‘Can Medicine Be Cured?’ – A critical review

There are many voices and currents out there that criticise ‘modern’ or ‘western’ medicine for having a mechanistic notion of the human body and mind, being symptom-focused and fetishising technological and scientific progress. The author of ‘Can Medicine Be Cured’, Seamus O’Mahony, is one of these voices, but unlike many others, he is able to criticise ‘the medical-industrial complex’ and ‘Big Science’ from within, based on his own experiences as a research fellow, who conducted medical trials, and as a doctor. 

In that sense he is able to criticise modern medicine not by discarding it per se, but by demonstrating its inner contradictions, which he sees based on the profit interests of the pharma and medical device industry, the promotion of individual career-drive of doctors and academics, and the managerialism of a bloated bureaucracy. He is able to situate his critique within an historical framework, by distinguishing a ‘golden age’ of medical progress, that lasted from 1880 to about 1980, from a turn towards detached ‘lab medicine’ and bureaucratic marketisation from the 1980s onwards. He refers a lot to the philosopher Ivan Illich (author of ‘Medical Nemesis’) who criticised ‘modern institutions’ such as medical establishment, education etc. in the 1970s, claiming that due to institutional self-interest they would produce opposite results: “the medical establishment has become a major threat to health”.

O’Mahony’s summary of the systemic problems of modern medicine will be shared by many on the political left who are looking for alternatives to capitalist medicine:

“These forces include the commodification of all human life, the over-weening power of giant international corporations, the decline of both politics and the professions, the sclerosis of compliance and regulations, the fetishization of safety, the narcissism of the Internet and social media, but above all the spiritual dwarfism of our age, which would reduce us to digitized machines in need of constant surveillance and maintenance.”

O’Mahony’s descriptions of capitalist medicine and science are largely spot on, but when it comes to presenting alternatives he turns into a conservative humanist. Facing a detached and commerce-oriented science sector, he claims that scientific work cannot be ‘planned’ and done in cooperation, but was always based on unconventional eccentric individuals seeking truth. Facing an impersonal medical sector that ‘manages’ both doctors and patients, he speaks in favour of reinstating the personal authority of doctors and a benevolent paternalism towards patients. According to him, the impetus for a change that would orient medicine away from global corporations, managerial power and detached lab science can only come from an external crisis, such as climate change, that threatens modern civilisation.

The author doesn’t see a force of emancipation that could overcome the contradictions of modern medicine and science by socialising knowledge and equalising access to both care and work. He has no trust in health workers, from nurses to doctors to science workers, reshaping medicine as part of a wider revolutionary movement. We cannot blame him for this, as there have been only a few indicators in recent history that this movement is a realistic option. But the consequence of such analytical pessimism leads him towards a fairly conservative, if not reactionary path. This is not a moral judgement. The fact that he has little understanding of, and faith in, collective and social processes clouds his wider analytical view. He denies that there is a ‘progressive element’ in capitalism’s contradictory tendency to socialise and standardise work, for example when it comes to ‘evidence based medicine’ (EBM). EBM means that rather than relying just on the personal experiences and intuitions of individual doctors, all empirical evidence concerning specific symptoms, treatments and outcomes are systematised and fed into a general database, which then becomes the basis for medical recommendations. He raises the critique, rightly, that EBM has been used to shift the power from doctors to managers and led to an often detached medicalisation of patients based on protocols, rather than personal relations. While the aim of capitalism is to use standardisation of the labour process, through methods such as EBM, to lower the necessary labour time and centralise the command over the work process, it also points beyond a capitalist application. A generalisation and systematisation of human knowledge can become a base for emancipation, for a society that does not rely on a strict division of labour and hierarchy.

Lacking both understanding and hope that (health) workers could transform the contradictions of capitalist development into an emancipatory force, he himself turns conservative and wishes for the return of ballsy genius scientists and paternal doctors. This is not uncommon amongst disillusioned, but often socially isolated specialists or experts. They experience the contradictions first hand, but only within their particular bubble. For us the problem is that their ‘expert opinion’ can then be used to justify a more general reactionary turn. O’Mahony criticises the ‘consumerism’ and the ‘empowerment’ of patients through concepts of neoliberal choice, which is fair enough, but then uses the reactionary anti-immigrant politician Enoch Powell of all people, to justify a rationing of health provisions, based on expert opinion. 

He criticises the over-medicalisation of old people, the useless battle against ‘old age’ and the illusion that death could be overcome, which is fair enough, again, but in an age of austerity his ideology could just as easily be used by the state to justify defunding medical care, disguising it as humanism. 

A wider movement of health workers and a new debate on an emancipatory communist way to produce and heal our lives has to reach out to these ‘expert dissidents’ and break their melancholic link with ‘the good old times’. A critique of anti-modern tendencies, namely the fear of a more global world in which technology and science becomes more important, within social movements is vital, from anti-globalisation to the Yellow Vests to the anti-lockdown protests during Covid.

O’Mahony’s book can serve as an inspiration to engage in serious research about how the main pillars of the medical field, from pharma to surgery to care, are structured by money relations and hierarchy – and how these become limits of medical progress in a social term. Given the acuteness of his descriptions and his insights in the workings of the medical field it is worth it for our debate to summarise each chapter.  

