The Rise and Fall of Modern Medicine

by James Le Fanu

  The scale of the great cholesterol deception as outlined above might seem so extraordinary as to raise doubts about its veracity. But it was the inevitable consequence of the official endorsement of a false theory which, beyond a certain point, admits of no going back without destroying the professional reputations of its protagonists. Further, the chronology of these events cannot be emphasised too strongly. The experimental evidence refuting the diet-heart thesis emerged at precisely the moment in the early 1980s when the claims of The Social Theory to provide a new paradigm for medicine were in the ascendant. Its proponents therefore had no alternative other than to assert its validity by the means outlined above.

  Before examining the other aspects of The Social Theory, readers should now try to imagine themselves back in those times when the link between food and heart disease (and much else besides) was almost universally accepted as being correct, when distinguished professors were regularly appearing on television to assert that ‘the modern British diet is killing thousands from heart attacks’. They must try to imagine how the apparent plausibility of Keys’s thesis gave credence to the notion that the causes of all common diseases lay simply in the manner that people lived their lives, where the Western diet was held responsible for virtually all cancers other than those caused by smoking and where the presence of minute concentrations of chemicals in the air and water apparently caused a bewildering variety of illnesses. It is gratifyingly unnecessary to examine each of these other aspects of The Social Theory in the same detail. It is quite sufficient merely to focus on the same cross as that on which Keys’s thesis was crucified – the cross of biology. It is a biological fact that it is very difficult to influence the milieu intérieur of physiological functions such as cholesterol or blood pressure by simple changes in the extérieur, such as small changes in what one eats. It simply cannot be done, and no matter how beautiful and plausible the statistics about heart disease mortality rates in Finland compared to Japan, statistics cannot change the laws of biology. And so now we turn to see how the statistics sustaining the two further instances of The Social Theory are similarly crucified by biology. We start with the ‘causes’ of cancer.

  (iii) BEYOND TOBACCO: SIR RICHARD DOLL

  AND THE ‘CAUSES’ OF CANCER

  Cancer is a grievous illness that causes much misery not just to those who are afflicted but to their friends and relatives as well. It goes without saying that it would be very desirable to be able to identify its causes and thus prevent it but, with a handful of admittedly important exceptions (tobacco and lung cancer, asbestos exposure and mesothelioma), this goal has proved elusive mainly because for most there is no single cause. Rather, cancer is so strongly related to age – the risk increasing by a factor of ten with each passing decade – that it is best seen as intrinsic to the ageing process itself. There are several reasons why this might be so. The replication and repair mechanisms of DNA become impaired with age, increasing the risk that individual cells might turn malignant. Similarly, the immune system loses the ability to identify and destroy potentially cancerous cells, allowing them to ‘escape’ and multiply. Whatever the precise mechanism, the relationship between cancer and ageing is so powerful that it is fair to infer that it could only ever be prevented were ageing itself to be preventable – which would seem unlikely.

  Confronted by this admittedly harsh reality, the notion that cancer might simply be caused by the sorts of food we eat is strongly suggestive of quackery. Yet from 1980 onwards, for almost two decades, persistently and without equivocation, the Social Theorists have insisted that, excepting those cancers attributable to tobacco, virtually all the rest are caused by the Western diet. Why so?

  By 1980 cancer had become vulnerable to the arguments of those, like McKeown, who maintained that social factors were the main cause of disease and hence prevention, by ‘changing lifestyles’, was a much better option than being treated, often unsuccessfully, with nasty anti-cancer drugs. Ten years earlier, in 1971, Dr Donald Pinkel of St Jude’s Hospital had astonished the world with his news that a gruelling regime of four anti-cancer drugs given for two years combined with radiotherapy to the brain had increased the cure rate of childhood leukaemia from 0.07 per cent to over 50 per cent. But leukaemia and the other treatable cancers of childhood and young adult life represent only a small fraction of the total number of cases and so, fuelled by Richard Nixon’s billion-dollar War Against Cancer, specialists took up the challenge of applying the same principles of treatment to the vastly greater numbers of age-related cancers – of the breast, bowel, brain and so on – that occur overwhelmingly in those aged sixty and over.

