If something is either essential or good for the health, surely more of it must be good for you? Such at any rate is the reasoning of half the American population who, between them spend more than $30 billion on dietary supplements, that is to say $200 a head per annum. All things considered, these supplements must be pretty safe, unlike prescription drugs, for few people die or have serious side-effects from them. Whether they do any good, other than as placebos, is another question entirely of course.
According to an article in a recent edition of the New England Journal of Medicine there are 85,000 different supplements and combinations of supplements on the market, meaning that each of them sells, on average, approximately $375,000 worth per year. Given the popularity of some, this must mean that many are in a very small way of business indeed. It is the job of the Food and Drug Administration to monitor the safety of all these preparations: a task, one might have supposed, quite beyond the capacity of even the largest bureaucracy.
Not all the supplements are safe. One, called OxyElite Pro, caused hepatitis and even liver failure, first spotted by a liver transplant surgeon in Honolulu. It was used by body-builders to “burn off” fat, and it is isn’t difficult to find people on the internet who mourn the fact that the product has been withdrawn from the market, despite its potentially dangerous side-effects (one person died).
Dietary supplements do not undergo the rigorous testing, either as to efficacy or safety, that pharmaceuticals undergo. The author of the article points out that many supplements contain newly-devised amphetamine-like stimulants, anabolic steroids, untested chemical analogies of Viagra and various antidepressants, and weight-loss substances that have already been banned from the pharmaceutical market.
Nearly half a century ago, in 1965, the Rolling Stones wrote a song called Mother’s Little Helper. The words went:
Kids are different today, I hear ev’ry mother say
Mother needs something today to calm her down
And though she’s not really ill, there’s a little yellow pill
She goes running for the shelter of a mother’s little helper
And it helps her on her way, gets her through her busy day…
And if you take more of those
You will get an overdose
No more running for the shelter of a mother’s little helper
They just helped you on your way
Through your busy dying day…
The pill was valium (diazepam) and the yellow pill was 5 milligrams – as it still is. White is 2 milligrams and blue is 10.
The song was not great poetry, perhaps, but for pop music it was prescient pharmacovigilance, the epidemiological study of the adverse effects of drugs: though strictly speaking overdoses of diazepam are not dangerous. Many thousands of people have taken overdoses of diazepam in attempts to kill themselves with it, but few have succeeded unless they took something else with it.
However, it has long been known that diazepam and other similar drugs cause falls in the elderly, and such falls are often the precursor of death. It has also been suspected that, by some unspecified mechanism, diazepam (and sleeping draughts of all kinds) promote death.
A paper in a recent edition of the British Medical Journal compares the death rates of primary care patients who were prescribed diazepam-like medicines and hypnotics with those who never were prescribed them more than once (they excluded patients who had been prescribed them only once because it was possible that they had never taken them, which was unlikely if they were prescribed them twice). The authors compared the records of 37,000 of the former with 63,000 of the latter. They attempted to match them for such variables as age, social class, sex, and medical and psychiatric history. They followed the patients for an average of 7.6 years.
Good and bad news often go together, for what is good news for some is bad for others. Shareholders in pharmaceutical companies that produce statins will have been heartened (no pun intended) by a paper in a recent edition of the New England Journal of Medicine in which the authors calculated that, under the new guidelines of the American College of Cardiology and the American Heart Association with regard to lipid levels in the blood, 12.8 million more adults in the United States alone would be “eligible” for (i.e. ought ideally to have) treatment with statins. In fact, very nearly half the population older than 40 ought to take them, and seven eighths of the population over 60. As a man over sixty who never has any blood tests done, my heart sinks (again no pun intended). We are all guilty of illness until proven healthy: not good news.
The authors compared the therapeutic consequences of the old guidelines with the new. In effect the new guidelines lowered the threshold for treatment. According to these guidelines, anyone over 40 with known cardiovascular disease should receive statins, irrespective of their level of Low Density Lipoprotein (LDL); while anyone with a level of 70 milligrams per decilitre or more and who has diabetes or a statistical risk of a heart attack of more than 7.5 percent within the next ten years should also receive them.
Taking a rather small sample of adults over 40 from the National Health and Nutrition Examination Survey whose blood lipids were measured and extrapolating it to the U.S. population as a whole, the authors conclude that, if the new guidelines were put into practice rather than the old, 14.4 million adults in the U.S. who would not have been “eligible” for treatment under the old guidelines would now be “eligible” for it, while 1.6 million who would have been “eligible” under the old guidelines would no longer be “eligible.”
