Can Medicine Be Cured

  CAN MEDICINE BE CURED?

  Seamus O’Mahony

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  About this Book

  About the Author

  Table of Contents

  AN APOLLO BOOK

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  About Can Medicine Be Cured?

  A fierce, honest, elegant and often hilarious debunking of the great fallacies that drive modern medicine, by the award-winning author of The Way We Die Now.

  Seamus O’Mahony writes about the illusion of progress, the notion that more and more diseases can be ‘conquered’ ad infinitum. He punctures the idiocy of consumerism, the idea that healthcare can be endlessly adapted to the wishes of individuals. He excoriates the claims of Big Science, the spending of vast sums on research follies like the Human Genome Project. And he highlights one of the most dangerous errors of industrialized medicine: an over-reliance on metrics, and a neglect of things that can’t easily be measured, like compassion.

  Contents

  Welcome Page

  About Can Medicine Be Cured?

  Dedication

  Chapter 1. ‘People Live So Long Now’

  Chapter 2. The Greatest Breakthrough since Lunchtime

  Chapter 3. Fifty Golden Years

  Chapter 4. Big Bad Science

  Chapter 5. The Medical Misinformation Mess

  Chapter 6. How to Invent a Disease

  Chapter 7. ‘Stop the Awareness Now’

  Chapter 8. The Never-Ending War on Cancer

  Chapter 9. Consumerism, the NHS and the ‘Mature Civilization’

  Chapter 10. Quantified, Digitized and for Sale

  Chapter 11. The Anti-Harlots

  Chapter 12. The McNamara Fallacy

  Chapter 13. The Mendacity of Empathy

  Chapter 14. The Mirage of Progress

  Epilogue

  Acknowledgements

  Bibliography

  Index

  About Seamus O’Mahony

  Also by Seamus O’Mahony

  An Invitation from the Publisher

  Copyright

  This book is dedicated to the memory of

  Julia O’Connor (1924–2018)

  1

  ‘People Live So Long Now’

  We take our health for granted, a luxury unknown throughout most of human history. My mother was born in 1932, in a rural hamlet in West Cork, the youngest of nine children. When she was ten years old, she fell seriously ill. It was unusual to summon the doctor in those days, but her parents were so worried that the local GP was called. The doctor drove the ten miles from his surgery, and arrived in bad temper. He examined the child, and told her parents that she had pneumonia. He prescribed sulfapyridine, an antibacterial drug developed only a couple of years before, and known colloquially as ‘M&B’, after the manufacturer, May & Baker. Sulfapyridine was commonly used during the Second World War, but fell into disuse when penicillin became widely available. The GP also ordered my grandparents, for reasons which I can’t fathom, on no account to give her water. They would not countenance going against the doctor’s advice, and my mother endured the torments of both the pneumonia and a raging thirst. She was saved by her sister, Margaret, who under cover of night went to the well and fetched water. Whether because of her sister’s forbidden ministrations, or the M&B tablets, or both, my mother survived.

  Her brother Billy was not so lucky. At the age of seventeen, while at boarding school, he became ill; he had lost weight and complained of pains in his back. He was sent home, and eventually was diagnosed with spinal tuberculosis (TB). At his school – a seminary – he was in close proximity to hundreds of other boys, several of whom must have been infected with TB. The prison-like food rations (exacerbated by wartime shortages) meant that these boys were chronically malnourished, and thus more susceptible to infection. There was no effective drug treatment for TB at that time. His parents chose not to send Billy to hospital; the doctor told them that his disease was advanced and incurable, and nothing could be done for him. His mother nursed him at home; the local women rallied to her aid, looking after the house and the children. Billy died in 1946, aged eighteen. His sister, Julia, who had entered the Loreto order of nuns a few years before, was not allowed to leave the convent to attend his funeral. She died, aged ninety-four, during the writing of this book.

