Editorial Note: This post follows from Vampire Medicines and Cisparency and Transparency and links to Relationship Based Medicine on Rxisk. The painting is of Joshua crossing the Jordan with the Arc of the Covenant – an image that catches the essential features of climactic scene of Raiders of the Lost Arc with Joshua in the Indiana Jones position.
In every generation, there is a slayer. In this generation, s/he will probably be female. She need not be a doctor. She might work for a pharmaceutical company. She could be a patient or a family member. She will likely be a woman, if only on a probabilistic basis, as more women are injured by medicines and more women are involved in the lives of people who have been injured and now more women are in medicine than men. And as the BMJ has recently shown even in medical specialities, such as surgery, where until very recently it was common to hear it said women were just not suited, in fact they now do a better job than men. She might be the editor of a medical journal.
In-Diana, besides, looks much more like a girl’s name than a boy’s.
The Slightest Slope
Just as water flows down the slightest slope, so drugs flow at the slightest hint of benefit – in both cases the flow is inevitable unless there are bumps in the way. It’s a bit like taking an apple off a tree. Difficult not to.
Difficult not to, short of seeing the tail of a worm sticking out of the apple and wriggling.
This is where the harms come in. There is no such thing as a Free Apple. Its only in paradise there are worm free apples. Down here at the very least they have pesticides on them.
Since the Fall, we have lived in a world of Good and Evil – where sometimes what seems like the greatest good turns out to be more harmful than helpful. We need to be alert and make judgement calls that balance harms. In medicine, we were making progress at balancing harms to the point where we could make a reasonable stab at using poisons to do good provided everyone knew what they were doing.
But since 1990 that balance has been lost and the divide between good and evil is getting more marked. This might sound like a good thing but its not. We are increasingly ending up with fistfuls of medicines branded as All Good Zero Harms – Vampire Medicines. The systems most people now work in or seek medical help from with would shrink in horror from the idea of bringing good out of the use of a poison. We have infantilized. The infantilization is worse by systems that are becoming increasingly brutal to those trying to work within them and those seeking care from them.
Suffer the Children
One of the best symbols is what we are doing to children. There have been roughly 30 controlled trials of antidepressants in children labelled as being depressed – all negative. The Prozac trials the most negative of the lot.
Yet prescriptions for antidepressants are soaring among teenagers, especially girls, so that they may now be the most commonly prescribed drugs in this age group.
This is because of hints of efficacy and a sustained campaign to turn the evidence that there are harms – every trial done shows an excess of suicidal events on active treatment over placebo – into a “controversy”. The average doctor has been led to believe this is just an arcane dispute among academics. Nothing of consequence in the real world.
In the real world children’s mental health services are close to collapse because, despite money being poured in, children are waiting so long to be seen that given antidepressants by family docs – to help tide them over – they are attempting suicide while waiting. They then get seen by services who have no sense the suicide attempts might be drug induced and they get treated for something they don’t have. Meanwhile, the money going into children’s services goes into screening, and auditors and managers rather than clinicians in an effort to ensure adherence to guidelines. The only reason things could be going wrong is non-adherence to the guidelines – guidelines that say give Prozac.
Get that Crucifix out of Here
Another place to see the problem is with vaccines. BMJ have just bravely run a piece by Peter Doshi on the funding of vaccine propaganda groups. Few people other than Peter could have pulled off something like this. Others would be too scared. Still the impression left is that everything would be fine if there were transparency about the sources of funding and conflicts of interest.
The real problem is that in vaccine-land its not possible to mention harms. There can be no discussion of the fact that HPV vaccine causes problems, flu vaccines are for the birds, the Swine Flu vaccine caused narcolepsy, hundreds are suing Merck as a result of the Shingles vaccine, and earlier iterations of the MMR were withdrawn because the authorities accepted they were causing problems.
Not only is there a denial that there could be any problems but vaccine proponents have become thuggish and fascist, with alt-health diatribes turning up in the most unexpected of places – the Guardian. It’s enough to make anyone who believes in vaccination despair. The analysis of the growing vaccine resistance in healthcare professionals pays no heed to this. It scolds us for not telling the public that the safety of vaccines is monitored thoroughly – when this is self-evidently not true.
Medical academics now discuss company creativity at gaming efficacy in clinical trials – the way scholastics once debated the number of angels that might fit on the head of a pin. But company creativity at gaming efficacy is like nothing compared to their creativity at gaming safety. One of their best tricks is to get doctors and patients to report harms directly and independently to regulators. You might have thought this would help but reporting adverse events to a regulator is like pouring water into sand.
An entire science has been lost here – the science of adverse events/ drug wrecks. Doctors have no training in establishing when it is possible to say that drug X is causing problem Y. They are told that RCTs tell them what a drug causes.
The irony of this is that with most drug wrecks the causal chain is commonly so clear, so lacking in ambiguity, there is no need for an RCT – PSSD and PGAD offer great examples of this.
We Need to Medicalize
Many well intentioned people think they are contributing to a resolution of this epidemic by getting involved in campaigns against Overdiagnosis and Overmedication (ODOM). As things stand Overmedication Campaigns are like telling people they are a little Overweight – everyone agrees they need to change but, like Augustine of Hippo, they figure they will try to put it right but maybe not just yet. While everything works – is nutritious – or everything is good – like making a diagnosis – it’s difficult to stop feeding your diagnoses.
ODOM is like AllTrials – wonderful for industry. It gives the “good guys” the feeling they are doing something while behind the fig leaf industry get to hide ever more transformations of medical culture and practice. Centrally important to all this is that the proponents of ODOM or AllTrials be like BMJ and Fiona Godlee, its current editor, brave and beyond reproach and better again seen as trying to rein in industry.
But this won’t work. The only way the epidemic of treatment induced death and disability can be tackled is to return pharmacotherapy (not quite the same thing as medicine) to its roots which is that everything is a poison and physicians need to act accordingly.
We are Underdiagnosing the injuries being caused by treatment and Undertreating these injuries. We need to medicalize the problem. A campaign to recognize harms and manage them would require a lot more cojones from journal editors, scientific advisers and consultants than we are currently likely to get from any of these sources.
Relationship Based Medicine
But medicalization is not just about recognizing harms. It’s about managing harms in a relationship. We need to get back to a Relationship Based Medicine. The relationship used to be authoritarian. It needs to become consensual. It needs to harness the abilities of those of us who as patients take risks with medicines to contribute not only to our own wellbeing but to the wellbeing of all. A bunch of reasons why the slayer is likely to be a ….
Of course, doctors should probably also be told they are on the way out of business unless something like this happens. If drugs work wonderfully well and are so free of harms, nurses and pharmacists would be much cheaper prescribers.
And looming on the horizon are robots that can learn. Pretty soon putting a robot in charge of prescribing for patients, providing they were granted leave to learn by killing a few hundred patients first, would lead to fewer people being injured and fewer dying than is happening at now. If it was let learn rather than just follow a program, the first thing the robot would learn is to junk the evidence from RCTs.