Independent.ie Jan 28, 2019
Dr Seamus O'Mahony. Click to enlarge
‘I don't think I could have written this even 15 years ago," says Seamus O'Mahony, consultant gastroenterologist at Cork University Hospital, of his remarkable new book Can Medicine Be Cured?
The book tackles the state of modern medicine, from the highest reaches of technological research, down to the GP's surgery and front- line healthcare workers. "The perspective of three-and-a-half decades is fantastic," he continues. "It gives you knowledge, experience." And daring, I suggest - the book is subtitled The Corruption Of A Profession.
Might he have been wary, even afraid, at an earlier point in his career? "I might have been," he says. "I'm at a stage in my life and my career - I'll be 59 next month - where I'm not looking for promotion or advancement so I'm not worried about any fallout in that regard. I think writing it at this stage gives you the freedom to say what you want to say."
That said, he also believes that "the overwhelming majority of doctors who read this would be in agreement with what I say. All I've done in this book is put together what people in medicine and medical science have agreed is happening".
So, what does he say? Plenty - this is a book shored up by deep medical, historical and sociological knowledge and research, which it wears so lightly that it is, as well as deeply provoking, even game-changing, a compulsive read.
He challenges the usefulness and credibility of medical research; the illusion of progress; our stubborn belief that we can be perfected; over-prescribing; poly-prescribing; the efficacy of many drugs that are routinely administered; the corruption of academic medical research; our collective failure to accept that medicine cannot cure everything, and indeed can cause trouble of its own; over-reliance on metrics; the pharmaceutical industry and its vast reach and influence, and far more.
There was, he points out, a ‘Golden Age' of medicine, from the 1930s to the 1980s, during which a number of huge advances were made. TB, smallpox, polio, all huge killers, were effectively eradicated in the developed world. This Golden Age ended "just as I came into it, I caught the end of it. There have been very big advances since then, but nothing like that accelerated level of discovery and innovation that occurred in those 50 years." Since then, medicine has increasingly lost its way.
Starting with ‘research' - that great hope that will save us all - he is fairly scathing. I suspect that many of us believe (as I did) that medical research is being conducted in a coherent, structured, completely credible way, such that it will gradually solve all ills. That all one has to do is wait, and research will do the rest, finding cures for sicknesses long before we succumb to them. Maybe not, it seems. "Contemporary bio-medical research is itself very sick as an endeavour," O'Mahony says. "There is even an acknowledgement and a consensus within bio-medical science that it has lost its way. It's been estimated that anything up to 85pc of all bio-medical research is a waste of time. And that's at a cost of $170bn (€150bn) annually."
So what about the Human Genome Project, another shining light to many lay people with health issues? "The clinical applications from the humane genome project have been very few. And even the people who led the project, freely admit that the practical applications have been very disappointing. We're nearly two decades on from it now and very little has emerged that has been useful to sick people. It's a way of doing science, not a way of doing medicine."
There is a fairly negative trickle-down effect to this; "frontline workers, GPs, hospital doctors, who may not be carrying out any of the research, who just do what they're told in a way. I've drawn a parallel between modern medicine and medieval church: the higher level lay out dogma, the lower level work on the front line and implement it. They are not supposed to question any of it".
At a more practical level, there's the routine over-prescribing that goes on. "Pushing people into patient-hood," as O'Mahony describes it, "for marginally elevated cholesterol levels, for example. The statin story is a great example of how the medical-industrial complex works. The overwhelming majority of people prescribed statins for high cholesterol levels are never going to benefit from taking this medication, and may experience harm."
Connected with that, is poly-pharmacy, in which patients are prescribed further medication to deal with the side effects resulting from the primary medication, to the point where many elderly patients in particular are now taking five or more medications daily, all with their own side effects and possible complications.
This is O'Mahony's second book. His first, The Way We Die Now, published in 2016, won a British Medical Association book award, and this is very much a follow-on. "One of the themes that emerged from that book was that modern medicine has become this culture of excess, this technological runaway train. I took that theme and ran with it for this book."
Seamus studied medicine at UCC - he was the first person on his father's side to go to university. "There's a big thing in Ireland for doctors' children to become doctors," he says, "but I didn't come from any kind of medical background. My father worked in Ford's in Cork, he was a plasterer by trade and worked in the maintenance department. He was 20 years older than my mother. My mother's 86 now, my dad died 34 years ago; he was 71. I was only a year qualified when he died."
After UCC, he spent about four years doing junior hospital jobs in Cork, "then I emigrated to the UK". He worked in Edinburgh, Yorkshire and finally as a consultant in Leeds for five years, then moved back to Ireland in 2001.
"A job came up, and at the time I was about 40, and it was then or never. I was very happy working where I was, but I did have this feeling of questioning myself: ‘Do you want to grow old and spend the rest of your life in England?' The answer to that was I'm not sure, I don't think so. So I came back to Ireland, at peak Celtic Tiger."
He was married with two children - "I met my wife in Edinburgh. She's Scottish. We met while she was doing a PhD in the same lab but her background was science, not medicine. She subsequently retrained as a solicitor, working mainly in medical negligence."