Editor’s Note: Dr. Theodore Dalrymple has been contributing thoughtful pieces on medicine, culture, and politics to PJ Media for a number of years. This is the beginning of an attempt to collect and organize some of his writings on similar subjects. Here is an assortment of 10 articles weighing in on perpetual medical controversies.
A moment’s reflection is all that should be necessary to convince anybody that our passions are not necessarily engaged by public controversies in proportion to the numerical or statistical importance of the question in hand. The debate over euthanasia and physician assisted suicide (PAS) is deeply impassioned everywhere; but not even the most enthusiastic advocate of euthanasia supposes – at least not yet supposes – that the question will ever affect other than a very tiny percentage of people.
The fact is that man is an animal that quarrels over symbols, and euthanasia is as much a matter of symbolic as of practical importance. How else are we to explain the fact, cited in an article in a recent edition of The Lancet about the new Belgian law extending the benefits of euthanasia to children, that there have been dozens of bills before the Belgian parliament desiring either to extend or to limit the scope of the current euthanasia legislation?
Reading the article and the articles to which it was linked, I came across two statements, one startling and the other importantly revealing. The starting fact was the following:
Recent studies have shown that the proportion of deaths that are the result of euthanasia or PAS in Oregon, USA as a whole, and The Netherlands, are 0.09%, 0.4%, and 3.4%, respectively.
Assuming this to be no misprint, why should the rate of physician-assisted suicide be more than four times higher in the United States as a whole than in Oregon, which is one of only four states (with a total of only 5 percent of the U.S. population between them) to permit it? Is it under-reported in Oregon? Is it carried out surreptitiously and illegally elsewhere? Are all the figures so inexact as to be virtually bogus? And if they are bogus, what does that tell us about the whole matter?
Another question is why there should be nearly forty times as many deaths by euthanasia and PAS as there are in Oregon. Is unbearable end-of-life suffering forty times more frequent in Amsterdam than in Portland? This is prima facie most unlikely. The pattern of disease in most western countries in very similar, and both in Oregon and the Netherlands cancer is by far the most common cause of requests for easeful death. Is there something sinister in the disparity?
When I was young enough still to consider myself rational, I was irritated by patients who tried any remedy in desperation to save themselves from their fatal disease. I have long since mellowed and when an acquaintance of mine with glioblastoma, a rapidly fatal brain tumor, decided recently to go to India to try Ayurvedic medicine, all I could do was wish him luck – sincerely so. After all, the scientific medicine — which he would continue to take while there — offered him little enough hope, a few months at most. (This case, incidentally, illustrates an important point: alternative medicine, so called, is not generally alternative, it is additional.)
Two trials of a very expensive monoclonal antibody, bevacizumab, in glioblastoma, published recently in the New England Journal of Medicine, make disappointing or even dismal reading. This antibody is directed at vascular endothelial growth factor that promotes the growth of new blood vessels; glioblastoma is a tumor particularly rich in new blood vessels, and so it was hoped that by preventing them from forming, tumor growth would either be prevented or at least slowed. Early results were promising but as has so often been the way in the history of medicine, early promise is not fulfillment of promise.
In one trial, for example, 637 patients with this terrible tumor were randomized to conventional treatment plus placebo and conventional treatment plus bevacizumab. Although the latter had a slightly longer period free of progression of the tumor, their overall length of survival was not increased, and indeed they suffered so many more side effects that the overall quality of their lives was worse. The patients taking bevacizumab survived on average 15.7 months; those taking placebo survived 16.1 months. The authors of the paper end:
In conclusion, we did not observe an overall survival advantage first-line use of bevacizumab in patients with newly diagnosed glioblastoma. Furthermore, higher rates of neurocognitive decline, increased symptom severity, and decline in health-related quality of life were found over time among patients who were treated with bevacizumab.
This makes rather odd the concluding words of an editorial that accompanies the trials in the Journal:
Finally, it is worth noting that despite its limitations, bevacizumab remains the single most important therapeutic agent for glioblastoma since temozolemide. Ongoing and future trials will better define how and when it should be used in this population of patients for whom so few treatment options currently exist.
