiotic stage. It occurs when, without observable changes in the structures, specific functions and/or overall systemic performance, the dynamic connections of the patient operative network has been altered but the compensatory mechanisms were sufficient to allow some form of overall systemic activity. The patient has vague symptoms but no clear signs and/or quantitative evidence of the illness other than some alterations resulting from hyperactivity of the SNS (sympaticotonia).

Paraturbiotic stage. In this stage the structures and the overall systemic performance are conserved but the network communications and the specific functions are altered. Here it is possible to detect more precise signs and symptoms but again the most noticeable ones are related to the presence of hyperactivity of the SNS

Paramorphotic stage. It comes when, to the already established changes in the network connections and the specific functions, we also find structural changes in the tissues and organs. In the paramorphotic phase the overall purposes of the system is still preserved. In this stage identifiable symptoms and signs are better recognized and some quantitative evidence of the illness can be documented and measured.

Paranecrotic stage. It arrives when, to the observable changes in the anatomical structures and network interconnections, there are also altered specific functions and the system is not functioning properly; in other words, all components of the system are affected. In this last stage the distorted activities and the disturbed biochemical composition of the tissues trigger responses that correlate with clear and evident symptoms and signs. Quantitative measurements of these disturbances are much easier to obtain than in the paranecrotic stage.

Components Phases	Connections/ Network	Specific Functions	Architecture	Overall Process/ Activity
Normobiotic	Preserved	Preserved	Preserved	Preserved
Parasymbiotic	Altered	Preserved	Preserved	Preserved
Paraturbiotic	Altered	Altered	Preserved	Preserved
Paramorphotic	Altered	Altered	Altered	Preserved
Paranecrotic	Altered	Altered	Altered	Altered

Table 1 The different stages of illness and its components

In dealing with illness it very important to realize that, usually, patients do not consult with medical practitioners until late in the staging process. Ill subjects ordinarily consult in the paramorphotic or in the paranecrotic phases, when it is, sometimes, too late to be effective.

Clinically, to treat illnesses we recommend that practitioners be pragmatic and use a combination of intuition with logical deductive reasoning to arrive to decisions (Streiner 2003) “aimed at sensing the needs of the individual person at a particular moment of the case history” (Svenaeus 1999).

First it is critical to make (if possible) a precise nosological diagnosis using all clinical and para-clinical tools available. At the bed side, it is recommended to avoid being pessimistic and/or tragic about illness, because it can shift the patient and/or the family into a state of panic. We propose that medical providers refrain from using connotations about being “terminal”, “you have days to live”, “no hope” etc. and rather be positive and empathetic. Furthermore, this is an issue related to ethnicity and cultures, so it is crucial to ask patients and relatives how they prefer to receive the information and make decisions (Blackhall 1995).

Second, it is also imperative that the patient actively participates in his/her healing process. The patient not only needs to want to be “cured” but she/he must be actively involved in adopting the necessary changes to activate the healing process. Ironically, the initial element of such process of active participation consists in mental and physical rest in order to reduce distress and to concentrate on the healing process.

We propose that illness be treated as follows: A. Eliminating direct sources of imposed demands and B. increasing internal defensive mechanisms

· A1 - Eliminating recognizable external sources of excessive imposed demands

o Example 1: stopping alcoholic abuse that is damaging the liver, the brain and other vital organs in a cirrhotic patients

o Example 2: treating an abscess paronychia with proper surgical drainage and antibiotic therapy

· A2 - Modifying internal factor(s) responsible for imbalance(s)

o Example1: performing a pyloromyotomy to solve a case of pyloric stenosis

o Example 2: using diuretics to eliminate retained fluids and electrolytes in a case of primary hypertension

· B1 - Improving internal defensive mechanisms to withstand stress overload

o Example1: using silymarin (milk thistle) and curcumin to improve liver metabolic efficiency and bile flow in a case of NASH.

o Example 2: use vaccines to improve defenses against viral diseases.

