All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India. E-mail: ksreddy{at}ccdcindia.org
The preface provided by George Bernard Shaw to The Doctors Dilemma1 is a profoundly insightful and deliberately provocative essay on the short-comings of health care, as provided by doctors who are deficient in scientific thought and are driven by petty profit motives. It is also an eloquent espousal of an ideal public health system, devoid of those flaws. Though Shaw was unduly harsh on Pasteur, improperly critical of the efforts to eliminate smallpox and his prototype of an underpaid doctor driven to malpractice no longer exists in many parts of the world, most of the ideas developed in the preface are of great contemporary relevance.
Shaws consistent demand for credible evidence is the hallmark of a truly scientific mind. He expresses despair, and even disgust, at the usual medical practitioner not applying the methods of scientific enquiry and the principles of statistical analysis to evaluate the efficacy and safety of the treatment methods which they espouse with ill-informed enthusiasm and willingly inflict on an unsuspecting public. The situation has not improved greatly since Shaws time. Even as evidence constantly accumulates in the pages of prolific research publications, the average practitioner is often distanced from its message. Even when a part of that message does reach him or her, often through the pharmaceutical industrys sales promoters or through the lay media, the aptitude and the ability to subject that message to serious scientific scrutiny are severely deficient.
Shaw protests against the incorrect use of statistics and the lack of matched comparison groups. He argues convincingly that apparent benefits of interventions are easily demonstrable in the absence of a matched comparison group and cautions that such spurious interpretations ought not to guide medical practice. He makes out a good case for employing the scientific design of a controlled trial for evaluating medical interventions. He is particularly caustic about the ecological fallacies that arise from analyses that depend on time trends and do not take into account the confounding effects of concomitant changes in other determinants. The example he provides, of the relationship between disappearance of typhus and amputation of the little finger, is particularly telling. The clarity with which he identifies and describes confounding as a factor which bedevils causal associations would do an epidemiologist proud.
He especially emphasizes the role of socioeconomic status as an important determinant of differences in the levels of health and as a powerful confounder which influences the effect of interventions which aim to alter health. His socialist ideology and scientific temper blend into a brilliantly incisive analytical tool as he dissects out the contributions of poverty and deprivation to ill health and pours out his convictions in a passionate piece of advocacy urging greater attention to such broader determinants of health. The adverse health implications of a low socioeconomic status have now been widely documented in virtually all areas of health, from under-nutrition and infectious diseases to many of the non-communicable diseases. While a Virchow, a McKeown, or a Marmot may call attention to this from among the public health fraternity, it requires the writing power of a Dickens or a Shaw to stir the conscience of the world to take heed and initiate action.
The issues related to confidence intervals and absolute risk also come up in Shaws preface, although the specific terms are not used. He questions the validity of drawing conclusions from estimates based on a zero numerator and a denominator which is very small (he uses a sample size of one in the smallpox vaccination example). The need to estimate confidence intervals and use them for judging the possible range of the effect size associated with an intervention has been emphasized often enough in statistics. Yet a substantial section of published research, and clinical practice even more so, have not yet benefited from the statistical lesson that Shaw provides us. Too often the zero numerator exercises a seductive appeal that clouds judgement, as the upper confidence limit is blissfully ignored by those who interpret the numbers.2 Similarly, published studies too often focus on relative risk to put a spin on the results of trials, without informing the practising doctor as to the difference that is likely to occur in the absolute risk of an event. Thus a measure of risk which is relevant to the study of aetiological associations is substituted, in a pseudoscientific sleight of hand, for a measure of risk which is relevant to decision making on individual management in clinical practice. The cruder tricks which disturbed Shaw continue to dismay us when results of scientific investigations are inaccurately interpreted, either out of ignorance or with deliberate intent to mislead.
Shaw is particularly lucid when he talks of the benefits of attention to health, which need to be accounted for, before ascribing the virtue of independent benefit to an intervention. The beneficial effects of placebos and of the attention bestowed on the participants in a clinical trial have been well described in many recent publications on clinical research methodology. That Shaw demanded rigorous proof of a truly independent contribution made by an intervention is remarkable, when we consider that even now policy and practice are all too frequently swayed by the results of uncontrolled or inadequately controlled studies (such as some demonstration projects) wherein the effects of co-intervention and confounding are poorly assessed.
