American Medicine Meets the American Dream Safe Food - The BMJ

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Murray's own medical training is drawn upon to great effect, as he describes ... of danger and fortitude, the young surgeon discovers that he and his European ...
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Better than Well: American Medicine Meets the American Dream Carl Elliott W W Norton, £19.95/$26.95/C$38.99, pp 357 ISBN 0 393 05201 X www.wwnorton.com Rating: ★★★

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oncepts of the self and self identity are part of the stock-in-trade of academic philosophy. However, grappling with such ideas is not an element of the day to day work of busy clinicians. The self rarely, if ever, shows up in an undergraduate medical curriculum, except perhaps in psychopathology. This may need to be remedied as we enter the post-genomic age and as clinicians face the advent of “enhancement technologies,” many of which are within the scope of

Safe Food: Bacteria, Biotechnology and Bioterrorism Marion Nestle University of California Press, £19.95/$27.50, pp 356 ISBN 0 520 23292 5 www.ucpress.edu Rating: ★★★

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here is much distrust of both the food industry and the ability of government agencies to protect the public from unsafe food. The current debate over genetically modified (GM) crops is a good example of the concern. One of the reasons for the distrust is that scientific risk assessments do not convince the many

Items reviewed are rated on a 4 star scale (4=excellent)

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general practice. Such technologies constitute a wide range of medical and surgical interventions, whose purpose is neither restorative nor curative (at least in principle) but transformative. One essential component of such technologies is that they can transform human self identity. What sorts of things are enhancement technologies? Carl Elliott, an American physician-philosopher, explores the use of medications such as selective serotonin reuptake inhibitors (SSRIs), human growth hormone, and cosmetic and other forms of surgery that can enhance or improve human appearance and wellbeing. He explores the history of psychiatry, the rise and fall of such conditions as a fugue state, repressed memory, and attention deficit hyperactivity disorder, as well as the emergence of new concepts such as “apotemnophilia” (an attraction to the idea of being an amputee, despite there being no medical reason for it). Therapies to reduce shyness, alter accents, and promote sexual function, and surgery to alter virtually any facet of appearance are now common. The development of gene based therapy will no doubt extend the range of enhancements available to biomedicine.

A book offering an account of such conditions runs the risk of sensationalism, but this is far from the case here. Elliott raises serious questions about the scope and nature of medical care. How do we (or can we?) make legitimate and defensible distinctions between medically necessary and superfluous therapy? Are happiness and enhanced self image the appropriate outcomes of medical intervention? Elliott intertwines his discussion of enhancement technologies with an examination of important issues in bioethics and philosophy. What is a person? To what extent are our ills socially constructed? The problems associated with enhancement technologies are also deeply related to affluence. It is fitting that the book’s subtitle refers to American medicine meeting the American dream. The enhancements that the book describes are most likely no more than a remote thought to the vast majority of the world. However, this is not to detract from the book, but to underline the importance of exploring how medical resources are developed and distributed in an inequitable world.

people who make value based judgments on the safety of consumer products. Another factor is that safety, whether of food or another product or service, has a political dimension that cannot be ignored, a theme throughout Safe Food and a help in understanding people’s concerns. There are interesting transatlantic similarities and differences in food safety. In both the United States and the United Kingdom, there have been scares caused by salmonella and Escherichia coli O157 food poisoning. In both countries, the agencies responsible for food safety have been perceived to put the interests of food producers ahead of public health. There have been calls for a single organisation that has overall responsibility for food safety in the United States, something that the United Kingdom has gained from the Food Standards Agency. A difference is that the American public has been much more accepting of GM crops than Europeans. True stories about outbreaks and legal actions can be exciting as fiction. In this book, the stories enlighten the more analytical sections, which are scholarly. The episodes of food contamination in the United States reveal the complex links in the food and pharmaceutical industries, and the

diffusion of responsibility that followed takeovers, mergers, and sales of parts of companies with their patents. Matching this scattering of accountability is the labyrinth of American government supervision and control. An impression left by the ineffectiveness of government agencies is that consumer organisations must exercise their powers if food is to be kept safe. A stimulus for the book was the terrorist destruction of the World Trade Center on 11 September 2001. This brings the discussion back from consumerism to the importance of the proper governmental organisations to monitor food safety and to respond to suspected contamination, whether accidental or deliberate. The book concludes with a clear statement of what needs to be done to ensure safe food, listing actions to be taken by the food industry, by the US federal government, and the public (for example, GM foods should be labelled in America, just as they have to be in Europe). This book is a good read for anyone trying to decide about GM food.

