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Human Frontiers, Environments and Disease: Past Patterns, Uncertain Futures Tony McMichael Cambridge University Press, £14.95, pp 413 ISBN 0 521 00494 2 Rating: ★★★
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he growing public protests that have been punctuating G8 and World Trade Organization meetings remind us that the globalisation of trade and finance is giving rise to ever greater social and economic disparities. There are other challenges associated with ongoing global change. Health inequalities across a wide
Bodies Politic: Disease, Death and Doctors in Britain, 1650-1900 Roy Porter Reaktion Books, £25, pp 328 ISBN 1 86189 094 X Rating: ★★
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his book comes well announced: “. . . splendid book . . . a tonic to those dismayed by the current writingdown of English history” (Sunday Telegraph); “. . . exhilarating” (Sunday Times); “simply superb” (New Statesman). This should be enough not only to whet the reviewer’s appetite but also to bias opinion. And yet my reaction at the end of an enjoyable read is one of Items reviewed are rated on a 4 star scale (4=excellent)
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range of diseases, risks, and consequences suggest cultural, economic, and political causes. There is also an emerging pattern of health associated with the permeability of national borders to old and new infectious threats; to violence and substance abuse; to the growing prominence of chronic diseases; and to environmental hazards. Disparities in health between social groups exist in all cultures, but are not inevitable. These inequities can be challenged with purposeful public policy. The combination of infection, malnutrition, and population pressure has sapped the vitality of communities for generations. New problems are being added constantly. Industrial development, often without restraining regulations, is causing environmental damage and disease; some of the worst health dangers of the industrialised world, such as cigarette smoking and traffic injury, are becoming increasingly common. Fortunately both political and industrial leaders are beginning to accept the concept of global interdependence. They are recognising that the action of groups, communities, and nations in one part of the world
affect those living at a distance and react ultimately on all of us. McMichael has produced an excellent treatise on these changing patterns of human ecology and disease. He steps back successfully from the more biographical accounts of disease risk to which we have been exposed in recent times and concentrates on cultural, evolutionary, and historical influences. Cogently he advocates for man not to try to reverse the clock—all of Earth’s ecosystems being already under human domination—but instead to reduce “the size of our collective ecological footprint.” He reminds us forcefully that time is relatively short to seek sustainable ways of living. The issues are complex, communities resist change, and politicians have short term goals. If we are to stem the tide of inequity, we need dynamic international leaders to make concerted efforts. These prominent individuals and their advisers should use McMichael’s analysis to inform their actions.
disappointment, disappointment that a magnificent opportunity to do justice to an immense and unique labour of historiography has been squandered. Let me explain. Roy Porter’s purpose in Bodies Politic is to rescue imagery from obscurity and academic denigration, and to integrate it with the traditional way of portraying history in writing. He rightly sees the microcosm of medicine as “a costume drama or a travelling circus, embodied in performance, rhetoric, and ritual history,” which is therefore ideally suited to the application of an added dimension, namely the pictorial medium. On one front he succeeds, but his publisher fails him, and fails him badly. In a book that espouses imagery, presentation, design, and reproduction of the chosen imagery are paramount, and this book fails in all of these and does the author a grave disservice. Bodies Politic, by the author’s own admission, purports to be a “coffee table” book, yet it lacks all the merits of that often deprecated species. It is too small to allow for illustrative display, the design is awful, the pictures are badly reproduced (especially the black and white illustrations), the colour illustrations are grouped in sections so that the reader is forced to flick forward or back to find them, and when they are located the print size of the captions is so small as to be painful to read.
Leaving aside these criticisms, the text is indeed a rollicking jaunt through a quarter century of English medical history. The extent of Porter’s research is truly vast, and yet he manages to assemble his material in an erudite and readable style full of surprises and not infrequent gems. For example, when John Radcliffe, who often assumed an anti-intellectual pose, even going so far as to claim he had never read Hippocrates, bequeathed his library to Oxford, Samuel Garth quipped that “it was a bit like a eunuch founding a seraglio.” The social attitudes of the times are joyously put in perspective (and not so joyously illustrated) from Swift’s denigration of the aging trollop, to James Graham’s exhortation that “the genitals are the true pulse, and infallible barometer of health,” and onwards to the Victorian era and the likes of Lancet founder Thomas Wakley, whose contribution to progress, in Porter’s view, was his recognition that the sorry state of medicine was attributable to it being “a house divided against itself.” Bodies Politic is both a failure and a success. One hopes that the book can be published again doing justice to the illustrative material.