  This approach, as we now know, did not work. With a few exceptions these ‘old-age’ cancers failed to respond or became rapidly resistant to the anti-cancer drugs, whose main consequence was to make the last few months of patients’ lives even more burdensome with their grievous side-effects. Thus by the end of the 1970s, despite the hundreds of millions of dollars a year being spent on cancer chemotherapy in the United States, the number of children and adults being cured – 5,000 a year – was dwarfed by the 700,000 a year with age-related cancers who were not.31

  The futility of such massive and injurious overtreatment is obvious, and provided the right climate for those who argued there ‘must be a better way’: ‘80–90 per cent of all cancers in Western nations are caused by environmental factors’, observed John Bailar III in the Journal of the National Cancer Institute, and insisted it was time to switch attention to finding out what these might be.32 The same argument would be restated many times over the next few years: the war on cancer had failed, vast funds were being wasted and patients’ lives were being made miserable by chemotherapy, to no good purpose. How much better it would be to prevent these cancers in the first place! It sounded plausible enough, but there was only one problem. Besides tobacco, no one knew what these causes of cancer might be – until, in 1980, Sir Richard Doll, Emeritus Professor of Medicine at Oxford University, and now one of the world’s most eminent cancer epidemiologists, found the answer. After an exhaustive review of all the relevant evidence, he concluded that, besides the role of tobacco in lung cancer, the Western ‘high-fat’ diet was the major cause of cancer which might be avoided were people to switch to a ‘healthier diet’.

  It was all very astonishing. For years doctors and scientists had struggled to understand the causes of these diseases and it seemed that all along the explanation was staring them in the face every time they sat down to a meal. Indeed it was only curious how long it had taken Sir Richard himself to make his sensational discovery. Fourteen years earlier, in 1967, he had drawn attention in a prestigious lecture to the well-recognised causes of cancer such as tobacco and high-level exposure to certain chemicals in the workplace, but failed to mention the role of food at all.33 Subsequently, it seemed, he had become persuaded by the evidence from international comparisons, which showed that common cancers in the West like that of the breast and colon were rare in Japan and – vice versa – stomach cancer was common in Japan but relatively rare in the West. It is of course precisely this type of evidence with which Ancel Keys had incriminated the Western diet in heart disease, so it shares its weaknesses. Even if it were true that the pattern of food consumption was the cause, then presumably switching to a Japanese diet would merely mean switching the risk of dying from the types of cancer common in the West to those common in Japan.34

  Nonetheless, this notion that most cancers, not just those of the lung, might be ‘preventable’ had enormous appeal, especially for policy-makers and legislators apprehensive at the escalating costs of health care. In the late 1970s, they approached Sir Richard to produce a much more detailed review, duly published in 1981 as The Causes of Cancer, in which he makes the claim that, excluding tobacco, food causes 70 per cent of cases of cancer.35

  The Causes of Cancer is an impressive document, with an abundance of graphs and statistics, hundreds of references and no less than five appendices. T
he crucial argument centres on a comparison between the rates of specific cancers as recorded in the Connecticut Cancer Registry and the lowest recorded incidence of the same cancers elsewhere in the world. There are 60.2 cases per million of cancer of the pancreas in Connecticut, compared to 21 per million in India; presumably ‘something’ explains the difference. What could it be other than the fact that the citizens of Connecticut eat different sorts of food from the inhabitants of the Indian subcontinent? And that, astonishingly, is all there is to it.