Ross Upshur Departments of Family and Community Medicine and Public Health Sciences and Joint Centre for Bioethics, University of Toronto [email protected]

Richard Mayon-White epidemiologist, Department of Public Health and Primary Care, University of Oxford [email protected]

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A Few Short Notes on Tropical Butterflies John Murray Viking, £14.99, pp 274 ISBN 0 670 91347 2 Rating: ★★★

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or anyone still looking for holiday reading and wanting to escape all things medical, this debut collection of short stories may, at first glance, not appeal. Most of them focus on a doctor as the main character, while others have medicine or medics as a brooding background presence. It is no surprise, perhaps, that all of the stories are written by a doctor. If none of these factors puts you off, you may be interested to know that this book is full of dramatic moments, insights, and images that grip, enlighten, and linger in the memory. The stories’ medical subject matter reminds us of the privileged access that doctors have into the lives of others. Their achievement also makes me wonder whether being a doctor lends itself, in some unique way, to the practice of creative writing. Murray’s own medical training is drawn upon to great effect, as he describes his characters’ practice with slick and authoritative detail. He also uses anatomising skill to get under the skin of these shifty doctors. He considers why they ended up in their chosen

Silent Scourge: Children, Pollution, and Why Scientists Disagree Colleen F Moore Oxford University Press, £24.95, pp 318 0 19 515391 X Rating: ★★

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olleen Moore is professor of psychology at the University of Wisconsin, United States. Her book reviews how pollution affects children’s development, looks at issues regarding how science and ethics are involved in environmental policy, and expands on the precautionary principle adopted in a 1992 United Nations declaration. She argues that preventive action should be taken in the face of uncer568

profession, by delving into their secret thoughts, their memories, and their family stories. In doing so, he makes exciting discoveries. He presents the discomforting paradox that physicians, who obtain more intimate knowledge of their patients than anyone, cannot easily commit to relationships themselves; or that they approach the relationships they do have with bizarre moments of detachment, because of their professional role. Thus, in the title story, a neurosurgeon daughter operates on her own father because she cannot trust her colleagues to “look after him.” Similarly, he presents doctors who take on massive responsibilities for others’ lives, but who are in denial about the need to safeguard their own. One such is the nameless narrator of “Watson and the Shark,” who has been posted to a besieged Médecins Sans Frontières trauma unit. In this tense account of danger and fortitude, the young surgeon discovers that he and his European medical colleagues are more lost and rootless than those they have come to help. Only emotional casualties volunteer for such ultimately pointless work. However, Murray then counterbalances such nihilism with the idea that it is this very process of emotional drift that drives these doctors to help their fellow human beings. As one senior surgeon puts it: “Every life saved is a triumph. That is what keeps us human.” This more hopeful message is developed in “The Hill Station.” It tells the story of Elizabeth, a 40-something clinical bacteriologist, who has dedicated her working life to the understanding of Vibrio cholerae, but who has never seen an actual clinical case. Her future takes a dramatic turn when she follows an uncharacteristically rash instinct tainty, involving public participation and wider alternative action. Children have less control over their environment than adults, and environmental policies that damage the present generation may affect future generations. Moore focuses on the effects of mercury, noise, pesticides, polychlorinated biphenyls (PCBs), lead, and technological disasters, partly because of the availability of research results on behavioural and psychological effects from these pollutants. In each chapter Moore examines why experts disagree, looks at problems with the way episodes of pollution have been handled, and concludes with a list of action points for parents, and those working for organisations that could control pollution exposure. The issues covered are undoubtedly thought provoking, and challenging. There have been huge improvements in the knowledge and the control of some pollutants, but we have not always learnt from past mistakes. The level of protection and strategies for dealing with adverse events are not evenly distributed across all sections of society or across different countries. There are also many unknowns. Moore has been ambitious in trying to cover all aspects of these pollutants and in

