Hive Health

This book has nothing to do with adherence. This is a history book that charts the rise to evidence-based medicine in a light, provocative format.

The author is a former NHS doctor who scrutinizes how we have treated and trusted.  He points out the one truth behind centuries of unscientific meddling:  for better or worse, nothing in medicine is as difficult as doing nothing at all. Amongst the hard-learned lessons stitching these chapters together, people like to be helped and doctors like to help.

The problem, says Burch, is that this altruism has been through a mangle of self-delusion. Even those who truly believed in their cures ended up inflicting a lot of nastiness and suffering.  Burch doesn’t reserve this contempt for pre-science cranks – in fact he regards most treatment prior to the mid 20^th century as dangerous tinkering by candlelight.

Rhetoric by the spoonful kept western medicine going. Increasing urbanization meant failings went ever more public, so an eloquent get-out clause could save the day. It was generations of genius that produced what we know as good practice – starting with people like Francis Bacon facing up to their ability to be wrong. But while theory was coming on, practice meant practice – every treatment was an experiment on an actual living person.

Beyond tales of the big drug discoveries –insulin, aspirin, penicillin – we are reminded that drugs work in many ways. One way is to make you better (quinine), another is to make you imagine so (morphine). Before we get too abstract, let’s gaze into the terrifying cradle of the modern randomized trial – which is really what this book is about.

Far from the laboratory or bewigged Royal Society halls, it was the battlefield or POW camp where the boys (control arm) were separated from the men (active arm). Each time, a tiny percentage of mistakes was ironed out, and the method improved time over time. As you can imagine, ethics back then meant being extra nice to the prison guard in return for more gauze, or agonizing (as Cochrane did) over how to divide prisoners up into treatment and placebo arms.  Sociologically, it’s interesting to see how ethics has evolved from a quickfire mental calculation into whole conundrums that demand the attention of all soceity. We engender more subtle kinds of warfare when we talk about designer babies and radical life extension.

While the author can be quite vehemently dismissive of altruism (far from being ignorant chancers, our deluded quacks have actually foisted “evils” on the world), and even more so of alternative and non-traditional medicines, he avoids preaching on the modern scientific method as a moral elixir. “Trials tell you certain truths about the world, but not others.  They add to your ability to make decisions – not to your ability to make them” (p.304).

It is not smug progress but a sense of enfeebled ignorance that lingers. We’re back where we started with the desperate trust we place in those we think know more than us. Burch’s final warning is on this self-delusional blinding. So that, what we are pressed to solve is not immediately gene therapy and machine intelligence; what we are left muddling over is not which of our very own “evils” a future society will look back on in shame. We have a pretty good design for finding out what works empirically. We have a grand design where the more we don’t know, the more violently we defend our opinion. Where’s the medicine for that?

Charlie Brooker wrote about his triumph over cigarette addiction in May 2007 and, because it is January, and it is CB, his article is still surfacing on the Facebook Guardian app.

I used to think New Years’ resolutions were cynical and flimsy. Now I act upon the clarity that comes with early January. You know it: after the cleansing rituals of giving and eating, taking stock of our human treasures, contemplating the mouthfeel of true happiness. Time slows. A light snowdrift may pass.

At some point, heart and mind airpunch their way off the sofa. This is so good it must never ever end! We delve for the will to be less apathetic, to punch up the system.

This year I’ve got the big one. I’ve stopped smoking. For a long time my habit has housed me like a condemned building. I was smoking because I didn’t know what to fix first. Trigger:  a natural spasm in concentration – you think you need a change of scene. Trigger: all kinds of hunger. Trigger: tired. Feeling awkward in company.

I’m 8 days in. I feel good. The lust has needled only once: when I got off the phone from Haringey Council. Trigger: despair.

This January the general kick-butt movement hears from the Harvard School of Public Health that, in the long term,  nicotine replacement is no more effective than cold turkey.

This was by no means a massive study, with only 787 smokers followed over three non-consecutive time periods. While many studies have shown that NRT significantly aids quitting, the study does remind us of the importance of a sustained outlook (read Brooker’s article for an insider’s take on that). We all know behaviour change doesn’t stop being hard.

I’ll be looking to find out whether patients who received professional or self-directed support had better luck with their quits – in the UK at least, NRT is bundled with patient support programmes and efficacy is rarely attributed to the product alone.

To my mind, understanding your smoking habit is key to cutting it loose. Charlie Brooker had plenty of relapses, mostly on pub doorsteps. If we know our weak points, let’s never leave them undefended, and not just for January. I’ve boarded up the condemned house and I’m out of there, but not in the pub just yet.

I took a solo trip to the Egyptian peninsula for scuba diving and sun. I had this in abundance, and I also had a glimpse of how they do healthcare over there. I was not conducting fieldwork, I was having fun. So here are some simple stories.

1. The GP

At the dive centre I had to fill out a medical pre-assessment form. I ticked two boxes – chronic medication and asthma – and so I was advised to seek counsel from Polyclinic Dr Sadek.

