![\"richard_smith_2014\"](\"https:\/\/stg-blogs.bmj.com\/bmj\/files\/2014\/12\/richard_smith_2014.jpg\")
<\/a>Sometimes you read something that shakes you to your core. Often you are shaken because the piece expresses clearly and strongly something you\u2019ve vaguely thought for yourself. It\u2019s as when the clouds clear on the top of a mountain and all is laid out before you. I had that experience a few days ago when I read “How American medicine is destroying itself<\/a>” by Daniel Callahan, the philosopher, and Sherwin B Nuland, the surgeon and author of the important book How We Die<\/em>.\u00a0These two men, both born in 1930, have, I suggest, thought more deeply about medicine than perhaps anybody else in recent times.<\/p>\nI have found that since I read it, the article has come into my mind during every conversation I have had about healthcare: all of those conversations were concerned in some way with improving healthcare, but the article led me to think that they were all trivial compared with the way that medicine is destroying itself. Thinking about the extraordinary impact that climate change will have has the same effect and does, of course, trump the destruction of medicine. We carry on with the trivial, however, for what else can we do?<\/p>\n
Before I summarise the article by Callahan and Nuland, I want to warn against the immediate dismissal of the article on the grounds that it\u2019s about \u201cAmerican medicine\u201d and so not relevant to other countries, including Britain. American medicine may be further ahead than any other with destroying itself, but they are writing about what might best be called \u201cWestern medicine,\u201d which sadly is being snapped up by the middle classes even in low and middle income countries.<\/p>\n
Callahan and Nuland begin with a quote from the landmark book Mirage of Heath<\/em> published in 1959 by Ren\u00e9 Dubos: \u201ccomplete and lasting freedom from disease is but a dream remembered from imaginings of a Garden of Eden.\u201d Unfortunately, the dream is alive and well, and since the Second World War \u201cthe medical profession has been waging an unrelenting war against disease.\u201d Indeed, the Chan Zuckerberg Initiative, funded with the profits from Facebook, has made explicit that it aims to end all disease. Behind medicine\u2019s aims lie three assumptions: \u201cthat medical advances are essentially unlimited; that none of the major lethal diseases is in theory incurable; and that progress is economically affordable if well managed.\u201d Callahan and Nuland question all of these assumptions.<\/p>\n After the successful eradication of smallpox \u201cit was commonly assumed that infectious disease had all but been conquered.\u201d But since then we\u2019ve had HIV and other epidemics of emergent infections\u2014with more guaranteed. Plus antibiotic resistance is moving fast. \u201cBased on what we now know of viral disease and microbial genetics, it is reasonable to assume that infectious disease will never be eliminated.\u201d<\/p>\n They continue: \u201cIf the hope for eradication of infectious disease was misplaced, the hopes surrounding cures for chronic diseases are no less intoxicated.\u201d Nixon\u2019s \u201cwar on cancer\u201d was a flop, although slow progress has been made, and \u201cno one talks seriously of a near-term cure\u201d for Alzheimer\u2019s Disease.<\/p>\n One of the most attractive of medical fantasies was the idea of \u201ccompression of morbidity\u201d advanced by James Fries in 1980<\/a>\u2014that after a long healthy life we would fall apart and die rapidly. The result would be little suffering and lower costs. Unfortunately, Fries\u2019s idea remains a fantasy. Callahan and Nuland quote a study<\/a> from Eileen Crimmins and Hiram Beltr\u00e1n-S\u00e1nchez, which found that \u201cthe idea has no empirical support.\u201d \u201cHealth,\u201d Crimmins and Beltr\u00e1n-S\u00e1nchez concluded, \u201cmay not be improving with each generation\u201d and \u201ccompression of morbidity may be as illusory as immortality. We do not appear to be moving to a world where we die without experiencing disease, functioning loss, and disability.\u201d<\/p>\n Yet since Callahan and Nuland wrote their article the fantasy\u2014far from fading\u2014has been supplemented by an increasing number of scientists believing immortality to be achievable, while at the same life expectancy in the United States and some parts of Britain has begun to fall. This makes me think of Aguirre, the Wrath of God<\/em>, the film of Werner Herzog, where the fantasies of the conquistador Lope de Aguirre of the unlimited wealth of El Dorado grow ever grander while his circumstances, adrift on a raft in the Amazon beset by disease and Indian attacks, grow ever worse.<\/p>\n Callahan and Nuland point out that \u201cthe \u2018breakthroughs\u2019 that have been predicted for such scientific sure things as stem cell technology and medical genetics\u2014\u2026have yet to be realized.\u201d And seven years later they still haven\u2019t, although the rhetoric continues unabated. \u201cWe have arrived at a moment, in short, where we are making little headway in defeating various kinds of diseases. Instead, our main achievements today consist of devising ways to marginally extend the lives of the very sick.\u201d<\/p>\n Advances have, of course, been made, and we should all be grateful for advances that have led to big reductions in morbidity. I have a 60% cataract in my left eye, and I confidently expect that, far from going blind, I will be able to see better than ever with my myopic eye once I have the cataract removed and a lens implanted.<\/p>\n \u201cAdvances, however, should,\u201d warn Callahan and Nuland, \u201cbe balanced against another factor: the insupportable, unsustainable economic cost of this sort of success. Twenty years from now, the maturation of the baby boom generation will be at flood tide. We will have gone from 40 million Americans over the age of 65 in 2009 to 70 million in 2030.\u201d The same is true across the world\u2014with differences in timing. The diseases of the elderly will not be cured\u2014and even if they are they will be replaced by others, perhaps more terrible. (Is it progress, I ask, to cure cancer so that people can die slowly of Alzheimer\u2019s?) \u201cThe best we will be able to do in many cases,\u201d conclude Callahan and Nuland, \u201cespecially those of the elderly and frail, is extend people\u2019s lives for a relatively short period of time\u2014at considerable expense and often while causing serious suffering to the person in question.\u201d<\/p>\n