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This is an important and thought provoking book which should be read widely not only within the medical profession but also by interested parties such as health economists and government officials whose responsibility it is to set budgets for healthcare programmes. I think it will also be of great interest to the lay public. The practice of medicine is as susceptible to the whims of fashion and pervasive ideology as any other human activity. It is therefore interesting to investigate how these fashions are set. James Le Fanu has a background in medical and scientific journalism, having spent time on the staff of the Daily Telegraph, one of the UK's broadsheet newspapers. His thesis is that despite the significant advances in combatting disease which reached their peak in the post-war years, the promise of modern medicine as we are at the end of the century has failed to materialise. In fact, Le Fanu contends that much of the advances in the first half of the 20th century were accidental or at best serendipitous, citing as examples the discovery of antibiotics, which was never predicted, or the use of chloroquine for rheumatoid arthritis, which was based on clinical observations of patients treated for malaria. Even the success of aggressive chemotherapy for childhood cancer was the result of a determined but empirical approach of testing systematically multiple drugs in combination. The same approach has now been shown to be successful in the treatment of AIDS where three or more drugs are more successful that one. This “success” is not based on scientific knowledge, despite the vast amount that has been discovered about the AIDS virus, but simply on a “suck it and see” approach.
In contrast, the great promise of the new genetics or of the social theory of disease has not held up according to the author. The amazing strides in our knowledge derived from molecular biology led to the rapid acceptance of the possibilities of gene therapy but these have emphatically failed to deliver, despite the intellectual satisfaction that these smart ideas generate. Similarly, in the wake of studies showing a clear epidemiological correlation between smoking and lung cancer the social theory has sought to link almost every disease for which there is not an obvious infectious cause to some lifestyle or nutritional source mostly blamed on Western society. Le Fanu firmly lays these conceptual errors at the feet of a few individuals who inveigled themselves into influential positions—for instance, in the American Medical Association, and with the support of the major drug companies have utterly changed our lifestyles to the point where the vast majority of healthy individuals are worried more about their health than ever before while being encouraged to ingest drugs such as cholesterol lowering agents for which there is little evidence that they will actually do for the individual what the statistics tell us let alone prevent the individual patient from dying of a heart attack. Le Fanu suggests that it would be possible to rectify this situation overnight by closing down all university departments of epidemiology. Ophthalmology has not been immune to these problems (see the revised recommendations concerning laser treatment for diabetic patients with clinically significant macular oedema and 20/20 vision,Arch Ophthalmol1999; 117:675).
This book is not a sustained attack on modern medical practice nor is it written purely to debunk all of medicine's current fashions. It has been written, I think, to call a halt to the band wagon which produces contradictory statistical theories for the cause of disease and to instil a little circumspection in the scientists who undoubtedly are unravelling the secrets of life but are a long way from translating these into new cures for disease. The book does contain implicit and sometimes explicit criticism of medical scientists who selectively present evidence to fit their current theories and who then promulgate these in a way that alters people's lifestyles. In particular, the book has much to say about the dangerous part played by the major pharmaceutical companies in medicine. Many who read this book will be able to relax about their imputed health problems, to feel confident about their ability to ward off many of the supposed hidden dangers which face them out there, and to take much of what they hear from the medical pundits with a pinch of salt. The author offers hope for the future and, in particular, calls for a return of the experienced physician who exercises good clinical judgment, with a dash of common sense.
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