Doctors nowadays prescribe too many pills – a regular topic of conversation around the dinner table, down the pub and on the golf course. Some are apprehensive less they be prescribed yet more: ‘Quite a lot of people I know are fearful of visiting their doctor’s surgery because of this’. Dutiful children visiting parents or elderly relatives are rightly concerned at the plethora of drugs cluttering the bathroom cabinet. The relevant statistics might be described as awesome – in just fifteen years the number of prescriptions issued by family doctors has increased almost threefold – an additional 600 million each year. Four times as many now take five drugs or more – almost half of those in their seventies and beyond – three times as many taking ten or more.
These drugs on are of course very effective so many may well have benefited from this vogue for polypharmacy (literally many pills) as it is known. Still there is no drug with its chance of good that does not have adverse effects in some. The more taken, the greater the risk – a massive upswing by more than thirty thousand a year of those requiring emergency admission to hospital with potentially fatal drug induced complications (falls, confusion, bleeding from the gut) – a contributory factor to the recently noted decline in life expectancy.
My first intimation of the scale of this debacle came just over a decade ago in a letter from a reader of my Telegraph column who, eighteen months earlier, had required a major operation to repair an aortic aneurysm – ballooning of the main blood vessel in his abdomen. He recovered well but had subsequently gone progressively downhill, becoming increasingly decrepit, immiserated by muscular aches and pains that his doctors were unable to explain. He was determined at least to make it to his son’s wedding in Hawaii – not an easy journey, requiring a wheelchair at the several transfer stopovers. Reaching his destination, he realised he had forgotten to pack the cholesterol-lowering statins prescribed after his operation but was so markedly improved by three weeks not taking them, he was able on his return to walk unaided back through Heathrow.
This account of his near miraculous recovery was promptly corroborated by hundreds of others describing how their impaired mobility, lethargy, poor concentration or insomnia often misattributed to anno domini (‘what can you expect at your age?’) had similarly resolved after discontinuing for one reason or another their medicines. And as time has passed, so the toll of polypharmacy has become ever more apparent. For those who are otherwise fit and healthy, the onset of side effects soon after initiating treatment will indicate the cause. The difficulty arises when these symptoms are more insidious or their doctors obtusely refuse to acknowledge the drugs might be responsible – as with the following from a woman whose 71-year old husband is taking eight pills in the morning, five in the evening. “He has lost all confidence”, she writes, “He gets up in the morning with no energy unable to work in the house or garden. When our grandchildren visit, it is all too much for him. His life stretches out with no hope of improvement. On enquiring about the necessity for taking so many medicines, the doctor said he would not be here if he stopped taking any of them.”
The main engine driving polypharmacy is, if predictably, Big Pharma which since the 1980s has deployed its immense wealth and influence to blur the boundaries between the normal and abnormal, extrapolating in devious ways the undoubted merits of their drugs for the relatively few with, for example, markedly raised blood pressure or cholesterol levels to the vastly greater number in whom these indices are only marginally raised, if at all. Who would know, given the current enthusiasm for mass medication, that the benefits of commonly prescribed drugs are systematically exaggerated fiftyfold or that in certain instances 98% of those taking them gain no benefit from doing so?
Then in 2004 a Faustian deal between family doctors and the government – in which they would in future be ‘paid for performance’ – ensured polypharmacy would become deeply entrenched in routine medical practice, their income dependent on their success in hitting more than fifty targets for the numbers of patients diagnosed and treated for a given set of conditions.
Fourteen years on virtually everyone agrees this needs to be reversed (nine out of ten GPs in a recent straw poll) but this is unlikely to happen any time soon. This leaves little alternative for the public other than to take the initiative and by acquainting themselves with the merits (or otherwise) of the drugs they are taking then have a properly informed discussion with their doctors on whether they really need to ‘keep taking the pills’.
