The Vermont Department of Health recently sent an update on arthritis in which it stated that arthritis costs Vermonters $189 million per year in medical costs and lost work time.  Arthritis was the most expensive chronic disease in Vermont between 2004 and 2006; it is also the most common chronic disease in the state (as well as in the nation).   Since arthritis is quite prevalent and has a big impact on the lives of individuals affected by it as well as on Vermonters collective, understanding it would seem to be a very good idea.      

What is arthritis?  The prefix “arth” refers to joints, while “itis” refers to inflammation, so the word literally means “inflammation of the joints..”  This is hardly news to anyone who suffers from one of the many arthritides!  Practically speaking, arthritis is used to encompass a wide variety of diseases and dysfunctions: osteoarthritis (a.k.a. degenerative joint disease, or DJD) and Rheumatoid Arthritis are fairly well-known members of this family, while Ankylosing Spondylitis and Gout are less familiar to most of us.  It might surprise many of us to learn that rheumatologists consider Lupus, Fibromyalgia, Chronic Fatigue Syndrome, Lyme Disease, Reynaud’s Syndrome and Carpal Tunnel Syndrome and a host of even lesser known conditions to be arthritides.
  

Do these diverse conditions have anything in common?  Well, of course, all of them affect the joints and the soft tissues that surround and move the joints in some way.  By “joint” we generally mean two contiguous bones, the cartilage that covers their articulating surfaces, and the ligaments that hold them in relationship to one another.  Arthritic disorders can affect any part of the joint complex.  They can also affect tendons (the tough soft tissue that attaches muscles to bones) as well as muscles. 

The other thing that arthritic disorders have in common is that they involve poor modulation of inflammation.  Inflammation is a critical component of the body’s healing process; without appropriate activation of our complex inflammatory responses, we would be unable to fight infection, repair wounds, or heal injured bones, soft tissues, or organs.  In a healthy body, processes and chemicals that focus, contain and quiet inflammation balance those that activate inflammation is balanced by processes that focus, contain, and quiet inflammation.  Loss of balance between pro- and anti-inflammatory chemistry is both an early hallmark of disruption of homeostasis and a precursor to an array of serious, chronic disorders.  Indeed most of the conditions which plague populations of “developed” nations—not only arthritis but also cardiovascular disease, diabetes, cancer, Alzheimer’s , inflammatory bowel disorders, asthma and allergies—all revolve around loss of modulation of inflammatory processes.

The VT Department of Health states that “2/3 of adults with arthritis are overweight, and arthritis is a risk factor for other chronic conditions such as hypertension.”  We could interpret this sentence in a variety of ways.  First, we might assume that the fact that 2/3 of adults with arthritis are overweight means that being overweight causes arthritis.  While it is logical to assume that asking our joints to bear increased weight would increase the stress on them, what seems logical is not always true in the world of causality.   We could also assume that since arthritis generally causes pain and stiffness, it tends to limit sufferers’ ability to exercise, predisposing them to weight gain.  This may also be true as far as it goes.  But what is most likely true is that arthritis, as a group of disorders caused by poor modulation of inflammation, arises within a field of imbalance that also predisposes people to gaining weight.  

Similarly, we could take the above sentence from the Department of Health to mean that arthritis causally contributes to the development of cardiovascular disease.  Again, it is certainly logical to think that since arthritis sufferers tend to become less active, their arthritis predisposes them to the development of cardiovascular disease.  Perhaps this is true, but I have not seen research that convincingly demonstrates this.   Again, given the research evidence that is accumulating about the diffuse effects of inflammatory dysregulation and the complex interactions between dysregulation in diverse bodily systems, I suspect that the truth is that arthritis, metabolic syndromes, and cardiovascular disease arise together within a greater field of imbalance.  While all these conditions may then amplify each other, addressing them effectively requires attention to their shared deep roots. 

In addition to inflammatory dysregulation, another factor plays a significant role in the development of the most common form of arthritis, osteoarthritis or degenerative joint disease.  This is  “wear-and-tear” or “old age” arthritis.  Unlike rheumatoid arthritis, which often affects extremities bilaterally and symmetrically, osteoarthritis is often asymmetrical.  It often affects areas that have experienced acute injury or chronic overwork: that knee you injured back in college that now predicts the weather more effectively than a barometer, the thumbs that swell and hurt after years of gardening, pruning, and knitting.  This kind of arthritis afflicts the lower back and the lower neck far more frequently than it afflicts the middle back; this is not what one would expect if systemic inflammation were its sole cause.   Osteoarthritis mercilessly reflects our self-neglect—the injuries we didn’t bother to rehabilitate—and our imbalanced self-use—the daily patterns of awkward sitting, standing, walking, and lifting which school and work seem to  compel and which our culture teaches us are either insignificant or unalterable.      
So if we’re going to talk about prevention of osteoarthritis—which public health statistics suggest would be a really good idea—we need to start early and think big.  We need to radically revise our picture of the importance of the neuromusculoskeletal system(s): although these interrelated systems comprise more than 50% of the body and are the number one cause of visits to allopathic doctors, medical school devotes only 10-15% of the curriculum to their study.   We need to give childhood injuries (including birth injuries) proper attention and teach kids that graceful, efficient use of the self is not only possible but desirable.   We need to redesign school and workplace furniture so that it is friendly to good self-use; more than that, we need to move away from our obscenely sedentary way of life.  We need to revise our ways of learning and working to reward attention to balanced use of the body, recognizing that dynamic movement is critical not only to future health but also to efficient learning and intelligent action in the present.

In short, effective public health responses to the epidemic of arthritic disorders demand an approach that resembles deep ecology.  A deep ecological approach to arthritis must go to the myriad, tangled roots of the problem.  It must be, by definition, multi-dimensional and multi-disciplinary.   It must recognize and address a variety of aspects of sufferers’ health simultaneously: diet, exercise, habits of moving, feeling and thinking.  On an individual level, a deep ecology approach to preventing or addressing arthritis may require the cooperation of a variety of health care practitioners as well as the energetic, observant participation of “patients.”  But if a deep ecology approach to arthritis is ever to affect more than a few relatively privileged and enlightened individuals, if it is ever to actually reduce the economic and other costs arthritis currently exacts from us collectively, it must address the public sphere—our cavalier attitude toward toxic chemicals and waste generation and disposal, our anti-body, inhumane approach to schooling and working. 

Unfortunately for the tens of thousands of arthritis sufferers in Vermont (as well as the millions in the U.S. as a whole), such an approach runs headlong into many of our deepest cultural habits.  It especially challenges our tendency to locate the responsibility for ill health (as well as other kinds of ill fortune) squarely and solely with the individual, ignoring or underplaying causes rooted in collective actions, causes that can only be addressed by collective action.  So, for instance, we are much more comfortable blaming the epidemic of diabetes on the expanding girth of the American population than we are with acknowledging that environmental toxicity appears to play a critical role in the metabolic disruption that predisposes people to both obesity and diabetes (please see my earlier blog on diabetes for more information).   It is easier to blame the epidemic of arthritis on individuals’ laziness and poor eating habits than to acknowledge that environmental toxicity and centuries of escalating and widespread enmity toward the body and its most basic needs play a role in the genesis of these disorders.

Allopathic medicine is unlikely to be a strong leader in the development of a new paradigm around the prevention and treatment of arthritis (or chronic disease in general).   Allopathic medicine remains deeply uncomfortable with, even hostile toward, any approach that veers away from the “one cause, one cure,” model—even when it is apparent that the one cause, one cure model is radically ineffective.  The waning of general practitioners and the waxing of the power of specialists within allopathic medicine both reflects and reinforces this bias.  While chronic diseases like arthritis demand multidisciplinary and multidimensional thought and action, collaboration between allopathic practitioners is infrequent and inefficient; collaboration between allopaths and holistic practitioners is even rarer.  The whole institutional structure of allopathic medicine (i.e., eight minute office visits as a practice norm—how can you possibly address a complex, multi-causal problem in eight minutes?) and its incestuous relationship with the insurance and pharmaceutical industries mitigates against the development of a truly different approach from within allopathy.  So while allopathy will clearly always have a role to play in helping people with arthritides, it appears to me that the public, the holistic practitioners the public are increasingly choosing as their primary care physicians, and a small cadre of enlightened people in public health will have to lead the way toward a new overall approach to these devastating diseases.