Precautionary Tales


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Shared reading


A friend of mine, an internet consultant, refers to blogs as 'shared reading'. Very sensible. In that vein, I'm going to be placing my notes about what I'm reading online. They may help you, dear reader, and they will certainly help me. Because I'll be able to find them!

The Rise and Fall of Modern Medicine, by James Le Fanu

Published in 1999, by Little, Brown & Co. These notes published: 22 June 2003

Le Fanu's starting point is a paradox: we are now healthier than at any time in our history. We live longer lives, and those lives are less blighted by illness, than ever before. And yet, the morale of the medical profession is low, and the esteem in which medicine is held is also in decline. We spend more and more on health care for apparently diminishing returns.

His explanation of this situation focuses on the contrast between a highly successful, 'golden age' of medicine, in which most of the pressing problems for medicine were solved, and the last 20 years or so, when the kinds of new solutions presented in the golden age ran out of steam, and in which no new paradigm emerged of similar utility. Instead, this recent period has been dominated by genetics and epidemiology, two schools which have not, and probably could not, have the same dramatic effect.

Twelve definitive moments

Le Fanu begins the book with a list of twelve definitive breakthroughs. All of them have had a major influence on mortality and/or quality of life:

1. Penicillin (1941)
2. Cortisone (1949)

These two drugs provided therapy for previously untreatable disease, either by killing the disease directly (as in the case of antibiotics) or by mobilising the bodies own defences to deal with the infection (as with cortisone).

3. Streptomycin, smoking and lung cancer (1950)

At last, in combination with PAS (para-amino salicyclic acid), a treatment for tuberculosis with a high degree of success. At the same, Austin Bradford-Hill was demonstrating the link between smoking and lung cancer. Thus began the shift from a concern with germs to behaviour and lifestyle.

4. Chlorpromazine (1952)

The first successful treatment for schizophrenia. Until then, mental illness had been treated by locking people up, electrocuting them, lobotomy or any number of other barbaric and ineffective methods. While drug thereapy has its critics, this was still a vast improvement for the treatment of many, if not most, schizophrenics.

5. Intensive Care (1952)

The Copenhagen polio epidemic proved the catalyst for the development of a means to keep people alive during the worst periods of illness.

6. Open-heart surgery (1955)

The heart had previously been thought to be inoperable. The creation of a heart lung machine allowed surgeons to stop the heart, operate on it, and restart it, while the patient's life was maintained.

7. Hip-replacement surgery.
8. Kidney transplantation.
9. Preventing strokes

Le Fanu points out how reducing high blood pressure was successful in reducing strokes, and how this led to the creation of a paradigm of prevention, largely unsuccessful in other situations.

10. Curing childhood cancer

A process that developed through a lot of trial and error (like a number of these developments) but which allowed whole lives to be led normally. Quite different from treating adult cancer, which mostly occurs in old age, and does not have the same dramatic effect on life expentancy (although it is useful nonetheless).

11. Test-tube babies
12. Discovery of helicobacter as a cause of peptic ulcers

Interesting that a disease previously thought to be caused by stress or poor diet, actually had an infectious cause.

The rise and fall

Le Fanu notes why there was a golden age:

1. There was a lot of premature death due to infectious disease.
2. Some fortuitous discoveries were made in relation to drugs.
3. Biochemistry had developed such that thousands of compounds could be created and tested for therapeutic value, by a process of trial-and-error.
4. Importantly, little was known as to why these therapies succeeded in many cases.

And why there was a fall:

1. There is a limit to how much you can reduce premature death - most of these are now preventable. The room for further progress is small.
2. There are few fortuitous discoveries to be made.
3. The paradigms that have followed on from the golden age are limited.

Genetics

The basic problem is that not many diseases are caused by genetics directly, and producing a therapy based on an understanding of that cause is not straightforward.

Epidemiology

A few limited successes with finding causes e.g. smoking and cancer, and one major success in devising a therapy - reducing blood pressure to cut the risk of strokes - has been turned into a whole worldview. However, there are problems. The biggest risk factor with heart disease and cancer is age. Even if much of that disease could be got rid of, the actual increase in life expectancy would be small.

Moreover, many of the alleged links between behaviour and disease have proven illusory. For example, diet does not seem to be strongly linked to heart disease, except perhaps in relation to obesity. Absolute poverty may be a cause of disease - but relative poverty? Cholesterol may be linked to heart disease but the mechanism is still unclear - and in any event, controlling cholesterol is both difficult and doesn't seem to have much affect on outcomes.

Conclusions

Le Fanu argues that the golden age has given us a lasting legacy of medical success. We still can't cure everything, but we can cure most infectious disease. What we can't treat are mainly the diseases of old age. Much that has happened in the last 20 years has actually hindered medical progress, mainly as a futile distraction.

Le Fanu argues that actually, some good old doctoring is as good a way forward as any, and that some forms of lost therapy, replaced by more hi-tech alternatives, may have more efficacy than their modern replacements.


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