Too much medicine?
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7342.859 (Published 13 April 2002) Cite this as: BMJ 2002;324:859
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
non
sequitur!
Editor - No doubt that there is too much medicine in some parts of the
world. There is also too little in other parts. Ray Moynihan and Richard
Smith try to homogenise the world by drawing in examples out of their context
(1). A case in point is their use of Amartya Sen’s analysis of the health
situation in Kerala and Bihar in India (2) to support the much-admired,
iconoclastic critique of industrialised medicine by Ivan Illich.
Firstly, the two extreme examples of Kerala and Bihar are misleading
when assessing the association between health investment and reported morbidity
or medical action. The table shows data on four states which spend the
highest per capita amount for health in India and the state of Bihar which
spends the least amount (3; 4). The data indicate that investment in health
is not consistently associated with either reported morbidity or health
actions taken. For example, Rajastan has the highest per capita
health expenditure but the lowest prevalence of reported reproductive health
problems.
Table: Health indicators of selected states of India
| Bihar | Kerala | TamilNadu | Punjab | Rajastan | |
Health expenditure 1990-91 (Indian Rupees per capita) |
24.34 |
49.08 |
50.29 |
57.64 |
60.04 |
Infant mortality rate 1995 (per 1000) |
72.9 |
16.3 |
48.2 |
57.1 |
80.4 |
Proportion of births (1998-99) assisted by a: |
|||||
| - doctor (%) | 14.5 | 91.4 | 60.1 | 35.1 | 19.5 |
| - midwife (%) | 5.7 | 2.7 | 22.2 | 27.0 | 16.1 |
| - TBA (%) | 65.8 | 3.1 | 9.9 | 37.2 | 40.8 |
Proportion of women aware of AIDS 1998-99 (%) |
11.7 |
86.9 |
87.3 |
54.6 |
20.8 |
Proportion of women reporting a reproductive problem 1998-99 (%) |
44.2 |
42.4 |
27.8 |
35.1 |
19.5 |
Secondly, the available data on morbidity in India are generally based
on patients reporting to government hospitals. It is difficult to believe
that people in Bihar are not taking any action to ameliorate their suffering
due to a health problem. They may not go to a government hospital, but
approach an indigenous practitioner or any available service instead. The
assumption that they do use services is supported by the high proportion
of assisted births (table).
Finally, we do not think that encapsulating Illich’s suggested preventive
and primary care strategies within the so-called “truly modern culture
that fostered self-care and autonomy” would help the millions of under-medicalised
people of the world. Self-help and self-care are increasingly being instrumentalised
in a neo-liberal agenda to replace government support to health care in
developing countries. They may or may not help in de-medicalisation and
de-professionalisation but they would certainly further reduce access to
health care in such populations.
We agree that increasing medical inputs will at some point become counterproductive
but it seems populations in many developing countries are drifting farther
away from that point rather than approaching it. As long as there is widespread
death and suffering from diseases such as tuberculosis, malaria, pneumonia,
measles, and polio, people have a right to expect to “get things”, i.e.
effective prevention and care, through a government health system, rather
than being expected to “find their own way”.
K. R. Nayar associate professor in Social Sciences
Centre of Social Medicine and Community Health, School of Social Sciences,
Jawaharlal Nehru University, New Delhi 110 067, India
krnayar@edumail.nic.in
Oliver Razum epidemiologist
Department of Tropical Hygiene and Public Health, Heidelberg University,
69120 Heidelberg, Germany
Competing interests: none declared
References:
1. Moynihan R, Smith R. Too much medicine? Almost certainly. BMJ 2002;324:859-60.
2. Sen A. Health: perception versus observation. BMJ 2002;324:860-61
3. UNDP. India: the road to human development. India development forum,
Paris 23-25 June, 1997. Document of the United Nations Development Programme,
New Delhi.
4. IIPS. National Family Health Survey II. State final reports. Mumbai:
International Institute for Population Sciences, 1999.
Competing interests: No competing interests
Ray Moynihan and Richard Smith ask whether we might have reached the
point where medicine is counterproductive. Their answer, in careful
journalese, is short on figures. Here are some which suggest that we have
reached that point at least in one field.
