Bad Pharma by Ben Goldacre

Ben Goldacre’s previous book, Bad Science, was effectively an adaptation of his Guardian columns of the same name, and although it wasn’t a straightforward compilation, it had something of the same character: a bit of a grab-bag of subjects, held together by the broad theme of bad science and bad science journalism, with a emphasis on trying to entertain as well as inform.

This is a more focussed book. And a drier one, which you may or may not think is a good thing, depending on your tolerance for the occasionally clunky attempts at wackiness and humour that characterise a lot of popular science writing.

Personally I thought Bad Pharma did a good job of taking a potentially tough subject and presenting it in a clear, engaging way. It’s not, btw, a tough subject because it is full of difficult science or complicated statistics, but because it’s a book about institutional and bureaucratic failings within the healthcare industry. Institutional structures, bureaucracy, regulation, professional standards: this is not the sexiest subject matter. But Goldacre did a good job of convincing me that it was important enough that I should keep reading, and making it readable enough that I was able to do so.

The book follows all aspects of the life of a drug — the way it is developed, tested, licensed, marketed, prescribed — and talks through all the ways that biases get into the system and distort medical practice. There is plenty of evidence that these distortions make healthcare worse and more expensive; the only question is how badly. But the same processes that distort the science make it impossible to accurately judge the damage.

The pharmaceutical companies are the major villains of the piece, unsurprisingly; they are the ones doing badly designed trials, hiding the results of trials with flattering outcomes, paying academics to put their names to ghostwritten articles, and spending twice as much on marketing as they do on R&D. But as Goldacre points out, they are only able to get away with it because of repeated failures by everyone else involved: regulators, governments, journals, professional bodies, patient groups, and so on. All of whom have been at the very least complacent, and often suffer from deep conflicts of interest, since the drug companies seem to be the only people in the whole system who actually have a lot of money to throw around. So they spend a lot of money advertising in the medical journals, they donate money to patient groups, they sponsor conferences and training for doctors.

It’s a worrying book, which deserves to be widely read.

» Doctor Themed Cupcakes is © Clever Cupcakes and used under a CC attribution licence.

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Say aaah.

I went to the doctor today about a sore throat; he took a quick look down my throat, made me go aah, asked me where it hurt, and recommended that I just wait for it to get better.

Which is both reassuring — I’m glad he didn’t take one look down my throat and gasp in horror Oh my God, what is that thing? —  and curiously disappointing. Because, you know, you want your doctor to do some doctoring.

He obviously understood this, because he offered to write me a prescription for antibiotics if I really wanted, while making it very clear that he didn’t think I should use it.

Ridiculous though it is, I almost would have been happier to be given some pills which I knew were a placebo and told to take them three times a day.

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The Checklist Manifesto by Atul Gawande

This book is a paean to the power of checklists and specifically a call for their use in medicine — Gawande is a surgeon. I bought it after reading a couple of fascinating articles he wrote for the New Yorker, and to be honest if you’ve read those articles (and watched his TED talk) you have a pretty good idea of what’s in the book.

But I still found it absolutely fascinating reading it again. It’s that thing Malcolm Gladwell is so good at: an idea simple enough that it can be explained in a paragraph but with far-reaching implications. The difference is that while Gladwell’s ideas give people a lot of pleasure they don’t actually seem very useful, whereas this idea has specific, practical [cheap!] applications which can be tested. It really could change the way medicine is practiced.

At its simplest, the idea is that when performing a complicated task like surgery, it is not enough to know what the best practices are, because people are fallible. And so a simple checklist to make sure that the basics are done properly can significantly reduce the rate of complications like infection. And it really is the basics: making sure that everyone knows what they’re doing, that they have the right patient, that pre-operative antibiotics have been given at the right time, that everyone is sterile, that they have an ample supply of blood on hand and so on.

Apparently the idea is most well-developed in aviation; ever since planes became complicated enough that missing a pre-flight check might mean a fiery death, pilots have formalised the process. And not just pre-flight checks, or the obvious things like take off and landing procedure. Apparently pilots have whole collections of checklists for use in specific situations like particular warning lights coming on.

As yet, in medicine they have apparently only tested a simple checklist for surgery, which did successfully improve outcomes, and they have come up against resistance because, I guess, doctors feel it undermines their expertise and knowledge. This book makes a convincing case that medicine would be better if it was a lot more like aviation. Being methodical and disciplined may not be the most glamorous or heroic sounding qualities, but they can be life savers.

It’s hard to do the book justice — checklists just don’t sound very interesting — but I found it completely gripping as well as persuasive.

» 757/767 Mechanical Checklist – Landing is © Kent Wien and used under a CC by-nc licence.

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Wolf flu

The swine flu outbreak had me thinking: presumably the very nature of infectious diseases means that, if you want to beat them, you have to act fast and take large-scale measures. You have to act, every time, as though this one is The Big One because if it is, then time is of the essence.

But of course it means the authorities are open to accusations of needless alarmism and crying wolf. This is the third ‘pandemic’ this decade, after SARS and bird flu; how many times can we have these alerts before people stop taking them seriously?

Although as long as governments keep taking them seriously, perhaps it would be no bad thing if the media treated them more as routine news stories and less like the first horseman of the apocalypse had just appeared.

I’m assuming, btw, that the swine flu is not going to be the pandemic that kills us all. I hope I’m not tempting fate.