and travels to the slums of Bombay. Elizabeth’s emotional detachment is broken down, even “cured,” by the physical reality of a cholera epidemic that she encounters first hand. In turn, her emotional life becomes more available to her. Although such direct handling of doctors’ lives and their work is undoubtedly one of this book’s strengths, Murray also manages to say something about what medicine does to non-medics. In “The Carpenter Who Looked Like a Boxer” we encounter a bereft spouse and his bewildered children who have been abandoned by their psychiatrist mother, with no word of explanation. Murray unpicks their collective mystification with masterly restraint. Other important themes are also explored, such as how Western and developing world cultures interconnect and interact. Some of the main characters are of Indian descent, but living in north America. Some have travelled in the opposite direction. Even the contrasting cultural mindsets of the Western doctors, working side by side in stressful conditions, are delineated with great insight. Murray explores all of these themes with delicate skill. Mostly he uses his surgeon’s instinct to follow the dictum of the great American short story writer Raymond Carver: “Get in and get out fast.” On occasion, I felt that some of the narrative was over-inclusive, but, overall, with this impressive collection, Murray has fulfilled Chekov’s definition of good writing: “You feel life as it should be, in addition to life as it is, and you are captivated by it.” Iain McClure consultant child and adolescent psychiatrist, Vale of Leven Hospital, Alexandria [email protected]

providing background information with which to appraise different scientific approaches, summaries of statistical techniques, as well as details of the pollutants, their effects on health, and specific episodes of pollution. It is also ambitious to provide for such a wide readership—from parents to environmental control organisations, and across countries. For people to be empowered to take action, they need to have reliable and timely information about their exposure. A series of steps is needed to provide relevant, often local, information, recommendations for effective action, and sometimes legislation and measures to be taken by organisations as well as individuals. The balance of methods of action will need to vary according not only to the type of pollution and source but the economy of the population exposed. In some societies, the pressure of other circumstances will result in priorities being made about health care, prevention, and pollution. The recommendations in this book need to be set in the context of these priorities. Jane Melia team leader in epidemiology, Institute of Cancer Research, Sutton, Surrey [email protected]

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PERSONAL VIEW

SOUNDINGS

Failure

Paradigm shift

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Where are all the big ideas in medicine? A few days ago I was cycling up an interminable hill in the Dordogne. Although it was still early in the day, the heat was already punishing and the gravity unforgiving. I was rounding one of those shadeless bends, deliberately angled to punish the quadriceps, when I found myself thinking about my life and the odd, random contingencies that determine the course one takes. Suddenly I realised how horribly difficult I have always found medicine. It isn’t only the practicalities of dealing with large numbers of patients and bureaucrats. It is the lack of any satisfying academic synthesis of the subject. Learning medicine is like learning large volumes of irregular French verbs for O level. At A level I remember things improved enormously. Large organising principles fell helpfully from the sky. In the 1930s chemistry, like medicine now, was buckling under a wealth of experimental detail. Dull old professors assured everyone that, unlike physics, chemistry was far too complicated a subject for simple codification. Then Linus Pauling published his book on the nature of the chemical bond and suddenly chemistry could be understood rather than memorised. The unread medical journals piled on my desk at home are full of minutiae. Fragmented superspecialists from Armpit University publish variants on their doctoral thesis that have been reviewed by other gimlet eyed superspecialists who don’t speak to anyone who isn’t interested in heat-shock proteins. As I scrutinise these journals I squint abjectly at the detail, as one too close to the tesserae of a mosaic. I feel that if I could move away then patterns would emerge. Bring on the generalist, I say. Anyone who can make some sense of this horrible, tangled thicket of detail. Let’s have fewer randomised controlled trials and more ideas. With the full clarity born of Cahors wine I can now see that medicine needs a paradigm shift. Actually, I’m pretty sure that, while finishing that bottle on a verandah high above the Dordogne river, I myself had the startling insight that would tie the whole of medicine together. Sadly the waiter, like some latter day Person from Porlock, interrupted me and the thought was lost forever.