Clearly the viewpoint of the oncological researcher is not that of the sufferer of the disease: he is looking far into the future, while the poor patient (all the poorer if he has to pay for his drugs) is thinking rather less far ahead.
Modern medicine’s ability to save life – to keep people alive who would once have died – gives rise to an increasing number of ethical dilemmas. An article in a recent edition of the New England Journal of Medicine discusses the case of Quelino Jimenez, a Mexican illegal immigrant who was employed as a construction worker in Chicago. He had a fall that rendered him tetraplegic; after emergency treatment to stabilize his condition, and some time in the hospital, he was repatriated against his will to Mexico, where, aged 21, he died because of a lack of medical care.
Jimenez, like the majority of the 11 million illegal immigrants in the Unites States, was uninsured. The law already prescribes that hospitals receiving Medicare funding must provide emergency care to anyone in need of it, without discrimination as to legal or insurance status. However, they are not under obligation to provide, nor will they be reimbursed for providing, long-term care for those who need it. Looking after tetraplegics is expensive and consumes much time and effort. Hospitals will therefore be anxious to transfer them (and the costs) elsewhere.
It is an elementary principle of medical ethics that doctors are not permitted to sort patients into deserving sheep and undeserving goats when providing treatment for them: they are supposed to do their best for everyone, prince or prisoner. The best for Quelino Jimenez was certainly not to be returned to conditions in which, only too predictably, he would be medically neglected.
The problem with banks, say their critics, is that they privatize their profits but nationalize their debts. But this is perfectly normal behaviour for human beings: did not Bastiat say that the state is the means by which everyone seeks to live at everyone else’s expense? How many people seek the freedom to behave as they wish while expecting others to pay for the adverse consequences? Moral hazard has become our way of life.
An article in a recent edition of the Journal of the American Medical Association advocates the distribution of a drug called naloxone to heroin and opioid addicts. Thousands of such addicts die of overdoses of these drugs each year in America, and naloxone is an effective antidote to them that reverses their effect. More than half of the 38,000 deaths from overdose in the United States are from prescription drugs, and 16,000 of them from prescribed opioids, more than from illegal heroin.
The article cites evidence from Wilkes County in North Carolina (the county with the third highest rate of deaths from opioid overdose in the country) that the distribution of naloxone to addicts has almost halved the death rate from overdose. Not all those whose lives were saved were either prescribed opioids by pain clinics or addicted to street heroin: they were foolish friends or acquaintances of either of these types of people who had been induced to try their drugs.
What is completely lacking in this article is any wider perspective. The people who pay for the naloxone are often not the people taking heroin or opioids; one might have supposed that those who can afford street heroin, at the very least, could also afford to buy their own naloxone. If they do not care enough for their own safety to do so, it can be argued that no one else should care – unless, of course, they are deemed, like Ophelia, to be “incapable of their own distress.” But if so, why should they be left free to take the heroin in the first place? In other words, like bankers, addicts want to be free to indulge in their own excess but want someone else to pick up the pieces when the excess leads to a smash.
Many medical papers nowadays have such complex statistics that not one in a hundred doctors understands them fully, and the rest have merely to hope or take it on trust that the authors’ conclusions really do follow from their data. I am afraid I hold to the rather crude view that, if results involving large numbers of patients need involved and sophisticated statistical manipulation to yield a positive outcome, they probably are not very important clinically, however statistically significant they may be. Clear-cut results are not very common these days.
I therefore rejoiced to see in a recent edition of the Lancet the report of an experiment so conclusive that it hardly needed statistical confirmation to prove it. The experiment was a double-blind trial of the desensitization of children with an allergy to peanuts by means of oral immunotherapy (OIT).
Ninety-nine children aged between 7 and 12 with proven allergy to peanuts were divided into two groups: those who, unbeknown to them, received small but increasing doses of peanut protein mixed into their food over a period of six months, and those who did not. At the end of that period, 62 percent of the treated group, but none of the untreated, tolerated a challenge of 1400 milligrams of peanut allergy. The children who had had the OIT were 25 times less sensitive than those who had not. When the control group who had not had it were given it, they too became less sensitive.
The authors also demonstrated that the quality of life of the desensitized children improved because they became less anxious that any food might ambush them, as it were, and cause an allergic reaction. Anyone who has seen an allergic reaction to peanuts (or other nuts) will understand this. Since the number of food products that bear the warning “may contain peanuts” is ever-increasing – peanuts seem almost as ubiquitous in our environment as rock music – the world must appear a dangerous place to those with the allergy.