  The Causes of Cancer may look impressive, but appearances can be deceptive. The intellectual rigour required by Sir Richard Doll’s mentor, Sir Austin Bradford Hill, for assessing the coherence of any hypothesised relationship between an environmental factor and disease – such as food and cancer – is conspicuous only by its absence. Thus the distinguishing feature between the Western diet, as eaten in Connecticut, and that of other countries, such as India, is the relatively high consumption of meat and dairy products. Hence cancers common in the West, such as those of the breast, colon and pancreas, are attributed to a ‘high-fat’ diet. True or false? The Mormons and Seventh-Day Adventists are identical in virtually every way: they lead sober lives, don’t smoke or drink and go to church on Sundays. The only difference is that the Mormons eat meat and the Seventh-Day Adventists on the whole are vegetarians. If the ‘high-fat’ diet explanation for cancer was valid, then the meat-eating Mormons must by definition have a higher incidence of these cancers than the Seventh-Day Adventists. But they do not. Such an important observation in the context of a report in which diet is strongly incriminated in cancer requires serious consideration. There is none.36

  But this omission fades into insignificance when compared to the manner in which Sir Richard Doll deals with the relationship between cancer and ageing. As pointed out, the likelihood of cancer is strongly age-determined, with an eighty-year-old having a thousand times greater risk compared to when he was a teenager. This is fifty times greater than the twenty-fold increased risk of lung cancer in the smoker compared to the non-smoker.37

  Ageing must therefore be right at the top of the list of ‘causes of cancer’, but Sir Richard dismisses it in the following manner: ‘It is sometimes argued that because cancer is ten or a hundred times more likely to occur in the old rather than the young then ageing per se might be thought of as an important determinant of cancer. We rather doubt whether this viewpoint is a scientifically fruitful one . . . ’ On the contrary it is scientifically very fruitful, for recognising the primacy of ageing as a powerful determinant of cancer is essential if one is not to fall into the trap of generating false notions about what else might be the cause.

  Sir Richard Doll subsequently conceded the weaknesses of The Causes of Cancer but never publicly retracted his conclusions, and his claim that he had ‘proved that food caused more than a third of cancers’ was repeatedly cited by all those who had an interest – nutritionists, health educationists, food fanatics and others – in incriminating the Western diet as a major cause of death and disease. And so it was that without the slightest hint of irony the Chief Medical Officer in 1998 advised that the recommended ‘safe’ level of meat consumption for those wishing to avoid cancer should be raised from two lamb chops (or its equivalent) per day to three. Medical advice had become indistinguishable from quackery.

  (iv) ENVIRONMENTAL ALARUMS

  Those who may find it difficult to take seriously the proposition that the number of lamb chops they eat a day might influence the risk of getting cancer or heart disease must look elsewhere for ‘causes’. The obvious other culprits are ‘environmental’ – the minuscule quantities of chemicals present in the air and water. At the beginning of the 1980s there was something of a turf war between these two contending theories, with the dietary protagonists such as Sir Richard Doll accusing (a bit richly perhaps) the environmentalists of ‘bias, exaggeration and lack of balance’.38 From the environmentalist camp Professor Samuel Epstein of the University of Illinois responded with the ‘tu quoque’ argument: ‘The scant scientific evidence for the dietary theory is contradicted by a substantial body of published evidence.’39 There turned out to be room for both explanations and, over the next fifteen years, the public were exposed to a double whammy of health fears, with those of Sir Richard Doll’s camp warning that bacon and eggs for breakfast were the culprits in heart attack, strokes and cancer, and those of Professor Epstein’s persuasion arguing that chemicals and radiation were responsible for everything else: electricity pylons were implicated in leukaemia, hormonal chemicals in falling sperm counts and testicular cancer, and pesticides, mobile phones and even sewing machines in many other types.