I was fascinated by Dr Sadek and his polyclinicians from the moment my pickup car cruised into Dahab. At the entrance to town you see the pride in their billboard. The eye is focused magnificently on the sun bleached promises of “cosmotic dentistry” and “supervised TB treatment”. On the drive from the airport, sleepy and thirsty, I’d watched the desert. The hessian coloured mountains slid slowly off the highway. Polyclinic reminded me that I was still on the earth, and I should probably brush my teeth soon.

So I took my diving form to Dr Sadek. The waiting room was humble and dusty, with two chairs seating a Bedouin woman and her daughter. I was ushered straight into an even tinier consulting room.  A young Egyptian doctor greeted me, certificates wonky on the wall behind his head. We communicated well. I sat on the bed while he fitted a thin, saggy BP cuff to my arm. He listened to my chest and stuck a thermometer in my armpit. He asked, what is your medication for? I felt like an affluent idiot, ashamed to talk about the antidepressant I have taken for 10 years. “Western neurosis.”  Tell me about your asthma? “It is very mild and only happens when I run.” The doctor signed me fit to dive. I shook his hand and gave him the fee of 40 egyptian (4 quid).

2. Behaviour change

Like most of the world, Egyptians pay insurance for their family’s healthcare. A dive instructor in Dahab earns about $500 American a month. I’m not sure how much medical insurance costs, but a box of 20 fat, short, filtered yet lung exploding cigarettes is 50¢. My dive instructor Emad, consummate professional of recreational scuba and corny jokes, told me how he’d managed to kick cigarettes.  “I used to smoke 40-60 a day!  Quitting was hard. I couldn’t stand that I was going up to people I didn’t even know to ask for a smoke.”

I relate completely. How did he quit? “I said to God: I’m dying. I prayed and prayed. And I asked my doctor to help me.”

3. The pharmacy

Every day a different driver took us out to the dive site. One day I was in the back of an open jeep, crunched in amongst the cylinders and other diving getup. We always had a rolled up plastic carpet to lay the gear on when assembling it pre-dive. On this day, as we were streaming along the desert road, the carpet flew out of the jeep. I yelled and grabbed it. Emad, in the front seat, freaked out thinking his student had hit the dirt. All was well and he got a new magic carpet joke out of it.

We had a day’s diving. Every time we removed gear from the jeep, the driver warned me about the hot exhaust pipe. Every time I was cautious, until we did the final unloading and I seared a strip of calf flesh. There was a sound like barbecue taking to the edge of a steak. There was pain flying like a burning plastic carpet. It was actually not a serious burn, but with all the diving, the dressings didn’t last. So I went to the pharmacy in the main drag of town. Each time, the guy put betadine on the wound and a nice clean dressing.

It was exactly the same as a pharmacy in the UK.

I sneaked peeks at the behind-the-counter stash. I couldn’t really make sense of the drug names. Most stuff was locally packaged and unbranded. I saw a blood glucose monitor, the same leading brand we have here. I saw boxes and boxes – huge boxes – of orlistat. I think the Egyptians have a lot of metabolic disease even though they eat lots of beans. Could well be the cheap fags.

More later. Go to Egypt and check it out. Don’t smoke the cigarettes, they’ll kill ya.

In the news today, NHS Scotland is being lobbied on the mass intake of newly qualified doctors into healthcare posts. This happens in August every year. Now the Royal College of Physicians (Edinburgh) links this practice to higher death rates and is proposing a more staggered approach of rotations.

Come back with me to February 1, 2002. The isle is burning in a cold storm. A South African disembarks in Durham City. Note the sleet melting into her clothing as she hauls 20 kg of backpack up a cobbled street. Hey Isle, it’s me! Luugging his own baggage up this hill, quite immune to my whining, is my fellow émigré Greg. Here we are in the picture on a Skype chat.

Greg was newly qualified in medicine and had secured a urology house officer post in Durham’s teaching hospital. I was a copywriter with an ancestral visa (4 years – sweet). We were best mates. We rented a stone cottage. I got a job helping farmers claim foot & mouth compensation. I also waitressed and went clubbing with my new friends. Come July, we had to get serious. I had to write, and Greg had to get on the proper rotation scheme. I was going to Ealing. He was going to Croydon for August intake. We divided our cups and spoons and we parted.

Greg is now almost in his consultant brogues and I’m doing pretty well my stuff too. I offer you this story because it frames the August system in a ten year period, a good time to assess whether it is working.

The firmament of the NHS is its focus on the patient. If the patient is dying, there is the rush of reflexive action. If the patient has died, there is, ideally, calm reflection. Studies like this one will now be pulled into many different shapes. The focus spreads to the carers and the cash. You have to keep the doctor on the most effective, least expensive training path. Staggering teaching would be difficult. If it means more red tape, the government probably doesn’t want to know right now.

You can read this training story here and do some reflection of your own. With all the cuts and punches, note that it hasn’t made the mainstream health news. Remind yourself that in 2012, training will be absorbed into the new Health Education England and NHS Trust Development Authority. And watch this space to see how our little Scottish study stands up in the storm.