Alternative reports

doi:10.1136/bmj.a2331

Published 30 October 2008, doi:10.1136/bmj.a2331
Cite this as: BMJ 2008;337:a2331

Editor's Choice

Alternative reports

Jane Smith, deputy editor

jsmith{at}bmj.com

Nicholas Christakis thinks that pharmaceutical drugs are terrific—yetthey work only some of the time. Alastair Santhouse thinks thatpsychiatry is the noblest branch of medicine—yet it ischaracterised by dullness of thought and practice. Ike Iheanachothinks predictive models have provided countless advances inthe understanding of disease and treatment—yet they aretoo easily believed.

All three offer alternative ways of looking at familiar things.Christakis’s point is that doctors and patients have differentunderstandings of what it means to say that a drug "works" (doi:10.1136/bmj.a2281).Against the patient’s standard most drugs don’twork. "For example, sildenafil works less than half the time...only48% of men are found to respond to the drug compared with 11%who respond to a placebo." If a toaster didn’t toast breadevery time, most people would take it back to the shop. He arguesthat doctors should routinely evaluate patients’ responsesto a drug.

Alastair Santhouse worries that psychiatry isn’t helpingpeople with the "vast bulk of mental illness largely ignoredby psychiatry"—depression, anxiety, conversion disorders,and somatiform disorders (doi:10.1136/bmj.a2262). He thinksthat reductionist thinking is reducing individuals to a functionof their genes. His prescription: to start again to understandthe lives and motivations of individual patients.

Ike Iheanacho attributes the credit crisis to risk models—orrather to our forgetting that models are merely frameworks fortesting speculative ideas (doi:10.1136/bmj.a2268). In the financialworld, models got to drive the real world too much; he worriesthat the same may happen in medicine. John Appleby meanwhilewrites about the likely real effects of the credit crisis onhealth. He paints a gloomy long term picture: a spiral of recessionleading to higher unemployment, less tax revenue, less moneyfor public services, yet increasing demand for those services(doi:10.1136/bmj.a2259).

The authors of Global Health Watch 2 would probably use thecredit crisis as an example of the failure of globalisation—oneof the determinants of health discussed in their "alternativeworld health report" on health inequities. As outlined by RonaldLabonté in his editorial (doi:10.1136/bmj.a2144), someof the analysis is familiar. The report argues for access tohealth care according to need and for support from pooled funding,and it criticises the World Bank for promoting entrepreneurialmedicine in the poorest countries. Yet this report, unlike mostmainstream ones, also discusses the role of violent change andthe politics of resistance: "Oppressed groups are not passive.They do resist, and in that resistance lies hope."

From Labonté to La Bohème is a short intellectualstep. In her account of Pucinni’s opera about povertyand tuberculosis (doi:10.1136/bmj.a2282), Trisha Greenhalghargues that although the diseases associated with poverty maychange over time, the underlying causes remain the same: "socialexclusion, insecurity, lack of access to basic health care,and the sociocultural preconditions for casual and transactionalsex."

Cite this as: BMJ 2008;337:a2331

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