The Rise and Fall of Modern Medicine (2 page)

P
ART
II: T
HE
E
ND OF THE
A
GE OF
O
PTIMISM

1 The Revolution Falters

2 The Dearth of New Drugs

3 Technology's Failings

4 The Clinical Scientist as an Endangered Species

P
ART
III: T
HE
F
ALL

1 The Brave New World of The New Genetics

  (i) The Beginning

 (ii) Genetic Engineering

(iii) The New Eugenics

(iv) Gene Therapy

 (v) The End

2 Seduced by The Social Theory

  (i) The Beginning

 (ii) The Rise and Fall of Heart Disease

(iii) Beyond Tobacco: Sir Richard Doll and the ‘Causes' of Cancer

(iv) Environmental Alarums

 (v) The End

3 The Unsolved Problem: The Mysteries of Biology Revisited

P
ART
IV: T
HE
R
ISE AND
F
ALL
: C
AUSES AND
C
ONSEQUENCES

1 Learning from the Past

2 Looking to the Future

E
PILOGUE TO THE
R
EVISED
E
DITION

Epilogue

Introduction: Ten Years On

1 Doing More

2 The New Genetics Triumphant – or Not

3 Big Pharma Rules

4 The Next Ten Years

Appendix I: Rheumatology

Appendix II: The Pharmacological Revolution in Psychiatry

References

Index

T
he arduousness of writing has been more than compensated for by the privilege of meeting so many of those who participated in the great events recorded in this book. To them; to the sympathetic souls whose interest has been more important than they realise; to the librarians at the Royal Society of Medicine and the Wellcome Institute for the History of Medicine; to my wife Juliet; to my agent Caroline Dawnay, publishers Philippa Harrison and Richard Beswick and editors Andrew Gordon and Victoria Pepe; and to Vanessa Adams and Caroline Sherbrooke for their prodigious secretarial skills: my thanks.

Dr Digby Anderson, Lord Annan, Bryan Appleyard, Mr John Ballantyne FRCS, Sir Douglas Black, Professor Nicholas Black, Sir Christopher Booth, Dr Thomas Boulton, Professor John Bunker, Dr Bruce Charlton, Mr Bill Cleland FRCS, Sir John Dacie, Dr Ann Dally, Dr Anthony Daniels, Professor Norman Dennis, Professor C. J. Dickinson, Sir Richard Doll, Professor Deborah Doniach, Professor Israel Doniach, Professor R. S. Downie, Sir John Ellis, Professor Peter Ellwood, Professor Renée Fox, Mr Michael Freeman FRCS, Professor David Galton, Dr John Glyn, Mr James Gow FRCS, Dr C. W. Haigh,
Professor John Hampton, Dr Myles Harris, Sir Donald Harrison, Dr I. D. Hill, Professor A. V. Hoffbrand, Dr Arthur Holman, Mr John Hopewell FRCS, Dr David Horrobin, Professor Bryan Jennett, Professor Trevor Jones, Dr Michael Joseph, Dr Leo Kinlen, Dr Ghislaine Lawrence, Professor John Marshall, Dr William Marshall, Dr Robert Matthews, Professor James McCormick, Professor Kenneth Minogue, Dr G. Misiewicz, Professor John Moorehead, Mr E. P. O'Donoghue FRCS, Professor Peter Openshaw, Mr Nicholas Parkhouse FRCS, Professor Michael Patton, Sir Stanley Peart, Mr Elliot Philipp FRCS, Mr Michael Powell FRCS, Dr David Pyke, Mr Gordon Rees FRCS, Professor Jonathan Rees, Professor Lesley Rees, Dr Henry Rollin, Dr Jack Scannell, Dr Rupert Sheldrake, Professor Peter Skrabanek, Professor Alexander Spiers, Professor Gordon Stewart, Mr John Studd FRCOG, Professor Raymond Tallis, Dr Tilli Tansey, Dr Wendy Taylor, Professor Tom Treasure FRCS, Mr Patrick Trevor-Roper FRCS, Dr John Wade, Sir David Weatherall, Dr Mark Weatherall, Professor Simon Wesseley, Mr Adrian While FRCS, Dr Elizabeth Whipp, Mr John Wickham FRCS, Sir Michael Woodruff, Dr Nigel Yeatman.

O
ver the past fifty years medicine has metamorphosed from a modest pursuit of limited effectiveness into a massive global phenomenon employing millions and costing (hundreds of) billions. Now, in the vast shiny palace the modern hospital has become, the previously unimaginable goals of transplanting organs and curing childhood cancer have become unexceptional, while every year tens of thousands previously doomed to blindness from cataracts or to immobility from crippling arthritis have their sight and mobility restored. Medicine has become the most visible symbol of the fulfilment of the great Enlightenment Project where scientific progress would vanquish the twin perils of ignorance and disease to the benefit of all.

