Why medicine is stricken by success

January 16, 1998


By a happy coincidence this book arrived just before I was due to travel to the United States to spend a few days at two of its oldest and most prestigious university teaching hospitals, and to join 14,000 other blood brothers at the Annual Meeting of the American Society for Hematology. Reasoning that it would provide an opportunity to see how a historian's view of present-day medicine matched up with the real world, I decided to take it along with me as a travelling companion. Apart from its bulk, which moved the person in the next seat on the transatlantic crossing to enquire whether I had had to pay an excess baggage fee to bring it on board, this proved to be an excellent decision.

Most of the major medical teaching centres in the US occupy acres of land covered with huge clinical and academic buildings. The needs of patients are catered for in specialist hospitals, packed with the laTEST in high-technology investigational and therapeutic aids. As far as the eye can see, old blocks are coming down and new ones springing up. These facilities, and the extensive research and development programmes that they house, are attracting massive sums of money, from both private and governmental sources. And apparently endless rows of buildings are arising to house the administrative staff required to cope with the organisation and finances of the medical schools, not to mention the business end of managed health care. At a quick estimate, the car-parking facilities at each of the centres that I visited occupy about the same space as the whole of my hospital and medical school in England.

Present-day medical congresses, equally imposing and expensive, have also spawned a completely new industry. Daily, thousands of doctors fly round the world to attend these rituals, at which they wander along miles of industrial exhibits offering almost everything free of charge, attend receptions funded by pharmaceutical companies, and, if they can fit in the time, pick up a few snippets of information of value to their clinical or research activities.

While the current scene in the US may reflect the extreme end of the spectrum of medical progress, the position is, if smaller in scale, similar in most rich, industrialised countries. Furthermore, modern medicine is not just a huge business concern. All the US newspapers carried accounts of government infighting over the inadequacy of medical care for the aged, and when I opened an English paper on the way home, banner headlines announced that the Labour party plans to emulate its predecessor, with yet another re-organisation of the NHS, with no pilot studies or apparent concern for those who have to maintain patient care in this state of chronic upheaval. Clearly, medical care is a major political issue on both sides of the Atlantic.

To try to piece together the events of the past few thousand years that have culminated in this state of affairs is no easy task. One approach, not popular with today's medical historians, is simply to catalogue the great names in the development of medical practice and science, starting in ancient Egypt and Greece and ending somewhere in the 20th century, usually in the US. The other way of telling the story, which seems to be finding increasing favour, is to describe health and disease as it has impinged on communities over the ages, with all its social, religious and political ramifications. In many of these latter accounts medicine and its institutions are depicted as entities with a life of their own, of little relevance to the health of society.

In this fine book, Roy Porter has managed to weave together both these approaches to the history of medicine. On the one hand he has drawn thumbnail sketches of the rich variety of personalities whose achievements were seminal to the slow evolution of the field. His choices are nothing if not catholic: Galen, William Harvey, Louis Pasteur and like giants were not unexpected; Jacob Bigelow, Dock and other pioneers of medical education may be less familiar; and the Egyptian healer Iri, keeper of the royal rectum, is a genuine collector's piece. Yet at the same time Porter has managed to set each stage of this complex story in its social and demographic framework. Even more remarkably, he has maintained this dualistic approach in accounts of medical practice in ancient Greece, China and India, through its Arab-Islamic period and in medieval England, to the present day. Yet this massive, fact-filled volume is written with such style, insight and humour that it is extremely difficult to put down.

Porter takes the view, generally held these days, that medical practice and science did little to alter the health of society until the beginning of this century, with the advent of genuine progress in the prevention and treatment of infectious disease. He is certainly right in saying that even now the situation is not looking so rosy, with the constant emergence of new or resistant infections. And it is also a fair criticism that modern medical science has made far less inroad into the prevention and definitive treatment of the major killers that have taken the place of communicable diseases.

In summing up his story, he suggests that medicine's finest hour is the dawn of its dilemmas. It has, he argues, grappled with meagre success to ensure live births, to manage pain and to combat infection. Having accomplished these missions, medicine's triumphs are dissolving in disorientation, he suggests the public expectations that have been generated are unfulfillable. Medicine will have to redefine its limits.

Is this gloomy postscript justified? In many ways Porter is right. Medicine will have to define its goals more clearly. It is now evident that even if we were to prevent or cure all our premature killers, we would add only about 15 years to our life potential. Given time, it is likely that the remarkable developments in the basic biomedical sciences of the past 20 years will go at least some way to achieving this end and to developing more humane approaches to prevention and therapy than the current high-technology, patch-up scenarios. But, as Porter describes so eloquently in the case of infectious disease, many advances in the laboratory sciences often take a century or more to reach their full potential for medical care. Furthermore, our present killers are much more complicated. Unlike infections, they do not result from a single cause. Rather, they reflect the interaction of our genetic make-up with our environment, together with the ill-understood mechanisms of ageing. Despite the pace of modern scientific advance their control is bound to take a long time, and may have its limitations, though patient care will surely improve slowly along the way. Somehow this message must be transmitted to a disillusioned public that, because of the wonders of vaccines and antibiotics, came to believe that medicine could offer a cure for anything, overnight. And, perhaps even more important, western society must shed its increasing obsession with immortality and come to realise again that death, at an appropriate age, is as natural as it is inevitable.

There is another cause for cautious optimism. Medical historians, like epidemiologists and health-care administrators, have to assess the impact of societal change and clinical practice on large populations rather than individuals. I still vividly remember the influenza epidemic in 1957 when, as a temporary general practitioner in the slums of Liverpool, I made up to 50 home visits a day. Even then it was possible to provide a great deal of relief with simple remedies, perhaps save a few lives by administrating antibiotics to the old folk, and, most importantly, reassure families that their relatives were likely to survive, sometimes during a friendly chat over tea served out of a jam-jar. Clinical practice is an extremely personal activity. Although it is impossible to measure its outcome, the one-to-one doctor-patient relationship, particularly its pastoral aspects, can be of enormous benefit in this increasingly complex world. While this vital aspect of care appears to have been lost in a sea of technology and pressure for greater efficiency, the fact has at last been appreciated by the General Medical Council and our medical schools. Major changes in medical education, addressed particularly at this problem, are well under way.

Porter has performed a great service to today's (and tomorrow's) doctors and to the community at large by placing the current medical scene in its broad historical perspective. And in doing so he has managed to write a wonderfully entertaining book. His synthesis of the modern doctors' dilemma is spot on. All those who have the daunting task of trying to redefine the goals of medical practice for the future should read this book, and then read it again. It is a magnificent achievement.

Sir David Weatherall is regius professor of medicine, University of Oxford.

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