First we must satisfy ourselves – for the last time – that the pattern of a Rise and Fall is indeed correct. There can be no doubting the concentration of major discoveries prior to 1975, while other evidence for the decline in innovation around this time, such as the Dearth of New Drugs and the demise of The Medical Annual, the ‘bulletin’ of the therapeutic revolution, is clear enough.
This interpretation of events is admittedly difficult to accept, primarily because the belief in the limitless possibilities of medical progress is so pervasive, but it is a common historical observation that such things do happen. Every field of human knowledge has its Golden Age, which is followed by a decline in creativity and new ideas.1 Geology’s ‘finest hour’ was the mid-nineteenth century, with the startling discovery that the world was billions of years old. Then it was the turn of natural history, with the Darwinian theory of evolution. The glory days of theoretical physics were between the wars, grappling with quantum physics and Einstein’s Theory of Relativity. The 1960s were the heyday of space exploration, and so on. Medicine’s Golden Age lasted longer than most and had a greater impact, but there is no reason why it should be an exception to this rule, for just as the nineteenth-century European explorers eventually found there was no more left of Africa to explore so, once hearts are being transplanted and childhood cancer cured, the potential for further progress in these areas is clearly constrained. Medicine, like any field of endeavour, is bounded by its concerns – the treatment of disease – so success necessarily places a limit on further progress. Indeed, according to the ‘Law of Acceleration’ proposed by the American historian Henry Adams, it is precisely at the moment that a scientific discipline is at its most apparently successful, as medicine was in the 1960s and early 1970s, that it will be approaching its apotheosis.
But there are also specific reasons why medicine should conform to this pattern of a Rise and Fall. First, it is limited to doing what is ‘do-able’, and by the 1970s much of what was ‘do-able’ had been done. The main burden of disease had been squeezed towards the extremes of life. Infant mortality was heading towards its irreducible minimum, while the vast majority of the population was now living out its natural lifespan to become vulnerable to diseases strongly determined by ageing. Second, these age-determined diseases, which are far and away the dominant preoccupation of Western medicine, are of two sorts. Some, like arthritis of the hips and furred-up arteries, can be markedly improved with drugs and operations, while others, like cancer and the circulatory disorders, can be palliated though not postponed indefinitely. Thirdly, and very importantly, the rate of medical innovation was bound to decline because so many of its important discoveries had depended on luck. The bountifulness of nature in providing the extremely potent but entirely unanticipated antibiotics and cortisone is unlikely to be repeated, while sooner or later research chemists will find they are scraping the bottom of the barrel of chemical compounds that can be synthesised and screened for their therapeutic potential. And finally, medical research is, in Peter Medawar’s memorable phrase, ‘the art of the soluble’. As of this moment, it is not at all clear whether or how the last challenge left – the discovery of the causes of diseases like multiple sclerosis and leukaemia – is indeed ‘soluble’.
Now this contention that science has ‘reached its limits’ has been expressed many times in the past, only to be repeatedly disproved. Famously Lord Kelvin, at the close of the nineteenth century, insisted that the future of the physical sciences was to be looked for in ‘the sixth place of decimals’ (that is, futile refinements of the then present state of knowledge). Within a few years Einstein had put forward his Theory of Relativity and the certainties of Lord Kelvin’s classical physics were eclipsed. Perhaps predictions about medicine ‘having reached its limits’ will be similarly overthrown in the coming years. Perhaps, but the brick wall blocking further medical progress is solidly built, being no less than four layers thick. The readily do-able has been done, the chronic diseases of ageing have been ameliorated, the bottom of the barrel of lucky drug discoveries has been scraped and the causes of the common diseases of mid-life remain a mystery.
The epochs of the Rise and Fall of medicine do not just follow each other chronologically, but are dynamically related. The Fall from the late 1970s onwards is best understood as a set of false strategies by which the express train of medical advance, fuelled by the successes of the Rise, sought to variously hammer away at, pole-vault over, circumvent or undermine this four-layered brick wall impeding further progress.
The essence of ‘hammering away’ is to do the same things but at greater intensity. We encountered this in Technology’s Failings, with the excessive use of new investigative techniques for straightforward medical problems: an endoscopy for everyone with a stomach ache, a CT scan for everyone with a headache, and complex studies of urine flow for every male with symptoms of an enlarged prostate. The potential for expanding the use of these diagnostic techniques is virtually limitless, especially if the age group being investigated is pushed upwards to include those in their eighties and nineties. There was also considerable scope for hammering away in the pursuit of marginal treatment benefits, as in the massive overuse of chemotherapy in the palliation of age-determined cancers or futile attempts to prolong life, as illustrated by the description of General Franco’s final illness. A quarter of all health expenditure in the United States, it will be recalled, is now spent on patients during the last six months of their lives.
The pharmaceutical industry has also had no alternative, in the absence of new and lucky drug discoveries, other than to keep hammering away. This takes several forms, of which the most obvious is the ‘better mousetrap’ – new and more costly variants of drugs already available. These may well be ‘better’ in the sense of being easier to take and having fewer side-effects, but they are no more effective therapeutically. Alternatively, when there is no effective remedy for a disease the drug companies have adopted the ‘useless mousetrap’ strategy on the grounds that patients and relatives want to be doing ‘something’. Thus new drugs for Alzheimer’s and multiple sclerosis are increasingly widely prescribed even though their efficacy is scarcely detectable.