It is a hard lesson in life that many of the most important things that happen to us are beyond our control. Indeed, a large part of wisdom consists of the willingness and ability to distinguish what is and what is not happenstance. The distinction, however, may be very difficult: and while too little fatalism leads to fruitless struggle, too much leads to acceptance of the avoidable.
A recent study from the Mayo Clinic published in the British Medical Journal examines patients with myocardial infarction (heart attack) presenting to hospital out of hours and those who present during normal working hours. They pool the data from all the studies that have been done around the world, and come to the conclusion that patients presenting at nights and weekends have a 5 percent increased risk of death. It therefore seems best, if you must have a heart attack, to have it during regular hours, though this is difficult to arrange for yourself.
Interestingly, subsidiary findings are first that the difference between the death rates has been increasing of late; and second that the difference is less in the United States than in Europe, where it is less than in other parts of the world. Could this mean that, at least in one respect, the American health care system is better than others around the world?
There is no subject that provokes conspiracy theories quite like the immunization of children. That innocent, healthy creatures should have alien substances forcibly introduced into their bodies seems unnatural and almost cruel. As one internet blogger put it:
Don’t take your baby to get a shot, how do you know if they tell the truth when giving the baby the shot, I wouldn’t know because all vaccines are clear and who knows what crap is in that needle.
The most common conspiracy theory at the moment is that children are being poisoned with vaccines to boost the profits of the pharmaceutical companies that make the vaccines. No doubt such companies sometimes get up to no good, as do all organizations staffed by human beings, but that is not also to assert that they never get up to any good.
A relatively new vaccine is that against rotavirus, the virus that is the largest single cause of diarrhea in children. In poor countries this is a cause of death; in richer countries it is a leading cause of visits to the hospital but the cause of relatively few deaths.
Since rotavirus immunization of infants was introduced in the United States, hospital visits and admissions have declined by four fifths among the immunized. However, evidence of benefit is not the same as evidence of harmlessness, and one has the distinct impression that opponents of immunization on general, quasi-philosophical grounds, almost hope that proof of harmfulness will emerge.
A study published in a recent edition of the New England Journal of Medicine examined the question of one possible harmful side-effect of immunization against rotavirus, namely intestinal intussusception, a condition in which a part of the intestine telescopes into an adjacent part, and which can lead to fatal bowel necrosis if untreated.
The authors compared the rate of intussusception among infants immunized with two types of vaccine between 2008 and 2013 with that among infants from 2001 to 2005, before the vaccine was used. There is always the possibility that rates of intussusception might have changed spontaneously, with or without the vaccine, but the authors think that this is slight: certainly there is no reason to think it.
Just as a more permissive attitude to cannabis gains momentum in the United States, so does a more restrictive attitude to tobacco. It is as if there were a law of the conservation of prohibition: if one substance is permitted after having been prohibited, another will be prohibited after having been permitted.
While Colorado permits the use of marijuana by those over 21 for any purpose, New York City prepares to prevent sales of tobacco to anyone under the age of 21. An article in a recent edition of the New England Journal of Medicine comes out strongly in favor of this more restrictive approach to the sale of tobacco. The arguments it uses and those it refutes are instructive.
Those who go on to smoke throughout their lives generally start at an early age: earlier, that is, than 21. Thus if adolescents could be discouraged from smoking, rates of smoking among adults would decline markedly.
Of course, it is not enough for something to be desired or desirable for it to be feasible. Such evidence as exists, however, suggests that restricting sales to minors might work. A town in Massachusetts, Needham, forbade the sale of tobacco to those under 21, and the rate of smoking among high school students declined by nearly half five years later. The rate in a neighboring town, which did not impose the ban, fell in the same time by only a third as much. Furthermore, raising the minimum drinking age to 21 was followed by (one cannot with absolute certainty say caused) a fall in alcohol consumption by adolescents, drunk driving, and motor accidents.
Scientists are often portrayed as archetypally rational men, mere calculating machines in human form who propose correct new theories by infallible deduction from what is already known. Science cannot possibly advance in this way, however, and the philosopher Karl Popper pointed out long ago that leaps of the imagination are as necessary to science as they were to art
I have never been able to make such leaps myself, which is why I admire them in others. I remember meeting a researcher into malaria who was trying to produce a vaccine, not against the malarial parasite itself, but against the stomach lining of the mosquitoes that carried the parasite. He hoped that such a vaccine would kill the mosquitoes – causing them to explode in mid-flight, perhaps – and thus prevent the spread of the disease. The idea did not work, but I was impressed by the boldness of the conception.
