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Medicine—Expectations and Reality

Medicine—the scale of the problem

When I started to plan this chapter on the dark side of medical practice, treatments, and drugs, I assumed that my problem would be to select the most entertaining examples, or the most horrendous. My view was conditioned by a vast number of anecdotes, experiences of friends, and examples from the numerous stories in the media, as well as the Internet, articles, and books.

These are frequently not just the views of outsiders, but include equally highly detailed and entertaining books, such as those of Ben Goldacre (BadScience) and Robert Winston (Bad Ideas?), both of whom are successful medical practitioners. In fact, these insiders’ views are revealing, and both authors are equally critical of past and current practices.

Therefore my first impression was that there are some aspects of medical practices that are seriously wrong. This is based on the wealth of examples of failures, incompetence, or unfortunate side effects that are being quoted. It is a vast field, so inevitably there are examples that fit this preconception. It is, however, only partly true, and I have tried to avoid falling into this simplistic trap, but instead have tried to rationalize why there are so many examples of failure (and, of course, success).

The essential realization is that I am not dealing with the simplicity of faults in Victorian plumbing, or some limited product from a few hundred producers, who may be entirely conscientious and hard-working, but have not predicted or expected a long-term side effect from their pride and joy. Instead I am trying to focus on the health and well-being of humans, and this seems to concern us so much that it was, and still is, an incredibly dynamic and competitive business. The sums of money involved worldwide are many billions, so I am not surprised it attracts not only highly intelligent, dedicated, and able people, but also those driven by ego and self-importance, as well as many who see it as a career with an easy source of income, rather than one for the benefit of humanity.

For us, the poor customers and patients, it is incredibly difficult to separate out the true and different qualities of experts, and the validity of claims made whilst marketing the products. Hence, we will eventually have many disappointments and bad side effects, as our expectations are too high. Rather worse for our public understanding is that medical opinion and knowledge are highly dynamic. New ideas and results emerge on a daily basis, so there are often bitter conflicts and public arguments as to the value of treatment and products. This is extremely confusing, as often the conclusions are based on precisely the same data, but the presentations are driven by egos and status. (This is not just a medical problem but is typical of many leading figures in all walks of life.)

In order to try to gain some appreciation of the scale of this industry, I can cite the current number of employees by the National Health Service in the UK. This is around 1.3 million employees, of whom nearly half a million are qualified doctors, nurses, and dentists, plus all the ancillary staff. This is in a country of around 56 million people. If we add in those employed in the pharmaceutical industries, those working in biological sciences, and people running private practices, a sensible guess at the overall total of skilled and qualified workers is nearer one million ‘experts’; i.e. around 3—4 per cent of the working population have different types of expertise in medicine and biology. It is high, but it is not an atypical percentage for advanced countries. For example, the US 2015 listing of professionally active physicians is almost 1 million. Inclusion of the other skilled support staff gives a similar percentage to the UK.

Such skilled people will be a smaller percentage in poorer or underdeveloped countries. So for the current 7 billion inhabitants of the planet, we can make a reasonable estimate that there are maybe 80 million people worldwide who influence our health. This is excellent news in terms of the probability of making progress and gaining a better understanding, but the sheer scale of the numbers means the literature and ideas they produce can be totally lost within the immense volume of data, knowledge, and statistics they generate.

Also, if just 1.25 per cent are incompetent, or charlatans, then we have bad input from more than a million people! Realistically, I am sure this will be an underestimate. Overall, with such a volume of effort, the presence of a serious side effect for some drug, or medical concept, may be totally buried in the literature, and be unread by most of the experts and the public. So rather than view all the problems we do know about as a dark side of medicine, most examples will still fall in the category of ignorance and inadequate dissemination of the facts.

We may also assume that we have a much higher percentage of the population involved in medicine than in the past, but realistically, even in small tribal communities, there will have been (or are) herbalists or witch doctors. Their knowledge and effectiveness may be less than that of modern doctors, but as a percentage of the community, they may well be a similar fraction of their communities as we have in more developed societies. We may not appreciate that in more advanced countries, there were also herbalists, apothecaries, and barber and battlefield surgeons, in addition to the more formal medical practitioners.

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