Two critics of the Healthcare System

"The Last Well Person: How to Stay Well Despite the Health-Care System" by Nortin M. Hadler. Published by McGill-Queen's University Press, 2004.

"The Patient Paradox: Why Sexed-Up Medicine is Bad for Your Health" by Margaret McCartney. Published by Pinter and Martin, 2012.

Rising healthcare costs are seen as a huge problem, even to those who are not aware of the need to totally overhaul the infra-structure of modern civilization in the coming (very) few decades. To those who are so aware, these two books give valuable insights.

The books would be more effective if they started with an introduction giving an outline of the development of medicine in the last few centuries. Such an introduction could be a summary of the essay "Becoming a Doctor" [1] by a wise old doctor by the name of Lewis Thomas (1913--1993) such as the following.

Doctors of one kind or other have been a feature of all civilizations. Their existence is the age-old reaction of humans to the onset of illness: they are scared. Hence the urgent call for a doctor, who has to do something. This something could not be just anything. The more esoteric, and the more restricted to the initiates in doctoring, the more highly valued. In Western civilization the prime example of such esoteric knowledge were the hundreds of treatises by Galen (ca. 130 -- ca. 200). Remarkably, as late as the 18th century Galen's doctrines were influential. An example occurred during the last days of George Washington's life (1732--1799). At age sixty-six he had gone for a horseback ride in the snow. Later in the day he had a fever and a severe sore throat, took to his bed and called in his doctors. Some of their ministrations were harmless, other ones less so: over the next two days he was bled from a vein for five pints of blood. His last words to his physician were: "Pray take no more trouble about me. Let me go quietly."

Beginning in the 1830s groups of doctors in Boston, Paris, and Edinburgh raised heretical questions concerning the efficacy of the traditional methods. Patients with typhoid fever and delirium tremens were divided into two groups. One was treated by traditional therapies. The other group was not subjected to any intervention, but was cared for with bed rest and nutrition.

The results were unequivocal, with the implication that many patients had been killed by their doctors. In the middle of the 19th century the era of "therapeutic nihilism" set in. The task of the doctor was seen, by doctors, as diagnosis and prognosis. The doctor had to know which of the many known diseases was causing the symptoms and what the likely course of the illness was.

The main new insight of this, the First Medical Revolution, was that many diseases are self-limited: with bed rest and good care they had their natural course ending in death or in recovery (70 percent of the cases in typhoid fever, one of the more dangerous diseases). This was an earth-shaking revelation to most physicians. The traditional certainty had been that every disease was aimed toward a fatal termination and that without a doctor and his energetic ministrations all sick people would be killed by their disease.

The Second Medical Revolution started in the 1930s with the introduction of sulfonamides, penicillin and other antibiotics. This led to unequivocal successes in the treatment of tuberculosis, tertiary syphilis, poliomyelitis, the childhood contagions, septicemias, typhoid, rheumatic fever and valvular heart disease, and most of the other great infectuous diseases.

These were the easy successes. On medicine's agenda there remains a long list of fatal or incapacitating diseases which manifest themselves increasingly as the beneficiaries of the Second Medical Revolution age.

So far my summary of "Becoming a Doctor" by Lewis Thomas, a summary that would be a useful prelude to the two books under review. What Thomas's essay does not touch on is that during the era of therapeutic nihilism it was mainly only the doctors who enlightened. The public was the same as before(, and after). When one is ill, one is scared, and something must be done. Thus the doctors of the era of therapeutic nihilism became adept at the art of the placebo, but with the novel benefit of ensuring that their ministrations were harmless.

The Second Revolution has been gathering pace ever since the mid-20th century. The result has been a bewildering variety new diagnostic techniques and plausible-sounding putative therapies. This could have been good if the new technology were slowly and conservatively adopted, always staying within the confines of evidence-based medicine. This has not been the case; the two books under review, each in its own way, explain what has been happening instead. Note the similarity of the subtitles: "How to Stay Well Despite the Health-Care System" and "Why Sexed-Up Medicine is Bad for Your Health".

The changes since the beginning of the Second Revolution are mainly due to medical insurance. Molière made fun of doctors and wouldn't have been in a hurry to pay doctors' bills, if he would have consulted one at all. In the 1920s, the family doctor who was the father of Lewis Thomas worked hard, lived frugally, and would not have any financial worries if his patients had paid their bills when due. In fact, he constantly had to worry how to pay his bills[2, pages 3-4].

No wonder the idea of medical insurance is popular. Doctors have a better prospect of getting paid; the public have the illusion of getting something for nothing. Unfortunately the idea of medical insurance gets translated to a reality that is disappointing for both parties. From the public's point of view there is always an enormous imbalance between demand by the insured and supply made available by the premiums minus the cost of the insurer's bureaucracy. The result is triage. But it cannot be acknowledged that triage happens, so it happens in obscure ways, with the suspicion that one's dying mother is being denied a life-saving procedure so that some VIP can be attended to expeditiously. It doesn't help to read accounts with glowing praise for the capabilities of modern medicine such as [2, pages 223-227] while Mum is stuck in a lengthy waiting list.