For the scientist no information is too obscure to be of potential use. And what information could be more obscure than that the desert-dwelling grasshopper mouse that likes eating the bark scorpion, whose sting causes severe pain in all other possible predators and makes them avoid it? Most of us, I think, would say, “All very interesting, professor, but so what?” The scientist, however, asks why the grasshopper mouse is immune to the painful effects of the scorpion venom, and whether, on discovering the reason, it might not help in the development of new analgesics. Mankind has long believed that remedies for its afflictions are to be found in Nature, but only scientists can go about systematically investigating the possibilities. Imagination is a necessary but not sufficient quality for scientific research.
A recent article in the New England Journal of Medicine, in a long-running series that tries to connect basic scientific research with clinical progress, draws attention to research on the grasshopper mouse. The article is provocatively entitled Darwin 1, Pharma 0, thereby drawing our attention to the fact that millions of years of natural selection have done for the grasshopper mouse what a century of research by pharmaceutical companies has not been able to do for Man. The comparison seems neither apt nor fair, but any stick these days is good enough to beat Big Pharma with.
The grasshopper mouse, it seems, has a mutant gene that prevents a component in the scorpion venom from activating the peripheral nerve cells involved in the transmission of pain. Could human pain be alleviated or even abolished if a compound were found that acts on the mechanism that the normal version of the gene, present in all other mammal genomes, controls?
The enormous, even exponential, advance in the understanding of human genetics over the past three decades has so far yielded much less improvement in clinical results than was once hoped. It has proved more difficult than anticipated to translate biological knowledge into clinical benefit.
This is not, of course, to say that there have been no benefits at all from the advances in genetic understanding, particularly in such fields as prenatal counselling. Another superficially promising field is that of pharmacogenetics, that is to say the prediction of responses to medicaments according to the patients’ genetic type. This is very important, for hitherto it has proved difficult to predict whether a patient will respond positively or negatively to a given treatment, and whether he or she needs a higher or a lower dose to produce a desired effect.
The latter is particularly important in the case of treatment with anticoagulants (blood-thinners) because a therapeutic dose is usually so close to a dangerous dose. If we could predict who needs what dose rather than, as at present, proceed essentially by trial and error, it would be of great advantage to patients who need anticoagulation. They would receive the benefit of anticoagulation – fewer heart attacks and strokes – without the risks of complications such as cerebral and other bleeds.
Three trials of attempts to tailor doses of anticoagulants according to the patients’ genetic type have been published in a recent edition of the New England Journal of Medicine. The authors compared prescription of anticoagulants by the normal methods with determination by genetic type. The results of the three trials were contradictory.
Prevention is better than cure provided (which is not always the case) that prevention does less harm than the disease it prevents. Since obesity is now of epidemic proportions all over the world, and it is estimated that in just over a decade’s time there will be 500,000,000 people with type II diabetes consequent upon obesity, prevention of obesity is devoutly to be wished – which is not to say that it will be easy or even possible.
An article in a recent edition of the New England Journal of Medicine asks the question of how early in life prevention of obesity should begin, given that once it is established it is refractory to treatment. Although the epidemic may have peaked in the United States, there is no room for complacency because the proportion of fat people is already enormous. A half of American pregnant women are seriously overweight or outright fat, and fat women tend to have fat children. They gain even more weight during pregnancy, and women who gain weight excessively during pregnancy are especially likely to have fat children.
The article is a typical example of what might be called risk factor medicine. A disease or disorder is found to be associated statistically with some independent variable which may or may not be causally related to that disease or disorder, so that doctors hope that by reducing the prevalence of the risk factor in some way they will also reduce the prevalence of the disease or disorder. Since many of the risk factors are behavioral rather than biological, and there is nothing as difficult to change as human behavior, doctors’ hopes are often frustrated.