Shaw discusses the influence of demand and supply on the nature of medical practice from two seemingly contradictory but essentially complementary viewpoints. On the one hand, he laments (and rightly so) that giving the doctor a pecuniary interest in prescribing costly tests, medication, or surgery motivates him to manipulate the demand to suit his interests. That such a supplier driven demand makes medical care a prime example of market failure is all too evident in the present era of technology-intensive high cost investigations and interventions. At the same time, he also argues that the laity can reset the nature of the supply, by demanding certain types of care or expressing a preference for hygienic modes of disease prevention. This too is true, as the growing market for complementary or alternative systems of medicine demonstrates. It is not surprising that practitioners of modern medicine are also now warming up to some of these treatment methods, after many years of scepticism. The fact that there is now a great scientific and public health interest in the health promoting effects of fresh fruit and vegetables as well as in the merits of a Mediterranean diet supports the contention that doctors recognize the need to respect conventional wisdom and respond to it with research which can confirm or repudiate.
However, the dominance of the profit motive in those who provide or control health care would still lead them to manipulate the demand to the maximal extent they can. They would employ reductionist research to seek out the protective phytochemicals, antioxidants or fibre from fruits and vegetables, so that they can be marketed as pills and potions. The imbalance between a supplier-driven demand and a consumer-generated demand would always be resolved in favour of the provider, till consumers (acting as communities and as individuals) become better informed and more assertive in resetting the demand for the health care they deserve and desire.
Shaw finally suggests a model, wherein pubic health which is protected and promoted by a Public Health Service comprising Medical Officers of Health who are committed to act as benefactors of the community, to replace the petty private tradesmen profiteering from illness. This is a model that has only been partly developed and insufficiently applied, even in countries with socialized systems of health care, and hence cannot be considered as one adequately tried and tested. It is tragic, therefore, that the model is being discarded as a failure and that national health services are being dismantled in a hurry to provide a free rein to privatized and commercialized medical care. Shaws vision is even more relevant today than at the time of his writing. This is because the commodification of health care has proceeded to far more sinister levels of organization than in the days of the precarious, shabby-genteel, irresponsible private practitioner whom he perceived as the principal danger. The Jekyll to Hyde pathway of transformation has proceeded through stages, from the benign family physician to the greedy private doctor to the medical cartels in larger hospitals to the present state where large corporations control the production and distribution of drugs, devices and other technologies for which the individual doctor is only a robotic sales agent. As the juggernaut of commercial medicine rolls on, the individual doctors role too becomes inconsequential and the citizens health is further forfeit to corporate profits.
It is tempting to speculate on how Shaw would have reacted to the social forces which are shaping global health today as well as to the new threats to public health that have emerged since his time. The epidemics of non-communicable diseases now sweeping across the world are being driven by some of the undesirable elements of industrialization, urbanization and globalization. From tobacco to processed food and from drugs to vaccines, the language of trade threatens to dominate the discourse on public health. The agents of ill health are marketed aggressively by transnational mega-corporations as they battle to win over the minds and the money of consumers spread over many countries. Even communicable diseases come in new forms as globalized trade not only speeds up human travel but also promotes livestock farming at an industrial level. One wonders what caustic comments would have come from Shaws critical pen about the factors that led to mad cow disease or even sudden acute respiratory syndrome (SARS), which may be a byproduct of an expanding animalhuman interface in a setting of unhygienic livestock breeding for commercial purposes.
The solutions needed today, therefore, go beyond the creation of a responsive and responsible Medical Officer of Health. We require a broader and stronger edifice of global public health in which the multiple determinants of health are addressed and influenced from a perspective where peoples health takes precedence over corporate wealth. The mould which makes the individual doctor too needs to be recast. Epidemiology, economics, and ethics which are sadly deficient in modern medical training need to be strengthened, so that the doctor who emerges from the portals of the medical college is endowed with a scientific temper, a spirit of social responsibility, and the ability to utilize available resources more efficiently for promoting better health outcomes. The role of non-physician health care providers has increased since Shaws time and needs to be further strengthened. Well informed involvement of communities in health promotion and of patients in self care are receiving greater emphasis in the participatory models of health care that seek to replace the prescriptive models. All of these components must contribute to a more scientific, efficient, and equitable pattern of health care. Towards the end of this preface, Shaw expresses optimism that public health will get the champions it needs to provide a social solution to the medical problem. I too will end this commentary with the hope that global consciousness will rise to ensure the triumph of public health over the many threats it faces.
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2 Hanley JA, Lippman-Hand A. If nothing goes wrong is everything is all right? JAMA 1983;249:174345.[CrossRef][ISI][Medline]