Donald Campbell public health medicine specialist, public health services, MidCentral Health, Palmerston North, New Zealand
Eoin O’Brien professor of cardiovascular medicine, Beaumont Hospital, Dublin, Ireland
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reviews
Scions made simple How the world’s media dealt with human cloning
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everino Antinori must be the most famous gynaecologist in the world. His plan to start human cloning by November has been universally condemned, in papers from Europe to Uruguay. The 55 year old doctor, who qualified in Rome in 1972, is not unused to making headline news. In 1994 he helped a 62 year old to conceive and go on to become the oldest woman in the world to give birth. His controversial infertility treatments have incurred the disapprobation of the international medical establishment and the wrath of the Catholic church. Ironically, Antinori’s clinic is located a few hundred metres away from the Vatican. These bare bones of a career have been rehashed in papers the world over since 7 August, when Antinori announced that he and two colleagues, Panayiotis Michael Zavos and Brigitte Boisellier, now proposed to impregnate up to 200 women with cloned embryos. Many papers were not surprised by the announcement. The New York Times (9 August) said: “With all the hoopla over advances in genetics and reproductive technologies in recent months, it was only a matter of time until some headline-seeking scientist would try to create a baby through
controversial cloning procedures. Even so the assertions this week . . . are appalling.” In many countries the media advanced religious arguments against the proposals, saying that to try to clone humans was to play God. Elsewhere the case against Antinori was that his plan was scientifically unsound and dangerous. The New York Times’s response was typical: “This is still a highly experimental technology that carries enormous and unpredictable risk for the wellbeing of any human that might result from this procedure.” Antinori sees himself as a man unfairly persecuted by the religious and medical establishment. In an interview with France’s Libération (10 August) he said: “They can call me Hitler or Frankenstein, if they want. Personally, I prefer to compare myself to Galileo. I am a victim of intolerance.” The Times of India (13 August) added to the similes: “He is already sounding like a pariah or a pirate rather than the Promethean pioneer that he wants to be.” But it added: “What if Dr Miracle does manage to pull off a coup de triumph thanks to his vaunted ‘refined methods of cloning and meticulous screening of embryos?’ ” This is a story in which clichés of scientific hubris have abounded. Time magazine, in a special issue (7 August) devoted to the question “Is human cloning an inevitability?”
Landfill sites The history of the world is contained in its waste. Back in the
WEBSITE OF THE WEEK
Gavin Yamey deputy editor, wjm—Western Journal of Medicine gyamey@ ewjm.com
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early 1900s, a city’s waste included horse carcasses, coal ash, and street sweepings. Today it contains cosmetics, cleaning agents, and compact disc cases, and it mostly ends up in landfill sites. Friends of the Earth, in its Citizen’s Guide to Municipal Landfills (www.foe.org/ptp/manual.html), calls modern waste “the detritus of modern civilisation.” While there is no dispute that landfills contain toxic chemicals, the health hazards remain controversial. Should we be concerned? After all, landfill sites, once they are full, are sealed with an impermeable cover that is supposed to stop or slow waste degradation. But on the web, there are plenty of sites arguing that the toxic byproducts can escape. The Action Center, a collective of activists in Philadelphia, maintains an impressive resource on landfill leaks (www.ejnet.org/landfills), including a link to a list of recent academic and popular publications on landfill safety (www.gfredlee.com/plandfil2.htm). A paper in this week’s BMJ (p 363) adds to the growing evidence of an excess risk of congenital anomalies and low birth weight near landfill sites. One of the joys of searching the web is that you get not only “the big picture” about a topic, but also some fascinating minutiae. With typical British understatement, the minutes of a local council meeting begin: “The community of Bletchley record [sic] that the WDA201 license site still smells” (http://members.netscapeonline.co.uk/westbletchley/report3.htm). The small US town of Brant has, it seems, fended off proposals for a local municipal landfill (http://nobrantfill.freeservers.com/). Maybe the anthropologist Margaret Mead was right in saying that we should “never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has” (www.quotegeek.com/Literature/Mead_Margaret).
