In his new book, ‘Can Medicine be Cured?’ Prof Seamus O’Mahony is highly critical of the medical system, particularly when it comes to spending huge amounts of money on drugs that do little to improve health or prolong life
Medicine has lost its way. I qualified as a doctor in 1983, near the end of a golden age which began in the mid-1930s.
Those 50 years saw mass production of penicillin, effective drug treatment for tuberculosis, kidney dialysis, organ transplantation, endoscopy, CT and MRI scanning, in-vitro fertilization, the eradication of smallpox and the discovery of the double helix of DNA.
Diseases that once ravaged Ireland either disappeared through vaccination (polio) or became curable (tuberculosis). During the golden age, medical science gained huge prestige: human life and death became medicalised, and a huge medical-industrial complex emerged.
Despite its global dominance, this medical-industrial complex has given us meagre, feeble comforts at vast expense. Its chief concern is its own survival and continued dominance, and its ethos is a betrayal of the scientific ideals of the golden age. It has been estimated that as much as 85% of medical research is useless.
This global waste amounts to about €200bn annually. Researchers are driven by perverse professional and commercial incentives to value quantity over quality — to “publish or perish” — the majority of studies are never repeated, or“replicated”, to ensure that the findings are real.
The Human Genome Project (completed in 2003) which identified and mapped all of the genes in the human genome was hailed as the greatest scientific achievement in history, yet practical applications of this knowledge in the treatment of disease have been few and modest.
Evidence-based medicine (EBM) emerged as the new orthodoxy in the 1990s. EBM was defined as ‘integrating individual clinical expertise with the best external evidence’; ie, doctors should only carry out treatments or prescribe drugs for which there was good evidence that they worked. Who could argue with such common sense?
Evidence, unfortunately, is very expensive to produce, and clinical trials of drugs are so costly that only pharmaceutical companies can afford to run them. Three-quarters of drug trials published in the major medical journals are industry funded.
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✨✨✨✨ Aside from a devotion to Casualty dating back to, ooh, 1994 or so (🙈) I never used to be particularly interested in medicine. Then I started hanging out in hospitals. And having to make decisions regarding medical trials. And so I started reading up on medical trials - and then reading everything, everywhere, about the state of the NHS and various drugs and NICE’s approval of such drugs..... which is essentially what this book is about, and it is FASCINATING. From the merits (or not) of mass murder of mice in the name of scientific research, to Cameron’s cancer drug fund for expensive drugs not approved by NICE (the amount spent could have covered the nationwide cost of running hospices for two years, and few of them actually made any difference) to the tragic cases of Charlie Gard and Alfie Evans and ‘trial by social media’, to comparing using data to run the NHS to McNamara’s planning for the Vietnam War, it is enlightening, thought provoking, and actually just a really good read: #SeamusOMahony #CanMedicineBeCured? ✨✨✨✨
If Big Pharma is paying for the evidence, it is hardly surprising if the evidence it produces shows its product in the best possible light. These trials are deliberately designed to maximize the commercial possibilities of the drug. EBM, which started as a noble, almost evangelical crusade, is now largely a construct of the pharmaceutical industry.
Medical research is now so sick that it has itself become a patient, and the object of critical study. John Ioannidis, a Greek-American professor of medicine at Stanford University is a “meta-researcher” - he researches research.
His famous 2005 paper entitled “Why most published research findings are false” demonstrated how most clinical trials asked the wrong question, recruited too few patients (and those they recruited were often atypical and unrepresentative), analysed the data incorrectly, and came to the wrong conclusions.
In 2016, Ioannidis concluded that EBM had been hijacked by industry: “corporations should not be asked to practically perform the assessments of their own products. If they are forced to do this, I can’t blame them, if they buy the best advertisement (i.e. ‘evidence’) for whatever they sell.”
EBM did not reflect the demographic shift in medicine towards older, frailer patients with several chronic diseases (comorbidities), taking its evidence from trials on younger patients with single diseases. Such evidence oversimplified the many complex variables of the clinical encounter, and the goals that are important to real people. EBM led to massive overprescribing, particularly in the elderly.
Overprescribing (‘polypharmacy’) is now a major public health issue: the direct cause of major side effects, increased mortality, and a huge waste of money.
One prescription often leads to another: a drug given for high blood pressure may cause ankle swelling due to fluid retention, leading to another prescription for a diuretic (water tablet), which may cause potassium depletion, leading to a prescription for potassium tablets, which may cause nausea, leading to a prescription for anti-nausea drugs, which may cause confusion, and on and on, a process known as the prescribing cascade. One in six acute admissions to hospital in elderly people is due to drug side-effects.
“Blockbuster” drugs are those products that generate $1bn or more every year for the companies that produce them. Statins (a family of drugs prescribed for high blood cholesterol) are among the most successful blockbuster drugs in history.
There is a consensus that people who have had a heart attack or a stroke should take statins regularly to decrease their risk of such events in the future: this is called ‘secondary prevention’.
Most people taking statins, however, do so for “primary prevention”: their only risk is a high blood cholesterol. Once started on a statin, the “patient” takes the medicine for the rest of their life, yet the vast majority of these ‘patients’ will not benefit in any way.
The West of Scotland Coronary Prevention Study, published in 1995, found that 111 men with high cholesterol had to take a daily statin for five years to prevent one death. We are treating populations, not individuals.
Diseases are now marketed as aggressively as any commercial product through “awareness” campaigns. Doctors have been willing recruits to these campaigns, playing the new game of My Disease Is Better Than Your Disease, a tacit acknowledgement that decisions on funding new treatments and deciding priorities in health spending are often influenced by grabbing the attention of the media and politicians: We’re All in Sales Now. In the hierarchy of awareness raising, cancer is king.
New cancer drugs are very, very expensive. Patients stricken with cancer, not surprisingly, want to access the very latest treatment, regardless of the evidence of benefit – or lack of it.
In Britain, new drugs are assessed by the government agency called the National Institute for Health and Care Excellence (NICE), which uses a number of criteria to determine whether these new agents offer benefit and value for money. Many such drugs are turned down by NICE, leading to a predictable public outcry.
In response to this protest, the prime minister David Cameron set up a special fund to pay for cancer drugs that had either been rejected by NICE or were waiting assessment. The fund paid out £1.27 billion between 2010 and 2016. Of the 47 drugs funded, only 18 (38%) improved survival, and then only by a meagre average of three months.
The remaining 29 had no benefit and caused significant side effects. The money wasted on the Cancer Drugs Fund would have paid for every hospice in the UK for a year and a half.
Medicine no longer knows what it is for. Is the ultimate aim of medical research to eliminate all disease? If so, then it must be aiming, too, to make us immortal.
Even if that were possible (which it isn’t), are we quite sure that we want it? Is the aim of clinical medicine now to keep the entire adult population under permanent surveillance by screening for an increasing number of diseases? Does longevity trump all other considerations?
Medicine, and particularly medical research, operates in an economic and moral vacuum, choosing to ignore the societal implications of new cancer treatments and “precision medicine” which often give tiny, incremental gains at huge cost.
We in the rich west cannot continue to spend vast sums for such modest gains while people die in poor countries of diseases that can be cheaply cured and prevented.
Medicine sees death as a failure and regards the alleviation of suffering and care of the dying as someone else’s problem. The new religion of Healthism ignores the eternal verities of sickness, old age and death. Medicine needs to embrace a new mission: to make the conditions of human life more bearable.