the self help organisation Alcoholics Anonyhe call from the emergency departmous. Yes, she had repeatedly tried AA. ment came in the wee hours of the Always dropped out. Why? There came a shy morning: the young woman was in. whisper: those darn reading assignments, not Again. Lynn. She was a frequent flyer, so only for studying but also to be read aloud in often in the hospital that many staff group sessions. She never had learned to members knew her and, unfortunately, read. Admitting illiteracy seemed too high a sometimes despised her. Incurable. Never a price to pay for sobriety. She simply stayed triumph. At best, one heroic stabilisation away. We called AA: “Yes, we expect them to before the next downfall. read. But they don’t have to.” Well, would you My patient was an alcoholic. Her cart want to appear obstinate? Or illiterate? slithered deeper into the morass, finally She bled again. No more varices to sinking, leaving just tears behind. What snare. Her jaundiced skin now shimmered medicine can do for alcoholics seems with a light green hue from biliverdin. The peripheral—a few drugs, some procedures to flood in her belly came back like a tidal wave. prevent or to stop bleeding, and, ultimately, Even our young students sensed that Lynn forced sobriety in an institution. was slipping away. We called Lynn was in her late 20s, her father and he came. Salt looking like 50-something Admitting of the earth, I thought. A and wheelchair bound after illiteracy seemed father who had borne his falling down a flight of stairs cross so long. Who could years beforehand. On this too high a price to ever fathom this tragedy? dreaded morning she had pay for sobriety He had no questions, no thrown up. Puked blood. suggestions in his quiet resignation, was as Again. Friends had dropped her off like a helpless as we. He handed me a business foundling, with her wheelchair as her cradle. card. Funeral director. Sensing my surprise, A heap of misery, guilt stricken and avoiding he said that he had prepaid Lynn’s funeral. eye contact, quivering and crouching in her Once it was over, just call the number on the dilapidated chariot that looked more like a card. He hinted that he might not come, now theatrical prop than a useful medical applior later. He might not see her ever again. No ance. Her lips stained red by blood, like exagtears. He was burnt out, used up, had all but gerated, careless make up. Her belly prolost his paternal love to an empty numbness truded as if she were with child. I thought of and perhaps long ago had joined the ranks an old Austrian term, armes Hascherl, a poor of shoulder shruggers. creature for whom one cannot help but feel Lynn died, of course. No postmortem tender pity. Her hobnailed liver barely examination. The pathologist’s findings sustained her life. seemed predictable: a shrunken hard lump I wondered why she was still at least in the right upper quadrant of her abdomen, somewhat alert, what with the ravages of once a liver. Still, no matter how meticualcohol on her brain. Unkempt, dirty, and lously we all would have searched, we would neglected by herself and those around her. not have found the cause behind the curse. Did anyone care? She thought dad might We cannot dissect a soul. come by. Mom? Lynn shrugged her shoulAlcoholism, a disease devoid of all glamders. So we tucked her in bed, repaired the our, is ill suited for a fundraiser in laboratory values as best we could and tried furtherance of care and to make her feel better, research. No poster child, dried her out, transfused Alcoholism is ill the drunkard is shunned, is her, and were again frusfrequently considered a trated at not having an arti- suited for a weakling and morally ficial liver, at least as a fundraiser bridge. But bridge to what? flawed, pushed to the I called our consultants and sensed increfringes of society. Does anything destroy self dulity. No, I was not joking, merely attempting esteem and pride faster than drunkenness? to leave my desperate patient with a tiny Yet happy people smile from billboards, flicker of hope. Well, OK, last spot on an drink in hand, luring us firstly to play volleyunmanageably long list. Now I could tell her ball and then to have a highball. Alcohol, she was on the desired roster. One condition: libation to the deity and old social lubricant, abstinence for at least half a year. Was I also greases the slide to skid row. deceiving her and myself? We talked about Where was the catastrophic failure? In Lynn’s genes? Did family, friends, and her teachers desert her early? Did our social fabric become so frayed that she slipped We welcome submissions for the personal view through? Maybe we all failed her . . . section. These should be no more than 850 words and should be sent electronically via our website. For information on how to submit a personal view Claus A Pierach professor of medicine, Abbott Northwestern Hospital and University of Minnesota online, see http://bmj.com/cgi/content/full/325/ Medical School, Minneapolis, USA 7360/DC1/1

Kevin Barraclough general practitioner, Painswick, Gloucestershire

[email protected]

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