asked, “Can this genie be put back?” Andorra’s La Vanguardia (9 August) was not sure: “Pandora’s box is half open.” How did the world’s media grapple with the science of human cloning? The answer is, very economically. The Borneo Bulletin (13 August) said: “The nucleus of a woman’s body cell is transferred into one of her eggs to begin the process which eventually leads to the creation of an embryo. The embryo is then transferred into the woman’s uterus to establish pregnancy.” Hey presto. Several papers made clear the distinction between therapeutic cloning—the reproduction of embryos for the purpose of gathering stem cells—and reproductive cloning, the method that produced Dolly the sheep. Any blurring of terms seemed to come from Antinori himself. Italy’s La Stampa quoted him saying: “Ours will be an experiment of therapeutic cloning for those couples who have no hope of having children.” The Gulf Daily News, also known as “the voice of Bahrain,” (13 August) thought that media coverage of Antinori’s proposal was more about a famine of hard news than serious science. The paper blamed the American National Academy of Sciences, which sponsored the international conference in Washington at which Antinori and his colleagues spelt out their plans, for giving the trio the time of day: “Free speech is important, but if the organisers thought that giving these three people a high-profile international platform would advance public understanding of the arguments for and against the cloning of human cells, they are hopelesslly naive about the media.” New Zealand’s Waikato Times (10 August) just couldn’t see the logic of it all: “On paper there is no good reason why human cloning should be of interest to science. There are already six billion people on the planet and there is no need to produce more at great expense.” An editorial in Uruguay’s Ultimas Noticias (9 August), however, expressed deep concern. “The unquestionable values of humanity allow and demand a clear stance of opposition in this issue against all the Antinoris.” How many Antinoris are there? Is there something we haven’t been told? Helen Barratt Clegg scholar, BMJ Trevor Jackson assistant editor, BMJ BMJ VOLUME 323
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reviews
PERSONAL VIEW
SOUNDINGS
The price isn’t right
Alphabet soups
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In June, regulatory authorities warned consumers against using colloidal silver, now widely advertised on the internet as a powerful antimicrobial medication. By now this agent has internet chat groups, user sites, accounts of how silver has an honourable history going back to the middle ages, and sites selling devices for making one’s own colloidal silver inexpensively at home. Prospective buyers are told to use silver at the first sign of a cold by rubbing it on to the oral and nasal mucosae. Other uses are listed in the form of an alphabet soup which includes acne, allergies, arthritis, athlete’s foot, burns, cancer, candida, chronic diarrhoea, cold, cuts, ear infections, emphysema, eye infections, flu, fungal infections, giardiasis, head lice, herpes, hepatitis B and C, hypertension, lyme disease, osteomyelitis, psoriasis, ringworm, sinusitis, skin infections, sores, surgery, throat infections, ulcerative colitis, urinary infections, warts, wounds, and yeast infections. Space does not allow me to list the many other alphabet soups that may be found on the internet. We find, for example, that sufferers of the common cold may be helped by Asian ginseng, astragalus, blackberry, boneset, coltsfoot, elderberry, eleuthero, eucalyptus, goldenseal, horseradish, marshmallow, meadowsweet, mullein, myrrh, red raspberry, sage, schisandra, slippery elm, usnea, wild indigo, and yarrow. Also on the internet, we find advertised the many disorders helped by local or systemic administration of St John’s wort. There are similar alphabet soups for garlic, for vitamin E, for zinc, and for glutamine. But the best medicine is the redoubtable Life Extending Preparation. It is effective in allergies, Alzheimer’s disease, amyotrophic lateral sclerosis, anaesthesia precautions, atherosclerosis, attention deficit, autoimmune disorder, cancer, catabolic wasting, depression, Down’s syndrome, emphysema, gingivitis, HIV, hypertension, immune enhancement, influenza, macular degeneration, menstrual disorders, multiple sclerosis, muscle building, nails, neuropathy, oesophageal reflux, osteoporosis, parkinsonism, retinopathy, thrombosis, and wounds. How much shorter is the list given by the great Paracelsus (1493-1541) for his Tincture of Philosophers: it merely cured cancer, colic, dropsy, falling sickness, fistulas, and noli-me-tangere.