We feel that even when all possible scientific questions have been answered, the problems of life remain completely untouched”
The triumph of science now seems almost complete. The extraordinary developments in cosmology and astronomy, the earth and atmospheric sciences and many other disciplines in the past sixty years allow us for the first time in human history (astonishingly) to hold ‘in our mind’s eye’ the entire history of the universe: from the moment of the Big Bang to the creation of our solar system, the formation of the earth and the subsequent emergence of life – culminating five million years ago when the earliest of our ancestors first walked upright across the plains of central Africa.
There remained, however, till recently two great unknowns, two final obstacles to a truly comprehensive theory that would also explain our place in that universe. The first is how it is that all living things reproduce their kind with such precision from one generation to the next. The ‘instructions’, as is well recognised, come in the form of genes strung out along the two intertwining strands of the Double Helix in the nucleus of every cell. But the question still remained, how do those genes generate that near infinite diversity and beauty of form, shape and size and behaviour that distinguish one form of life from another?
The second of those ‘great unknowns’ concerns the workings of the brain: how does the electrical firing of its billions of nerves ‘translate’ into our perception of the sights and sounds of the world around us, our thoughts and emotions and the rich inner landscape of personal memories.
But then, from the mid-1980s onwards, remarkable advances in genetics and neuroscience promised to resolve these final questions. They were the astonishing and technical achievement of spelling out the full complement of genes – the genome – of worms, flies, mice, primates and humans; and second, the immensely sophisticated brain scanning techniques capable of observing the brain ‘in action’ – seeing, thinking and acting on the world.
Their findings have indeed transformed, beyond measure, our understanding of ourselves – but in a way quite contrary to that anticipated. The genome projects were predicated on the reasonable assumption that spelling out the full complement of genes would clarify, to a greater or lesser extent, the source of that diversity of forms that marks the major categories of life. It was thus more than disconcerting to discover that virtually the reverse is the case the near equivalence of a (surprisingly modest) 20,000 genes across the vast spectrum for a millimetre long worm to ourselves. It was similarly disconcerting to learn that the Human Genome is virtually interchangeable with that of our fellow vertebrates the mouse and our primate cousins. “We cannot see in this why we are so different from chimpanzees,” remarked the director of the Chimp Genome Project. “The obvious differences cannot be explained by genetics alone.” This would seem fair comment but clearly leaves unanswered the vital question of what does account for those distinctive features of standing upright and our prodigiously large brain.
More unexpected still, the same regulatory genes that cause a fly to be a fly, it emerged, cause humans to be humans with not the slightest hint of why the fly should have six legs, a pair of wings and a brain the size of a full stop, and we should have two arms, two legs and a turbo sized brain. Those ‘instructions’ must be there, of course, but we have moved in the wake of these genome projects from supposing we knew the principles of that greatest of marvels, the genetic basis of the infinite variety of life, to recognising we have no conception of what they might be.
Paralleling such perplexities, neuroscientists observing the brain ‘in action’ discovered that it fragments the sights and sounds of every transient moment into a myriad of separate components, with no compensatory mechanism that would reintegrate them together into that personal experience of being at the centre of a coherent, ever-changing world.
Meanwhile, the greatest conundrum of all remained unresolved – how the monotonous electrical activity of those billions of neurons the brain becomes the limitless range and quality of subjective experiences of our everyday lives – where every fleeting moment has its own distinct unique intangible feel: whether cadences of a Bach cantata are so utterly different from the lingering memory of that first kiss.
The implications are clear enough while theoretically it might be possible for neuroscientists to know everything about the physical structure of the brain, its ‘product’ the mind with its thoughts and ideas, impressions and emotions, would still remain unaccounted for. “We seem as far from understanding the brain as we were a century ago,” remarked the editor of Nature John Maddox. “Nobody understands how decisions are made or how imagination is set free.”
These twin setbacks to the scientific enterprise might, at any other time, have been relegated to the category of problems for which science does not, as yet, have the answer. But when cosmologists can reliably infer what happened in the first few minutes of the birth of the universe, and geologists can measure the movements of vast continents to the nearest centimetre then the inscrutability of the genetic instruction that should distinguish worm from mouse, man from fly, and the failure to explain something as elementary as what constitutes a thought suggests we are in some way profounder and more complex than the physical world to which we belong.
