FIRST PRINCIPLES

FIRST PRINCIPLES – SECOND DRAFTCharles Medawar, Social Audit Ltd 1 Community predicates personal health 2 Health outcomes matter above all 3 Real health implies critical social endeavour 4 Knowledge of limitations fuels wisdom 5 Doctor no longer knows best 6 Science is (only) the protein of understanding. 7 Human inputs energise the system 8 We need scale models of benefit and harm 9 Progress may be largely an illusion 10 We are not collectively capable of realising this

Skeleton argument Slides 1 - 4 What are the main drivers of health? Slides 5 -8 What system deficits and limitations? Slide 9 What problem, real and perceived? Slide 10 Is the problem soluble?

HEALTH WISDOM … • Community predicates personal health • Health outcomes matter above all • Real health implies critical social endeavour 4 Knowledge of limitations fuels wisdom

Reality check - 1 Only 3% of the US population manage to maintain a normal weight, eat a nutritious diet, take adequate exercise and not smoke. (US Centres for Disease Control: MMWR, 2001, 50, 758-761)

Reality check - 2 In the UK, two out of three prescriptions for SSRI antidepressants (> 10m/year) prescriptions are written for patients with ‘mild depression’ – when there is still no good evidence they are effective when so used.

Reality check - 3 “… one product's brand team realized early on in development that the drug was going to suffer from a weaker safety profile and only moderate efficacy when compared to its competition. With this knowledge in hand the developer was wise to invest heavily in a thought leader program that allowed it to make a strong connection with the medical community, thus easing fears about the drug's safety.” ‘Cutting Edge’ report on European Pharmaceutical Marketing ($6,995), press release, 15 September 2005.

System deficits and limitations 4. Doctor no longer knows best 5. Science is (only) the protein of understanding 6. Human inputs energise the system 7. We need scale models of benefit and harm

Progress may be an illusion – Slide 9 Understanding health outcomes depends on disentangling pervasive conflicts of interest The driving emphasis on development of new drugs is neither rational nor economically sustainable. Over-consumption of drugs in richer countries drives deprivations in poorer ones. Micro-examination of drug effects is insufficient as a measure of health gains; definitions of ‘effective’ and ‘safe’ invite misunderstanding. Quantity tends to crush quality in relation to drug information uptake. We have yet to address ‘the more-is-less health paradox’

The elusiveness of solutions – Slide 10 Such is the distribution of ‘power’ and ‘dependence’, the extent of secrecy, the rate of change of change, and the gulf between appearance and realities - and so deep is the ‘Conspiracy of Goodwill’ – that understanding and appropriate action will always tend to come too late, if indeed they arrive at all. Market values, extending to bought opinion and devious mass marketing of drugs, surely tends to be sickening? They increase ‘health anxiety’ – to an extent unknown. They upset the balance of interests and drive demand to extremes. Is pharmaceutical medicine really capable of improving - or is it doomed?

Community predicates personal health The notion that community is the bedrock of personal health and wellbeing is both self-evident and infinitely deniable: • personal health is overwhelmingly predicted by the example, attitudes, standards, traditions, behaviour and health and wellbeing of others. • but competitive and survival instincts, spurred by information mismanagement, promote denial of that reality.

Health outcomes matter above all Something rotten is happening to health. The gulf between ‘health’ and ‘healthcare’ is growing. “Organically grown health” is becoming a thing of the past in richer countries, and the over-consumption of drugs this drives in richer countries, causes deprivations in poorer ones. Understanding health outcomes depends on disentangling pervasive conflicts of interest Micro-examination of drug effects properties is insufficient as a measure of health gains. We are bedazzled by drugs and treatments that really are wonderful …

Real health implies critical social endeavour What is the meaning of ‘choice’ – and what are drugs for health - when only 3% of the US population manage to maintain a normal weight, eat a nutritious diet, take adequate exercise and not smoke? Health policies must reflect common sense; and health should reflect what society wants to be. Health also thrives on democratic process because it promotes the transparency and accountability without which both science and common sense are damned.