· B2 - Coaching the patient to avoid entering a state of panic. Eliminating panic does not equate to ignoring the illness. On the contrary, the effective practice will be to attack the problem with determination and confidence. If the patient enters in a state of panic, the defensive mechanisms are impaired (Hou 2011), and the illness escalates from parasymbiosis that is relatively simple to control to the next levels of illness that are far more difficult to handle.

o Example 1: getting to terms with psychological /sociological sources of distress using, psychotherapy, meditation, praying, hypnosis and any other mind-body interventions

o Example 2: trusting the medical team to perform the surgical repair of an indirect inguinal hernia

o Example 3: using moderate exercise, music therapy, art therapy, psychotherapy, breathing exercises, yoga, prayer and other mind-body therapies to “distract” the conscious mind while healing from an episode of Crohn’s disease

· B3 - Recommending the patient to rest and to concentrate on healing. While resting and allowing the subconscious to take control, the body may heal “spontaneously” (Weil 2000). For that purpose, “detaching” the conscious mind from the body may be useful. When a person is sick, there is an intensification of the sympathetic tone that is characterized by alertness and consciousness dominance with anxiety, tachycardia and elevation of the corporal temperature. While resting and sleeping well, just the opposite occurs, and there is an intensification of the parasympathetic tone (vagotonic activity) with less cerebral, renal and cardiac activity that may allow the body to “self-repair” with efficiency. “Sick individuals feel tired and want to sleep as polar bears do” (Irene Scarlata personal communication).

o Example 1: using neuropharmacological agents to control pain and anxiety allopathic drugs such as benzodiazepines or gabapentin (Gao 2010) or phytopharmaceuticals with parasympathetic activity such as hops, valerian, chamomile, Avena Sativa, Passion Flower, Kava-Kava and others to assist relaxation and decreased activity of the major body systems while recovering from a case of acute pancreatitis

o Example 2: using metoclopramide to improve gastric emptying in a case of severe GERD

· B4 – Restoring the balance of the autonomic nervous system to influence the inflammatory processes that accompany illnesses (Koopman 2011, Fisher 2009).

o Example 1: Treat with Lavender or Lobelia a patient with an hyperactive SNS that is suffering from an acute exacerbation of CUC.

o Example 2 Using beta blockers to neutralize an overactive SNS in a case of hypertension, tachycardia and angina

o Example 3 Using exercise training to control an elevated SNS activity in a diabetic patient

· B5 - Adapting and compensating the imbalances in a synergetic way that allows a return to the state of dynamic balance

o Example 1: using biofeedback techniques to modify and control external stress (hyper vigilance, hypo satisfaction) responsible for hypertension, vascular vasoconstriction, and the increased risk for myocardial infarction and/or cerebrovascular accidents

o Example 2: changing the composition of the intestinal microflora with probiotics to improve digestive functions

· B6 - Re-establishing the healthy mind/body synchronization characteristic of wellness

o Example 1: utilizing psychotherapeutical techniques to deal with reduced food ingestion after having bariatric surgery

o Example 2: engaging in moderate physical exercise (in conjunction with proper use of lowering sugar medication) to improve diabetic induced poor circulation to the legs

· B7 - Undergoing a process of self-transformation resulting in a new state of dynamic balance that includes adhering to sound hygienic principles: balanced diet, proper hydration, moderate physical exercise and good ratio activity/sleep

o Example 1: changing dietary habits and starting a low carb,, high fiber, no alcohol and low sodium diet to modify internal conditions responsible for metabolic syndrome

o Example 2: establishing new life and hygienic routines to recover from a severe concussion that occurred while playing contact sports

It is recommended to avoid the use of remedies for life, with some exceptions such as certain replacement hormones. Remember that during the initial stages of illness, as a result of the hyper stimulated SNS, the body increases its metabolic activities, elevates corporal temperature and produces energy. The body also manufactures edema in particular areas to allow increased concentration of substances necessary for the healing process. At that time it is very important that the practitioner remain composed and control the anxiety of the patient and the family. During those initial steps of mending, it is recommended not to eliminate those responses completely but just reduce their magnitude by using drugs and/or herbs with parasympathetic and slightly diuretic effects, as well as any psychological technique designed to calm and soothe the SNS( Qian-Qian 2013; Jhaveri 2011).

