René Dubos (1901–82), the French-American microbiologist, environmentalist and writer, wrote Mirage of Health (1959) more than twenty years before James Fries came up with the idea of the compression of morbidity, and observed that this fantasy has been with us since antiquity:
In Works and Days Hesiod wrote of the golden age when men ‘feasted gaily, undarkened by sufferings’ and ‘died as if falling asleep’. The oldest known medical treatise written in the Chinese language also refers to the health of the happy past. ‘In Ancient times,’ states the Yellow Emperor in his Classic of Internal Medicine published in the fourth century BC, ‘people lived to a hundred years, and yet remained active and did not become decrepit in their activities.’
The Marquis de Condorcet (1743–94), the Enlightenment figure most associated with the new religion of progress, predicted a future in which ‘man would be free from disease and old age and death would be indefinitely postponed’. Several books were written in the late eighteenth century on this theme, such as The Art of Prolonging Life by C. W. Hufeland and Johann Peter Frank’s A Complete System of Medical Policy. The Enlightenment, having banished religious superstition, created a new belief – and a new form of enslavement – that the human body is a machine, governed by mechanistic and deterministic laws. Mirage of Health appeared at the peak of medicine’s golden age. Dubos, indeed, had contributed significantly to one of the great achievements of the golden age – the development of antibiotics. In the very first page, Dubos cast doubt on the great project of which he was a part:
Complete freedom from disease and from struggle is almost incompatible with the process of living… The very process of living is a continual interplay between the individual and his environment, often taking the form of a struggle resulting in injury or disease… Complete and lasting freedom from disease is but a dream remembered from imaginings of a Garden of Eden designed for the welfare of man… it is easier for the scientific mind to unleash natural forces than for the human soul to exercise wisdom and generosity in the use of power… solving problems of disease is not the same thing as creating health and happiness.
Dubos argued, as did others – most notably Thomas McKeown – that the great improvements in public health and longevity happened long before the golden age of medical research and was achieved by better sanitation and nutrition. He wittily observed how medicine took credit for these gains: ‘When the tide is receding from the beach it is easy to have the illusion that one can empty the ocean by removing water with a pail.’
Mankind has always yearned for utopias, but only in our age did this yearning become medicalized. The World Health Organization (WHO) was established immediately after the war in 1946, and in its constitution defined health as ‘not merely the absence of disease or infirmity, but a state of complete physical, mental and social wellbeing’. Petr Skrabanek joked that ordinary people might achieve this sort of feeling ‘fleetingly, during orgasm, or when high on drugs’. In 1975, the director-general of the WHO, Dr Halfdan Mahler (a Dane) gave an address to the organization entitled ‘Health for All by the Year 2000!’ This ludicrous slogan was adopted by the WHO as a mission statement for the 1970s and 1980s, but the millennium came and went without Mahler’s utopia. He wasn’t alone: in 1987, the eminent Irish cardiologist Professor Risteard Mulcahy told the Irish Times: ‘By the year 2000 the commonest killers such as coronary heart disease, stroke, respiratory disease and many cancers will be wiped out.’ Many people in rich countries began to believe the WHO’s definition of health, and when they found themselves experiencing the inevitable hardships of human life, and thus temporarily not in a state of ‘complete physical, mental and social wellbeing’, presented themselves to doctors so that they might be restored to the blissful state promised by the WHO as the birthright of all humans. This intolerance of distress is partly to blame for the exponential rise in the prescribing of antidepressant and anxiolytic drugs. The criteria now used by GPs to diagnose depression are now so flimsy that a combination of two weeks’ unhappiness accompanied by other symptoms such as insomnia is enough to diagnose a ‘major depressive episode’: up to 50 per cent of the population may experience such an event over a lifetime. Meanwhile, those with severe, persistent depression – what used to be called melancholia – struggle to access psychiatric services. The vast increase in diagnosis of attention deficit hyperactivity disorder (ADHD), autism and bipolar disorder cannot be accounted for by an increase in prevalence. Neither religion nor philosophy claims that life should be happy, but the WHO does.