cost me £3,600. This was a price our (now) s practising doctors we both knew the one income family could afford (just). After a diagnosis. But there is still a seismic few weeks and several letters from the shock to the soul when the words British suppliers offering me the drug at two multiple sclerosis pass the neurologist’s lips. and a half times what I had paid for it, I My wife’s mildly inconvenient limp had sudbecame increasingly angry. When I wrote to denly become a life sentence of wondering my MP pointing out the appalling price diswhat terror each new day would bring, and a parity, I received a bland reply from the sense of loss of one’s future, not unlike a Department of Health saying it was because bereavement. of “factors beyond our control” and “overall A few days later we went on holiday. The little difference in price.” limp was no worse and we needed time to I decided that I had to make the public think. We decided to try to carry on as aware of the ridiculously inflated price in the normal for as long as possible, my wife as UK. I went on national television and radio, part time specialist registrar in microbiology in the national and local papers. All I have and myself as a consultant anaesthetist. Our received are dozens of heartbreaking letters two children were too young to understand from people in a similar any implications. position to ourselves, who Stupidly, we thought that cannot afford the drugs in some form of treatment Why does a drug the UK, but could just afford would be available, certainly the same drug in Australia: physiotherapy, possibly that costs £6000 a general practitioner, for interferon. In fact, physio- in Australia cost example, who was on intertherapy took many weeks to feron for years with no arrive. As for interferon, nei- £13 800 in the relapses, only to be taken off ther of us was keen. We read UK? it when funding was about the trials, we learned withdrawn—less than three of the side effects, and we thought that perhaps we might be lucky: it years later he is in a wheelchair; parents, dismight be years before another attack. But we traught at a loved one’s plight but too poor weren’t lucky. My wife continued to get small to help; a man who sold his house to pay for attacks—weakness in her hand, patches of his wife’s interferon and now lives in a caranumbness, worst of all the terrible fatigue that van. A patient four miles up the road from finally curtailed her career. him, one of the lucky few, receives funding We decided to accept the neurologist’s for the drug from the state. offer of a short (outpatient) course of high These are not easy letters to reply to. As dose methylprednisolone. That certainly a doctor it wasn’t too difficult to import improved my wife’s neurological problems, interferon at a realistic price. As a patient it but at the cost of crippling postural would be much more difficult. I am not hypotension. When the attacks returned we angry at the cruel blow fate has dealt my decided there was no choice but to consider wife. I am not angry that we have to pay for interferon. Our neurologist agreed. “Frankly treatment ourselves. I am angry for the 20% she should have been on it on day one, of MS sufferers who would benefit but who but there is no funding—you have to find cannot get the drug from the state, or at a £13 800 per annum.” With 300 or so equally realistic price, and for whom hope has all suitable patients and funding to treat only but been extinguished. Most of all, however, 17, I could sympathise with him, but I still I am angry at a Department of Health that felt bitter at our circumstances. A chance doesn’t care enough about the people it is remark gave us an intriguing possibility of there to serve to be able to ask why a drug obtaining the drug more cheaply. “Of that costs £6000 in Australia costs £13 800 course, on the continent you’d get the drug in the UK. paid for by the state as you would in In May, health secretary Alan Milburn Australia, but in Australia it’s less than half told people with MS that they should lobby the UK price.” pharmaceutical companies to reduce drug Australia. I had contacts in Australia. I costs. Peter Cardy, chief executive of the MS made a few calls and found a mechanism for Society, said at the time, “This latest turn in getting the stuff. A few days later I picked up deciding whether the NHS should give a shipment. I purchased three months’ people with MS the drugs they need is supply for £1,642 after shipment and insurabsolutely astonishing. They have already ance. In the United Kingdom this same endured years of the postcode prescribing drug, made in the same factory, would have lottery and many months of bungling by the National Institute for Clinical Excellence. Now, incredibly, they are being told that the answer lies in their own hands.” If you would like to submit a personal view please send no more than 850 words to the Editor, BMJ, Andrew Dyson consultant anaesthetist, King’s BMA House, Tavistock Square, London WC1H Mill Centre for Healthcare Services 9JR or email
[email protected]
George Dunea attending physician, Cook County Hospital, Chicago, USA
[email protected]
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