David Peters, Editor

Published in JHH12.3 – Beyond Peak Medicine?

Not long ago many of us were talking about ‘peak oil’; thinking that the world order would have to change radically as petrochemical costs rose through the roof. Impossibly expensive oil, we thought, was just around the corner and it would mean cold turkey from oil addiction and an end to global warming.

We can play around with the obvious drug addiction parallels: an addict’s physical decline, moral compromise and crimes committed to ensure unceasing supplies. For chilling examples of where oil addiction has taken us see recent military adventures and a string of failed climate change summits.

Falling oil prices have muted the transitionista conversation about low carbon imperatives, human flourishing post-oil, and small is beautiful local economies. We can afford our oil junkie ways for a while longer – at least until OPEC hikes up the price again. Meanwhile the pusher-man, seeing the stupid addict doing so little to get clean, is rubbing his hands with glee, because low-cost crude has pulled the rug from under our renewables industry.

All the same, peak oil is coming despite the timetable change, and so is peak medicine: a time when – if we carry on doing medicine the same way – the state won’t be able to afford healthcare free at the point of delivery. Why so? Chancellor George Osborne would probably blame having to pay an extra £8 billion a year into the NHS on inefficiency, perverse incentives, agency staff, PFIs, junior doctors, old people with long lives etc. But he would be wrong; the NHS needs ever-deeper pockets in its struggle to deliver excellence a million times every 36 hours, because its way of doing medicine is no longer fit for purpose.

Lately, to make matters worse, two dark clouds are looming on medicine’s horizon: the first, growing cynicism over medical research; the second, mounting alarm at the extent of medicine-related harm. Richard Horton, fearless editor of The Lancet, recently wrote, ‘The case against science is straightforward: much of the scientific literature, perhaps half, may simply be untrue. Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness’ (Horton 2015).

Right now, university finances are bolstered by the brownie points they get for academic staff’s published output. Points mean prizes because they turn into departmental top-up funding, star ratings, academic career advancement, bigger salaries and power. With so much depending on individual research track record, small wonder if, as Horton believes, the feeding frenzy for national assessment points lures some researchers into unethical practices.

More proof that skeletons are rattling their bones in Big Pharma’s cupboard came in the form of Peter Gøtzsche’s (2015) broadside against biological psychiatry. In a May BMJ he claimed that psychiatric drugs kill more than half a million people every year in the United States and Europe and that 98% of psychotropic drugs could be stopped without causing harm. Several of Gøtzsche’s Cochrane Collaboration colleagues published their dissent, but they did agree that the benefits of psychotropic drugs have long been exaggerated, and that harms (including suicide) have been underestimated.

Evidence-based medicine and industrial scale healthcare are based on the assumption that science works. But behind the scenes it is widely understood that all is far from well. So we should thank Gøtzsche and Horton for pointing their searchlights at these twin icebergs. For though the consequences of changing course are perhaps too alarming to contemplate, they have been drifting for many years in the darkness towards Big Pharma’s luxury liner.

Horton concludes that iceberg one – bad scientific practices – could be avoided if researchers were incentivised to prioritise being right rather than putting academic productivity and innovation first. Horton says science is starting to take its worst failings more seriously, but nobody is ready to take the first step to clean up the system. Iceberg two – medicine’s over-reliance on the pharmaceutical industry and acceptance of collateral damage, reminds us of an addict’s capacity to deny there’s a problem. Is healthcare’s addiction to pharmaceuticals just too deep?

Battling with crises of cuts, cost, cure, care and commitment the NHS has simply had to carry on doing the same old thing, not necessarily expecting a different outcome; peddling ever faster just to keep the lights on as the demands and expectations multiply. For 12 years, JHH has been commenting on biomedicine’s journey into a gathering storm, trying at the same time to be a shop window for other ways of thinking and doing healthcare. In the spirit of lighting a single candle rather than raging at the darkness, this issue of JHH takes a look at some ideas and innovations that could be part of the solution.

References

• Gøtzsche P (2015) Does long term use of psychiatric drugs cause more harm than good? BMJ, 349, h2435 doi: 10.1136/bmj.h2435
• Horton R (2015) Editorial. The Lancet, April 11. Available at: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140- 6736%2815%2960696-1.pdf (accessed 21 November 2015).