The second response to the brick wall was to try and pole-vault over the lack of effective treatments with complex and expensive strategies. The saga of foetal monitoring introduced in the 1970s in the hope of preventing cerebral palsy belongs in this category, as do the national screening programmes for the early detection of cancers of the breast and cervix. Screening certainly can work. There is no simpler and more effective medical intervention than screening every newborn baby to detect those at risk of mental deficiency from an underactive thyroid. A spot of blood obtained from a heel prick can be automatically processed at virtually zero cost to establish the diagnosis, while treatment – thyroxine replacement – is 100 per cent effective. By contrast, the principle behind screening for cancer may be the same – the detection of disease at an early enough stage for it to be curable – but that is all. Cancer screening is logistically very complex to organise, the techniques of diagnosis – cervical smears and mammography – require considerable skill, while the distinction between the normal and the pathological is uncertain. Finally, even though cancer screening involves the dedicated skills of nurses, radiologists, pathologists, gynaecologists and surgeons, the impact is marginal, because the most aggressive cancers that need to be caught early arise so rapidly.2
The third option, circumventing the brick wall, sought to bypass the dearth of new treatments by preventing disease in the first place. This was The Social Theory. Its approach, if not examined over-critically, certainly appeared plausible enough and indeed was widely perceived as representing a further stage in the evolution of medicine, where prevention was a more sophisticated response to the problem of illnesses such as cancer and heart disease than an attempt to ‘cure’ them with relatively ineffective medical therapies. Enormous sums of money have been expended on ‘health
promotion’ to achieve these ends. Its drawback is that it does not work. The Social Theory fulfilled another important function by expanding the influence of medicine beyond the traditional confines of the consultation between doctor and patient to reach out to the healthy too. It provided apparently authoritative advice to the public on how they should lead their lives, instructing them in what they should and should not eat, while alerting them to previously unsuspected hazards in their everyday lives.
Finally, The New Genetics sought to undermine the wall by illuminating the workings of the human organism at its most fundamental level with the promise that at some indefinable point in the future the wall would come tumbling down, leaving a long straight road to health and happiness for all.
The perverse consequence of all these unsuccessful attempts to hammer, pole-vault, circumvent and undermine the brick wall is that medicine has sustained, even enhanced, its dominant position within Western society. Medicine has never been so powerful, and yet its success is seriously compromised by another ‘rule of four’, the four-fold paradox noted in the Introduction.
The causes of these four paradoxes are diverse and complex. Nonetheless, as was suggested in the Introduction, an historical perspective suggests they can also be seen as the multi-faceted side of the singular phenomenon of medicine’s Rise and Fall.
Paradox 1: Disillusioned Doctors
Medicine is, sadly, no longer as satisfying as in the past. Many of the most interesting diseases that tested the doctor’s clinical acumen have simply disappeared, and a family doctor is lucky to see a patient with a serious acute medical problem from one week to the next. This lack of satisfaction has been compounded by the rise of specialisation, so the cardiac surgeon who in the early days of the pump was faced by the challenge of repairing many different complex anatomical defects of the heart now spends all his time routinely doing coronary artery bypass grafts. Further, the dearth in therapeutic innovation now means that doctors are doing much the same as they were twenty years ago and what seemed very exciting in the 1960s and 1970s, such as transplantation and CT scans, has become routine. In short, medicine is duller, as can readily be ascertained by contrasting the sparkle and interest of medical journals from two or three decades ago with those of today, where impenetrable genetics and improbable epidemiology jostle for space and no one is any the wiser.
Paradox 2: The Worried Well
It is most peculiar that as medicine has become more successful, the proportion of the public who apparently are ‘worried’ about their health has increased. This could be because people ‘don’t know when they are well off’, certainly when compared to their parents’ generation, who lived through the privations of the Depression and war. But equally importantly they have been encouraged by the falsehoods of The Social Theory to become more neurotic. If it were correct that so innocent a pleasure as eating bacon and eggs for breakfast can lead to an untimely demise from a heart attack, then there is no reason to doubt the myriad other hazards of everyday life that have been identified over the last decade. It would be most surprising if people did not, as a result, become more alarmed about their health. This in turn has compounded the professional discontent of Paradox 1 as an excessive concern about ‘health’ can only too obviously encourage people to see their doctors unnecessarily. They in turn become frustrated at the time they have to spend dealing with the ‘Worried Well’.3
Paradox 3: The Soaring Popularity of Alternative Medicine
The ‘alternatives’ – in their various different guises of homeopathy, naturopathy, acupuncture and so on – are now so popular, being used by one-third of adults in any one year, that it is difficult to appreciate that prior to the 1980s they were very much a minority interest and widely perceived as quackery. The surging popularity of these alternatives might be explained by the undivided attention offered by its practitioners which, to many, might seem preferable to being expensively overinvestigated and overtreated in a hospital bed.
