Gabor Maté’s issues are with evidence, not the West and with public health, not medicine, but who takes him seriously? Lots of otherwise smart people seem to…or maybe not.
I chose to discuss Why We Get Sick, a lecture Maté delivered in London because it puts Maté’s ideas on full display.
The complete video of the lecture was uploaded in August 2019 by How To Academy Mindset. The video is part of a series that includes Jordan Peterson and Bessel van der Kolk. On Google, the YouTube video is re-titled Dr. Gabor Maté on The Connection Between Stress and Disease.
Struggling to get through this video, my mind wandered to thoughts of how lucky I would have been to be in London, maybe at the same theatre, when a true Canadian gift to the world, Leonard Cohen performed the concert captured in the Live in London 2-CD set.
Like Maté, Cohen is a member of the Order of Canada, the highest honor the Crown gives to a civilian. Both must somehow exemplify the order’s Latin motto, desiderantes meliorem patriam, meaning “they desire a better country.
”Live in London (Leonard Cohen album) – WikipediaLive in London is a (double) live album
After a few minutes, I could not stand watching Gabor Maté piling bonkers claims on bonkers claims anymore. It was just too painful to endure the stream of nonsense he was spouting, but I felt it was my duty.
I had taken the challenge of exploring and explaining the hidden-trauma/polyvagal theory/psychedelic psychotherapy nexus of nonsense. . I needed to provide a report of an investigation in progress.
Taking a break, I sought relief in listening to The Future, my favorite song in Cohen’s 2-CD set.
My wife is grateful that I have noise-suppressing headphones that keep my noise out of her ears. She finds Leonard Cohen’s music depressing. She is not a music snob, having played a variety of instruments in rock and country-western bands. She is just more susceptible to the mood contagion from music and language than I am.
I can’t explain to her why I find Cohen’s apocalyptic, dystopic vision in The Future an antidote for Maté, who has a similar vision. I guess Cohen is entertaining and does not tempt me to argue with his “Truth” delivered in well-crafted songs with brilliant lyrics.
Maté offends me by preaching a “Truth” with a call to action.
Maté urges us to abandon what has evolved over time to be evidence-based solutions to health and social problems. We should get involved in long-term, perhaps interminable therapy to exorcise the demons of trauma hidden in our subconscious.
There is no evidence that this prescription would improve our health or extend our life, but Maté claims we would be living more authentically.
The large, well-dressed crowd packing the London theatre enthusiastically cheered as if Gabor Maté were a rock star when the emcee announced:
I am honored and thrilled to introduce you tonight to the renowned physician Dr. Gabor Maté, one of the world’s leading experts in trauma, child development, addiction, and the relationship between stress and disease, please give him a huge welcome.
I am not embarrassed to admit I did not know that Dr. Maté was an expert of such eminence. I looked up his name in the usual places where such eminence should be documented, like Google Scholar. I could find insufficient evidence that he deserves such accolades.
A lot of people are convinced otherwise. They listen intently and find validation in the wild things that he says. I thought it was worthwhile to probe a bit of stuff he said in this lecture.
Maté comes to the podium, looking distinguished, but a bit haggard and world-weary. At first, his eyes are nearly closed. He squints and discloses that he has 55 minutes to lecture. He announces the topic:
We’re looking at two questions, basically one is what is disease, number one, and number two, how do we understand the human beings’ relationship to illness, which really comes through the heart of what is humanity really now.
Whoa, drag me into shallow waters before I go too deep. I do not think you will lend me enough of your attention to answer these questions, nor do I feel up to it.
I admit I was tempted to pounce on this next statement:
Western medicine in which I was trained sees illness or the whole person is somehow a random victim of either genetics or external invaders such as bacteria or virus or toxins or possibly as even a culpable instigator of their own pathology by certain so-called lifestyle choices like eating too much drinking too much or smoking
I developed acute genre confusion. I could not decide whether Maté was making a falsifiable scientific claim, trying to practice philosophy with only a degree in medicine, or reciting bad poetry.
I regained my confidence in my ability to discuss Maté when he said soon thereafter:
Let me just give you three medical facts here and you’ll see immediately how inadequate and insufficient the Western medical perspective is in explaining these facts…
The first fact there is a study that was done in the United States last year that shows that the more episodes of racism an American black woman experiences, the greater the risk for asthma.
Let me give another fact. In the 1930s and 40s the gender ratio of multiple sclerosis — which is an inflammatory degenerative disease of the nervous system — was 1:1. In other words for every man, there was a woman diagnosed. You know what the ratio now is? it’s three and a half women to every man. That immediately tells us it can’t be genetic because the genes don’t change in a population over seven decades or even ten decades or longer.
Number two, it can’t be diet because that doesn’t change for a population. It didn’t change more for women than for men. Nor can it be the climate. There is something going on and whatever it is it can’t just be biological now.
What’s interesting is that when you look at how you treat asthma. If you give to open up the airways and to suppress inflammation that happens in the asthmatic airway you give inhalers or medications by mouth, which are copies of adrenalin and cortisol.
