The core of modern doctoring is diagnosis, treatment and prognosis. Most medical schools emphasize little else. Western doctors have been analyzing the wheezes and pains of their patients since the 17th century to identify the underlying disease of the cause of complaints. They did it well and good diagnosis became the hall mark of a good physician. They were less strong on treatment. But when sulphonamides were discovered in 1935 to treat certain bacterial infections, doctors found themselves with powerful new tools. The area of modern medicine was born. Today there is a ever-burgeoning array of complex diagnostic tests, and of pharmaceutical and surgical methods of treatment. Yet what impact has all this had on health?
Most observers ascribe recent improvements in health in rich countries to better living standards and changes in lifestyle. The World Health Organization cities the wide differences in health between Western and Eastern Europe. The two areas have similar pattern of diseases: heart disease, senile dementia, arthritis and cancer are the most common cause of sickness and death. Between 1947 and 1964, both parts of Europe saw general health improve , with the arrival of cleaner water, better sanitation and domestic refrigerators. Since the mid 1960s, however, E. European countries, notable Poland and Hungary, have seen mortality rates rise and life expectancy fall. Why? The WHO ascribes the divergence to differences in lifestyle-diet, smoking habits, alcohol, a sedentary way of life (factors associated with chronic and degenerative diseases) rather than differences in access in modern medical care.
In contrast, the huge sum now spent in the same of medical progress produce only marginal improvements in health. America devotes nearly 12% of its GNP to it high technology medicine, more than any other developed country. Yet, overall, Americans die younger, lose more babies and are at least as likely to suffer from chronic diseases. Some medical producers demonstrably do work: mending broken bones, the removable of cataracts, drugs for ulcers, vaccination, aspirin for headaches, antibiotics for bacterial infections, techniques that save new born babies, some organ transplant, yet the evidence is scant for many other common treatments. The coronary bypass, a common surgical technique, is usually to overcome the obstruction caused by a blood clot in arteries leading to the heart. Deprived of oxygen, tissues in the heart might otherwise die. Yet, according to a 1988 study conducted in Europe, coronary bypass surgery is beneficial only in the short term. A bypass patient who dies within five years has probably lasted longer than if he had simply taken drugs. But among those who get to or past five years, the drug-takers live
longer than those who have surgery.
An American study completed in 1988 concluded that removing tissue from the prostate gland after the appearance of (non-cancerous) growth, but before the growths can do much damage, does not prolong life expectancy. Yet the operation was performed regularly and cost Medicare, the federally – subsidized system for the elderly, over $1 billion a year.
Though they have to go through extensive clinical trials, it is not always clear that drugs provide health benefits. According to Dr. Louise Russell, a professor of economics at Rutgers University, in New Jersey, although anti – cholesterol drugs have been shown in clinical trails to reduce the incidence of deaths due to coronary heart disease, in ordinary life there is no evidence that extend the individual drug taker’s life expectancy. Medical practice varies widely from one country to another. Each year in America about 60 of every 100,000 people have a coronary by-pass; In Britain about six Anti-diabetic drugs are far more commonly used in some European countries than others. One woman in five, in Britain, has a hysterectomy (removal of the womb) at some time during her life; In America and Denmark, seven out of ten do so.Why? If coronary heart problems were far commoner in America than Britain, or diabetes in one part of Europe than another, such differences would be justified. But that is not so. Nor do American and Danish women become evidently healthier than British ones. It is the medical practice, not the pattern of illness or the outcome, that differs. Perhaps American patients expect their doctors to “do something” more urgently than British ones? Perhaps American doctors are readier to comply? Certainly the American medical fraternity grows richer as a result. No one else seems to have gained through such practices.
To add injury to insult, modern medical procedures may not be just of questionable worth but sometimes dangerous. Virtually all drugs have some adverse side-effects on some people. No surgical procedure is without risk. Treatments that prolong life can also promote sickness: the heart attack victim may be saved but survive disabled.
Attempts have been made to sort out this tangle. The “outcomes movement” born in America during the past decade, aims to lessen the use of inappropriate drugs and pointless surgery by reaching some medical consensus–which drug to give? whether to operate or medicate?–through better assessment of the outcome of treatments.