CLOSING REMARKS

The orthodox Biomedical model of Medicine views disease independently from the person who is suffering from it and from his or her social context. For the orthodox model, each disease has a specific causal agent, and it is the goal of the physician to discover them and to administer specific remedies aimed at removing the cause or relieving the symptoms. In such model, the physician is a detached neutral observer, and the patient is a passive and grateful recipient of care. That description is not compatible with what medical providers experience in daily practice now-a days. Furthermore orthodox Biomedicine has become complicated, expensive, and to a certain extent ineffective. As a consequence, patients demand other forms of medical care that are many times ignored by orthodox biomedicine. Here we present a medical model, a neo-dualist one, which integrates body and mind and all aspects of humanity, physical, psychological and social in a way that is better tuned with today’s practice of Clinical Medicine.

REFERENCES

Aldwin, CM (2007) Stress, coping and development. The Guilford Press, New York

Almeida-Filho, N (2001). For a general theory of health: preliminary epistemiological and anthropological notes. Cadernos de Saude Publica; 1: 753-770.

Badash, I, Kleinman, NP, Barr, S, Jang J, Rahman S, Wu BW (2017). Redefining Health: The Evolution of Health Ideas from Antiquity to the Era of Value-Based Care Cureus.7 Feb 9;9(2):e1018. doi: 10.7759/cureus.1018.

Baer, H (2004). Toward an integrative medicine. Altamira Press, Maryland

Bateson, G (1980). Mind and nature. A necessary unity. New York: Bantam Books.

Beck, AH (2004). The Flexner Report and the Standardization of American Medical Education. JAMA; 291: 2139-2140.

Bell, IR, Caspi, O,Schwartz, ER, Grant, KL, Gaudet TW, Rychener D, Maizes V, & Weil, A. 2002. Integrative Medicine and systemic outcomes research. Archives Internal Medicine; 162: 133-140.

Berliner, HS (1975). A larger perspective on the Flexner report. Int. J. Health Ser; 5: 573-92.

Blackhall LJ, Murphy ST, Frank G, Michel V, Azen S (1995). Ethnicity and attitudes toward patient autonomy. JAMA; 274:820–825.

Blendon RJ, Benson JM, Hero JO. (2014) Public trust in physicians—U.S. medicine in international perspective. N Engl J Med. 2014; 371(17):1570-1572

Boorse, C (1975). On the distinction between disease and illness. Philosophy and Public Affairs; 5: 49-68

Boorse, C ( 2004). On the distinction between disease and illness. .In Health, Disease and Illness. Caplan, A.L., McCartney J.J. and Sisti D.A. (Eds). Washington DC: Georgetown University Press

Boyd, KM ( 2000). Disease, illness, sickness, health, healing and wholeness: exploring some elusive concepts. J. Med. Ethics; 26: 9-17

Caplan et al (eds) (2004) Health, disease and illness. Georgetown Univ Press, Washington DC

Carpenter, W. (2017). Organizing knowledge in the biopsychosocial medical model. Psychiatry, 80(4), 318-321.

Dacher, ES (1995). A systems theory approach to an expanded medical model: a challenge for biomedicine. J Altern Complement Med;1(2):187-196.

Dhabhar FS (2014) Effects of stress on immune function: the good, the bad, and the beautiful. Immunol Res;58(2-3):193-210. doi: 10.1007/s12026-014-8517-0.