“There is a powerful impression,” writes James Le Fanu, “that science has been looking in the wrong place, seeking to resolve questions that somehow lie outside its domain. It is not just a matter of not knowing all the facts but rather a sense that something of great importance is ‘missing’, that might conjure the richness of the human experience from the bare bones of our genes and brains.”
We are, argues James Le Fanu, on the brink of a major intellectual shift – comparable perhaps to that of Galileo’s liberation of astronomy from an earth centred cosmos. We are compelled by the recent findings of genetics to recognise the deep inscrutability of the near infinite variety of forms of the living world. Again we are led through the recent findings of the neurosciences to recognise the insuperable gap that separates the working of the brain’s neuronal circuits from the powers of perception, reason and imagination of our extraordinary minds. Certainly, for the foreseeable future, there seems no need to defer to those who would appropriate our sense of wonder at the glorious panoply of nature by their claims to understand it. Rather, every aspect of the living world from a humble fly to ourselves now seems once again infused with that deep sense of mystery of ‘how can these things be?’
“Scientifically erudite and beautifully written… a sense of wonder is evident on every page”
Christopher Booker: The Spectator
“An extraordinary work of science… quite wonderfully refreshing.”
A N Wilson: Readers Digest
The Rise and Fall of Modern Medicine investigates a baffling contemporary paradox. The medical achievements of the post-war years rank as one of the supreme epochs of human endeavour. It is now almost impossible to imagine the world of sixty years ago when children still died from polio and diphtheria; when there were no drugs for treatment of Parkinson’s, rheumatoid arthritis or schizophrenia; and when open-heart surgery, kidney transplants and test-tube babies were unrealisable fantasies.
Yet despite this exemplary vindication of the power of science, the future of medicine is dark and uncertain, its practitioners no longer sustained by the sense of optimism of earlier decades. Meanwhile the public are encouraged quite wrongly to believe their everyday lives are full of hidden hazards and the escalating costs of medical care undermine the ideal of a universal and equitable treatment for all.
The answer to this paradox, James Le Fanu argues, lies in the changing fortunes of the intellectual forces that created the post-war medical achievement – clinical science, technology and pharmaceutical innovation. He describes the people and events of medicine’s ‘Golden Age’ of the three decades following the end of the Second World War during which virtually all the most significant medical developments occurred. And then, for complex reasons, medicine’s apparently relentless march of progress confronted a seemingly insuperable barrier to further advance. This created an intellectual vacuum rapidly filled by two powerful and radical ideas: The Social Theory that proposes the cause of most common illnesses lies simply in people’s social habits; and The New Genetics which promises to explain disease at its most fundamental level of the genes strung out along the Double Helix. These theories are certainly plausible and still dominate medical research – but their promises remain unfulfilled. Meanwhile the last great problem confronting medicine, the causes of common diseases, remain unresolved.
The Rise and Fall of Modern Medicine is a riveting human drama in which the virtues of imagination and perseverance give way to the vices of hubris and self deception. It illustrates both the power of the scientific method in pushing forward the boundaries of knowledge, but also the constraints imposed by the inscrutable mysteries of biology.
“The best book on the history of medicine I have ever read. Thoroughly fascinating, immensely readable.”
Norman F Cantor, Professor Emeritus of History at New York University.
“Perhaps the finest, most informative, most interesting historical review of modern medicine now available. The book is a gem.” Robert J White, Professor of Neurosurgery, Cleveland, Ohio
“Well written, fascinating and informative…”
Anthony Daniels, Sunday Telegraph
“Le Fanu’s book is as lucid as it is comprehensive… An easy and fascinating read, studded with little-known facts…”
Thomas Stuttaford, Literary Review
“The skill [of medical journalism] is to write with humanity and objectivity, a dual responsibility brilliantly fulfilled by the author… This excellent book has changed many of my views.”
David Owen, Spectator
“James Le Fanu writes with clarity and authority and has the great knack of making even the most complex technical developments exciting and intelligible… Erudite and absorbing.”
Roy Porter, The Observer