Ordinary clinical trials measure the safety and immediate efficacy of products or procedures. The outcomes enthusiasts try to measure and evaluate far wider consequences. Do patients actually feel better? What is the impact on life expectancy and other health statistics? And instead of relying on results from just a few thousand patients, the effect of treating tens of thousands are studied retrospectively. As an example of what this can turn up, the adverse side-effects associated with Opren, an anti-arthritis drug, were not spotted until it was widely used.
Yet Dr. Arnold Epstein, of the Harvard Medical School, argues that, worthy as it may be, the outcomes movement is likely to have only a modest impact on medical practice. Effectiveness can be difficult to measure: patients can vary widely in their responses. In some, a given drug may relieve pain, in others not: is highly subjective. Many medical controversies will be hard to resolve because of data conflict.
And what of the promised heart-disease or cancer cures? Scientists accept that they are unlikely to find an answer to cancer, heart disease or degenerative brain illness for a long while yet. These diseases appear to be highly complex, triggered when a number of bodily functions go awry. No one pill or surgical procedure is likely to be the panacea. The doctors probably would do better looking at the patient’s diet and lifestyle before he becomes ill than giving him six pills for the six different bodily failure that are causing the illness once he has got it.
Nonetheless modern medicine remains entrenched. It is easier to pop pills than change a lifetime’’ habits. And there is always the hope of some new miracle cure -–or some individual miracle. Computer technology has helped produce cameras so sensitive that they can detect the egg in the womb, to be extracted for test tube fertilization. Bio-materials have created an artificial heart that is expected to increase life expectancy among those fitted with one by an average of 54 months. Bio-technology has produced expensive new drugs for the treatment of cancer. Some have proved life-savers against some rare cancers; none has yet had a substantial impact on overall death rates due to cancer.
These innovations have vastly increased the demand and expectations of health care and pushed medical bills even higher – not lower, as was once hoped. Inevitably, governments, employers and insurers who finance health care have rebelled over the past decade against its astronomic costs, and have introducedbudgets and rationing to curb them.
Just as inevitably, this limits access to health care: rich people get it more easily than poor ones.
Some proposed solutions would mean no essential change, just better management of the current system. But others, mostly from American academics, go further, aiming to reduce the emphasis on modern medicine and its advance. Their trust is two headed:
(i) prevention is better – and might be cheaper – than cure; and
(ii) if you want high-tech, high-cost medicine, you (or your insurers, but not the public) must pay for it,
especially when its value is uncertain.
Thus the finance of health-care systems, private or public, could be skewed to favour prevention rather than cure. Doctors would be reimbursed for preventive practices, whilst curative measures would be severely rationed. Today the skew is all the other way: Governments or insurers pay doctors to diagnose disease and prescribe treatment, but not to give advise on smoking or diet. Most of the main chronic diseases are man-made. By reducing environmental pollution, screening for and treating biological risk indicators such as high blood pressure, providing vaccination and other such measures – above all, by changing people’s own behavior – within decades the incidence of these diseases could be much reduced. Governments could help by imposing ferocious “Sin taxes” on unhealthy products such as cigarettes, alcohol, maybe even fatty foods, to discourage consumption.
The trouble is that nobody knows precisely which changes – apart from stopping smoking – are really worth putting into effect, let alone how. It is clear that people whose blood pressure is brought down have a brighter future than if it stayed high; It is not clear that cholesterol screening and treatment are similarly valuable. Today’s view of what constitutes a good diet may be judged wrong tomorrow.
Much must change before any of these “caring” rather than “cure” schemes will get beyond the academic drawing-board. Nobody has yet been able to assemble a coherent preventive programme. Those countries that treat medicine as a social cost have been wary of moves to restrict public use of advanced and / or costly medical procedures, while leaving the rich to buy what they like. They fear that this would simply leave ordinary people with third-class medicine.
In any case, before fundamental change can come, society will have to recognize that modern medicine is an imprecise science that does not always work: and that questions of how much to spend on it, and how, should not be determined almost incidentally, by doctor’s medical preferences.
Modern cure are known to be expensive because