The Department of Health tell us (1) that there is a risk of more
than two per million courses of polio vaccine, of contracting the disease,
polio, from the vaccine itself (both vaccinee and contacts being at risk).
In the same publication we are told that natural polio infection no longer
occurs in the UK. So for a child not travelling to polio infected areas it
is safer to remain unimmunised.
In fact, a child's only risk of contracting polio in the UK is from
his friends' immunisations. Medical Nemesis or what?
1. Polio Vaccine Factsheet; Department of Health: November 1997
Competing interests: No competing interests
Illich's words, but not his teachings, had faded away a bit from my
memory over the last 25 years. I thank you for recalling him, and
reminding me that I, too, have fashioned large segments of my career
based on Illich's inspirational message.
Competing interests: No competing interests
Sirs,
Ray Moynihan and Richard Smith (BMJ 2002;324:859-860, 13 April) state that
most doctors believe medicine to be a force for good, as can be clearly
seen. I am certainly allowed to pronounce the same statement as regards
science in general, of course: even a lancet can be for good or, by
contrast, it can become harmful. In reality, we have to think first that the
actual “medicine” is ruled unfortunately by economists, politicians,
business-men, a.s.o., and secondly confront it with a desirable one, not
necessarily ruled as we observe nowadays. I agree, from this point of
view, with who says that “The medical establishment has become a major
threat to healt” (1), adding, however, for completeness reason, “to
medical science”.
Certainly, in western countries no one wants to keep cutting back on
education, the arts, scientific research, good food a.s.o., but all people
would like surely to see their money spent in a better way. For example,
there is a bias (or, perhaps, something else)in our actual cancer
screening (BMJ.com, Rapid Response, 14 May 2001) and , moreover, an
useless waste of money, time, energy follows to it, as a plain consequence
of that situation. As a matter of fact, not all individuals can be
involved by malignant tumour, solid or liquid, because exclusively 30 % of
people (at least, in my little town, Riva Trigoso, near Genoa) are
positive for particular abnormality of psycho-neuro-endrocine-
immunological system, I termed “Oncological Terrain”, recognizable at the
bed-side “quantitatively” by means of a simple stethoscope (See the site
HONCode ID N.233736 http://digilander.iol.it/semeioticabiofisica, and the
weekly Page, Semeiotica Biofisica, I held on the italian site
www.Katamed.it) (1,2). I certainly appreciate (and agree with) the
critique of modern, or industrialised, medicine (1), which consider the
limits of present health care, but, after the diagnosis it is necessary
the proper therapeutic intervention. Therefore, I would be really
delighted with a possible, honest discussion about such argument,
unavoidable for a successful cancer prevention, i.e., the existence of
“Oncological Terrain” with who are responsable for Health Care, including
Health Ministers, of course.
Sergio Stagnaro MD. Active Member NYAS.
1.Illich I. Limits to medicine. London: Marion Boyars, 1976.
2) Stagnaro-Neri M., Stagnaro S., Cancro della mammella: prevenzione
primaria e diagnosi precoce con la percussione ascoltata. Gazz. Med. It. –
Arch. Sc. Med. 152, 447, 1993.
3) Stagnaro S., Auscultatory percussion of the cerebral tumour: Diagnostic
importance of the evoked potentials, Biol. Med., 7, 171-175, 1985.
Competing interests: No competing interests
A history lesson
Who better to help us understand contemporary debates about
medicalisation than a world class historian.
In 1996 the late great Roy Porter wrote ".....an expanding medical
establishment, faced with a healthier population of its own creation, is
driven to medicating normal life events (such as the menopause), to
converting risks into diseases, and to treating trivial complaints with
fancy procedures. Doctors and 'consumers' alike are becoming locked within
a fantasy that unites the creation of anxiety with gung-ho 'can-do, must-
do' technological perfectibilism: everyone has something wrong with them,
everyone can be cured."
Guest Editor
Ray Moynihan
Competing interests: No competing interests