Adrenaline and cortisol are stress hormones of the body. I’ll talk about them later. They’re secreted by the adrenal gland in response to a threat so there’s a drone and cortisol. So, we’re treating asthma with stress hormones. How do we treat multiple sclerosis?
Where this is headed is Maté will explain that everything we don’t understand about health and disease, everything that is inadequate in Western medicine is a matter of ignoring the role of stress and hidden trauma in causing illness and death. Shortly into the lecture, we will un into an impenetrable fog of pseudoscience and nonsequiturs. I will get off the train before the inevitable wreck ahead.
I found the article to which Maté was referring to his comment about asthma in black women.
Coogan PF, Yu J, O’Connor GT, Brown TA, Cozier YC, Palmer JR, Rosenberg L. Experiences of racism and the incidence of adult-onset asthma in the Black Women’s Health Study. Chest. 2014 Mar 1;145(3):480–5.
The authors hypothesized
Chronic stress resulting from experiences of racism may increase the incidence of adult-onset asthma through effects on the immune system and the airways.
We conducted prospective analyses of the relation of experiences of racism with asthma incidence in the Black Women’s Health Study, a prospective cohort of black women in the United States followed since 1995 with mailed biennial questionnaires.
The authors used a large data set that had been collected without their specific hypothesis in mind. They had to improvise in reducing and analyzing the data.
An everyday racism score was created based on five questions asked in 1997 and 2009 about the frequency in daily life of experiences of racism (eg, poor service in stores), and a lifetime racism score was based on questions about racism on the job, in housing, and by police. We used Cox regression models to derive multivariable incidence rate ratios (IRRs) and 95% CIs for categories of each racism score in relation to incident asthma.
*The IRRs were 1.45 (95% CI, 1.19–1.78) for the highest compared with the lowest quartile of the 1997 everyday racism score (P for trend <.0001) and 1.44 (95% CI, 1.18–1.75) for the highest compared with the lowest category of 1997 lifetime racism. Among women who reported the same levels of racism in 1997 and 2009, the IRRs for the highest categories of everyday and lifetime racism were 2.12 (95% CI, 1.55–2.91) and 1.66 (95% CI, 1.20–2.30), respectively.\
*Given the high prevalence of experiences of racism and asthma in black women in the United States, a positive association between racism and asthma is of public health importance.
There is no surprise in these results. I do not think that anyone having the expertise to interpret these results would find cause to lose their faith in Western medicine.
The authors discarded the middle half of their sample, based on subjects’ scores on everyday racism. That is not a terrible decision, but the strategy inevitably exaggerates the size of the effect that will be reported. I prefer analyses that do not involve throwing away half the data.
If we are looking for determining effect sizes of noteworthy public health significance, I think a reasonable rule of thumb is IRR = 2.5. If we are going to ramp up and demand intervention, the consensus is IRR = 4.0. We can quibble about these somewhat arbitrary cutoffs, but I think experts would still agree that the effect size found in this study is not impressive.
These are correlational data, so we have to be careful about making causal interpretations. We have to acknowledge that we have a crappy self-report measure constructed after the authors obtained this data set. We have to contend with an incomplete specification of variables that need to be statistically controlled and crude measurement. These are standard critiques of such studies.
I would say at least as it is measured in this study “everyday racism” is not causal, but a risk marker related to other risk factors that might be suitable for intervention. I would say that modifiable risk factors were exposure to dust mites, asbestos, cigarette smoke, and poor air quality in cramped, inadequately ventilated living spaces. I would add poor access to quality medical care, specifically inadequately managed respiratory infections and lack of insurance.
I have some experience with this population. I collaborated with Dr. Jen Culane on the Philadelphia Preterm Birth Prevention Project and wasthe Principal Investigator in my own NIMH study of socially disadvantaged inner-city postpartum women in Philadelphia, mostly black.
As the authors of this study, I am convinced without ever seeing their results, that both racism and high rates of incidence (onset) of asthma are serious problems. Subtle and blatant racist acts against black women are highly prevalent and objective, not subjective. We do not have to go rooting in the subconscious of black women to find evidence of this racism.
However, I am not convinced that these particular findings add to what we already know.
Figuring out what to do about increasing rates of new cases of asthma among black women involves problem-solving that applies evidence accumulated using the diagnostic categories supplied by medicine.
The diagnostic categories have undergone considerable evolution over time, revision of what signs and symptoms, what lab test values to include or exclude, based on how they worked in predicting associations among variables and improving health outcomes. Biomedical research is involved but includes microbiology, immunology, and also epidemiology, including social determinants of health. The goal is to bridge these fields, to establish connections that make a difference in health outcomes.
To call this “Western Medicine’ is an act of cultural imperialism. If the rest of the world had survived to now without the influence of the West or Capitalism or whatever, it would be because similar methods had evolved and had produced similar knowledge.
Casually attaching such labels to phenomena his audiences do not understand scores points with them. It allows Maté to dismiss the knowledge and tools we need to prevent new cases of asthma among these women and reduce the toll of asthma among those women who have already developed this chronic, recurring condition.