  Tuberculosis was a blight on Ireland throughout the nineteenth century and the first half of the twentieth century. William Wilde (father of Oscar) worked as a census commissioner, and estimated that between 1831 and 1841, TB caused 11.4 per cent (135,590 of 1,187,374) of all deaths in the country. The disease carried a social stigma, as it was associated with poverty and malnutrition, and was known by a variety of euphemisms, such as ‘decline’ and ‘delicacy’. So great was this stigma that many sufferers were hidden away by their families. In 1948, two years after Billy’s death, a young doctor called Noël Browne was appointed health minister in the new Irish coalition government. He introduced mass population screening for TB, along with BCG vaccination (Bacillus Calmette-Guérin vaccine, the standard immunization against tuberculosis). Browne’s programme was moderately successful; the tuberculosis death rate dropped from 123 per 100,000 of the population in 1947 to 73 per 100,000 in 1951. He funded the construction of several new ‘sanatoria’ – specialist hospitals for the treatment of TB patients. Sanatoria had been well established in continental Europe since the mid-nineteenth century; Thomas Mann’s The Magic Mountain is set in a Swiss TB clinic. The sanatoria offered bed rest, fresh air, sunshine and nutritional supplements such as cod liver oil. Some recovered under this regime; many died. A variety of surgical procedures were carried out on patients with pulmonary TB, including pneumothorax (collapsing the lung to ‘rest’ it), crushing of the phrenic nerve to paralyse the diaphragm (also to ‘rest’ the lung) and partial pneumonectomy (removal of a portion of an infected lung). These procedures were of dubious and unproven benefit. I still see elderly people who survived them.

  Around the time of Billy’s death, streptomycin became available for treatment of TB in the US, but it would be several years before British companies started producing the drug. In 1948, George Orwell was one of the first TB sufferers in Britain to be treated with streptomycin. Through his connections with David Astor, the editor of the Observer, and the health minister Aneurin Bevan, a supply of streptomycin was obtained from the US. Royalties from Animal Farm paid for the drug. Orwell, unfortunately, did not respond, suffering severe side effects. He donated whatever streptomycin was left over to Hairmyres Hospital near Glasgow, where he was treated. Two doctors’ wives received the drug, and both were cured of their TB. The Medical Research Council started recruiting patients into their streptomycin trial in 1946. It was the first ever ‘randomized controlled trial’: i.e. patients were randomly allocated (to eliminate bias), in equal numbers, to the active drug (streptomycin) and a placebo, or control. The trial was concluded in 1948; it showed clearly and unambiguously that streptomycin was effective. With the advent of streptomycin, and later, other more effective drugs, deaths from TB continued to fall. Some argued that the disease was on the decline anyway, long before these drugs became available. TB hasn’t gone away; it still kills millions of people in poor countries. In Ireland, the disease lingers on, targeting the poor, the marginalized, the old and immigrants. TB patients are now generally treated at home, and the sanatoria have been put to other uses. The Cork sanatorium, St Stephen’s Hospital, is now a psychiatric hospital, grappling with a new blight. My mother’s father was also stricken with TB (of the lungs), and spent several months in the late 1960s in St Stephen’s. Children were not allowed to visit, so he would wave at us from a balcony on the first floor, a distant, ghostly, solitary figur
e. He was born in Lowell, Massachusetts in 1887. His father died in his early thirties of typhoid fever, forcing his widowed mother to return to Ireland and the charity of relatives. Typhoid, which once killed millions, has all but disappeared, due to vaccination and sanitation.