» The photo is ‘Padrecito Posero’, © Eneas De Troya and used under a CC attribution licence.

Kidneys! Kidneys! Get your kidneys here!

I’m fascinated by this story—that the British government is considering changing organ donation to an opt-out system. So the surgeons would be able to presume consent unless the patient had specifically asked that his organs not be used.

I think it’s such an interesting ethical question. In some ways it would so clearly be a good thing: having organs which could save someone’s life and not using them just seems criminally wasteful. But I don’t think you have to be a full-blown libertarian to feel uncomfortable with the government giving itself the right to treat the bodies of its citizens as a resource to be harvested.

Anyway, at least having the story in the news made me finally get round to registering as an organ donor, something I’ve vaguely been intending to do for years. So even if the law doesn’t change, they can have any squidgy inside bits they have a use for.

George III and the Mad-Business by Ida Macalpine and Richard Hunter

I highly recommend this fascinating book; it seems to be out of print, but there are lots of second-hand copies on Amazon. As the title suggests, it’s about poor mad George III. And even Americans, brought up to think of George III as a tyrant, might have a little sympathy for him after reading this.

detail of Hogarth

It starts with a detailed account of his illness—or his illnesses, really, since he initially suffered from relatively brief bouts, separated by long periods of good health. Having offered a diagnosis of porphyria, which is a hereditary condition, Macalpine and Hunter examine the medical histories of George II’s relatives and demonstrate that porphyria can be identified, with varying degrees of confidence, in a startling number of them; most notably perhaps in James I, Mary Queen of Scots and Frederick the Great of Prussia.

detail of Hogarth

The book then moves on to a survey of C18th psychiatry, both in terms of its theoretical basis and treatment, and looks at the way it developed. Not surprisingly, George’s illness had a huge impact on the mad-business because of the publicity surrounding it. The idea of a king being forcibly confined in a strait-waistcoat focussed people’s minds on the treatment of the insane. The book traces developments in the treatment of patients and the law surrounding insanity, both in terms of treatment and things like criminal responsibility. Finally it looks at the way developments in psychiatry have affected historians’ portrayal of George III.

mad ‘king’ in Bedlam

It is, as I say, fascinating. The account of his illness is remarkable, not least because of the political chaos around it. It was just the moment when, although Britain was increasingly recognisable as a modern democracy and decision-making increasingly rested with the Prime Minister and parliament, the king was still an important enough figure that his incapacity led to a crisis. And since the question of whether or not to establish a Regency depended on it, and a Regency would mean a change of government, his treatment was incredibly politicised. His doctors issued regular bulletins about his status, which were pored over by all concerned; his doctors themselves became associated with different political factions and found it very difficult to agree on anything.

Meanwhile the king was kept from his loved ones, frequently confined to a strait-waistcoat, and was subjected to a variety of unpleasant and intrusive treatments—bleeding, cupping, blistering, emetics—none of which, we now know, did him any good at all. And at least one aspect of his treatment, a ‘lowering’ diet without any meat in it, will have been actively making him worse.

detail of Hogarth

Still, interesting though all that is, it was starting to get a bit repetitive—thoroughness is a great quality in a historian, but doesn’t always make for riveting reading—and I was glad to get past the details of George’s case and onto the broader stuff, which I found fascinating. For example, as psychiatry increasingly worked under the theory that mental illnesses are self-contained and separate from physical illnesses, the king was retrospectively diagnosed with ‘manic-depressive psychosis’ , and all of his various and violent physical symptoms—pain, fast pulse, colic, sweating, hoarseness, stupor—were interpreted as hysterical, or even as invented by the Court to disguise the truth of his condition.

detail of Hogarth

And because it was assumed that he must always have been manic-depressive, the diagnosis colours historians’ portrayals of his whole personality:

Watson, in the standard Oxford history of the reign, writes : ‘He lacked the pliability and easy virtue of less highly strung people. When his obstinacy encountered an immovable obstacle, all his resources were at an end and the black humour claimed him… Madness was but this mood in an extreme form.’

The book quotes a whole series of similar descriptions. But the king’s early biographers presented a completely different picture, and in fact, we now know that between bouts of illness, sufferers from porphyria can be very healthy. Macalpine and Hunter are pretty scathing about psychiatry generally; the book was written in 1969, and it would be interesting to know whether they thought there had been any progress in the meantime.

» the pictures are details from ‘The Interior of Bedlam’, the final scene in Hogarth’s A Rake’s Progress. It predates the king’s first bout of madness, so the fact that one of the inmates thinks he is the king is not a jibe at George III. I got the picture from this site about the history of Missouri’s first state mental hospital.

Self-portrait with peristalsis

Actually it’s not a self-portrait—I certainly wasn’t operating the camera—but it is a picture of me. Since my blogging is generally short on personal details and I’ve never even posted a photograph of myself before, I suppose a shot of the inside of my colon seems like a rather radical step. But what the hell, it’s not like any of you are are likely to get the chance to pick my bowel out of an identity parade.

The inside of my bowel

My local hospital consists of a whole lot of buildings added at different times, all joined together by labyrinthine corridors, and all the buildings are referred to as ‘wings’: the Golden Jubilee Wing, for example. I can’t help feeling that it does serious damage to the metaphor; it would be a seriously deformed bird that had five wings, all pointing off in different directions.

They didn’t seem to be terribly worried by anything they found up there, btw. Although I suppose they might be trying to hush up the fact I’ve been impregnated by aliens.

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