Dilley, FB (2004). Taking consciousness seriously: A defense of Cartesian dualism. International Journal for Philosophy of Religion 55: 135–153

Dossey, L (1982). Space,time and Medicine

Dubos, R (1959). Mirage of health New York: Harper.

Elkins, G, Fisher, W., and Johnson, A., (2010). Mind–body therapies in integrative oncology. In Current treatment options in oncology, Vol. 11, Nos. 3-4, 2010, pp128-140.

Engel, GL (1977). The need for a new medical model: a challenge for biomedicine. Science; 196: 129-136.

Einstein, A (1949). Religion and Science. The world as I see it. New York: Phylosophical Library.

Eyer J, Sterling, P (1977). Stress related mortality and social organization. Rev. Radical Polit Econ: 9: 1-44

Farre A & Rapley T (2017). The New Old (and Old New) Medical Model: Four Decades Navigating the Biomedical and Psychosocial Understandings of Health and Illness

Flexner, A (1910). Medical Education in the United States and Canada. New York: Carnegie Foundation for the Advancement of Teaching.

Fabrega Jr, H (1975). The need for an ethnomedical science. Science. 189 (4207): 969- 975.

Fisher JP, et al. (2009). Central Sympathetic Overactivity: Maladies and Mechanisms. Auton Neurosci.; 148(1-2): 5–15.

Fontanarosa, PB & Lundgberg GD (1998). Alternative Medicine Meets Science. JAMA; 280(18):1618-1619.

Frangogiannis NG (2014). The inflammatory response in myocardial injury, repair, and remodeling. ; 11(5):255-265.

Fromm, E. (1955). The sane society. Greenwich, Conn: Fawcett Premier,

Gao H., Smith, BN (2010). Zolipiden modulation of phasic and tonic GABA currents in the rat dorsal motor nucleus of the vagus. Neuropharmacology. 58: 1220–1227.

Giordano, J & Jonas, W ( 2007). Asclepius and Hygieia in dialectic: Philosophical, ethical and educational foundations of integrative Medicine. Integrative Medicine Insights; 2: 53-60

Gold J (1985) Cartesian dualism and the current crisis in medicine--a plea for a philosophical approach: discussion paper. J R Soc Med. 78(8): 663–666.

Juckett, G (2005). Cross-Cultural Medicine. Amer Fam Physician; 72(11):2267-2274.

Hall JF (2014). The Microbiome and Diverticulitis: A New Target for Medical Therapy? Diseases of the Colon & Rectum: 57 (4) : 544–545

Heil J & Rodd D. 2003. Mental properties. American Philosophical Quarterly 40 (3):175-196.

Heil J (2012). The Universy as we find it. Oxford Uni v.Press, New York

Hart, WD (1996) "Dualism", in A Companion to the Philosophy of Mind, ed. Samuel Guttenplan, Oxford: Blackwell, pp. 265-267.

Hofmann, B (2002). On the triad disease, illness and sickness. J Med & Phil. 2: 651-673.

Hou R & Baldwing DS (2011) . A neuroimmunological perspective on anxiety disorders. https://doi.org/10.1002/hup.1259

Hungelman, J, Kenker-Ross, E, Kassen, L, & Stollewerk, R (1996). Focus on spiritual well-being: harmonious interconnectedness of mind-body use of JAREL spiritual well-being scale. Geriatric Nursing; 1: 262-266

Jhaveri R et al. Management of the non-toxic-appearing acutely febrile child: a 21st century approach. J Pediatr. 2011;159(2):181–185..

