The history of medicine in the fifty years since the end of the Second World War ranks as one of the most impressive epochs of human achievement. So dramatically successful has been the assault on disease that it is now almost impossible to imagine what life must have been like back in 1945, when death in childhood from polio, diphtheria and whooping cough were commonplace, where there were no drugs for tuberculosis, or schizophrenia, or rheumatoid arthritis, or indeed for virtually every disease the doctor encountered; a time before open-heart surgery, transplantation and test-tube babies. These, and a multitude of other developments, have been of immeasurable benefit, freeing people from the gear of illness and untimely death, and significantly ameliorating the chronic disabilities of ageing.
This post-war medical achievement is well recognised but much less appreciated is the means by which it was brought about. For the previous 2,000 years doctors had sought in vain for the ‘magic bullets’ that would alleviate their patients’ suffering and then, quite suddenly and without warning, they came cascading out of the research laboratories just as if medicinal chemists had hit the jackpot (as they had). Or again, in 1945, desirable objectives such as transplanting organs or curing cancer were rightly perceived as being unattainable, as there was simply no way of overcoming the biological problems of the rejection of foreign tissue or the selective destruction of cancer cells. But these and many other obstacles were surmounted. The past fifty years have been a unique period of prodigious intellectual ferment that, quite naturally, invite investigation.
There is a problem, however, in knowing where to start. The scale of the therapeutic revolution has been so vast that any comprehensive history would necessarily run to several volumes. Decisions had to be made about not only what to include and what, regretfully, to leave out, but also how to go beyond a simple chronological account to illuminate themes of more general significance. The compromise I have chosen is illustrated by the list of the major events of this period which identifies ‘twelve definitive moments’ that are considered in depth in a prologue that is necessarily longer than is customary.
* = A ‘definitive’ moment
The rationale of this selection is not of immediate concern but several themes are easy enough to identify, including the decline of infectious disease (sulphonamides, penicillin and childhood immunisation); the widening scope of surgery (the operating microscope, transplantation and hip replacements); major developments in the treatment of cancer, mental illness, heart disease and infertility; and improvements in diagnostic techniques (the endoscope and the CT scanner).
Each of these events is a remarkable story of human endeavour in its own right, but when they are assembled together then, as with dots of the pointillist, a coherent picture should begin to emerge. The value of such an historical perspective is not necessarily obvious. ‘Medicine pays almost exclusive homage to the shock of the new,’ writes the editor of The Lancet, Richard Horton. ‘We place constant emphasis on novelty … this is an era of the instantaneous and the immediate.’1 This preoccupation with ‘the new’ leaves little room for history and indeed medicine has got by well enough with no sense of its immediate past at all. Perhaps the history of twentieth-century medicine is solely of academic interest, an intellectual pastime for retired doctors but of little practical importance?
Needless to say, I do not share this view, but rather, taking my cue from T. S. Eliot – ‘the historical sense involves the perception not only of the pastness of the past, but of its presence’ – maintain it is not possible to understand the present, and in particular present discontents, outside of the context of this recent past. And what is the nature of these ‘present discontents’? Any account of modern medicine has to come to terms with a most perplexing four-layered paradox that at first sight seems quite incompatible with its prodigious and indubitable success.
It might be expected that the success of modern medicine should make it a particularly satisfying career, but recent surveys consistently reveal that increasing numbers, especially of younger doctors, are bored and disillusioned. The London-based Policy Studies Institute has found the proportion of doctors ‘with regrets’ about their chosen career has increased steadily from 14 per cent of the 1966 cohort to 26 per cent of the 1976 cohort to 44 per cent of the 1981 cohort and to 58 per cent of the 1986 cohort.2 These findings should not be taken at face value, as spasm of self-doubt may become commoner for any number of reasons. Nonetheless, they would seem to be symptomatic of a genuine – and serious – trend. Until very recently – and in marked contrast to the experience of the other liberal professions, virtually all medical graduates went on to practise medicine. But no more. In 1996 one quarter had no plans to work in the Health Service, accounting for both the progressive decline in the numbers entering general practice and many hospitals reporting difficulties in recruiting junior doctors. What has happened to explain why today’s young doctors are so much less content than those who qualified thirty or more years ago? It is important to know, not least because those unhappy with their trade may lack the passion necessary to practise it well.