But these alternatives are more than just ‘feel-good therapies’. The effectiveness of the modern drugs that came tumbling out of the drug companies in the 1960s and 1970s led to the neglect of simpler, more traditional remedies and the dismissal of anything that did not fit the ‘scientific’ ideas of the nature of disease. Thus, following the discovery of cortisone and other anti-inflammatory agents, the skills of rheumatologists devolved around juggling various toxic regimes of drugs in the hope that the benefits might outweigh the sometimes grievous side-effects. Meanwhile, all the other therapies for rheumatological disorders – such as massage, manipulation and dietary advice – were abandoned virtually wholesale, only to be ‘rediscovered’ by alternative practitioners in the 1980s.
Paradox 4: The Spiralling Costs of Health Care
The more that medicine can do, the greater will be the demand and thus the greater the cost. But it is incorrect, as is often asserted, that the demands for health care are potentially limitless. On the contrary, it is quite possible to spend too much on health. The negligible cost of the consultation for a tension headache becomes substantial when a brain scan is thrown in for good measure. Such examples could be multiplied a thousand-fold.
Further, the pattern of a Rise and Fall indicates that the future scope of medicine will primarily be directed at the amelioration of the chronic degenerative diseases of ageing, such as hip replacements and cataract operations. The rising numbers of those needing such procedures will certainly continue to push up the cost, but this is finite and measurable. The paradox of the rise of medical expenditure rather lies in the lack of any obvious correlation between the phenomenal rise in health service funding of the recent past and any measurable or subjective impression of improvements that could justify such an increase. It is accounted for, at least in part, by the processes already described of hammering away at the obstacles to further medical progress that have already been outlined. These escalating costs are an enormous cause for concern, as the state has many other responsibilities just as, or indeed more, deserving than health.
In summary, the four paradoxes of the success of modern medicine can all be understood as different aspects of medicine’s Rise and Fall. By now it will be clear there is more to the Fall than a sloping-off in the rate of medical innovation. Medicine’s moral and intellectual integrity has also been eroded over the last two decades, as revealed by the obvious contrast between, for example, the protracted engagement with the profound problems posed by transplantation or curing childhood cancer and the illusory promises of The Social Theory and The New Genetics. The distinguished social historian Roy Porter elaborates on the consequences:
The irony is that the healthier Western society becomes, the more medicine it craves . . . Immense pressures are created – by the medical profession, by the media, by the high pressure advertising of pharmaceutical companies – to expand the diagnosis of treatable illnesses. Scares are created, people are bamboozled into lab tests, often of dubious reliability. Thanks to diagnostic creep or leap, ever more disorders are revealed, extensive and expensive treatments are then urged . . . [This] is endemic to a system in which an expanding medical establishment, faced with a healthier population, is driven to medicalising normal events, converting risks into diseases and treating trivial complaints with fancy procedures . . . The law of diminishing returns necessarily applies. Extending life becomes feasible, but it may be a life exposed to degrading neglect as resources grow overstretched. What an ignominious destiny if the future of medicine turns into bestowing meagre increments of unenjoyed life!4
And yet the everyday practice of medicine belies this gloomy interpretation because, despite everything, it delivers and, thanks to the therapeutic revolution, much more so than fifty years ago. Consequently doctors do find their work satisfying and their patients do get better. The public is probably less concerned about the alleged hazards of everyday life than surveys would suggest and, when the crunch comes, most would put their trust in the orthodox rather than the al
ternatives. Still, this analysis of the past certainly makes sense of present discontents, which, if confronted and corrected, are the best guarantees of medicine’s continuing success in the future.
2
LOOKING TO THE FUTURE
For I dip’t into the future, far as human eye could see Saw a vision of the world, and all the wonders that would be.
Alfred, Lord Tennyson
At the mid-point of the century, a few years after this historical account opens, Lord ‘Tommy’ Horder addressed a meeting on the theme ‘Whither Medicine?’. The miraculous effect of cortisone had just been described, there were encouraging signs that children with leukaemia were responding to anti-cancer drugs, both the cure of tuberculosis and the implication of tobacco in lung cancer were imminent. In the midst of such momentous events, Lord Horder suggested, a visitor from Mars would have thought the subject of his address incomprehensible: ‘“Whither Medicine?” the Martian would say, “Why, whither else than straight ahead; forging still more weapons with which to conquer disease.”’ And, as we have seen, the Martian would have been absolutely right.1
But the burden of the history of post-war medicine that emerges from this book is that such genuine and unbridled optimism is no longer possible. The race has been run, the Golden Age is over and so for a contemporary Martian the most likely scenario for the future would seem to be at best a continuation of the present. Medicine will continue to be a powerful and immensely successful enterprise, ameliorating the chronic diseases associated with ageing and, where possible, saving the lives of the acutely ill. But, equally, medicine’s discontents are also likely to continue. The next surveys will reveal a yet higher proportion of doctors ‘with regrets’, and a yet higher proportion of the public who are neurotically concerned about their health. Yet more unanticipated hazards of everyday life will be identified and the cost of medical care will continue to spiral upwards.
The Rise and Fall of Modern Medicine Page 38