Maté paints a cartoonish caricature of medicine locked in silos. He confuses the maps that specialist researchers and clinicians use with the territory they cover. There is so much complexity in methods and findings in immunology. While those who study immune function should be able to communicate with those who are experts on the sources of environmental exposures like mites or black mold, but they cannot reasonably be expected to be experts in those areas.
Overspecialization in research and clinical practice is an important issue, especially for the management of difficult-to-diagnosis, multiple comorbidities with multiple medications. Management must collaborative care between professionals and especially with active patient involvement.
There is no cause for lighting anyone’s hair on fire and putting it out with hammers or other cynical, nihilistic high drama of the kind that Maté acts out in front of audiences who come for the spectacle.
I have less to say about Mate’s claims about the changing gender ratio in multiple sclerosis. For a start, studies in different populations do not consistently support a dramatic trend.
Here is one relevant Canadian study in a top-quality journal.
Orton SM, Herrera BM, Yee IM, Valdar W, Ramagopalan SV, Sadovnick AD, Ebers GC, Canadian Collaborative Study Group. Sex ratio of multiple sclerosis in Canada: a longitudinal study. The Lancet Neurology. 2006 Nov 1;5(11):932–6.
The article summarized the existing literature
Incidence of multiple sclerosis is thought to be increasing, but this notion has been difficult to substantiate. In a longitudinal population-based dataset of patients with multiple sclerosis obtained over more than three decades, we did not show a difference in time to diagnosis by sex. We reasoned that if a sex-specific change in incidence was occurring, the female to male sex ratio would serve as a surrogate of incidence change.
The study found:
The female to male sex ratio by year of birth has been increasing for at least 50 years and now exceeds 3·2:1 in Canada. Year of birth was a significant predictor for sex ratio (p<0·0001, χ2=124·4; rank correlation r=0·84).
The authors’ interpretation:
The substantial increase in the female to male sex ratio in Canada seems to result from a disproportional increase in incidence of multiple sclerosis in women. This rapid change must have environmental origins even if it is associated with a gene–environment interaction, and implies that a large proportion of multiple sclerosis cases may be preventable in situ. Although the reasons why incidence of the disease is increasing are unknown, there are major implications for health-care provision because lifetime costs of multiple sclerosis exceed £1 million per case in the UK.
This is solid, normal science, representing one step on the path to finding a solution, not at all revolutionary or cause for the fuss that Maté is making.
I’ll pass on commenting on Maté’s claims that we treat asthma or multiple sclerosis with stress hormones. Similarly, for his leap that these “facts” justify a deep dive into the subterranean world of subconscious hidden trauma accumulated in early life.
I have collaborated in the successful writing of major grant applications for these diseases. I am sure the grateful principal investigators would answer any questions I forwarded them, but I think they would think I was smoking medical cannabis if I asked them to comment on choice direct quotes from Maté’s talk.
Leonard Cohen engaged in banter with his audience expressing thanks for the ‘geographical and economic inconvenience’ they had suffered to come to hear his concert in London. Of course, he did not have time set aside for questions and answers at the end. Maybe he did an encore.
Members of Maté’s audience competed at the end of his lecture to get his opinion on a variety of health and social issues.
I guess they thought they had enjoyed a scientific lecture from a rock star celebrity, not a rock concert. I cannot fathom why and I will have to do some more investigation but I will have to prepare if this means I have to watch any more Maté lectures.
Perhaps I can find a lecture that is mercifully short. I will keep some Leonard Cohen music handy, like an epi-pen that I can use if I find myself experiencing an adverse reaction.
Postscript
I was expecting to upload this article last night, but an intense storm rushed through my village, uprooting trees, and cutting off power and internet. I refuse to think that was some divine sign that I should post it.
Sitting in the dark, I reflected on these presumably intelligent English people sitting through Maté’s lecture without leaving, and then some of them asking questions with no challenge to the outrageous things he had said.
The next time they went to a GP or medical specialist, would they chastise her if she did not start by asking them about their hidden trauma? If their parents had cancer, would they rush them into trauma-informed treatment or would they seek the best oncologist available and maybe even get a second opinion.
I think not. The audience knew they had not been to a Leonard Cohen concert or a lecture that should change their patterns of health care.
The audience knew they had been to church and had heard an eminent preacher from Canada, Gabor Maté’s who did his best to whip up an old-time sermon with terrifying hellfire and damnation. Some of the audience talked about his religion with him but they knew they did not have to do anything different in their lives. They were familiar with this genre. They would continue to seek the best health care available, even outside the National Health Service if they had to.
You don’t go to sermons like this and then go home and do anything differently. No intelligent person does that.
My worry is that many people who are respectful of the authority reflected in membership in the Order of Canada, might take Gabor Maté’s words literally and seriously.
I worry about my Canadian neighbors who are not so savvy or cynical. I worry about Americans who are already heeding what Prince Charles and Prince Harry say. Their lives are put at risk by the serious nonsense that Gabor Maté is spreading about cancer and other illnesses and his contempt for medicine and science more generally.