We are very interested in hearing about your thoughts on the book or this review!  

 

Chapter 1 – ‘People Live So Long Now’

The author tells us a bit more about himself, e.g. that he worked three years as a research fellow on drug trials for coeliac disease funded by a pharma company. In hindsight he questions the motivation of the trial as, for example, the simple removal of gluten from the diet had been a sufficient treatment. He states that the way that medical careers are organised makes people blind and opportunistic: too many exams, too much night-work, it takes too long before actual research can be engaged with. It is removed from medical application in the hospitals, one has to chase for funding and often it is random where one finds a research job. He describes his disillusionment with his medical career and medicine in general:

“My apostasy did not extend to the clinical encounter, and old fashioned doctoring. I lost faith in all the other things: medical research, managerialism, protocols, metrics, even progress. I became convinced that medicine had become an industrialized culture of excess…”

He then sketches out his periodisation of the ‘golden age of medicine’, which he dates from 1880 to 1980, though in other parts of the book from 1930 to 1980, during which the main scientific breakthroughs were achieved. “Something radical happened in the first half of the twentieth century” – between 1885 and 1985 infant mortality dropped from 140 in 1,000 to 5 per 1,000 and life expectancy rose from 50 to 80. Here he quotes Lewis Thomas: 

“The major threats to human life were tuberculosis, tetanus, syphilis, rheumatic fever, pneumonia, meningitis, polio, and septicaemia of all sorts. These things worried us then the way cancer, heart disease and stroke worry us today. The big problems of the 1930s and 1940s have literally vanished.”

As a side note, we should mention that it is not a coincidence that the ‘golden age of medicine’ also overlaps with the golden age of working class movements and their fight not just for better working and living conditions, but fundamental change. So ‘something radical’ happened indeed, which forced the ruling class to take the exploited class and its reproduction more seriously. The pressure of working class struggles forced capitalists and politicians to introduce more sanitary living and working conditions and to invest more money in public health, which included research in mass treatments, such as polio vaccines. The founding of the NHS itself was related to the fear of the ruling class of social upheaval after both World Wars.

In O’Mahony’s narrative, a shift happened after the ‘golden age’ towards major investments in lab research, detached from medical experience, with little outcome for the general public. Despite major investments, for example into research of the genetic code, there were not similar scientific or medical breakthroughs. He describes in later chapters why he thinks that Big Science does not deliver the goods, or at least not for the wider population. It is interesting to note here that there is a parallel when it comes to investment into IT technology in manufacturing since the 1980s and the fact that despite a similar hype like with genome-technology, these investments did not lead to a significant increase in productivity, but rather to an increase in ‘data’.

He concludes the chapter with a definition and blunt critique of medicine in the age of the medical-industrial complex. According to O’Mahony the complex comprises Big Pharma, biomedical research, the health food industry, medical devices manufacturers, professional bodies, medical schools, insurance companies, health charities, regulatory and audit sector. Medicine itself has become a kind of social force:

“Medicine has extended its dominion over nearly every aspect of human life.”

At this point it remains unclear what the author identifies as the main dynamics that have turned medicine into such a dominating force, whether it is a profit motive of an expanding sector, a modern death fear or a state bureaucracy interested in controlling its population. A hint could be found in the feminist debates of the 1980s and 1990s, which were very critical towards reproductive technologies, such as IVF or medical ‘advances’, such as organ transplants. They saw these efforts as a commercialisation of (female) bodies – of a capitalist society in search of market expansions.

 

Chapter 2 – The Greatest Breakthrough Since Lunchtime

The second chapter focuses on the shift within medical research in the 1980s away from hospital reality and concrete medical applications. The author claims that current medical research is a waste of social resources, as it is done badly and in the interest of researchers and allied commercial interests. Academics today are primarily interested in promotions, grant money and awards. Professors, who he calls ‘Brahminate’, have great power over appointments and grants, while teaching hospitals are run by very experienced junior doctors. 

“Up to that point, a professor of medicine was a sort of first among equals: he – it was usually a he – had to command the respect of his colleagues as a clinician, was expected to take a lead in the teaching of medical students, and, if time permitted, to carry out research. By the late 1980s and early 1990s, this model was discarded, ushering in a new breed of senior academic, whose main role was the generation of grant money for laboratory research. (…) This new breed delegated teaching to more junior colleagues, and did little or no clinical work.”

He contrasts this new type of academics with the old-school scientists, who were individualist, thirsty for truth, idealists and mavericks. While this perspective remains fairly blunt, his own insights as a researcher doing trials on ‘whole gut lavage’ treatments are sharper. Some of thefirst critical remarks about the scientific methods are made here:

“Instead of starting with a question, or a hypothesis, we began with a technique, and then produced as much data as possible” (…) “What went on in the nearby wards seemed of little consequence, apart from being a source of bodily fluids (‘clinical material’) from which the data emerged”.

It is interesting to note that the revolutionary movement of the 1960s and 1970s attacked in fact this patriarchal power of professors who ruled universities and university clinics like feudal forces. For example, the struggle of the health workers committee at the university clinic in Rome in the mid-1970s called these professors ‘barons’ and made them their main target. The ‘barons’ ruled the hospitals and also ran their own private clinics. We can see how this wider social attack ‘from below’ on personal power in the 1960s and 1970s was integrated into the marketisation and modernisation of the capitalist counter-revolution in the 1980s.