There is nothing quite as difficult to predict as the future. In my lifetime I have already lived through an “inevitable” ice age that never materialized and “inevitable” mass starvation (through overpopulation) that also never happened. When I was in Central America I remember reading a book called Inevitable Revolutions by the historian Walter LaFeber, but more than a quarter of a century later the inevitable still had not taken place. By now, according to predictions, most of us should have been dead from AIDS, that is if variant Creutzfeldt-Jakob Disease or Ebola virus had not got us first. The repeated failure of confident predictions is therefore almost enough to make one sceptical of dire visions of the future. Only the sheer pleasure of contemplating catastrophe to come keeps the market for apocalypses alive.
One of our present concerns in the western world is the rapid aging of the population. Never have so many people lived to so ripe an old age, and this at a time when the birth rate is falling. Who is going to support the doddering old fools who will soon be more numerous than the energetic and productive young?
A recent article in the New England Journal of Medicine points out that something unexpected has happened to confound the gloomy prognostications of epidemiologists and demographers. As the percentage of people surviving into old age increases, so the proportion of them who suffer from dementia decreases. People are not only living longer, but living better. This is a phenomenon that has happened across the western world.
The article states that “in 1993, 12.2% of surveyed adults 70 years of age or older [in America] had cognitive impairment, as compared with 8.7% in 2002.” Similar results have been obtained elsewhere. In the light of this unexpected and unpredicted trend, estimates of the prevalence of dementia in England have had to be revised downwards by 24 percent. The burden of the elderly on the economy will therefore not be as great as was feared.
What accounts for the decline in the prevalence of dementia?
Some years ago a medical paper was published that caused a run on Brazil nuts throughout the western world. For a time they disappeared entirely from supermarket shelves; for Brazil nuts contain a high level of selenium and the medical paper had suggested that the high rate of heart attacks in a certain province of China was caused by the exceptionally low level of selenium in the inhabitants’ diet.
But of course for every panacea there is an equal and opposite health scare. Brazil nuts concentrate radium and give off more radiation than any other food; they also often contain relatively high levels of aflatoxin, produced by a fungus of the Aspergillus genus. Aflatoxins are very carcinogenic, leading to cancer of the liver.
So where Brazil nuts are concerned, the question boils down to whether you would prefer to die of heart attack or cancer.
A paper in a recent edition of the New England Journal of Medicine suggests that, overall, nuts are very good for you. The authors compared the death rates among female nurses and male health nurses according to their self-reported consumption of nuts. They divided nut consumption into true nuts and peanuts, the latter being legumes rather than nuts.
I never cease to be amazed at the organizational feat of such studies: 76,464 women and 42,498 men were followed up between 1980 and 2010 and 1986 and 2010, respectively. After various statistical manipulations which 99 percent of the readership of the NEJM would not understand it was found that the more nuts people ate (including the false nuts known as peanuts), the lower their all-cause mortality. They didn’t just die less of such illnesses as heart attack, stroke and cancer, but of all illnesses whatsoever. At last, then, the panacea!
People who ate nuts more than seven times a week(!), hunter-gatherer style, had a 20 percent less chance of dying in the period of follow up than those who never ate nuts. This is a very big effect, for me almost too big to be believed.
Some of the residents of Hyde, the town in Cheshire, England, where the late Dr. Harold Shipman practiced family medicine, used to say, “He’s a good doctor, but you don’t live long.” Indeed not: it is now believed that Dr. Shipman, over a period lasting a quarter of a century, murdered 200 or more of his elderly patients with injections of morphine or heroin.
If the preservation of life be not the definition of a good doctor, what is? Here is the definition published in a recent edition of the New England Journal of Medicine:
The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and, the community being served.
Whatever one thinks of this definition, it is clear that it would not make the goodness of doctors altogether easy to measure.
It does not follow from the unmeasurability of something, however, that it does not exist or is unimportant: nor, unfortunately, that what is measurable truly exists or is at all important. Nothing is easier to measure in an activity as complex as medical practice as the trivial, and nothing is easier to miss than the important.
The above definition of a good doctor appeared in an article on the need for Obamacare to ensure that doctors provide value for money so that they can be paid by result. This is a potential problem whenever there is a financial intermediary between the doctor and the patient. Thenceforth it is not the patient who decides what he wants from a doctor but an insurance company or, increasingly under Obamacare, the government.
When I was a very young doctor I had an enormously fat patient – in those days it was rare to be so fat – who was admitted to the hospital for a long time to try to get her to lose weight more or less by starving her. I still remember her semi-liquid form flowing over the sides of the bed. I tried to be nice and understating.
“I suppose you eat for comfort,” I said to her.