And yet the more powerful and prestigious medicine has become, the greater the impetus to extend its influence yet further, resulting in the progressive ‘medicalisation' of people's lives, to no good purpose and potentially harmful consequences. This takes many forms, from the overinvestigation and over treatment of minor symptoms to the inappropriate use of life-sustaining technologies, anxiety mongering about trivial (or non-existent) threats to health in people's everyday lives, and the propagation of unreasonable expectations about what the current state of
medical research can reasonably expect to achieve.

These are no trivial matters. They warrant clear analysis and, if possible, remedial action; yet their significance has for the most part been concealed from view by the common perception, profoundly influenced by medicine's historic achievements, of it being on a continuous and upward curve of knowledge. Here the unknown is merely waiting to be known with, in principle, no limits to its further beneficent advance.

Yet it is not so, for as I proposed a decade ago in the first edition of
The Rise and Fall of Modern Medicine
, the current difficulties and discontents of medicine are ultimately linked to the changing fortune of the three forces that forged the therapeutic revolution of the post-war years – clinical science, pharmaceutical innovation and technical progress. This, in turn, has created an intellectual vacuum within which faulty and unrealistic assumptions of medicine's ‘tasks and goals' have flourished. Now, ten years on, the ‘massive global enterprise' of medicine remains as powerful as ever – if not more so, and as suggested by the continued exponential increase in National Health Service expenditure and the revenues of the pharmaceutical industry.

But the central thesis of
The Rise and Fall
. . . still holds, and so for this second edition I have revised but made no substantial changes to the original text. To this I have added an epilogue examining the three most significant factors in the continuing expansion of the medical enterprise over the past decade: the technical innovations that have extended the benefits of medical intervention to an ever ageing population; the ascendancy of The New Genetics in the aftermath of the completion of the Human Genome Project to become the dominant form of medical research; and, most importantly of all, how an ever wealthier pharmaceutical industry has successfully subverted the proper aims of medicine to its own very profitable advantage.

T
he history of medicine in the fifty years since the end of the Second World War ranks as one of the most impressive epochs of human achievement. So dramatically successful has been the assault on disease that it is now almost impossible to imagine what life must have been like back in 1945, when death in childhood from polio, diphtheria and whooping cough were commonplace; when there were no drugs for tuberculosis, or schizophrenia, or rheumatoid arthritis, or indeed for virtually every disease the doctor encountered; a time before open-heart surgery, transplantation and test-tube babies. These, and a multitude of other developments, have been of immeasurable benefit, freeing people from the fear of illness and untimely death, and significantly ameliorating the chronic disabilities of ageing.

This post-war medical achievement is well recognised, but much less appreciated is the means by which it was brought about. For the previous 2,000 years doctors had sought in vain for the ‘magic bullets' that would alleviate their patients' suffering and then, quite suddenly and without warning, they came cascading out of the research laboratories just as if medicinal chemists had hit the jackpot (as they had). Or again, in 1945,
desirable objectives such as transplanting organs or curing cancer were rightly perceived as being unattainable, as there was simply no way of overcoming the biological problems of the rejection of foreign tissue or the selective destruction of cancer cells. But these and many other obstacles were surmounted. The past fifty years have been a unique period of prodigious intellectual ferment that, quite naturally, invite investigation.

There is a problem, however, in knowing where to start. The scale of the therapeutic revolution has been so vast that any comprehensive history would necessarily run to several volumes. Decisions had to be made about not only what to include and what, regretfully, to leave out, but also how to go beyond a simple chronological account to illuminate themes of more general significance. The compromise I have chosen is illustrated opposite. This list of the major events of this period identifies twelve ‘definitive moments' which are considered in depth in a prologue that is necessarily longer than is customary. The rationale of this selection is not of immediate concern but several themes are easy enough to identify, including the decline of infectious disease (sulphonamides, penicillin and childhood immunisation); the widening scope of surgery (the operating microscope, transplantation and hip replacements); major developments in the treatment of cancer, mental illness, heart disease and infertility; and improvements in diagnostic techniques (the endoscope and the CT scanner).

Each of these events is a remarkable story of human endeavour in its own right, but when they are assembled together then, as with the dots of the pointillist, a coherent picture should begin to emerge. The value of such an historical perspective is not necessarily obvious. ‘Medicine pays almost exclusive homage to the shock of the new,' writes the editor of
The Lancet
, Richard Horton. ‘We place constant emphasis on novelty . . . this is an era of the instantaneous and the immediate.'
¹
This preoccupation with ‘the new' leaves little room for history, and indeed medicine has got by well enough with no sense of its immediate past at all. Perhaps the history of twentieth-century medicine is solely of academic interest, an intellectual pastime for retired doctors but of little practical importance?

The Twelve Definitive Moments of Modern Medicine

Needless to say, I do not share this view, but rather, taking my cue from T. S. Eliot – ‘the historical sense involves the perception not only of the pastness of the past, but of its presence' – maintain it is not possible to understand the present, and in particular present discontents, outside of the context of this recent past. And what is the nature of these ‘present discontents'? Any account of modern medicine has to come to terms with a most perplexing four-layered paradox that at first sight seems quite incompatible with its prodigious and indubitable success.