Insights
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 domes- tic 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 degen- erative 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 infec- tions, 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 bypass; In Britain about six Anti-diabetic drugs are far more com- monly 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 out- comes
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 proce- dure 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 introduced budgets 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 sys- tem. But others, mostly from American academics, go further,
aiming to reduce the emphasis on modern medicine and its advance.