Knowledge of limitations fuels wisdom The wise consumer leaves expertise to the experts, but develops a shrewd understanding of how much even they do not know. Drug promotion and the abuse of secrecy tend to promote complacency, ‘ignorance of ignorance’ and indifference to enlightenment. No-one needs to apologise for not knowing the answer: experts who claim to know best often don’t, and relative levels of understanding may be a poor guide to the value of the knowledge base. The worship of new drugs is a case in point: better and fairer use of existing technologies may well be the healthier option.

Doctor no longer knows best … Thank God for good doctors – but medical interventions are no longer mainly determined by a doctor-patient relationship. The doctor is the last but one in a chain of understanding whose reliability is compromised by ‘Chinese whispers’ Doctors are overwhelmed: market values have already tainted medicine and threaten it as a health endeavour. Your doctor may be wonderful too, but in no position to move the system that ultimately defines what health means to you and me.

Science is (only) the protein of understanding Science is indispensable but also insufficient The dogma that discounts the therapeutic value of placebo effects, equating them to nothing, seems deeply health averse. The mindset that validates only the evidence produced by ‘science’ – and the assumption that no evidence of harm provides evidence of no risk – is appalling. VIDEO CLIP

[Re: the stranglehold of commerce and politics] “… one product's brand team realized early on in development that the drug was going to suffer from a weaker safety profile and only moderate efficacy when compared to its competition. With this knowledge in hand the developer was wise to invest heavily in a thought leader program that allowed it to make a strong connection with the medical community, thus easing fears about the drug's safety.” ‘Cutting Edge’ report on European Pharmaceutical Marketing ($6,995), press release, 15 September 2005.

Human inputs energise the system Human inputs, carbohydrates, complement proteins as vital nutrients of health. Hope and belief, tempered by experience and common sense are vital parts of effective medicine – also as feedback for the medicine itself. Information overload, data obesity, ‘viral marketing’ etc are overwhelming common sense. Quantity tends to crush quality in relation to drug information uptake. User reports of drug and treatment experience provide essential evidence on professional performance and drug value. They need systematic investigation.

We need scale models of benefit, risk and harm Present understandings are both intensely patchy and highly polarised. Close examination of molecules and cells cannot tell us much of what we need to know about the attainment of health and the avoidance of harm. The championing of drug benefit largely drowns honest, intelligent discussion of possible harms. We need urgently to develop taxonomies of drug benefit, risk and harm factors, and to understand the relevance of each. Medicalisation threatens global environmental disaster?

Progress may be largely an illusion Lack of fairness, access and equity underpin the global instabilities that none of us escapes . The driving emphasis on development of new drugs is neither rational, in health terms, nor economically sustainable. The present definition of an “effective drug” is damaging to health understanding – as is the dearth of information about adverse drug effects. We must address ‘the more is less health paradox’: take antidepressants or anxiolytics, for example

We are not collectively capable of realising this Such is the distribution of ‘power’ and ‘dependence’, the extent of secrecy, the rate of change of change, and the gulf between appearance and realities - and so deep is the ‘Conspiracy of Goodwill’ – that understanding and appropriate action will always tend to come too late, if indeed they arrive at all. Market values, extending to bought opinion and devious mass marketing of drugs, surely tends to be sickening? It increases ‘health anxiety’ – to an extent unknown. It upsets the balance of interests and drives demand to extremes. Is pharmaceutical medicine really capable of improving - or is it doomed?

FIRST PRINCIPLES 1 Community predicates personal health 2 Health outcomes matter above all 3 Real health implies critical social endeavour 4 Knowledge of limitations fuels wisdom 5 Doctor no longer knows best 6 Science is (only) the protein of understanding. 7 Human inputs energise the system 8 We need scale models of benefit and harm 9 Progress may be largely an illusion 10 We are not collectively capable of realising this

FIRST PRINCIPLES – SECOND DRAFT Charles Medawar, Social Audit Ltd