Saving medical practice from the tyranny of health
Dr Michael Fitzpatrick talks to James Le Fanu, the one-time scourge of those medical practitioners who blamed lifestyle or pollution for ill health, to find out if he really has made peace with the medical establishment.
In 1999, in the first edition of his prize-winning history of medicine in the postwar period, The Rise and Fall of Modern Medicine, James Le Fanu insisted that ‘much current medical advice is quackery’. In response, he recommended ‘the simple expedient of closing down most university departments of epidemiology’, which ‘could both extinguish this endlessly fertile source of anxiety-mongering while simultaneously releasing funds for serious research’. More than a decade later, though his second edition claims ‘no substantial changes to the text’, this controversial proposal has been discreetly dropped. Has Dr Le Fanu made his peace with the medical establishment? I went to find out.
As its title suggests, The Rise and Fall is a book in two halves. In the first, Le Fanu tells the stories of ‘12 definitive moments’ in the triumph of scientific medicine in the second half of the twentieth century. His list includes the discoveries of penicillin and cortisone, the developments of kidney transplantation, hip replacement and test-tube babies. He also provides a back-up list of a further 24 significant innovations, including kidney dialysis, the oral contraceptive pill, CT scanning and Viagra. The key theme running through these accounts is the ascendancy of luck and serendipity over major scientific insights, of accident rather than design, in the emergence of these diverse discoveries and developments. (This is reinforced in appendices on therapeutic advances in rheumatology and psychiatry.)
Yet, as I put it to Le Fanu, was it not the pioneering experimenter in microbiology Louis Pasteur who observed that ‘in the fields of observation, fortune favours only the prepared mind?’ ‘Of course this is true’, says Le Fanu, ‘particularly in regard to drugs, though less so in relation to the technological advances. The problem was that, given the limitations of the biological sciences in the mid-twentieth century, research could only proceed in a largely empirical way. Driven by the dynamism of the chemical industry, this approach achieved impressive results – but it also paved the way for later problems.’
Turning to the fall of modern medicine, Le Fanu diagnoses the onset of the current malaise of the world of medicine in the 1970s, when ‘the revolution faltered’ and ‘the age of optimism’ came to an end. Clinical science went into decline, the flow of new drugs slowed and technological innovation stalled. The resulting ‘intellectual vacuum’ has been filled by what Le Fanu regards as the specious notions of the ‘New Genetics’ and the ‘Social Theory’ (blaming lifestyle, pollution and poverty for much current ill health). He blames the twin influences of genetics and epidemiology for leading modern doctors (and their patients) down ‘blind alleys’.
Le Fanu’s exposure of the pretensions of the ‘genetic revolution’ and the hype surrounding the human genome project and all the claims for imminent dramatic developments in genetic engineering and gene therapy will strike a chord with many doctors. As he observes, we have witnessed ‘a relentless catalogue of failed aspirations’; despite a vast investment of energy, resources and hopes, the practical benefits of the ‘New Genetics’ in our surgeries are ‘scarcely detectable’.
In his new edition Le Fanu brings the critique of the New Genetics up to date with an appraisal of the ‘wishful thinking’ of ‘personalised genomics’ and a discussion of the ways in which ‘genome-wide association studies’ have thrown up more new problems than potential solutions, particularly in relation to chronic diseases. Though he acknowledges the emergence of new cancer drugs such as Herceptin and Avastin, he neglects wider developments in cancer genetics where advances in molecular biology have led directly to therapeutic innovations. For example, the introduction of Imatinib (Gleevec) for the treatment of chronic myeloid leukaemia in 1998 has been followed by the development of more than 20 new drugs for the treatment of cancer, including myeloma (which until recently had a grim prognosis). ‘I accept that these drugs mark a major conceptual advance’, says Le Fanu, ‘but the problem here is that we have a handful of very expensive drugs which provide modest benefits to small numbers of people with relatively rare conditions. We were promised personalised treatments for common chronic conditions and these are still over the horizon.’
It is when we come to talk about the Social Theory that the gulf between Le Fanu and the theory and practice of contemporary medicine is most apparent. It is around 20 years since he first exposed ‘the great cholesterol deception’ (the claim that diet is a major cause of heart disease) and tackled ‘the phantom carnage’ (the claim that social inequality is a major cause of premature mortality). Le Fanu’s early arguments are substantially reproduced in the The Rise and Fall. Yet, as I put to him, it seems that the faith of the medical profession – and the public – in these theories remain unscathed by the exposure of the lack of scientific evidence for them. Have the doctors and their patients been duped?
‘I think things have moved on. I don’t think anybody seriously believes any more that diet is a major factor in heart disease, or that environmental toxins are a major factor in cancer or, for that matter, since the passing of New Labour, that relative poverty is an important cause of premature mortality.’ Le Fanu dismisses the great obesity scare and the apparent popularity in the medical establishment of the epidemiologist Michael Marmot and the arguments of Spirit Level authors Richard Wilkinson and Kate Pickett as being of marginal influence. (Though ignored in The Rise and Fall, these arguments have been comprehensively debunked by
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