Is less medicine a bad thing?

Medical consultants are anxious that too few acute medical cases are being reported at A&E departments during the on-going crisis. This they claim predicts a potential surge in morbidity and mortality from diseases such as; heart disease, lung disease, mental illness and cancers, once Covid-19 is dealt with. It seems a logical conclusion given that there was, for example, in one Health Trust, a 33% reduction in reported heart attacks in March and April. Consultants reason that people are having the same number of heart events as in previous years but simply not reporting due to fears of entering the health system.

GP’s too are concerned. In an open letter to Robin Swann published in the Irish News they say it is time to get back to normal. Too many patients, they claim, have been denied, or have been afraid, to access care over the past three months. How many additional deaths are we willing to accept? they ponder. With the unknowns in February and March it was right to shut the Health Service down and keep our hospitals and general practices as Covid-19 free as possible. It was also right to transform it to manage an unknown surge of very ill patients. But things have moved on. The SARS-CoV-2 virus is a killer but not on the biblical scale predicted; remember the 14,000 deaths Robin Swan announced? Rather than be swamped, our main hospitals have been eerily quiet, the Nightingale hospitals were not really used and the Covid Centres- set up to deal with community based covid-19 cases – on reflection were surplus to requirements and should have been stood down when that became apparent in mid-April.

Sandeep Janhur, a US cardiologist writing in the New York Times is relaxed about the public’s lack of access to American healthcare over recent months suggesting that in the round this might be a good thing. He identifies a recent survey which shows that where most citizens had less contact with healthcare during the pandemic only 10% felt their condition had got worse. American healthcare is wasteful and Janhur suggests that up to 30% of American healthcare provided is unnecessary. Unsurprisingly there was a quick response from his colleagues accusing him of endangering patients.

Off course this is an old argument raised first by Ivan Illich in his book Limits of Medicine back in the 1970s and it’s a theme we keep coming back to. Richard Smith when editor of the BMJ had a themed edition of the magazine on this topic and produced, with medical journalist Ray Moynihan, an excellent editorial “Too Much Medicine?”. This explored the limits of medicine but also the vested interests of the medical professions and pharmaceutical industry through the benefits derived from even more interventions.

When doctors go on strike, fewer people die. In 1973 doctors in Israel staged a month-long strike and during that month, mortality fell by 50 percent. A couple of years later, a two-month work stoppage by doctors in the Columbian capital of Bogotá led to a 35 percent decline in deaths. And during a “work slowdown” by doctors in Los Angeles protesting against the sharp increase in premiums for liability insurance, the number of deaths fell by 18 percent. The worrying thing is that once doctors were back at work full-time, mortality immediately jumped back to the previous level.

Medical interventions are not without risk. Every year, 1.2 million of us across the UK are hospitalized as a result of improper medical care. In the United States – where 40,000 people are shot dead each year – the chance of getting “killed” by a doctor is three times greater than being killed by a gun. And every year significantly more people die from an infection sustained while in the hospital than as a result of traffic accidents.

The Covid-19 crisis has reminded us of the significant limitation of medical interventions and the real importance of public health. Over the past 50 years the public has been willingly lulled into a false sense of security that when they get ill there will always be a cure or a treatment to save them. When official medical support is removed such as happened in Israel and Columbia and more recently across the World due to Covid-19, people seem to take more responsibility for their own health and this may result in better health outcomes.

It will be some time before the true health impact of the last three months becomes clear. What is already clear is that a stronger focus on self-care and disease prevention should be a greater feature of the future of our health service and of course this is exactly what Professor Rafael Bengoa prescribed for us but it is a medicine our politicians up to now seem less willing to swallow.

Photo by DarkoStojanovic is licensed under CC BY-NC-SA