The ancient Greeks had two separate, rival and distinct medical traditions, those of Aesclepius and Hygieia. The Aesclepian tradition, which the late GP Ian Tate called the ‘for God’s sake do something’ school, has come to dominate medicine. This model concentrated on the specific causes of disease, whereas the Hygieian tradition emphasized health as being in harmony with oneself and the environment. Hygieians recommended correct living and taking responsibility for one’s health, while Aesclepians went to doctors instead: ‘While Asclepius is in Luther’s words only “God’s body patcher”,’ wrote Dubos, ‘the serene loveliness of Hygieia in the Greek marble symbolizes man’s lofty hope that he can someday achieve a state of harmony within himself and with the surrounding world.’ Aesclepian thinking led to the concept of a ‘magic bullet’ for every disease. René Dubos called this Aesclepian formulation of disease ‘the doctrine of specific aetiology’: ‘By equating disease with the effect of a precise cause – microbial invader, biochemical lesion, or mental stress – the doctrine of specific aetiology had appeared to negate the philosophical view of health as equilibrium and to render obsolete the traditional art of medicine.’ The doctrine of specific aetiology stands on some shaky scientific foundations. Tuberculosis, for example, is assumed to be ‘caused’ by the tubercle bacillus, yet many millions carry this organism and never develop the disease of tuberculosis. The bacillus generally requires the assistance of poverty and malnutrition. Helicobacter pylori similarly ‘causes’ duodenal ulcer, yet the vast majority of people infected with the bacterium will never develop a duodenal ulcer, a disease that was in steep decline long before Helicobacter was identified as the ‘cause’. This Aesclepian thinking may also account for the failure, so far, of Big Science, the new genetics and precision medicine to deliver the kind of advances predicted of them. ‘Despite its obvious limitations,’ observed Richard Smith, ‘the magic bullet model seems alive and well in the age of genetics and personalized medicine. Pharmaceutical companies are merchants of magic bullets and keen to keep the fantasy alive. It’s also very attractive to the public, which can fantasize that a pill will fix their problems.’ Humans, and human diseases, are infinitely more complex than we imagine, a truth which the great cancer biologist Robert Weinberg was humble enough to admit to. We may have already achieved most of the medical advances we are ever going to achieve, and in some areas – such as antibiotic resistance – we are going backwards. Many have argued that if we simply applied uniformly, equitably and rationally all the scientific knowledge we currently possess – that which we already know – medicine and health would be transformed.
People have always been enchanted by the prospect of miracles. As faith in God and gods has waned, we look to science. Both René Dubos and Ivan Illich argued that medicine had taken over the role of religion in the Western world; we now expect the partnership of medicine and the state to oversee our health. Dubos observed that this pact came at a cost:
But too often the goal of the planners is a universal grey state of health corresponding to absence of disease rather than to a positive attribute conducive to joyful and creative living. This kind of health will not rule out and may even generate another form of ill, the boredom which is the penalty of a formula of life where nothing is left unforeseen.
Medicine is now ruled by a very feeble philosophy that sees man as a machine, concerned only with material comfort and survival into extreme old age. This philosophy, as René Dubos obser
ved, might be applied to ants and cows, but not to humans. We are made to struggle, to embrace dangers. We value some things beyond mere comfort: ‘The satisfactions which men crave most and the sufferings which scar their lives most deeply, have determinants which do not all reside in the flesh or in the reasonable faculties and are not completely accounted for by scientific laws.’ Our faith in progress, and that science will deliver it, perpetuates the illusion that we can plan our society to maximize health and happiness. This faith is, in the unlikely phrase of Bertrand Russell, a form of cosmic impiety. We know we have despoiled the environment, and suspect we may pay a heavy price. We know that human life, art, religion, spirituality and love are based on the eternal verities of growing old and dying, yet we now subscribe to the notion that we should struggle against these verities. It is a struggle that we are not winning, that we cannot win, and that we shouldn’t win. Ivan Illich took from Greek mythology the example of the brothers Prometheus and Epimetheus. Prometheus stole fire from the gods, and for his hubris suffered the eternal punishment of having his liver pecked out every day by an eagle (and also the indignity of being used as an illustration by liver specialists for every lecture on the remarkable capacity of that organ to regenerate itself). Epimetheus allowed Pandora to open her box of plagues, but held on to hope. Illich called for ‘the Rebirth of Epimethean Man’, whose guiding spirit is hope, rather than the Promethean spirit of expectation. Epimethean Man stands in a humble, creaturely relationship to nature and his creator. Promethean Man, with his institutions, regulations and predictions, expects to control his destiny and conquer nature.