 

Chapter 3 – Fifty Golden Years

The author reflects on institutions such as the British Society of Gastroenterology (BSG), which he knows from first hand experience, in order to shed more light on the ‘golden age of medicine’. The BSG was founded in 1937, at the time it was an exclusive membership club with 40 members. During the 1950s and 1960s it became an association that anyone could join. By the time the author joined its conferences in the 1980s, membership had grown to 1,500 and its conferences attracted thousands of delegates from all over the world – but now they were funded by the pharma and medical device industry. Quoting a senior member of the BSG, the author narrows the historical view to the period from the founding year 1937 to 1987, which saw the arrival of penicillin, drug therapy for tuberculosis, kidney dialysis, organ transplantation, CT and MRI scanning, in vitro fertilization, discovery of double helix of DNA. At this point it seems slightly arbitrary that the author limits the list of medical inventions to 1987 and it becomes unclear what or when exactly he reckons the ‘golden age’ was. Furthermore, at least the three or four ‘inventions’ of his list were surely products of the ‘lab science’ that he criticises. 

He then uses research into treatments for peptic ulcers as an example for the arbitrary character of medical science. He details that in the first half of the 20th century surgery was the prime way to treat the ulcers, creating thousands of ‘gastric cripples’. These surgical interventions were pretty unfounded and harmful, similar to surgical treatments of lung tuberculosis, such as pneumothorax (collapsing) and removal of parts of the lung. By the 1970s the treatment shifted to pharmaceutics when the industry developed the blockbuster drug – Cimetidine – to reduce acid secretion. The drug had to be taken indefinitely, it was not a cure – but it persisted as a treatment because it was profitable. The discovery of the bacterium Helicobacter pylori as the alleged cause for peptic ulcers was the next big hype, producing a large amount of academic papers. The author seems sceptical, as for example many people carry the bacteria related to tuberculosis without ever becoming sick. He states further: 

“Many of the important discoveries – again, Helicobacter – were often serendipitous findings by enthusiasts with prepared minds, rather than the result of planned, lavishly funded institutional research. Diseases come and go, and effective treatment often arose when the disease was declining anyway (peptic ulcer, tuberculosis).”

These examples are interesting from a historical point of view, but the actual position of the author remains opaque. Were surgical treatments conducted because of a lack of alternatives or because the surgeons were the most powerful medical figures at the time? Did the blockbuster drug delay further research or was it just a necessary stop-gap due to a lack of actual insights?

The author then looks at why so much medical progress took place from 1930 to 1980. He states:

“The Second World War drove technological innovation; the post-war years saw a dramatic expansion of academic medicine and biomedical research, particularly in the US.”

This seems a contradiction to the previous paragraph, where he states that medical research cannot be planned or is not produced by ‘lavishly funded institutions’. It is true that the US military-complex massively funded the manufacturing of penicillin in the 1940s, knowing that during previous wars most soldiers didn’t die from gunshot wounds, but from the resulting sepsis and infections. Otherwise the ‘innovative drive’ of wars is contested amongst medical historians, which we will cover in a future article on the class history of surgery.

The author further states that there was a tenfold increase in government funding from 1940 to 1960s in scientific research in the US, which would mark a significant shift. In the UK the NHS was established and the doctors and consultants were bribed by the government to participate, by retaining their rights as private entrepreneurs and by keeping privileged positions within the hospitals. The author describes, rather melancholically:

“Consultants – particularly those based in the great teaching hospitals – enjoyed almost complete professional and academic freedom. They answered neither to administrators nor to the general public. Their eccentricities and scientific passions were not only tolerated, but actively encouraged.”

He repeats that by the 1980s this power was eroded:

“Power in medicine slowly shifted from the teaching hospital clinician-aristocrats to the new laboratory-based professional researchers, the Big Science Brahmins.”

For us it would be important to know whether this shift from hospital-based and more practical research to ‘lab-based’ science was also, and perhaps primarily, due to the shift in the object of research towards entities that could only be researched in labs, such as DNA or micro-biological organisms. To what extent does this type of research require ‘higher levels of investments’ or an expanded network of teams that no individual hospital can provide? The author vilifies this shift, rather than analysing the objective requirements and how corporations and bureaucracies can present themselves as the only sources that can satisfy these requirements. 

 

Chapter 4: Big Bad Science

This is one of the central chapters of the book, looking at the problems with the current science sector. 

According to O’Mahony the problem is the “professionalization, industrialization and globalization” of medical research. He claims that by the 1990s “bureaucracy around medical research grew to the point where only full-time research professionals, supported by the secretariat to handle all the red tape, could do it”. When it comes to a clearer definition of Big Science he quotes Alvin Weinberg, who contends that it is lab based, dependent on massive amounts of external funding and large research facilities, and overseen by academic managerialists. 

The author then refers to various studies which are meant to prove that Big Science is actually not very effective or producing results that benefit wider society. One of his main fellow scientists who share his point of view are John and Despina Ioannidis who examined 101 proclaimed ‘science discoveries’ published in the top science journals between 1979 and 1983. They claim that 25 years later only 27 of these technologies have been tested, 5 were approved for marketing and only 1 had clinical benefit. 