Kim, J (2005). Physicalism, Or Something Near Enough, Princeton University Press, Princeton, NJ, 2005

Kostro, L (1998). Albert Einstein’s hypothetism. Science & Education. 7: 317-322

Koithan M, Farrel, C (2010). Indigenous Native American Healing Traditions. J Nurse Pract; 6(6): 477–478

Kopman FA et al (2011). Restoring the Balance of the Autonomic Nervous System as an Innovative Approach to the Treatment of Rheumatoid Arthritis. MOL MED 17(9-10)937-948

Kuzawa, CW. (2005). Allostasis, Homeostasis, and the Costs of Physiological Adaptation. Human Biology; 77(4): 532-536

Lanza R. Beyond biocentrism (2016), Ed BenBella Books, Dallas Texas

Lowe EJ (200). Non-Cartesian Substance Dualism and the Problem of Mental Causation. Erkenntnis 65 (1): 5–23

Mangum, CP & Towle DW (1977). "Physiological adaptation to unstable environments". American Scientist; 65: 67–75.

Mc Inerney, SJ (2015). Introducing the Biopsychosocial Model for good medicine and good doctors BMJ; 324:1533

McWhinney, IR. (1988). A Textbook of Family Medicine. London: Oxford University Press.

Maller, AS ( 2007). The evolution of human spirituality. The Linacre Quarterly. 74: 111-121.

Margulis, L (1998). Symbiotic Planet: A New Look at Evolution. London: Weidenfeld & Nicolson.

Maturana, HR & Varela FJ (1991). Autopoiesis and cognition:the realization of living Google Books

Meeroff, M (1992). Medicina Antropológica. Buenos Aires: AMA,

Meeroff, M & Candiotti, A. (1996). Ciencia, tecnica y humanismo. Buenos Aires, Argentina: Bios.

Meeroff, M ( 2004). Cambio de Modelo Medico. De la Medicina Biologica a la Medicina Bioantropologica. Fundamentacion Cientifica. En Del Cano et alt. Teoria y practica de la Medicina Antropologica. BsAs, Argentina: Sociedad Argentina de Medicina Antropologica Chapter 1: 16-39

Meeroff, JC (2007). La medicina asistencial contemporanea bajo la lupa del paradigma integralista. Medicina Antropologica; 3: 48-54

Mehta N (2011) Mind-body Dualism: A critique from a Health Perspective. Mens Sana Monogr; 9(1): 202–209

Mordacci, R, Sobel, R. (2004). Health: A comprehensive concept. In Caplan A. L., McCartney J.J. & Sisti D.A. (Eds) Health, disease and illness. Washington DC: Georetown Univ. Press, Chapter 11: 104-109

Nordenfelt, L (1987). On the Nature of Health : An Action-Theoretic Account. Dordrecht/ Boston: Kluver Academic Publishers,

Novack, G (1979). The Origins of Materialism, New York: Pathfinder

Orgaz, J (1953). Infancia y vocaciôn. Cordoba: Editorial Assandri

Parnia, S (2006). What happens when we die. Carlstad, California: Hay House Press

Parker, BM, Henderson, JM, Vitagliano, S, et al. (2007) Six sigma methodology can be used to improve adherence for antibiotic prophylaxis in patients undergoing noncardiac surgery. Anesth Analg; 104(1):140-146.

Qian-Qian Li et al. (2011). Acupuncture Effect and Central Autonomic Regulation. Evid Based Complement Alternat Med.;2013 (:267959): 1-6.

Quirle, V, Gaudillere, JP (2008). The Era of Biomedicine: Science, Medicine, and Public Health in Britain and France after the Second World War. Med Hist; 52(4): 441–452.

Robbins, JA & Dewar, J (2011). Traditional Indigenous Approaches to Healing and the modern welfare of Traditional Knowledge, Spirituality and Lands: A critical reflection on practices and policies taken from the Canadian Indigenous Example. The International Indigenous Policy Journal 2, (4): article 2:

Robles, TF, Glaser, R, Kiecolt-Glaser, JK (2005). Out of Balance. A new Look at chronic stress, depression, and immunity. Psychol Sci; 14:111–115.

Ross, J (1992). Immaterial Aspects of Thought. Journal of Philosophy; 89): 136–50.

