VII. Answer the questions.

1. Why in 1960 did the value of scientific medicine seem indis­putable?

2. By how many years did the life expectancy of a 50-year-old man increase between 1841 and 1976?

3. In which two common conditions have there been major advances in treatment since 1960?

4. What are the new treatments for these diseases?

5. What was the difference in percentage of gross national product spent on health between Britain and the USA in 1978?

6. Why does the general public put money into medical practice and research?

RECENT PROGRESS IN HEALTH CARE

Twenty-five years of relative failure

By I960 few could seriously dispute the value of scientific medicine. In the western world in the first half of the nineteenth century infectious diseases were the scourge. Cholera, smallpox, puerperal fever, surgical infections, pneumonia, tuberculosis and typhoid were names to strike ter­ror. One does not need to read the medical textbooks: the novels of the time are amply sufficient to recreate the atmosphere. But Jenner's vacci­nation, improvements in sanitation and the understanding of the germ theory of disease derived from the works of Pasteur, Koch and Lister changed things irrevocably. By 1900 transmission of infectious diseases had been severely curtailed even though their cures remained intractable problems.

Paul Ehrlich's idea, based on differential staining of bacteria, that chemicals might be found which would kill living micro-organisms but not the cells of the host, produced a second major type of success for scien­tific medicine. Salvarsan, of value only in syphilis, was nevertheless cru­cial because it opened the way to acceptance of the concept that selective killing of parasites was not an insubstantial dream. Domagk's sulphona- mides, Florey and Fleming's penicillin and several discoveries in tropical medicine led to the world of active therapy so familiar to us today.

The vaccines to combat polio followed so that by I960 it seemed that the dramatic quarter century since Domagk's 1935 discovery would inevitably be followed by comparable advances in the field of non-infec­tious diseases. The success of scientific medicine opened up both public and private purse strings and an unprecedented flood of cash poured into medical schools and research institutes. It was anticipated that this flood would lead to research which would conquer cancer, heart disease, gas­trointestinal and renal illnesses and psychiatric disorders which, follow­ing the rout of the infections, became the major concerns of sick people.But something unfortunate happened. The expected success did not materialize. In 1841 the life expectancy of a 50-year-old man in Britain was 20 years. In 1976 it was 22.7 years and has changed little since (see Sinclair, 1982). There have been considerable advances in some rare con­ditions but with perhaps two exceptions, peptic ulcer and renal failure, there is no major common disease in which it is possible to demonstrate convincingly that those receiving the best treatment in 1985 are much better off than those who received the best treatment in 1960. H2 antag­onists have revolutionized peptic ulcer treatment and, for those who have access to them, dialysis and transplantation have changed the way in which we look at renal failure. But in other common conditions there is nothing which medical science has done which has dramatically improved either the survival or the comfort of the patient.

Something has gone badly wrong. The money poured into scientific medicine since 1960 has produced nothing like the returns provided by the much smaller sums spent in the 25 years before that. The usual easy explanation is that the problems have become much more difficult. That may be true but we have a strong suspicion that it is merely a self-serv­ing excuse.

The astonishing increases in the amounts of money spent on medical research have been matched by equally astonishing increases in the costs of the medical care system. Yet those escalating costs have not been accompanied either by equivalent objective therapeutic success or by equivalent rises in patient satisfaction. Modern medicine, called scientif­ic by both its defenders and its detractors, has not been able to change by very much morbidity or mortality for those who are over 40. What it has done is to ensure that dying, in comparable or even greater discomfort costs vastly more than it did 25 years ago. Our patients die marvellously documented, technologically assisted deaths, but they die in much the same ways and at much the same ages as they did in 1960.