“No, dear,” she replied. “I just like the taste.”
I did no know then that she was (if I may be permitted what in the circumstances is a slightly ridiculous metaphor) the canary in the mine, and that only 40 years later many human mastodons would bestride the world, at least in America and Britain.
With this epidemic has grown a new surgical speciality: bariatric surgery, that is to say surgery to correct obesity. A paper in a recent edition of the Journal of the American Medical Association reports on the results of two types of such surgery to treat obesity, gastric bypass and laparoscopic gastric band. (How long before a rock group calls itself the Laparoscopic Gastric Band?) The authors conglomerated the results from 10 hospitals so that the results should reflect average practice, not just the very best practice.
Gastric bypass proved to have better results all round than gastric banding, except that there were a small number of deaths immediately after surgery. But the results were distinctly variable even for the same procedure; for example, at three years after operation those who had had a gastric bypass varied between having lost 59.2 per cent of their baseline weight and having gained 0.9 per cent. Those who underwent the gastric banding varied between having lost 56.1 per cent of their original weight and having gained 12.6 per cent. On average, however, the two groups had lost 31.5 per cent and 15.9 per cent respectively of their original weights after their operations.
Most of the weight loss was within the first year after the procedures; one sub-group among the patients began to regain weight after six months, and all began to regain weight after two years. The weight they gained after two years, however, was slight by comparison with what they had lost.
It has long been my opinion that all notions of human equality, other than that of formal equality before the law, are destructive of human intelligence and sensibility. My opinion was confirmed recently when I read an editorial in the Lancet, one of the two most important general medical journals in the world.
The title of the editorial was “Equity in Child Survival.” I could have written the editorial myself from the title alone, so utterly predictable was its drift:
Although Indonesia has reduced child mortality by 40% during the past decade, data from 2007 show that children in rural areas were almost 60% more likely to die than those living in urban ones, while those in the poorest 20% were more than twice as likely to die as those in the richest 20%, and girls were 20% more likely to die than boys.
Note here that even if inequality were the same as inequity, there is nothing in these figures to show that inequity had increased in Indonesia during the decade, or to show that it had not actually decreased; and if equity in this sense were an important goal in itself, it would matter little whether the health of the poorest improved, or the health of the richest deteriorated.
In a country the size and complexity of Indonesia, with hundreds of inhabited islands, some of them very remote, it is hardly surprising that there should be quite wide geographical variations in health, wealth and productivity. It is no more inequitable that there should be these variations than that the French should have so much better health than the Americans, or for that matter than the Bangladeshis.
Not long after I suggested satirically that money might be the cure for the terrible disease of burglary, experiments were performed to bribe drug addicts into remaining abstinent. I had suggested that money was a genuine pharmacological treatment of burglary because there would be a dose-response relationship (the larger the dose of money given to burglars, the greater and longer-lasting their law-abidingness) and that, as with most drugs, there would be treatment failures. Some burglars are more interested in the excitement of burglary than in its material rewards; money would have little or no effect on them.
It turns out that money as a drug is a bit like aspirin: it can be used for many illnesses. The fat have been bribed to lose weight; the drunk to stop drinking; the diabetic to take their pills and stop eating sugar; the smokers to stop smoking; and the indolent to start taking exercise. It’s enough to make you wonder whether there is anything that can’t be cured by money. The latest disease to yield to money’s curative, or at least alleviatory, properties is schizophrenia.
Medication can improve this condition but unfortunately patients often do not take it for long and then relapse. This is partly because they do not accept in the first place that they are ill and partly because the medicine they are supposed to take has many, and sometimes very disagreeable, side effects.
To counter the propensity of schizophrenic patients not to take their medicine, long-acting injectable forms were developed; but it is easy for schizophrenics not to accept them either. Researchers in England and Switzerland wondered whether, if patients were bribed to take the injections, they would do so with greater regularity. Their trial was a small one, involving only 131 patients, divided into those who were offered a bribe (in the paper, published recently in the British Medical Journal, it is more delicately called a financial incentive) and those who were not. The bribe was not large, $22 per monthly injection; but it must be remembered that most of the patients were probably unemployed and living in relative poverty. There are still people in our society to whom $264 a year would be well worth having.