Saunders, J.(2000). The practice of clinical medicine as an art and as a science Journal of Medical Ethics 26:18-22

Sapolsky, RM (1994). Why zebras don’t get ulcers? New York: W.H. Freeman

Saracci, R (2011). How should we define health? BMJ;343:d4163

Salata, OV (2004). Applications of nanoparticles in biology and medicine 2004: Journal of Nanobiotechnology; https://doi.org/10.1186/1477-3155-2-3.

Stapp, HP (2004). Mind, Matter, and Quantum Mechanics. Springer, Berlin & New York,

Schulkin J (2003) Rethinking Homeostasis: Allostatic Regulation in Physiology and Pathophysiology. Colorado: Bradford Book

Sender R et al (2016) Revised Estimates for the Number of Human and Bacteria Cells in the Body. https://doi.org/10.1371/journal.pbio.1002533

Shelton W. (2013). A new look at Medicine and the mind-body problem: can Dewy’s pragmatism help Medicine connect with its mission? Pers Biol Med 56 (3):422-441

Shusterman R. (2008). Body consciousness: A Philosophy of Mindfulness and Somaesthetics ; Cambridge University Press

Sledge WH & Feinstein A R (1997). A Clinimetric Approach to the Components of the Patient-Physician Relationship JAMA;278:2043-2048

Sterling, P (2004). Principles of allostasis: optimal design, predictive regulations, pathophysiology and rationale therapeutics. In Allostasis, homeostasis and the cost of adaptation. Massachussets: Cambridge University Press.

Streiner D (2003). Clinimetrics vs. psychometrics: an unnecessary distinction. J Clin Epidemiol; 56(12):1142-5

Svenaeus, F (2003). Hermeneutics of medicine in the wake of Gadamer: the issue of phronesis. Theor. Med. Bioeth. 24: 407-31.

Taylor, HCD.(1979). The component of sickness, illness and predicaments. Lancet,; November 10: 10-11.

Taylor, JG (2012). A final solution to the mind-body problem. J of Mind Theor; 1:25-58

Tsuei, JJ (1978). Eastern and western approaches to Medicine. West J Med.; 128(6): 551–557.

Twaddle, AC (1973). Illness and deviance. Soc. Sci. Med.: 7: 751-762.

Varela, F, Maturana, H, & Uribe, R (1974). Autopoiesis: The Organization of Living Systems, Its Characterization and a Model. Biosystems ; 5(4): 187-196.

Varkey, R, Reller, MK, & Resar, RK (2007). Basics of quality improvements in health care. Mayo Clin. Proc. 82(6):735-739

Von Bertalanffy, L (1976). General System Theory: Foundations, Development, Applications. New York : George Braziller.

Wilson, HJ (2000). The myth of objectivity: is medicine towards a social constructivist medical paradigm? Family Practice: 17, 203-209

Wikman, A, Marklund S, Alexanderson, K (2005). Illness, disease, and sickness absence: an empirical test of differences between concepts of ill health. J Epidemiol Community Health; 59:450–454

Weil, A (2000). Spontaneous Healing: How to Discover and Enhance: Your Body's Natural Ability to Maintain and Heal Itself. Alfred H Knopf Inc.

Zeff, J, Snider, P & Myers SP (2005). A hierarchy of healing: the therapeutic order. The Unifying theory of Naturopathic Medicine. In Pizzorno J.E. and Murray M.T. (Eds) Textbook of Natural Medicine (3rd Edition). Elesvier: Amsterdam pp 27-40

How to cite this article:

Meeroff JC. (2018). A pragmatic model of health and disease under the integrative paradigm. https://drfarolito.blogspot.com/articles/The contemporary pragmatic model of health and disease.

INTEGRATIVE MEDICINE by Dr. MEEROFF

Pages

Thursday, May 3, 2018

THE CONTEMPORARY PRAGMATIC MODEL OF HEALTH AND DISEASE