Medicine no longer knows what it is for. Is the ultimate aim of medical research to eliminate all disease? If so, then it must be aiming, too, to make us immortal. Even if that were possible (which it isn’t), are we quite sure that we want it? Is the aim of clinical medicine now to keep the entire adult population under permanent surveillance by screening for an increasing number of diseases? Does longevity trump all other considerations? Medicine, and particularly medical research, operates in an economic and moral vacuum, choosing to ignore the societal implications of cancer treatments and ‘precision medicine’ which give tiny, incremental gains at huge cost. We embrace the advantages of globalization, but not the duties. We in the rich West cannot continue to spend vast sums for such modest gains while people die in poor countries of diseases that can be cheaply cured and prevented. They also die without adequate pain relief or palliative care: the Lancet Commission on Alleviating the Access Abyss in Palliative Care and Pain Relief (2017) described how ‘61 million are affected by severe health-related suffering, 80 per cent of whom live in low and middle-income settings. 45 per cent of those dying annually experience severe suffering, including 2.5 million children.’ Richard Horton, the editor of the Lancet, wrote an extraordinary editorial (which could have passed as the work of Ivan Illich) in which he laid the blame for this ‘sea of suffering’ on the medical–industrial complex:
Medicine regards the alleviation of suffering as someone else’s problem. Palliative care is too often seen to indicate failure – the failure of medicine to cure. The hubris of modern medicine is that it cannot face up to failure. The deification of biomedicine as a discipline dedicated exclusively to survival has created an anti-humanist and quasi-theocratic science of health.
Some, such as Richard Smith, have argued that we should concentrate on getting treatments that work to those who currently have no access to them, rather than developing new highly expensive treatments which only increase inequality. Julian Tudor Hart (1927–2018), a GP who campaigned against health inequality, coined the phrase the ‘Inverse Care Law’ in 1971: ‘The availability of good medical care tends to vary inversely with the need for it in the population served.’ North America, for example, has 2 per cent of the health burden, but 25 per cent of the health-care workers, while Africa has 25 per cent of the burden and 2 per cent of the workforce. In the twenty-first century, the main determinants of health are income and living environment, not medicine.
The trench war will eventually end, through either sheer exhaustion or the collapse of the civilization that sustains it. Ronald Wright, in his book A Short History of Progress, described how various civilizations throughout history (Sumer, Rome, the Maya) collapsed, mainly because they destroyed the environment that had supported them. Polynesians settled on Easter Island around the eighth century AD. Ancestor worship was the main religious observance of these settlers, and each clan constructed stone images to honour their forefathers. The construction of these images required large quantities of wood, rope and manpower, and the statues grew ever larger. The island’s trees were being hewn down faster than they could be replaced by growth, and eventually the land was desolate, leading to wars over the scarce resources and a collapse in population: ‘The people had been seduced by a kind of progress that becomes a mania, an “ideological pathology”, as some anthropologists call it. When Europeans arrived in the eighteenth century, the worst was over; they found only one or two living souls per statue, a sorry remnant, “small, lean, timid and miserable”, in Cook’s words.’ The statue cult of Easter Island was an ideological pathology. Medicine’s Aesclepian/Cartesian quest to abolish or prevent all disease is an equally self-destructive mania. It may also be proved irrelevant far sooner than we think. Our overcrowded, hyperconnected world is an ideal incubation environment for new infectious diseases, against which our current antimicrobial drugs may be impotent. The anthropologist and historian Joseph Tainter warned that ‘collapse, if and when it comes again, will this time be global… World civilization will disintegrate as a whole.’
The great medical statistician Major Greenwood was professor of epidemiology at the London School of Hygiene and Tropical Medicine from 1929 to 1945, and mentor to Austin Bradford Hill. In a speech to the Royal Society of Arts in 1931, he laid out the ethos of the school: ‘The ambition of the school should be to become the spiritual home of men and women, differing in race, education and practical ambitions, but all aspiring to do their part to make the conditions of human life everywhere more bearable.’ Greenwood’s humble aspiration is rather moving. He did not promise to ‘cure all disease’, or ‘defeat cancer’. Perhaps contemporary medicine should embrace as its mission ‘to make the conditions of human life everywhere more bearable’. That is what medicine is for.