  In 1956, there was an epidemic in Co. Cork of the viral disease poliomyelitis, or ‘polio’ as it is widely known. Hundreds of children contracted the disease, which causes paralysis and wasting of muscles. Some, whose chest muscles were paralysed, had to live within an ‘iron lung’ to survive. Many others, like the great Middle East correspondent Patrick Cockburn, endured long hospitalizations, and later, numerous orthopaedic operations. Thousands fled the city, which was effectively quarantined. The survivors of this epidemic are now in their sixties and early seventies, easily identifiable by the lifelong disability caused by polio. In the mid-1990s there were between 7,500 and 10,000 survivors of the disease still alive in Ireland. Cockburn wrote of polio in his memoir The Broken Boy: ‘As a killer it never compared with cholera, typhus, malaria, yellow fever or consumption, but it carried an extra charge of fear because like leprosy and smallpox it disfigured and disabled the living. Aids is the only disease in the last half-century to create comparable terror.’ The American virologist Jonas Salk had been working on a vaccine against polio since the early 1950s; in 1955, he announced the results of the first trial of his vaccine, which proved beyond doubt that it worked. The Salk vaccine was given by injection; it was replaced with Albert Sabin’s oral vaccine in 1961. This was the vaccine I was given – taken with a lump of sugar – as a schoolboy. Polio – at least in the rich West – has disappeared.

  The deaths of children and teenagers like Billy were a common tragedy for most of human history; a stroll through any old cemetery is a roll call of lost children. But something radical happened in the first half of the twentieth century. The infectious diseases which claimed the lives of so many children and young adults became curable or preventable by vaccination. Between 1885 and 1985 infant mortality in the US and Europe dropped from 140 per 1,000 (1 in 7 babies died) to 5 per 1,000 (1 in 200). Life expectancy rose from 50 to nearly 80. In 1930, maternal mortality in England was 1 in 250; it is now 8 per 100,000 (1 in 12,500). The death of a mother in childbirth is now so rare that when it does occur, it is often a national scandal. Most people with TB can be cured with prolonged antibiotic treatment. Smallpox killed more people (hundreds of millions) than the Black Death and the two world wars combined: in 1980 the World Health Organization declared it eradicated. Medicine, which for most of its history had very limited powers, was quite suddenly marvellously, miraculously effective. There was a golden age of about fifty years, from the mid-1930s to the mid-1980s, when almost anything seemed possible. Lewis Thomas (1913–93), the American doctor and essayist, wrote that when he qualified in the 1930s, ‘the major threats to human life were tuberculosis, tetanus, syphilis, rheumatic fever, pneumonia, meningitis, polio, and septicaemia of all sorts. These things worried us then the way cancer, heart disease and stroke worry us today. The big problems of the 1930s and 1940s have literally vanished.’

  I studied medicine from 1977 to 1983, towards the end of the golden age. Around this time, some critics began to question medicine’s hegemony: the greatest of these critics was Ivan Illich. Illich (1926–2002) was an Austrian priest, philosopher and social critic. His book Medical Nemesis (1975) opened with the famous and, to me at the time, intoxicating assertion: ‘The medical establishment has become a major threat to health.’ A superstar public intellectual in the 1970s, Illich is now all but forgotten. His central theme was that institutionalization had corrupted Western civilization. Modern institutions were characterized by what Illich called ‘paradoxical counterproductivity’, that is, they frustrated the very purpose for which they were originally designed. Thus, formal education led to ignorance, modern transport caused gridlock and environmental despoliation, and health care was sickening. He elaborated these ideas in a series of books published between 1970 and 1975, including Deschooling Society, Tools for Conviviality, and – most famously – Medical Nemesis. This brilliant polyglot was mobbed when he appeared at universities; when he spoke at University College Dublin in 1978, 8,000 people turned up. In Edinburgh in 1974, a medical student called Richard Smith (later editor of the British Medical Journal) was transfixed: ‘The closest I ever came to a religious experience was listening to Ivan Illich. A charismatic and passionate man surrounded by the fossils of the academic hierarchy in Edinburgh…’ Illich argued that scientific medicine had little effect on the overall health of populations; this argument had been made by others, most notably the epidemiologist Thomas McKeown, who believed that sanitation, nutrition and housing were more important determinants of health. McKeown thought that doctors contributed little to health, but Illich went even further, arguing that they were actively dangerous. He attacked institutionalized modern medicine because he saw it as a new religion, with its own rituals and dogma, and the medical profession as a new priesthood. He railed against the monopoly and dominance of doctors: ‘Modern medicine is a negation of health. It isn’t organized to serve human health, but only itself, as an institution. It makes more people sick than it heals.’

