New Internationalist Issue 272
Cure or curse
Medicine can be bad for your health. Dinyar Godrej investigates
the perils of treatment and the meaning of healing.
A proud woman, our friend lost all her hair. So she wore a bright orange headcloth with 'gypsy' earrings. Puffing on a forbidden cigarette, she'd fix you with her penetrating eyes, even more magnetic now that her eyebrows were gone, and ask: 'And how are you, my darling?'
Our enquiries about 'the treatment' would be met with a look of intense, almost theatrical pain. 'Ah, you don't want to know about that,' she'd say sharply, then ask: 'So what's the gossip?'
She didn't believe the treatment was any good and her family, friends and doctors knew it was next to worthless. However, it meant her incarceration in hospital. The regimes of chemotherapy and radiation - in some cases therapies in name only - often bleached out the person we loved. So I'd find myself inwardly applauding her when told she'd been caught yet again, strolling the streets in hospital gown and handbag, doing a bit of shopping.
Time was when the inevitability of illness and death commanded other kinds of ritual, the gathering together of kin, the uttering of a few well-chosen words. Death happened in the familiar surroundings of one's home. Now it's medicalized, socially acceptable only when every desperate remedy fails. 'Life' can become a drug- and machine-fed limbo which ends with the click of a switch.
A large part of modern medicine's brief seems to be about cheating death, devising more and more tortuous ways to stay alive. Medicine intervenes in our lives and deaths, in our pain and sickness, taking control, promising us health which becomes ever more elusive as treatment slips from our hands.1
Consider this: most common illness can be cured at home with proper medical advice and by eating well, resting, letting the body's defences do their stuff. Some infectious diseases need a doctor's attention, while others can be prevented by vaccines. Beyond this, doctors are of limited use. Apart from the obvious, life-changing benefits of operations like cataract removals and hip replacements, the vast majority of surgical interventions are 'unproven in their effectiveness and may actually do more harm than good.'2 Some prolong life while greatly diminishing its quality. As for chronic conditions related to the ageing of our bodies, doctors disguise the fact that they can do little by doing too much, prescribing pills and treatments with their attendant side-effects. In Australia a recent study based on 14,179 hospital patients found that the third-largest killer after heart disease and cancer was mistakes made by doctors and nurses.3
Why doctors persist in useless regimes - the repressive associations of the word are apt - is a good question. Cynics like George Bernard Shaw believed that a doctor was 'the grossest of impostors' whose 'abject [financial] dependence on his [sic] patient forces him to flatter every fashionable fad and practise every fashionable quackery'.4 But it is also the magician status we ascribe to the white coat that makes the doctor's position one that has to be bolstered with banks of pills and paraphernalia.
At present doctors prescribe far too many medicines, and we as consumers purchase too many off our own bat. This is increasingly true of many parts of the Majority World that are otherwise starved of healthcare provision. The roots of this drug abuse in Western medicine lie in the profession of the apothecary, who could not legally charge patients for health advice, only for pills and potions. But it was the advent of 'miracle drugs' - antibiotics - from 1930 to 1950 that led to the marriage between doctors and the drug industry and thence to the widespread susceptibility of the general population to pill-popping. Incurable, deadly diseases like tuberculosis, meningitis and syphilis could suddenly be blasted by drugs and a complete cure effected. This was a tremendous boost to all drug taking, not just antibiotics.
In the decades that followed we have been blasting away, indulging in a kind of germ warfare that has taken on heroic proportions. Here's an interested party's view of it: 'Our industry produces the enchanted substances that give healthcare professionals their real power to cure. Prior to the Second World War there really weren't too many things that would help. Doctors could tell you to keep in bed, keep warm, drink a lot of fluids, and they can make you feel better. But because of the investments in research and development that our companies have made, we really are making many diseases obsolete.'5
Don't you believe it. Antibiotics kill bacteria. They may be targeted against harmful forms, but they also create havoc among all the friendly bacteria that live on us - one million per square inch of skin. Friendly bacteria actually keep dangerous forms at bay. So when an antibiotic treatment knocks them out with a bit of friendly fire, our resistance to other infections is weakened.
Bacteria are single-celled creatures with great genetic adaptability. Antibiotic-resistant forms are now on the increase and the old medicines are not working. Even friendly bacteria have mutated into life-threatening forms. People are dying before doctors can identify the correct antibiotic. Antibiotics are in their third and fourth generation, increasingly expensive and, with the world set to use 50,000 tons of them by the year 2000, the drug companies are laughing all the way to the bank. Drug company profit margins have been compared by one critic to those of cocaine dealers.6
Antibiotics could still be effective if used sparingly and accurately, but this is often not the case. Doctors in one London hospital were found to be treating patients without first identifying the bug. Four out of five cases of tonsillitis are caused by viruses, not bacteria, yet doctors usually prescribe antibiotics which do nothing to viruses. They have no way of telling virus from bacteria by peering down your throat. I have an attack about once a year and my otherwise restrained GP normally prescribes penicillin.
The drug companies encourage this kind of thing. One drug on the Pakistani market is advertised as 'Curitol to Cure it all'. By reading the promotional literature one would think that every possible ailment would cower before its attack. Tucked away on another page in microscopic print are its side-effects - affecting most parts of the body one would care to name.
Drugs are toxic substances. A packet of pills I bought over the counter for my hayfever could have affected my heart rhythm. Some can cure, others will kill. Encouraging greater drug use lessens effectiveness and increases the potential for things to go horribly wrong. Drugs are usually researched and made by big businesses, not by practising doctors. These businesses give gifts to doctors, sponsor their conferences, donate money to hospitals. They keep medical journals alive with their advertisements. They spend more on marketing than on research. They are not interested in cures, but in lengthy, expensive treatments. Imagine the loss to the industry if a drug could actually cure heart disease or arthritis.
'Research' involves not just guinea pigs but monkeys, cats, dogs, rats, mice, sheep, rabbits. Hundreds of thousands of animals are killed each year in the name of putting 'safe' drugs on the market. In reality if experiments support the drug then they are cited as evidence; if there are contraindications then it is claimed that the physiology of the animals is too different to make an adequate comparison. What is needed is not more animal trials of dubious value, but more human trials.6
The word 'science' justifies anything. It is certainly used to bait alternative therapies, many of which have been around a lot longer than allopathic ('Western') medicine. The Western scientific approach is a single, closed system of rules which pooh-poohs other discrete systems and claims to be the only acceptable, universal approach. It has narrowed our conceptions of health and disease to biology, separating the individual from the wider environment. It takes up practices like acupuncture and some homeopathic remedies without buying into the holistic philosophies from which they spring.
The holistic promise has great appeal in an increasingly fractured world. Alternative therapies claim to look at the entire person, our physical-mental-spiritual condition, before making a diagnosis. They may be gentler than allopathic medicine but because they haven't been taken seriously the scope for uncritical worship and unjustifiable treatment is tremendous. One AIDS 'cure' marketed as Ayurvedic medicine turned out to contain a significant amount of dung - a literal case of treating the patient like shit. Homeopathy worked wonders for my father's piles and my mother's thyroid problems, but did nothing for my myopia.
Beneath the holistic idea lies the premise that we can control our own health. It is a short step from here to blaming a person for their ill health.7 Such is also the 'healthism' of conventional medicine. Under the guise of health promotion comes a long list of taboo activities to be avoided for one's own good. They are of little comfort to people with diabetes or epilepsy. For others they are a magic formula masking our desire to live forever. Sometimes I wonder if the extra years I might gain by jogging for half an hour each day is equivalent to the time I'd have spent on the exercise. My better health would doubtless add a glow to the quality of my life, but I refuse to perform any exercise that bores me (dancing another matter). I reckon that being able to choose the lifestyle I lead is more beneficial to my health in its entirety.
Healthism often divorces individuals from their environment, from which most ill health directly or indirectly arrives. Along the fault-lines in our world we can see the ills that attend them. Take gender. In India 330,000 more girls than boys aged under five die each year. Women aged over 15 consistently have higher death rates from major diseases than men. The genetic advantage that women have over men (living longer) has been wiped out in India by social disadvantage. Around the world women get prescribed tranquillizers and anti-depressants for their ailments by doctors who either feel powerless to change the domestic problems these arise from, or who just don't care. In Peru women's frustration and anger are made into an illness ('nervios') which can sometimes give them the right to leave their homes and act more independently. Research in the US found that women who had been raped were nine times more likely to attempt suicide than other women.
Medical research disadvantages women as well. Two major US studies on contributory factors in heart disease used huge samples of men and no women. Either the researchers were under the mistaken assumption that women's bodies were the same as men's, or they couldn't be bothered with the difference.8
When it comes to doctoring for women, their fertility and its control continues to be an obsession. Most contraceptives for women are invasive and risky. Women undergo far more sterilizations than men, even though the possibilities of complications are far greater.
The schism of race also influences the kind of treatment available and the degree of ill health. But by far the most important divide is money. The World Health Organization has woken up to the fact that poverty is the world's number-one disease. Overcrowding, lack of sanitation and hunger contribute more to ill health than any trendy virus or scare and no amount of medicine will put that right. Homeless New Yorkers die of tuberculosis for the same reasons as millions in the Majority World - their resistance is low due to the conditions they live in. The downward trend in TB in the West began before antibiotic use, as a direct result of improved living conditions and hygiene. Now that squalor is returning, so is that scourge.
Bereft of basics
For the Majority World grandiose schemes for Health for All by the Year 2000 were agreed in 1981. They resulted in aid action that looked good - immunization, the building of latrines and the like. Numbers became terribly important: the numbers of 'lives saved' or outhouses constructed. Emotions ran high. 'Child survival' became the buzzword for the US Congress, which gave generously to programmes promising this at the expense of less dramatic, unquantifiable ventures which attempted sustainability and local management.
The majority of the world still lacks decent, basic healthcare. The rich world indulges in increasingly sophisticated and mostly useless medicine. Can there be any vision of medicine that will bridge the two? Perhaps we need to reconsider what we mean by medicine. Should it mean pills and surgery? Or should it mean something more: basic rights for all, respect for the environment, an end to conflict? My disquiet about the ills of medical treatment may be a metaphor for the larger ills that thwart our happiness, the ills of greed, waste and want.
One thing is of the utmost importance - care. Many a patient who has been cured by an uncaring, brusque doctor lives with resentment at such treatment. The famed 'bedside manner' of doctors is often a casualty of increased management by business-school graduates. As a child I used sometimes to wish I would fall ill, because of the thorough pampering I would get from my family. Their care nursed me through bouts of malaria, jaundice, chicken pox, conjunctivitis, through surgery and mental turmoil. Within this aura of concern a healing took place that was deeper than biology.
Care is still a stranger to our plans for better health and better medicine. It needs to be invited in, before the priorities can ever be made right, before we can wrest healthcare from bureaucrats and big business, and think beyond individual health to the health of communities. With care also comes a sense of direction about our own mortality, other than merely wishing to stave it off. Think what the doctors at their conferences, the planners at theirs - and you and I going about our business - could achieve if we bore in mind this ancient exhortation of Pindar:
Dear soul, do not strive for immortal life, but exhaust the resources of the feasible.
1 See Ivan Illich, Limits to Medicine: Medical Nemesis: The Expropriation of Health, (Penguin Books, Harmondsworth, 1976 and 1985), for an early discussion of these ideas.
2 David J Hunter, 'From tribalism to corporatism: The managerial challenge to medical dominance', in Challenging Medicine, eds Jonathan Gabe et al (Routledge, London and New York, 1994).
3 New Scientist, 10 June 1995.
4 Quoted in Petr Skrabanek's The Death of Humane Medicine and the Rise of Coercive Healthism (The Social Affairs Unit, Bury St Edmonds, 1994).
5 Gerald Mossinghoff, President, US Pharmaceutical Manufacturers Association, 1989, quoted in Geoffrey Cannon's Superbug (Virgin, London, 1995). Information on bacteria and antibiotics mainly from this source.
6 Vernon Coleman, Betrayal of Trust, European Medical Journal (Lynmouth, 1994).
7 Rosalind Coward, 'The myth of alternative health' in Health & Wellbeing, eds Alan Beattie et al (Macmillan & the Open University, London, 1993).
8 Facts on women from Lesley Doyal, What Makes Women Sick (Macmillan, London, 1995), and The Health of Women, eds Marge Koblinsky et al, (Westview Press, Boulder and Oxford, 1993).
Zafar Mirza witnesses the benefits of
antibiotics being squandered in Pakistan
The drug-use situation in Pakistan is alarming. Anybody can step into a medical store and buy any drug. Usually a prescription is neither demanded nor shown. Antibiotics are no exception. People take them for trivial symptoms like headaches and other aches and pains. Among lay persons there is hardly any concept of infection or a course therapy. If a headache is ‘treated’ with one tablet of erythromycin, that is fine!
This liberal approach towards antibiotics is just as prevalent amongst medical practitioners. A typical prescription by a private general practitioner contains one or more antibiotic preparations, a painkiller/antipyretic (for lowering fever), a sedative and a vitamin or tonic preparation. One of these medicines is invariably injectable, which is the most risky way of taking medication. You are lucky if a steroid isn’t added to this list or if you don’t get more than one drug of the same category. Prescriptions of six to eight drugs are not uncommon.
The public sector spends 80-90 per cent of its drug budget on about 10 per cent of the population mostly in healthcare facilities in cities. Rural healthcare is fraught with a chronic shortage of medicines. Physicians prescribe whatever is available, with no special consideration for antibiotics. There are huge numbers of unqualified practitioners. Almost all of them, regardless of their type and school of thought, freely prescribe modern medicines, including antibiotics.
Antibiotics are, as a result, fast losing their potency and efficacy. Simple infections are becoming increasingly difficult to treat with first-line antibiotics. Alexander Fleming, after producing the ‘miracle’ drug penicillin in the first decade of this century, warned the medical world that ‘the greatest possibility of the evil in self-medication is the use of too-small doses so that instead of clearing up infection, the microbes are educated to resist penicillin, and a host of penicillin-fast organisms is bred out which can be passed to other individuals, and from them to others, until they reach someone who gets septicaemia or a pneumonia which penicillin cannot save’. He predicted a phenomenon we are witnessing today.
A survey of four hospitals by the National Institute of Health in Islamabad in 1991 revealed that Streptococcus Pneumonia and Hemophilus Influenza were 70-per-cent resistant to Septran and 40-per-cent resistant to Ampicillin. Both these drugs are considered the drugs of choice in the treatment of respiratory infections. In Pakistan, acute respiratory infections are the biggest cause of morbidity and mortality in children under five years of age. Every year approximately 250,000 die due to pneumonia. Having blunted their primary weapons, the prescribers are now resorting to second- and third-line antibiotics – inappropriately as well.
Penicillin resistance to gonorrhoea has emerged and there has been widespread resistance to shigella, with epidemics of resistant strains in Bangladesh and Nepal. Liberal and inappropriate use of anti-tuberculosis drugs on the Afghan-Pakistan border has produced bacilli which are multiple- resistant.
Pharmaceutical companies are busy making big money out of this therapeutic tragedy. Instead of promoting the correct use of first-line antibiotics, they look at the emergence of resistance to these antibiotics as an opportunity to push third-line antibiotics, as these are more expensive and make more money. Manufacturers enjoy patent protection for most of the new antibiotics, whereas almost all the first-line antibiotics are no longer protected.
In ‘developing’ countries, because of lax regulations, the industry has almost a free hand for promotion of its products. By enticing the prescribers and sponsoring their conferences they develop a symbiosis which ultimately works against the interests of the patients. Unethical promotion by pharmaceutical manufacturers has been the hallmark of their marketing strategies.
In Lahore recently Upjohn, a multinational drug company, was found to be offering a direct monetary incentive for prescribing one of their antibiotics, Lincocin. The modus operandi was simple; write down 500 to 1,000 prescriptions for this drug, keep copies as proof, hand them over to the visiting company rep and you will be compensated for each prescription at a fixed rate. A few conscientious professionals objected and the company had to roll back the scheme. Lincosin’s generic name is Lincomycin which, according to the WHO, is a non-essential antibiotic not even included in the National Essential Drug List and is not considered safe compared to the alternatives.
The single most important therapeutic discovery this century – the antibiotic – is losing its power. It is time to act.
Dr Zafar Mirza is National Co-ordinator for The Network for Rational Use of Medication in Pakistan, based in Islamabad.
©Copyright: New Internationalist 1995