From the doctors' point of view the advantage of getting their invoices reasonably promptly paid is offset by the fact that the insurer doesn't like paying doctors either and is enamoured by "hippie-dippie", as medical students affectionately referred to HPDP: Health Promotion, Disease Prevention. This notion conjures up a mirage that much, if not most, incidence of disease can be prevented by screening and preventive interventions. Of the two books under review, McCartney's is the more eloquent exposition of the waste, health hazard, and physician frustration caused by the monopoly in the UK of the National Health Service under the misguidance of HPDP.

Both books contain revealing information about statins, a class of cholesterol-lowering drugs. The more detailed account is in Hadler, pages 36-43. Statins are a big deal. According to Wikipedia (observed August 3, 2015), Pfizer reported sales of US$12.4 billion in 2008. The basis for prescribing the drug is the West of Scotland Pravastatin Study, a randomized trial comparing outcomes for two groups of three thousand men each, one group taking Pravastatin and the other receiving instead an inert placebo. At the conclusion of the trial thirty percent fewer men in the Pravastatin-treated group had died of a heart attack. Wouldn't you take Pravastatin if cholesterol screening indicated that you are at risk?

If you read this chapter in Hadler, you wouldn't. Four percent of the untreated group died of a heart attack. This means that taking Pravastatin reduced this cause of death from four percent to three. There was no difference in longevity between the two groups: the lives "saved" by Pravastatins tended to end soon after by any of the several fatal diseases that lurk in every human near the end of life. Add to that "the West of Scotland Study result failed to reproduce in a randomized controlled trial in the United States ..." (page 42). Oh yes, and there is a risk, admittedly small, of serious side-effects.

The enthusiasm of physicians is understandable:

The statins were produced because of spectacular Nobel Prize winning science (by Konrad Bloch, Michael Brown, Joe Goldstein, and others) pointed the way. Their development is a triumph of applied biochemistry. However, the "translational science", which seeks clinical effectiveness, is nearly as disappointing as the basic science is illuminating.

Time to wind up with a recommendation of the two books under review. McCartney is the more layperson-friendly, strong on the baleful influence of "health-delivery systems" [3]. Hadler goes deeper and it is with a summary of his book that I'm ending the review.

Hadler emphasizes the two inevitabilities that are hard to accept to the public: the inevitability of death (part I) and the inevitability of episodes of morbidity (part II). As to the first, the striking increase in longevity over the course of the 20th century, together with the impression that progress in medicine continues unabated, lead to the expectation of continuing increase in healthful longevity. However, the past increase in longevity was due to more people reaching the age of eighty-five, but not to more people becoming highly-functioning nonagenarians. As overall life exptancy approaches 85, further worthwhile increase is not to be expected. But such expectations make it harder for the medical profession to resist pressure, from the public and from industry, towards interventions that are useless or worse.

In part II, about the inevitability of morbid episodes, Hadler has this to say.

The assertion that coping with intermittent and remittent morbidities is "normal" is on firm scientific grounds. None of us will live long without headache, backache, heartache, heartburn, diarrhea, constipation, sadness, malaise, or other symptoms of some kind. When we pause in recognition of any such morbid challenge, we are faced with a predicament. For my purposes, "predicament" is a convenient term because it captures the challenge without casting aspersions or assuming causation. We all have presonal predicaments that often challenge our sense of well-being. Some are catastrophic: overwhelming chest of abdominal pain, acute neurologic symptoms, broken bones, and the like. For these events, choosing to be a patient of someone licensed to practise medicine or surgery is not more than sensible -- it is mandatory. Modern medicine has much to offer if we fall victim to such events: it provides cures for some and important comfort for others. Most personal predicaments are less catastrophic morbid events, but they are still disconcerting. Because they are less than catastrophic, we have the opportunity to pause and consider what to do.
(page 103)

When we so pause we should know full well that in choosing to consult someone licensed to practise medicine, we are crossing the line between being a well, though challenged, person, and being a patient.

The response to the global emergency has to be a drastic increase in productivity of the global economy. In the developed countries the possibility of such an increase is vitiated by the alarming increase in the percentage of GDP that goes to healthcare. This needs to be reversed. But this percentage is only part of the damage: GDP only shows the effort on the part of the healthcare providers. It does not show losses sustained by the public in terms of time lost in travel, waiting rooms, hospital visits, and so on.

[1] "Becoming a Doctor", in The Fragile Species by Lewis Thomas. Collier-McMillan, 1992.
[2] The Youngest Science by Lewis Thomas. The Viking Press, 1983.
[3] Or some such sample of healthspeak. Listen to the ultimate authority, the WHO (World Health Organization): "Integrated health services encompasses the management and delivery of quality and safe health services so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, through the different levels and sites of care within the health system, and according to their needs throughout the life course. "