Epilogue
During the golden age, medical science gained huge prestige, and human life and death became medicalized. Despite its global dominance, the medical–industrial complex has given us meagre, feeble comforts at vast expense. Its chief concern is its own survival and continued dominance, and its ethos now is a betrayal of the scientific ideals of the golden age. Clinical practice, too, has become a vast industry, concerned mainly with degenerative disease and old age, and the herding of entire populations – through screening, awareness raising, disease mongering and preventive prescribing – into patient-hood.
Patients are increasingly unhappy with medicine. This is because they expect too much of it, and because only people of my mother’s age remember what being sick was like before the golden age. Doctors are just as unhappy. They know, deep down, that their powers are limited, yet ever more responsibilities and demands are laid at their door. Hospitals have become clearing houses for old people; normal variations in human behaviour and emotion are now the object of pharmaceutical intervention; life’s inevitable existential problems are brought to the doctor to solve. What can we do? Medicine has become a pseudo-religion; our patients must be gently encouraged into apostasy and renunciation. George Bernard Shaw advised his readers to use up their health, and not to outlive themselves. We might similarly encourage our patients to lead what James McCormick called lives of modified hedonism, ‘so that they might enjoy to the full the only lives that they are likely to have, rather than to portray life as a journey beset with avoidable dangers’. We might admit to ourselves that we have over-valued our knowledge, and over-promised to o
ur patients. We might admit, too, that the war against death is unwinnable, and refocus our energies instead on an equitable sharing of what we already know and have, and towards a new medicine that values healing and the relief of suffering.
The current priorities of medicine – with the cathedral-like teaching hospitals and biomedical research at the top, and community and hospice care at the bottom – will have to be turned upside down. I am not optimistic that this will happen. Strong societal forces will almost certainly ensure that the current consensus prevails. These forces include the commodification of all human life, the over-weening power of giant international corporations, the decline of both politics and the professions, the sclerosis of compliance and regulation, the fetishization of safety, the narcissism of the Internet and social media, but above all the spiritual dwarfism of our age, which would reduce us to digitized machines in need of constant surveillance and maintenance. The medical–industrial complex is not some vast, organized, sentient conspiracy; it is as fallible, messy and irrational as the people who created it. It has become so powerful, however, that medicine has now passed the Illichian tipping point where it is doing more harm than good to the people it is supposed to serve. There are two simple questions to ask of any new development, treatment or paradigm in medicine: first, who benefits? Cui bono? And second, does it make life any sweeter? Ask these questions of genomics, digital health and awareness campaigns, and the answers are obvious.
Temperamentally, I was made for the cloister, for the library, but fate placed me in the dust of the arena. Aoibhinn beatha an scoláire (‘how sweet is the scholar’s life!’), wrote an anonymous seventeenth-century Irish poet. I sometimes speculate on what a life of the mind might have been like, but this is idle. I have lived instead in a world of pain, sickness and death, but also in a world of intimacy, humour and life. I look forward to being relieved soon of the sometimes unbearable burden of responsibility. My younger colleagues are as seduced by new fads and fallacies as I was at their age, but pointing this out to them would be sour and ungracious. It took more than three decades for me to figure out what was going on around me, and to realize that medicine – clinical medicine, that is – is a difficult career for a sceptic. Nevertheless, rational scepticism is as necessary to the practice of medicine as compassion: doctors need to be both Humean and humane. As I near the end of this career, I find it not exactly easier, but less difficult. I no longer worry about litigation and protocols, and talk to my patients as I would to a friend or a relative: honestly, as doctors should. I have been pleasantly surprised that they seem to find this candour a release, as it gives them the opportunity to talk about what really matters. Both we and our patients have been enslaved by the medical–industrial complex, and it is time we rebelled. Society needs to reach a new accommodation with old age and death. Doctors need to proclaim that professionalism and clinical judgement are still – and will always be – the core of what we do. We need to stop hiding behind protocols, edicts and fear of sanction, and simply try to make the conditions of human life more bearable. Orthodoxies in science and practice come and go, but the core of doctoring stays the same. We may not be able to cure, but we can still heal.
Can Medicine Be Cured Page 20