Intended for healthcare professionals

Editor's Choice

Alternative reports

BMJ 2008; 337 doi: (Published 30 October 2008) Cite this as: BMJ 2008;337:a2331
  1. Jane Smith, deputy editor
  1. jsmith{at}

    Nicholas Christakis thinks that pharmaceutical drugs are terrific—yet they work only some of the time. Alastair Santhouse thinks that psychiatry is the noblest branch of medicine—yet it is characterised by dullness of thought and practice. Ike Iheanacho thinks predictive models have provided countless advances in the understanding of disease and treatment—yet they are too easily believed.

    All three offer alternative ways of looking at familiar things. Christakis’s point is that doctors and patients have different understandings of what it means to say that a drug “works” (doi:10.1136/bmj.a2281). Against the patient’s standard most drugs don’t work. “For example, sildenafil works less than half the time…only 48% of men are found to respond to the drug compared with 11% who respond to a placebo.” If a toaster didn’t toast bread every time, most people would take it back to the shop. He argues that doctors should routinely evaluate patients’ responses to a drug.

    Alastair Santhouse worries that psychiatry isn’t helping people with the “vast bulk of mental illness largely ignored by psychiatry”—depression, anxiety, conversion disorders, and somatiform disorders (doi:10.1136/bmj.a2262). He thinks that reductionist thinking is reducing individuals to a function of their genes. His prescription: to start again to understand the lives and motivations of individual patients.

    Ike Iheanacho attributes the credit crisis to risk models—or rather to our forgetting that models are merely frameworks for testing speculative ideas (doi:10.1136/bmj.a2268). In the financial world, models got to drive the real world too much; he worries that the same may happen in medicine. John Appleby meanwhile writes about the likely real effects of the credit crisis on health. He paints a gloomy long term picture: a spiral of recession leading to higher unemployment, less tax revenue, less money for public services, yet increasing demand for those services (doi:10.1136/bmj.a2259).

    The authors of Global Health Watch 2 would probably use the credit crisis as an example of the failure of globalisation—one of the determinants of health discussed in their “alternative world health report” on health inequities. As outlined by Ronald Labonté in his editorial (doi:10.1136/bmj.a2144), some of the analysis is familiar. The report argues for access to health care according to need and for support from pooled funding, and it criticises the World Bank for promoting entrepreneurial medicine in the poorest countries. Yet this report, unlike most mainstream ones, also discusses the role of violent change and the 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 intellectual step. In her account of Pucinni’s opera about poverty and tuberculosis (doi:10.1136/bmj.a2282), Trisha Greenhalgh argues that although the diseases associated with poverty may change over time, the underlying causes remain the same: “social exclusion, insecurity, lack of access to basic health care, and the sociocultural preconditions for casual and transactional sex.”


    Cite this as: BMJ 2008;337:a2331

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