The benefits of modern medicine in alleviating the gear of illness and untimely death should have meant that people are now less worried about their health than in the past. But once again, the trend is the reverse of that which would have been expected. The proportion of the population claiming to be ‘concerned about their health’ over the last thirty years has also increased in direct parallel to the rise in the number of ‘regretful’ doctors – from one in ten to one in two.3 And the most curious thing about this phenomenon of the ‘worried well’ who are ‘well’ but ‘worried’ (that they might not be) is that it is not simply symptomatic of privileged life in the West, where ‘people don’t know when they are well-off’, but that it is medically inspired. The well are worried because repeatedly and consistently they have been led to believe their lives are threatened by hidden hazards. The simple admonition of thirty years ago – ‘Don’t smoke, and eat sensibly’ – has metamorphosed into an all-embracing condemnation of not just tobacco but every sensuous pleasure, including food, alcohol, sunbathing and sex. Further, every year brings a new wave of ‘dangers’, which in 1997 included low-fat milk and margarine, computer screens, head-lice shampoo, mobile phones and much else besides, while Britain’s Chief Medical Officer warned that eating three lamb chops a day or its equivalent increased the risk of cancer.4 This Healthism – a medically inspired obsession with trivial or non-existent threats to health whose assertions would in the past, quite rightly, have been dismissed as quackery.5
The demonstrable success and effectiveness of modern medicine should have marginalised alternatives such as homeopathy and naturopathy into oblivion. Not so. In the United States there are more visits to providers of ‘unconventional therapy’ (425 million) than to ‘primary care physicians’ (388 million). As the efficacy of alternative therapies is not routinely tested in clinical trials (which does not mean they do not work), it is only natural to ask why the public should appear to have so much faith in them.6
The more that medicine ‘can do’, the higher will be its cost, which will be further compounded by the continuing rise in the numbers with the greatest need – the elderly. Neither or these two factors, however, can begin to account for the massive escalation in the resources allocated to health care. Thus the budget of Britain’s famously ‘cheap and cheerful’ National Health Service has doubled in the last decade, from £23.5 billion in 1988 to £45 billion in 1998 – an increase of £21.5 billion. This financial largesse of the last ten years suggests that the almost universal belief that the problems of the health service would simply be solved by more generous funding, must be incorrect.7
In summary, then, the four-layered paradox of modern medicine that needs explaining is why its spectacular success over the past fifty years has had such apparently perverse consequences, leaving doctors less professionally fulfilled, the public more neurotic about is health, alternative medicine in the ascendancy and an unaccounted-for explosion in health-service costs.
It is important to keep a sense of proportion about all this. In general, doctors do find fulfilment in their work, and in general people appreciate the benefits of modern medicine, as anyone whose mobility as been restored by a hip replacement or whose spirits have been lifted by an antidepressant will testify. But the same point could be put the other way. It is precisely because medicine does work so well that the discontents reflected by these paradoxes are worthy of explanation.
These are complex matters and there are many reasons for each of these paradoxes. But ‘history is a high point of advantage from which alone men can see the age in which they are living’ (G.K. Chesterton), and from the high point of advantage of a historical perspective of medicine’s last fifty years it is possible to perceive there might also be a single unifying explanation that can readily be seen from the earlier chronology of major events. The crucial factor is the dates, with the massive concentration of important innovations from the 1940s through to the 1970s followed by a marked decline. There has been, as suggested in the title of this book, a ‘Rise and Fall’, which provides the key to understanding the paradoxical discontents of modern times.
But when this historical account opens, such matters are still a long way off. Imagine, rather, that Europe is in the throes of war, children are still dying from whooping cough and polio, the inmates of mental asylums are lucky to see a doctor from one year’s end to the next and curing cancer or transplanting organs seem like unattainable fantasies. And yet there is a terrific sense of optimism in the air. Medicine’s greatest epoch has already begun, and the possibilities of science seem limitless.