The move back wasn't without its traumas. "My wife liked the idea of Cork so she was happy to move. My daughter was five and my son was seven; he found it difficult to adjust to school in Ireland. He found it hard going. I found it hard going too, I'll be honest, coming back after 14 years. I left in the 1980s, I came back and everything's crazy. It's the Celtic Tiger. It took a long time to adjust." But, as time has gone on, he says, "I'm very glad I did make the decision".
What would he like readers to take away from this book? "I write about the bogus contract between doctor and patient that has existed for several decades. The basis of this contract is that we can diagnose everything, fix most things, we never make mistakes and medicine is not dangerous. All of these things are untrue. We have limited powers. Medicine is very often ineffective and sometimes dangerous. We can't fix everything, particularly social and existential problems. I think society needs to lower its expectations around what medicine can deliver. That's one message I'd like people to take away with them.
"Then, there's this cultural thing in Ireland where a consultation with a doctor must conclude with a prescription. I'd like people to think, ‘Is this medication really going to help me?' I'd think about that in particular when it comes to drugs like statins, drugs for high blood pressure, high cholesterol, osteoporosis - these drugs that you're going to take for the rest of your life, maybe 40 years, with an overwhelming likelihood that it will not give you any benefit whatsoever."
As for where the evidence is coming from that such drugs "will not give any benefit", there's a thing called Number Needed To Treat (NNT), which is simply the number of patients you need to treat to prevent one additional bad outcome. The ideal NNT is 1. Statins have an NNT of 104. Meaning that 103 people will not benefit, and may well suffer side effects.
The industry side effect is that, because the money is in drugs taken over the long-term, that's where the money and research goes. There is, O'Mahony says, "no money, or very little, going into antibiotic development, because a prescription for antibiotics is for seven days; a prescription for dementia, they'll take it for 10-20 years. The return for a drug company on a new antibiotic is pretty low. The return on a drug for Parkinson's, chronic lung failure, dementia - they're huge returns."
On the subject of patient support groups and ‘raising awareness', he is scathing. "Ireland is stuffed with patient support groups. We're a tiny country, but the number of these groups... it's quite a big sector. Often, they are paying relatively well-known people reasonable wages to be chief executives." The real problem is that the raising awareness leads to a kind of ‘my disease is better than your disease' type scenario, where those who shout the loudest get the most, even where, as in the case of Orkambi, one of the best-known drugs and used to treat cystic fibrosis, the cost is around €100,000 per patient per year.
"Funding treatment on the basis of those who can best advocate - those who shout loudest - is bad. It's unfair, it's unscientific. It isn't how we should be allocating what is a finite resource."
And of course there is a particularly nasty downside to the whole ‘raising awareness' notion: the neglect of those who don't fit the profile or tick the virtue boxes. "I deal with a lot of people who suffer from chronic liver disease - this is a relatively young population, in their 30s, 40s, 50s, with established liver cirrhosis due to alcohol. It has a worse outcome than most cancers, but because it is perceived as self-induced and because it afflicts poorer, less-educated people by and large, you don't have awareness campaigns for investing in treatment for chronic liver disease."
Perhaps most alarming of all is his analysis of the future of the world of digital health - "Anyone with a smartphone will be monitoring themselves, or - more likely - will be monitored by some external agency. Health and life insurance companies will offer financial inducements to people to be monitored, and big corporations will undoubtedly make the wearing of health-tracking devices mandatory. The danger of all of this is that in countries where health care is paid for by insurance, a new underclass of uninsured people will emerge. Digital health," he points out, "is presented as something empowering, but the reality is that it will lead to forms of enslavement that we can barely imagine. Facebook and Google have shown how easily people hand over their privacy and personal data in return for a few shiny trinkets. They have also shown how this personal data can be monetised."
There isn't a single bit of that analysis that seems far-fetched, indeed much of it is happening already, but it is chilling.
There is also a strong current of social conscience that runs through the book. "Medicine and healthcare has relatively little effect, now, on overall population health," he points out. "Your health is far more likely to be determined by your education, your income, your job and where you live. Take the USA where they spend around 20pc of the GDP on healthcare and yet they have some of the worst outcomes, healthwise, in the world in terms of infant mortality, longevity and so on. We're spending an ever-increasing amount of money on healthcare, but the benefit to us as a society is getting less and less as time goes on." That healthcare budget, he says, should be put into housing, education, the eradication of deprivation, a boost in opportunity, the arts - "that's a more effective way to treat the health of the population."
Equally, he has simple, obvious solutions to the growing gap in global health inequality: "If we simply applied evenly and fairly across the world what we know currently works, medicine and society would be transformed. If we never did another new research project, and just took what we know now, and gave everybody access to it, global health would be transformed."
Why has he written this book? "I'm still at the coalface - I'm down there, working in the medical department, seeing people on trolleys, and it seems an awful long way away from the journals, research departments.
"What I am seeing every day on the wards doesn't tally up with the narrative that we as a profession present to our patients and our politicians - which is that everything is getting better. We've come to believe that our core function in medicine is to cure everything, extend life as far as possible, prevent diseases by putting whole populations on drugs and into screening programmes."
Which is impossible. Because if there is one piece of ‘raising awareness' O'Mahony is in favour of, it's the obvious: "I've suggested we should have different awareness campaigns," he says; "we're all going to die".
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‘Can Medicine Be Cured?' by Seamus O'Mahony, €20, is published on February 7 by Head of Zeus