“Ioannidis, along with other meta-researchers such as Glasziou and Sir Ian Chalmers, estimate that about 85 per cent of medical research is useless and wasted. This global waste amounts to $170 billion annually.”

This begs the question why in a system that is geared towards profit, millions are spent on research that produces only a handful of marketable, meaning sellable, products. Is this due to an inability of the science sector to produce results or is it an expression of the power of the science sector, perhaps similar to the military-industrial-complex, to funnel off resources and to create its own legitimation for it? But what is this parasitic power based on?

It seems that O’Mahony reckons that at least one part of the answer why there haven’t been major breakthroughs recently is based on essential biology: most illnesses nowadays are age related – and the ‘war against age’ through scientific discoveries is a lost game. According to him, medicine contributes little to health in developed countries, as poverty, lack of education and deprivation are the main issues which determine the health of a person. Half of his own patients suffer from psycho-somatic expressions of the ‘shit life syndrome’, for which there isn’t a magic pill. “Inevitable vicissitudes of living” are “reconfigured as medical problems.” The author reckons that in the western world there are only a few illnesses that still deserve major research, such as Crohn’s disease.

It is not really clear whether O’Mahony thinks that Big Science is a failure ‘scientifically’, meaning, that the sector is not able to produce actual results, or whether he thinks that the problem is that it focuses on research that is profitable, e.g. expensive cancer research with limited benefits, while unable or unwilling to provide answers to wider medical issues. In the book the sector is both accused of ‘scientific failure’ and ‘moral failure’, in the sense that it can produce scientific results, but chooses to do so only for profitable purposes.  

According to O’Mahony there is an issue with the method of Big Science. He claims it produces data, rather than original ideas. It assumes that everything can be planned and nothing is unexpected. The sector pushes academics to publish a large number of papers and to be quoted by many fellow scientists, which encourages them to engage in bad or irrelevant science. He gives a good overview of how ‘p-hacking’ (relying on a large quantity of data, rather than a specific hypothesis), the impact factor of journals, peer reviews, ranking etc. encourages academic opportunism and a race to create ‘novelties’, rather than serious scientific results: between 1974 and 2014 the words ‘innovative’ and ‘ground-breaking’ in PubMed abstracts increased by 2500%. He quotes from an intelligent sounding article ‘The natural selection of bad science’ which tries to prove scientifically how the current system amplifies and proliferates shallow scientific research. This ‘politics of novelty’ is not confined to medical research or physical science, but also permeates the humanities and even supposedly revolutionary theory from the 1980s onwards.

O’Mahony doesn’t stop at criticising superficial methods or questionable motivations of modern academia, he also looks at the political-economy of academic publishing and science funding. 

Academic publishing is a £19 billion global business with a profit margin of 36%, as aspiring academics give the publishers scientific papers for free, while they are bought by government funded institutions. There is an overproduction of 420,000 articles a year, generated by 8,000 journals, dominated by a few global corporations. This means that the product is largely of dubious quality and hardly digestible, due to its sheer mass. It is good that he also sees a potential subject of revolt against this academic paper tiger, e.g. the push by some researchers for open source publishing.

He then looks at the capital streams for wider medical research, from venture capital that flows into biomedical research to ‘philantro-capitalist’ institutions set-up by the likes of Zuckerberg or Gates, which finance private medical research and fuse the shareholder-fueled bubbles of ‘artificial intelligence’, ‘data mining’ and ‘biotech’. He criticises that the focus on biotech will deepen the division between the rich in the western world, who consume the major share of medical resources, and the poor, who lack even the most basic medical provisions. 

“We in the rich West cannot continue to spend vast sums for such modest gains while people die in poor countries of diseases that can be cheaply cured and prevented.”

But he doesn’t limit himself to a criticism of the distribution of medical resources, he also questions the results that Big Science produces. He uses the example of the Human Genome Project, which was portrayed as a major breakthrough. As it turns out, the actual influence of genetic difference on disease is much less pronounced than expected and there are only very modest practical applications that follow from the generated data. At this point I want to refer to an article written by friends from Wildcat on Artificial Intelligence, where we see similar developments: 21st century capitalism creates large amounts of data, but no social insights or leaps in development.

As an isolated expert O’Maohny tries to explain this social and structural problem as a leadership issue:

“The decadence of contemporary biomedical science has a historical parallel in the medieval pre-Reformation papacy.”

It seems that the author picks out rather random facts and figures in order to demonstrate that current medical science has reached an impasse, but his yardsticks are unclear. Perhaps if we would choose a random point in time of the ‘golden age’ and ask an individual person whether ‘progress is being made’ we would receive a similar answer, e.g. that progress is slow and that the elite puts hurdles in its way. Perhaps we need a larger temporal framework in order to see what kind of outcome social investments into scientific labour have. It feels that confronted with a very complex social situation, in which ‘science’ depends on an ever more global social cooperation, the author wants to provide easy answers, last but not least, for himself:

“Real science is so hard that it can only be done by a small minority of people who combine high intelligence, passionate curiosity and a commitment to truth. Real science cannot be planned and carried out by committees of bureaucrats and careerists.”

 

Chapter 5: The medical misinformation mess

In this chapter O’Mahony focuses on the increased role of data and protocols in medical practice, e.g. in the form of ‘evidence-based medicine’ (EBM). He retells the process from the first randomized control trials in the late 1930s to the emergence of EBM in the 1990s. The latter he describes as a rebellion against ‘expert-based medicine’. 

He then criticises the EBM approach, firstly, by saying that its hierarchy of evidence (from random scientific trials to personal experiences) is nothing new, but that doctors have proceeded in this way before the official birth of EBM. 

Secondly he criticises the statistical methods of many EBM procedures, e.g. statistical concepts, such as ‘numbers needed to treat’ – how many patients do I have to treat with a certain medication in order to make a difference that would mark a noticeable improvement. As doctors and patients are often under-educated in statistics these benchmarks often become meaningless. EBM does not encourage the doctor to look at each individual, their particular conditions and already existing medical history, but encourages modular and standardised application.

He thirdly claims that EBM is costly, and therefore exclusionary: “Evidence, unfortunately, is very expensive to produce, mainly because clinical trials are so costly that only Big Pharma companies can afford to run them.” Three quarters of major trials are industry funded, with certain commercial interest, and often factually and statistically flawed. For example, evidence is often based on trials with young (male) patients, but then applied to largely elderly (and perhaps female) patients.

He blames the current application of EBM for overprescription: 25% of US citizens in their 60s are on five or more medications, 46% of people in their 70s. In the UK 15% of admissions of elderly people are due to drug side effects. EBM encourages a ‘serial’ approach to medicalisation, instead of a personal holistic approach. “A doctor who follows EBM might see an older patient with a certain symptom or lab results. EBM suggests a certain medication, but EBM standards are actually based on younger patients. Based on EBM the doctor prescribes a second drug to alleviate the side effects of the first drug etc..” 

He rightly criticises EBM for being used to undermine the knowledge, and therefore the wages and power, of doctors:

“Some believe that protocol-driven care is a prelude to a future when most medical care is provided by paraprofessionals, such as physician assistants and nurse practitioners.”

As mentioned earlier, he doesn’t want to or is not able to see the potentially positive sides of a standardised mass-knowledge, but retreats into the world of personal intuition. He quotes a colleague who claims that the best outcome for medical treatment requires ‘enthusiasm from the doctor and blind faith from the patient’.

“The idea of an individual doctor exercising clinical judgement, using unquantifiable attributes such as experience and intuition, has become unfashionable and discredited, yet it is this judgement, this human touch, which is at the heart of medicine.”

Personal experience and relationships are definitely an important part of any healing process and it is something that has been around for millenia. What is new is that thanks to wider access to education and means of communication we now have a chance that in addition to these personal elements we have a potential for the generalisation of global knowledge. This is something that we should be hopeful, rather than fearful about.

 

Chapter 6 How to invent a disease

The following two chapters have a more ranty character and it seems that O’Mahony is primarily dealing with his personal bugbears. He looks at how various symptoms are packaged into ‘new illnesses’ and then marketed. According to the author, non-coeliac gluten intolerance “might be called a post-modern disease. It does not have a validated biological marker (such as blood test or biopsy), and the diagnosis is made on the basis of a dubious and highly arbitrary symptom score. Its ‘discovery’ owes much to patient pressure and the suborning of expert opinion by commercial interests” in order to create a ‘free from’ boom for the nutrition industry. These examples are relevant, but not too insightful.

 

Chapter 7 Stop the Awareness now

In this chapter he looks at the cheerleaders of the ‘new illnesses’. Charities and patient support groups create a suffering competition. Those illnesses which get the most exposure through media and campaigns also get the most funding.

“Those with the least resources for advocacy and those least able to articulate their case will end up with the worst care.”

Many charity groups are pharma funded and mark pharma’s shift from the sick to the well by an inflation of ‘awareness days’. The healthy individual is bombarded with all sorts of health advice and encouragement for medical screening. He sees a big gulf between millions of screening programs on one side and the lack of capacity in hospitals and the long waiting lists on the other.

He criticises the trend of “sentimentality-based medicine”, where the unfortunate death of individual patients, e.g. due to sepsis like young Rory Staunton in 2012, is amplified and used by parental pressure groups to enforce new protocols. He describes the adverse effects of ‘sepsis screening’: old people are put on unnecessary fluids, catheter and antibiotics – introduced by intensive care specialists with little understanding of the wider conditions of elderly care.

“Stop pestering the healthy with awareness campaigns. Lobby, if you must, for humane treatment of frail, old people in emergency departments, but let’s not raise awareness.”

O’Mahony is on to something, but he conflates the form that ‘awareness’ takes under social conditions of commercial over-medicalisation and neo-liberal obsession with individual wellbeing, with its potentially emancipatory content: people want to know more about health conditions and people want to socialise the fact that they suffer of certain ailments that have been ignored so far. 

 

Chapter 8 The never ending war on cancer

In this more serious chapter the author uses cancer research as an example both for the current impasse of science and for the profit-oriented application of science. He claims that the 500 billion USD spent on cancer research in the US between 1971 and 2012 produced only negligible results. On the scientific side he sees the reason for this failure in the fact that Big Science devotes too much effort on mechanistic ‘explications’, e.g. by documenting the biology of cancer cells rather than looking at the whole human picture and acknowledging age as the main unbeatable factor. In order to disguise their own shortcomings, pharma companies use ‘meaningless surrogate endpoints’, such as ‘disease free remission’ and reduction in tumour size as benchmarks, rather than actual survival rates or added life time. 

The author recalls the pressure on the National Institute for Health and Care Excellence (NICE) to allow the funding of new cancer drugs. Surrendering to this pressure David Cameron set up a Cancer Drugs Fund of 1.27 billion, which funded 47 drugs. Only 18 of these drugs improved survival, but only by three months on average. The author claims that the money spent on these rather ineffective drugs would have paid for every hospice in the UK for one-and-a-half years. Similarly, the 48 cancer drugs approved by US FDA between 2002 and 2014 increased survival by a median of 2.1 months. In 90% of cancers (solid type), chemotherapy only adds a few months to the life of the patient, still they are largely applied. The author concludes:

“We live in a culture that focuses almost exclusively on benefit, and rarely considers cost.”

Here we can argue that rather than creating or accepting a funding competition between cancer patients and people in hospices, or even between cancer patients in the global north and malaria sufferers in the south, we should question the spending of much larger sums for global rearmament or bailing out banks – a fairly banal point. Still, a free communist society would also have to make decisions about where to focus social labour, so his point is not entirely irrelevant.

 

Chapter 9 Consumerism, The NHS and the ‘mature civilization’

O’Mahony proclaims that the NHS is not sustainable and that Enoch Powell had already predicted this in 1966 in his book ‘A new look at medicine and politics’. The founders of the NHS wrongly assumed that free health care would result in a healthier population, which in turn would mean less demand for its services. The author quotes Ivan Illich who also assumed that the more health care you give to people, the greater the demand and termed it ‘Sisyphus syndrome’. Neither Illich nor O’Mahony really substantiate this claim. In other parts of the book he actually contradicts this claim, by explaining that a healthier population lives longer, but that the greater demand is created by an increase in old age-related ailments, not by a reflexive or consumerist ‘sisyphus drive’. 

O’Mahony is against the marketisation of the NHS, he agrees with Powell’s solution of rationing health services – based on the decisions of medical experts. When it comes to Thatcher’s internal market (the idea that single departments or Trusts have to relate to other NHS departments or Trusts as if they would trade on a market) he acknowledges her assumption that the NHS is a monolithic bureaucracy, but rejects her conclusion that health care would benefit from competition, alleging that 10% of the annual NHS budget is spent on maintaining and managing the internal market. He criticises the private-public (PFI) drive of New Labour. Labour introduced a neoliberal culture of ‘patient choice’, which he equates with ‘consumerism’, and created a social illusion: “service can be both free and on consumerist principles of choice”.

“Consumerism has created patients who confuse needs and wants, and who often want the wrong things; it has created doctors who view medicine not as a profession, but as a service industry.”

There are at least two things wrong with his view. Firstly, to equate ‘patient choice’ with consumerism per se. Secondly, to assume that people actually overuse the health service. This sounds delusional if confronted with the reality of waiting times for basic surgeries or transferals to needed specialists. Of course, we also often see entitled and individualistic behaviour of patients, but the main reason is not that they have been given too much (choice), but because in a dog-eat-dog world of limited resources everyone wants to make sure they are not the last in the queue. 

 

Chapter 10 Quantified, digitized and for sale

Again, a rather ranty chapter, starting with a fairly solid definition of ‘digitalisation of health’:

“These include the use of biosensors to monitor health, tele-medicine – carrying out medical consultations via digital media, the digitization of individuals’ genomes, and the use of social media to create ‘communities of patients.”

The author is right that these tendencies appeal first of all to those who need health care the least: the young and the rich. We can also agree with him when he says:

“Digital health also reflects a global societal shift towards neo-liberal values of self-responsibility for health maintenance, along with a decline in state-provided health and social care.”

He mentions the Theranos bubble, a start-up company that created a huge (initial) stock-market success by claiming that with a new App everyone will be able to diagnose themselves for all sorts of slumbering or even future medical conditions. The start-up failed due to the actual limitations of digital health monitoring. O’Mahony believes that powerful forces will nevertheless be able to use these limited means to control the people. His world view that sees social developments mainly determined by good or bad elites causes O’Mahony to suffer slight paranoid episodes when it comes to future scenarios:

“It is highly likely that in the near future – particularly in the US – employees of major corporations will be required to wear digital devices which track their health and their behaviour.”

“The tech corporations and the medical-industrial complex will round up vast populations who will not resist, who are happy to be herded because they are assured that they are empowered members of a digital, and digitized, community.”

Having accused him of a slightly doomed perspective, historically speaking medicine and the ideology of a ‘healthy national body’ has been one of the main tools of dictatorial states to expand and legitimise control and violence.

At this point it would be interesting to know what O’Mahony thinks about the Covid-19 lockdown and the way that the state dealt with the pandemic – his book was written before. After a brief internet research it seems that he supported the vaccination program:

“I will be volunteering though to help out with the vaccine roll-out and am looking forward to that.”

And unlike some of his colleagues he didn’t write against the lockdown, despite acknowledging how devastating the effect was on communal and family mourning in Ireland. He concludes:

“Having been temporarily deprived, we might once again come to value the creatureliness of mourning rituals and the embrace of community.”

He also managed to write another book during lockdown, ‘The Ministry of Bodies’.

 

Chapter 11 – The Anti-Harlots

In this chapter he criticises the shift from a doctor-patient centred medicine to a management-target focused one. He claims that doctors have lost power to make decisions, while at the same time still being held accountable if something goes wrong. He sees a new professional elite in the form of managers, auditors, clinical directors, who are removed from actual practical medicine. 

“Power within medicine seeped out of the hospitals to the committee rooms and the universities.”

“All of this has left the hospitals essentially leaderless. Managers and clinical directors are nominally in charge, but they are motivated mainly by targets and metrics.”

He claims that metrics and protocols that were introduced after ‘scandals’ like at the Stafford hospital, where an increased number of so-called ‘excess deaths’ was observed in the early 2000s, will actually aggravate the problem, because they further remove power from doctors. He thinks that the reasons behind situations such as at Stafford are due to understaffing, but also due to ‘leaderlessness’. Furthermore he criticises that a lot of essential decisions that used to be made by doctors, e.g. to continue treatment for terminally-ill patients such as Charlie Grad, are now referred to courts. He sees a witch hunt against doctors in the fact that the NHS paid £1.4 billion to settle medical negligence claims in 2015-16, a figure that doubled in ten years.

And we can agree that power has been taken away from doctors as a well-organised professional group in order to enforce a more centralised and marketised health system. But this has happened with most groups of workers in any kind of industry. Instead of trying to imagine a situation where control can be taken back by doctors, health workers and patients together, O’Mahony insists on the defence of doctoral power and privilege.

“Consumerist movements like digital health have the explicit aim of reducing the power of doctors and rebalancing the doctor-patient relationship in the patient’s favour. The power of doctors, however, has been in steady decline for decades.”

“The removal of the white coat was a political act, taking away what some saw as an outdated symbol of doctors’ power.”

“The clinician-aristocrats may have been plutocrats at the top of a feudal medical career pyramid, but they were leaders and carried the memory of their institutions. Many had style and ‘bottom’ – a mysterious quality, a combination of personal substance and integrity.”

“Bullied by managers and frightened of their patients, overseen and regulated by an ever-increasing number of statutory bodies, we let this happen.”

He sees this development of disempowering doctors as part of a wider social trend:

“Why is this happening now? There are several reasons: the gradual disappearance of deference to professionals and authority figures; the democratization of knowledge via the Internet; the new distrust of ‘experts’ and the inflammatory effects of social media.”

We can see how he discards the emancipatory potentials of (working class) people being able to inform themselves and to question decisions by ‘the gods in white’. If we look into medical history we can find millions of examples how upper-class doctors have abused their power towards working class patients and other health workers, from self-important medical trials to participation in state-run forced sterilisation programs to collaboration with the various war machines in order to get wounded soldiers back to the front as soon as possible. In this sense some of the actions of management, e.g. the enforcement of evidence based-medicine against individual arbitrary decisions, have a progressive element within their capitalist trajectory.

He is pessimistic when it comes to solutions, as he sees little chance that doctors (alone!) can wrest back power from the managers. It would furthermore need a “radical reform” of the General Medical Council and an open dialogue with society about what medicine can do and can’t do.

 

Chapter 12 The McNamara Fallacy

In this chapter he deepens his analysis of how management is using seemingly objective ‘data’ and ‘statistics’ in order to cement their power. According to O’Mahony management claims that health care can be run like business and data is the key to success. Here he refers to the McNamara fallacy as a historical reminder. 

McNamara came from a background in mathematics, and when he became secretary of defence of the US in the 1960s he escalated the war in Vietnam, assuming that with a certain figure of enemy deaths the war would be won. The US army killed over 1 million people between 1965 and 1974, but lost the war. O’Mahony says that like war, medicine is messy and there are clear limits to numerical analysis. Managers move from one field to the other, just seeing figures.

He then uses the Hospital Standardised Mortality Ratio (HSMR) as an example, a mathematical formula that was created after the Stafford scandal. He points out that the audit companies that calculated the HSMR were semi-privatised and financially linked to some of the auditing managers. He goes further and says that actually, the target culture was partly to blame for the situation at Stafford hospital: 

“To meet financial targets to become a foundation trust, the hospital sacked 150 staff and closed 100 beds (18 per cent of the total).” Also the four hour target in ED (‘patient seen, assessed admitted or discharged’) meant that staff was transferred to ED and wards were understaffed.

“Numbers should be our tool, not our tyrant. Society’s main concern about medicine is lack of compassion.”

This is certainly right from a humanist point of view. But anyone working in the NHS can also see that it would be great if we could actually get the numbers right, too! There is actually so much frustrating waste of resources and time. The problem is not technical, a better algorithm would not help. The problem lies in isolating hierarchy, in trying to save money to create good balance sheets, in departmental management trying to look good at the cost of the overall organism, while most workers are stuck in repetitive jobs without a say at all. We need ‘good planning’, we need stats and figures, but as part of wider worker-patient control.

 

Chapter 13 The Mendacity of Empathy

This chapter expresses that the author is fed up with certain ‘modern’ means of communication and ideologies. He makes a difference between ‘empathy’ and ‘compassion’. For him the current focus on empathy is flawed, as it takes the immediate emotions, behaviour and needs of the individual as the starting point. He sees empathy as a mere mirroring of the patient’s (or other interacting human’s) emotions, which can be problematic in a doctor-patient relationship, e.g. heeding the immediate feelings and needs of one particular patient might clash with other moral considerations of the wider common good, or even the patient’s long-term cure. Compassion on the other hand involves courage and competence. I am not just saying that I can feel what you feel, which according to the author is questionable anyway, but I can see and understand your situation and take the responsibility to act. It seems that O’Mahony thinks that in current hospital set-ups there is too much focus on so-called ‘soft skills’, e.g. the right way to say things, rather than the actual content of what is said. He lumps ‘narrative medicine’ as a modern school of medicine into this trend of ‘post-modern’ ideologies, where truth and authority is questioned. At the same time he himself seems to argue for similar things, when he accuses: 

“The Narrative Medicine lobby believes that patients are ill served by a medical establishment that is relentlessly mechanistic and dehumanising.”

He is right to criticise that historically it were wider institutional changes that actually changed social and individual conditions, rather than efforts to change the behaviour of individuals. Again, a bit of a ranty chapter, but not entirely irrelevant. 

 

Chapter 14 The Mirage of Progress

The concluding chapter returns to his doubts concerning the entire concept of progress. Again, it does not become clear where and when ‘progress’ became a problem. He states:

“Progress – rather than compassion – is the core belief of the medical-industrial complex.” 

The question arises whether the surgeons in the 1880s, who based on the blessed early days of anaesthesia made great ‘progress’ in their field, were particularly compassionate. If we define progress more generally and objectively as ‘increase in human knowledge, increase of the numbers of people on the planet, increase in life expectancy’, then this progress was never based on compassion, but on struggle, primarily the struggle between exploiters and exploited, e.g. the struggle for a shorter working day in the 19th century forced capitalists to invest more into means and research to increase labour productivity. This ‘progress’ can be of hellish consequence for the exploited, if for example an increase in human knowledge is used to produce weapons of mass destruction or surveillance technology, but it deepens the contradiction between what is and and what could be – the conflict between how and with what purpose technologies and science are applied by the capitalist system and how we could apply them for our own interest. While subjecting the exploited, capitalist progress also raises their expectations. These contradictions are not for O’Mahony:

“At present, medical ‘progress’ gives us the dubious and ruinously expensive gift of helping us to survive long enough to experience loss of independence and chronic disease.”

“Medicine is the bully that is stealing from education, from decent affordable housing, from the arts, from good public transport.”

The latter is a brave statement from a man who worked in medicine all his life. It is a humble statement about the problematic state of his field, but the problem is not ‘medicine’ as such. O’Mahony waves back and forth between seeing ‘progress’ either as the outcome of a certain self-interested elite or as a mirage or new idol of a mesmerised human race. In either case only an external event could change things:

“The most likely events are economic collapse and a global pandemic of a new, untreatable infectious disease on a background of climate change and exhaustion of the earth’s resources by globalization.”

He criticises rightly that currently there is more research in expensive, but marginal drugs, rather than new and badly needed antibiotics that make less money. He is also right in repeating that the main improvements in terms of public health and longevity happened before the age of ‘medical research’. Instead of asking for the reasons for this fact, he turns against the definition of health that the WHO uses – ‘health equals complete physical, mental and social wellbeing’ – and asks us to change our minds, rather than reality. We should all get used to the fact again that life is hard and that distress and hardship is not an illness.

“This intolerance of distress is partly to blame for the exponential rise in the prescribing of antidepressant and anxiolytic drugs.”

This perhaps old-fashioned or stoic life-style advice is followed by a more sober assessment: 

“We may have already achieved most of the medical advances we are ever going to achieve, and in some areas – such as antibiotic resistance – we are going backwards. Many have argued that if we simply applied uniformly, equitably and rationally all the scientific knowledge we currently posses (…) medicine and health would be transformed.”

He concludes with a sentence that embodies the main shortcomings of his position:

“Our faith in progress, and that science will deliver it, perpetuates the illusion that we can plan our society to maximise health and happiness.”

He is right, let’s lose our illusion that ‘progress’ will deliver anything and let’s continue to struggle for a society where we can plan to maximise health and happiness for everyone.

O’Mahony’s book poses a challenge for us to actually research the current contradictions of capitalist medicine: capitalist medicine tries to catch up with the sickening conditions of class society, from nano-particles to chronic stress, but is at the same time geared to sustain the class structure of society; market relations and hierarchies prevent a widespread application of already available treatments, while research focuses increasingly on profitable niches; the actual form of how health work and research is organised creates massive hurdles for effective treatments and medical discoveries. At this point these are only hypotheses, we will have to uncover these contradictions in actual struggles.

 

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