  The concern that environmental pollution might pose a threat to health started in 1962 with the publication of Rachel Carson’s Silent Spring. The children of future generations, Carson argued, would never again hear the sound of birdsong in spring because pesticides thinned the shells of their eggs, resulting in a precipitous fall in their numbers. Carson’s claims were at least partially vindicated, and following instructions on pesticide use the threat of a ‘silent spring’ was averted. This episode was so powerful a pointer to the possible harm of man-made chemicals that, inevitably, the question arose as to the dangers they might pose to human health. It certainly seems plausible enough that pesticides might be responsible for several diseases for which there is as yet no satisfactory explanation, including falling sperm counts which, if true, would mean that not just birds, but the human species, could soon be facing extinction.40

  It is, of course, only sensible that the amounts of chemicals in the environment should be kept to the irreducible minimum, but the issue to be examined here is quite specific. Environmental pollution certainly posed a significant threat to health in the nineteenth century, when the all too readily detectable pollution of our great industrial cities, with their stinking canals and rat-infested tenements, limited the average lifespan to little more than forty years. It certainly can matter in situations of high exposure, as experienced by workers in the asbestos industry or following major catastrophes such as the Bhopal accident in India that killed 2,000 people. The question rather is whether, at the concentrations of these chemicals to which the general public is exposed – measured in parts per billion – they are injurious to health.

  Many believe they are, including leading academics in Britain and America. Thus in a discussion on the effects of water pollution, Professor Howard Hu of Harvard University observes: ‘The threat to health from water contamination remains high,’ and goes on to cite examples – traces of arsenic could cause cancer ‘in significant numbers’; nitrate residues from fertilisers have been linked to stomach cancer; pesticides have been linked with breast cancer; halogenated solvents ‘with childhood leukaemia’; and so on. It certainly sounds scary enough, and this is just water pollution. Parallel litanies of hidden dangers apply to air pollution, food contamination and radiation.41

  It should not be supposed that any of these allegations is scientifically proven for, as can be imagined, it is simply not possible to conduct the required experiments of exposing large numbers of people for long enough to any pollutant in the minuscule quantities that are present in air and water to detect whether it is indeed harmful. Rather, the argument rests almost entirely on extrapolation from the consequences of high levels of exposure or toxicology tests in rodents. Certainly these chemicals in high doses can have adverse effects in rats, and so, the argument goes, even at a millionth of the dose they might, theoretically, adversely affect one in a million people.

  The central assumption here, crucial to the environmental case, is that there is no ‘threshold’ of exposure below which even a scarcely measurable pollutant in the air or water can still be harmful to health. This ‘no threshold’ concept is best understood by analogy for, if it were correct, it would mean that not only the person drinking a bottle of whisky a day for five years is likely to damage his liver but also someone eating an alcohol-fl
avoured Christmas cake once a year for thirty years. This would seem unlikely and is contrary to the fundamental axiom expressed by the great French scientist Claude Bernard in the mid-nineteenth century: ‘Tout est poison, rien n’est poison, tout est une question de dose’ – everything is poisonous, nothing is poisonous, it is all a matter of dose.42

  It is clearly impossible to evaluate each and every alleged environmental threat to health. Some, such as global warming and the threat to the ozone layer from CFCs, are theoretical, in that the putative harmful consequences have not yet occurred. Clearly no definitive verdict, one way or another, can be given on such predictions, and they will not be considered further. The focus rather is on the claims of those like Professor Hu who maintain that pollutants are responsible for contemporary health problems in the Western world.

  It is customary to test the safety of chemicals such as synthetic pesticides, minuscule doses of which may be present in fruit and vegetables, by exposing experimental animals (such as rats) to the Maximum Tolerated Dose (MTD), and if a substantial number develop cancer, the chemical could possibly be carcinogenic in humans. Now, vegetables and fruit – such as bananas – produce their own ‘natural’ pesticides to discourage bugs and weevils and other small creatures who might wish to eat them. In the mid-1980s an eminent toxicologist, Dr Bruce Ames of the University of California, decided to test these ‘natural’ pesticides in precisely the same way as synthetic pesticides by giving the Maximum Tolerated Dose to rats. He discovered, to his surprise, that half of these naturally occurring ‘pesticides’ were similarly carcinogenic: