Health hazard / EXPERTS

Jeremy Horner / Panos Pictures

Trevor Turner doubts whether the
heroics of ER can save our bacon.

The health business is in crisis. Wherever you go in the world, debates about healthcare, funding, new breakthroughs and what we expect of our doctors continue unresolved. For example, patients in Britain are dying while on the waiting list for heart surgery. In the US, the process of ‘Managed Care’ is driving physicians up the wall. You’re allowed two to three days in hospital for acute schizophrenia, even though it takes a month to treat the symptoms of a serious, psychotic illness. In France health workers have been on strike, resisting attempted rationalizations by a government desperate to save money. The ageing population in Western countries adds more pressure – and we are running out of nurses. Yet the medical news that hits the public headlines is usually about a ‘major advance’ – designer pigs to provide organs, for example – or some dreadful scandal such as the paediatric heart-surgery deaths in Bristol, England.

The reason for this scandal was a combination of medical arrogance, regional pride and the sheer complexity of difficult surgery. But surgeons who continue to have a 30-per-cent mortality rate – that is, a third of their patients die after operations – rather than the average of say five to six per cent, clearly have a problem. There is a learning curve required to perform the kind of delicate operations that babies need; but it can’t go on too long. You have to do such operations regularly, that is to say to specialize, and increasingly medicine is dividing up into lots of mini-specialities. Dr X will take out your kidney, Dr Y will sew up your pile, Dr Z will do you a nose job.

There’s no big money in being a generalist and the decline of the general physician, with experience across the whole spectrum of medical illness, is hard to stop. This has gone hand-in-hand with doctors preferring, for financial reasons and personal kudos to concentrate on high-tech specialties. And who is the real hero – the chest cutter cracking that difficult lung cancer, or the community physician who persuades schoolkids, over several generations, not to smoke?

The history of medicine tells us quite clearly that if you want to improve people’s health, having more and more specially trained doctors, at high salaries, may not be the best way forward. For example, in nineteenth century London there were a number of outbreaks of cholera, typhoid and other infectious diseases. It took a series of Public Health Acts, complex sewerage design and enhanced education to make for the beginnings of a healthy environment. The same applies in the twentieth century, with a decline in tuberculosis (TB) largely created by better nutrition and living conditions. Of course drugs were helpful but the essence of the treatment programme was social and environmental manipulation. In England several years ago one of the Health Authorities refused to fund anti-leukaemia treatment for a six- year-old girl. She had already had two courses of treatment; these had failed. The chances of a third course being effective were zero. The challenge of treatment was actually taken up by a private-sector unit, but the girl sadly died anyway, as predicted. In other words, the Health Authority was entirely reasonable in refusing to fund an expensive, high-tech, but ineffective treatment, preferring to spend the money, for example, on a couple of community psychiatric nurses.

Disease and delusion
This sad case generated a considerable concern as to the unrealistic pressures being put on specialist units. Diseases long seen as untreatable and usually managed with sedatives or painkillers now have to be thought of as in some sense ‘curable’. In fact, so as to establish itself as a necessary part of society, the medical profession has seriously over-stretched what it can do, pushing the miracle cures and sophisticated gadgetry which cost more and more to achieve less and less. It’s as if society is addicted to delusions of immortality, and doctors are competing for the Pied Piper role. But after several decades of hyped techno-expansion, such as heart transplants, smart drugs and highly sophisticated diagnostic techniques, there is a new understanding emerging of the impact of social and environmental factors in health. In part this is due to the population pressures in many parts of the world and the misery and warfare that they bring. In part it is due to a sense of the cost of things. And people are increasingly seeking medical solutions for personal or social problems because that is how they perceive things going wrong with themselves. Relationships, addictions, bad habits, losing your temper – somehow it’s all neurones and brain chemistry, rather than homes and families.

If you take a common condition like clinical depression, we now have a much wider range of drugs available and licensed. Despite these ‘advances’ in treatment, particularly in the last 20 years, the prevalence of depression is increasing. Is this due to greater recognition, a secondary effect of people wanting to be diagnosed by doctors who also want to label conditions that are treatable; or a change in the meaning of the word ‘depression’? If expectations are raised, in terms of income, style and personal well-being – and such images of satisfaction are integral to daily life in the West – then the corollary is that more people will feel they don’t have what they want. Is not having what you want the same as ‘depression’? Should you just take Prozac, or should you have a think about what you are doing? There is good evidence that treatment called ‘cognitive therapy’ is very effective, involves no drugs, and can be easily taught as an effective health intervention. But most doctors don’t like learning up these techniques which don’t have quite the chutzpah and heroic ‘Dr Kildare’ dramatics of a risky and expensive operation. The glamour doctors of our times are the heart-transplant surgeons and the accident and emergency junkies of Casualty and ER – always shouting, great on technique, often too late.

In Britain now, the breakdown in available and effective social services and housing departments is such that doctors’ offices are swamped with the depressed, the desperate and the disenfranchised. The main problem is how to stop people coming to see the doctor. In this sense social medicine is the opposite of any profit-based corporate organization which wants as many people as possible coming in through its front door and buying things. And private medicine encourages trivialization – get your hair transplant, your boob job, your hormonal implant – sucking health resources away from the truly needy.

Go for a walk
There is reasonable evidence now that chronic stress, generated by social dislocation and gaps in income, does lead to insecurity, loss of self-esteem, and an understanding of how health and economic factors connect up. It is well known that animals lower down in the social order produce too much of the stress hormone cortisol and have higher blood pressures and other biochemical abnormalities. Much of this applies to human beings from lower social classes, thus their much higher rates of dying young. Whether it’s absenteeism, self-harm, mood disorders or sheer panic, though, there’s usually a medication out there to deal with the condition, to keep you in your slot. It is no coincidence that some of the world’s richest companies sell pharmaceuticals.

The relative expenditure on modern high-tech medicine as opposed to straightforward environmental and social improvement is quite out of proportion. The problem is how do you persuade populations to spend money that has both health and social benefits? Most people want to use their car, regardless. This was abundantly plain in Britain recently, when a mass hysteria swept the country and people spent hours queuing for petrol for no real reason. On the bright side: traffic and accident rates went down. Yet the fundamentally important environmentalist agenda got lost in the panic.

Likewise with individual health, people would rather go to see their physician than do the difficult thing like taking more exercise. And it is just this rather cheerless message that is not suited to medical practitioners, who are often rather gung-ho individuals. They want to go out there and cure people and the more the headlines, the more the complexity, the more costly the procedure, the more heroic they feel. Yet a senior professor of surgery in England recently came out with his assessment that half the operations for breast cancer were a complete waste of time. A long-standing statistic has been the acknowledgment that rates of operation – in any Western society and for a wide range of conditions – vary only according to how many surgeons are living and working locally. They have little relationship to the actual prevalence of particular illnesses.

In fact, we now have a health economy that reinforces and requires regular extra funding. It also requires lots of patients, so the expansion of diagnosis into areas of unhappiness, relationships and so forth, has come at a welcome time. Yet somehow we have to teach people about knowing their own health because, if we do not, the health budgets will simply burst. Demanding antibiotics for every little cough or cold, demanding X-rays and special investigations for every little niggle or bowel turnover, or asking a doctor to sort out your marriage problems – such attitudes just multiply the sense of dissatisfaction and expectation. There is a semi-magical belief that many people have, especially in the US, that they will never die, that everything can be sorted, and that if they want something they must (and deserve to) have it.

But medicine itself has to change its image, away from hurrying, green-swathed surgeons, doing high-risk operations in the middle of the night, to something more practical like telling people to eat two apples a day. It’s not a new task. For example, vaccination programmes have transformed the lives of children in the twentieth century. Clean air and clean water, anti-pollution legislation, better designed workplaces, 30 miles-per-hour speed limits for cars in towns, good dietary habits established at school – all these are measures that have improved and will continue to improve people’s health.

Of course we need some acute medicine because nothing is wholly preventable, but as Hippocrates wrote in around 480 BC: ‘First, do no harm’.

is a psychiatrist who occasionally writes on matters medical and psychological for the NI. [email protected]