Nothing I ever wrote provoked quite as many hostile responses as my suggestion in an article in Belgium that rock music of all kinds was a terrible environmental pollutant and ought to be strictly controlled, like car exhaust or industrial effluent. I also suggested that its agitating effect upon youth was a cause alike of much bad behavior and many car accidents. Moreover, in the future there will be an epidemic of well-merited deafness. The young were particularly infuriated.
Considering the awfulness of noise as a destroyer of quality of life, its effects on health have been comparatively little studied. Some time ago, however, it was discovered that those living near a major airport, Schiphol in Amsterdam, and subjected to aircraft noise had higher blood pressure than those who lived in its absence. Two papers in a recent edition of the British Medical Journal, one from Britain and one from America, confirm and extend this observation.
The American paper analyzed the admission rates to hospital for cardiovascular diseases such as heart attack and stroke of those who lived near airports and those who did not. They analyzed the data from 89 airports. They found that those exposed to 10 decibels extra of aircraft noise had a 3.5 percent increased admission rate for such diseases, and they estimated that overall 2.3 percent of all admissions for such disease were attributable to aircraft noise.
The British paper analyzed hospital admission rates for the same diseases in the geographical area around Heathrow Airport, the busiest long-haul international airport in the world (and the worst, in my experience). The authors controlled the results for such possible confounders as air pollution and road traffic noise; they found that those exposed to the highest levels of daytime noise had a 25 percent increased rate of stroke and a 20 percent increased rate of coronary artery disease. The authors warned, however, that they had not controlled for all possible relevant confounders, and therefore, in effect, that their results must be taken with the proverbial pinch of salt.
When I was a student, a trauma surgeon described how, in the early days of transplants, he had to physically restrain the transplant surgeons from “harvesting” the kidneys of potential donors. So enthusiastic were surgeons about this exhilarating technology that they were willing to sacrifice one life for another, for they tended to count a life saved by transplant as being of more than ordinary value, perhaps double; and, no doubt irrationally, I have remained mildly suspicious of them, the transplant surgeons, ever since.
There were two opposing articles in a recent edition of the New England Journal of Medicine about the ethics of transplantation. For a number of years the supply of organs for transplant has not equalled the demand, and one way of meeting it would be to relax slightly the rules governing the removal of transplantable organs from donors. At the moment the dead-donor rule (known as the DDR — an acronym that for me still brings first to mind the German Democratic Republic) prevails, according to which the donation of an organ must not kill the donor.
One of the authors suggests that the DDR is routinely violated in any case and that, in so far as it is obeyed, it limits the number of organs available for transplant and thereby allows people to die who could have been saved. But, says the author, “it is not obvious why certain living patients, such as those who are near death but on life support, should not be allowed to donate their organs, if doing so would benefit others and be consistent with their own interests. … Allegiance to the DDR … limits the procurement of transplantable organs by denying some patients the option to donate in situations in which death is imminent and donation is desired.”
Sir Winston Churchill was an inveterate enemy to all physical exertion that went by the name of exercise. He attributed his productivity in life to his physical indolence and once gave the advice that you should never stand when you can sit and never sit when you can lie. He did much of his work in bed.
Modern medicine is decisively against him in his opposition to exercise. Reading the introduction to a paper in a recent edition of the British Medical Journal, you might be forgiven for concluding that the panacea has at long last been found, and that it is exercise. People who are physically active live longer and suffer less from heart disease, strokes, cancer, and diabetes than do the sedentary. They do better in the hospital; and physical inactivity has been estimated to be the fifth most serious contributor to the disease burden of Europe.
The authors of this paper attempted to find out whether exercise is as effective as drugs in reducing mortality in a variety of conditions such as diabetes, stroke, coronary artery disease, and heart failure. They did no actual trial themselves, but rather performed a meta-analysis of the meta-analyses of all the trials that have been published and are relevant to this question: in other words their paper is what might be called a meta-meta-analysis.
Exercise has rarely been compared directly with drug treatments; the authors had therefore mainly to compare the published statistical effect of exercise (compared with no exercise) with that of medication of various sorts (compared with placebo or other medicines). They analyzed the results of 16 meta-analyses which were based upon a total of 254 trials, 54 of them on the effects of exercise and 248 of them on the effects of drugs, involving 339,274 patients in all.
In short they found that the only statistically significant differences in mortality were in stroke and in heart failure. Drugs (diuretics) were superior to exercise in the latter, and exercise to drug treatment in the former. Otherwise there was no difference between drug treatment and exercise.