  This was heady stuff. One of Illich’s many disciples was John Bradshaw, an English doctor who had abandoned medicine for writing. His 1978 book Doctors on Trial was an homage to Illich and a reworking of the arguments of Medical Nemesis; the introduction, naturally, was written by the great man. Bradshaw often used the word ‘prophet’ when referring to Illich, and saw himself as the interpreter of the Austrian’s more obscure pronouncements – John the Baptist to Illich’s Jesus. Bradshaw was one of the speakers at my university’s debating union in 1981, addressing the Illichian motion that ‘Medicine has become a threat to health’. The debate was a riotous event. Several doctors spoke against the motion, which they regarded as ludicrous, and dismissed Illich and Bradshaw as cranks. I sought out Bradshaw in the college bar, and over drinks we talked animatedly about our mutual hero, Ivan Illich. Later, as I walked home, intoxicated by the debate and the beer, I wondered what I was doing, training for a profession which had ‘become a threat to health’.

  More than most professions, medicine colonizes one’s life. After graduation, I was consumed by the demands of the job. Years went by in a blur of weekends on call and post-graduate examinations. My horizon was always near: the next job, the next qualification. For many years, I embraced this way of living and thinking. It is not without its advantages: medical career structures, and what passes for success in the profession, are so rigid and clearly laid out that the true careerist knows instinctively what to do in any given situation. I slowly ascended the ladder to the status of consultant in a British National Health Service teaching hospital, spending many years along the way in various training positions. As a young consultant, I became something of a Pharisee, a vector of institutional and professional culture. By the age of forty, I had achieved a state of perpetual busyness, and might have continued along this well-trodden pathway for the remainder of my career. A series of events during my forties changed everything; the details are both too tedious and too personal to recount here. When, at the age of fifty, I surveyed the wreckage, I concluded that I had somehow sabotaged this promising career. The sabotage may have been subconsciously deliberate: the real problem was a loss of faith, an apostasy. The cartoon character Wile E. Coyote falls to his doom in the canyon only when he no longer believes; as long as he is unaware of his situation, he remains blissfully suspended in mid-air. My apostasy did not extend to the clinical encounter, and old-fashioned doctoring. I lost faith in all the other things: medical research, managerialism, protocols, metrics, even progress. I became convinced that medicine had become an industrialized culture of excess, and that Ivan Illich’s assertion that it had become a threat to health – which seemed ludicrous to many doctors in the mid-1970s – was true.

  I qualified just as the golden age of medicine w
as ending. In the thirty-five years since then, I have worked in three countries and many hospitals. I have witnessed the public’s disenchantment with medicine, the emergence and global domination of what might be called the medical–industrial complex, and the corruption of my profession. This medical–industrial complex includes not just the traditional villain known as Big Pharma, but many other professional and commercial groups, including biomedical research, the health-food industries, medical devices manufacturers, professional bodies such as the royal colleges, medical schools, insurance companies, health charities, the ever-increasing regulatory and audit sector, and secondary parasitic professions such as lobbyists and management consultants.

  Every age has its own foolishness, and medicine is a great barometer of contemporary fads, an ‘early adopter’ of new technologies and new fashions in personal behaviour, management and education. Far from being conservative and resistant to change, the medical profession forms new enthusiasms with alarming haste. If you want to know what will exercise the world next year, look at what medicine is excited about now. Doctors, both researchers and clinicians, have adopted the language, ethos and mindset of marketing: We’re All in Sales Now.

  Medicine has extended its dominion over nearly every aspect of human life. In doing so, it raised expectations such that disappointment was inevitable. My professional lifetime started at the end of the golden age and the beginning of the age of unmet and unrealistic expectations, the age of disappointment. Patients, doctors and society at large are the victims, dupes and slaves of this medical–industrial complex. We are treating, and over-treating, but not healing. After three-and-a-half decades, I look back with a mixture of amusement, perplexity and shame.