Demographic entrapment

reviews BOOKS • CD ROMS • WEBSITES • MEDIA • PERSONAL VIEWS • SOUNDINGS • MINERVA The Baby Makers Jack Challoner Channel 4 Books, £14.99, pp 176 ISBN 0752217011 Rating: ★★★★ B aby making is supposed to be fun and—judging from this overpopulated planet—straightforward. Not so for the one in six infertile couples, an estimated 80 million worldwide. Their devastation may be like that of Rachel, the barren biblical character, who said: “Give me a child else I die.” Enter the baby makers; How the Idea of Profession Changed the Writing of Medical History John C Burnham Wellcome Institute for the History of Medicine, £32, pp 195 ISBN 0854840672 Rating: ★★ S o, what is a profession? The modern French word is general, referring to the civil status of having an occupation, such as being an artisan or even unemployed. The German Beruf carries the idea of the Latin “vocation”—a calling to which one responds by professing. After finding no word in his language, a Japanese researcher declared that the term was parochial, only making sense in European history since late medieval times. Different then in time and place, the concept of the profession has evolved, and Burnham’s intriguing thesis is that it can be understood only through a historical, if not a historiographical, approach. BMJ VOLUME 319 9 OCTOBER 1999 www.bmj.com those who have dreamt of, and achieved, the revolutionary breakthroughs and advances in assisted conception. Probably the most memorable date in the history of assisted conception is 25 July 1978, when Louise Brown, the world’s first in vitro fertilisation baby, was born in Oldham. This was made possible by the collaboration of the scientist Robert Edwards and the gynaecologist Patrick Steptoe. Since then, in a relatively short time, the technique has spread considerably, with over 150 000 cycles reported worldwide every year. This has led some people to consider in vitro fertilisation as the most important medical advance of the 20th century. Probably the hundreds of thousands of babies born as a result of in vitro fertilisation would agree. Jack Challoner recounts the struggles, both practical and political and moral and ethical, that led to this event and explains the development of many other assisted concep- tion techniques. This is a rapidly changing subject, but he manages to include recent developments such as cloning, ectogenesis, and microsort sex selection. His explanations are precise and clear for lay people, and he has the gift of being simple without being simplistic. I, for one, have learnt from this book better ways of explaining to my patients what happens behind the closed doors of the in vitro fertilisation laboratory. This is also an intensely human story with strongly opinionated opponents and proponents. Challoner manages to put the arguments for and against objectively—so much so that you cannot tell his own position and you may start to question yours. The historical background, scientific facts, future developments, and ethical arguments are blended together by a master storyteller. And fascinating it is, to study the writing of medical history with this question in mind. We can trace no less than the rise and fall of the medical profession. From the 17th century onwards, medical historiography can be followed as it defines, redefines, and revises the idea of profession—the one influencing the other. Physicians have always had a habit of writing the history of medicine in an attempt to understand what medicine is. To begin with, “Great Doctors” dominated, as “Great Ideas” do so now. The first key concept of the profession is the idea of a body of knowledge—special learning that represents the joint stock, the defining and proved possession of the professional. The discoveries of scientific medicine contributed to this, redefining the professional as one who had particular expertise as well as knowledge. Gradually, the sense of belonging to a group created a collective noun: the profession was a social entity. Group standards reinforced exclusivity, disqualifying outsiders—thus institutions grew, and ethical and behavioural considerations developed. In 1804 the professional was “distinguished for liberal knowledge, and honourable from the rank assigned in society.” By 1912, “professional” included an inquiring mind, hard work, tolerance of adversity, and not charging the poor. Learned, practical, disciplined, altruistic—perhaps the Flexnerian definition of the professional holds good for many today. But by the 1960s a wave of antiestablishment anger hit the professions, and expertise itself—the original basis for professional authority—came under attack from books such as The Tyranny of the Experts: How Professionals Are Closing the Open Society: “The failure of the professions has become increasingly apparent . . . the professions justify themselves as organised efforts to assure that society’s vital needs are met . . . [they] are unmet, and the organised professions seem perversely or arrogantly opposed to change.” Thus, Freidson asked the question Are Professions Necessary? (1984) and asserted that “societal trends, both technological and ideological, are rendering the concept of profession obsolete.” Undoubtedly, professions evolve according to changing economic and social circumstances. Whether the professions have suffered (or should suffer) irretrievable decline is arguable, but definitely topical. What seems certain, however, is that the concept of professionalism continues to intrigue, remaining historical and local, ambiguous and even contradictory—like the writing of history itself. Khaldoun Sharif consultant and director of assisted conception services, Birmingham Women’s Hospital, Birmingham Richard Westcott general practitioner, South Molton, Devon Reviews are rated on a 4 star scale (4=excellent) 1011 Curing the incurable Equinox, Channel 4, Monday 4 October at 9 pm T he human brain is the most complicated machine in the known universe. In “Curing the Incurable” biotechnologists explain how to repair it when it goes wrong. It’s amazingly simple really. Attach a stereotactic frame and locate the target with magnetic resonance imaging, make a burr hole, insert a fine cannula into the damaged area, squirt in a few specially engineered cells, and wait for them to reinnervate and restore lost function. Early on, we are introduced to two victims of stroke. Both had a moderately severe right hemiparesis and a degree of dysphasia and, understandably enough, were desperate to find an effective treatment. They were two out of a dozen stroke patients who had volunteered to receive an intracerebral transplant of a cell line derived from a testicular teratocarcinoma. We watched one of them having the cells injected. Five months later, he had regained some movement in his right thumb. But this rather modest improvement doesn’t dampen the optimistic tone. Stem cell transplantation, we are told, is the key not only to repairing damaged brain but to thwarting the whole ageing process. Stem cells have the potential and contain all the necessary instructions to transform themselves into any type of cell. So all you have to do is find the right trigger to make them differentiate. Why shouldn’t stem cell transplants be used to repopulate a failing heart with vital young myocytes? Or a diabetic pancreas with new islet cells? Or an arthritic joint with fresh chondrocytes? Hold on a moment. The first intracerebral transplants in humans were carried out in the 1980s with grafts of adrenal medulla or fetal neural tissue in an attempt to treat Parkinson’s disease. Since then, progress has been made but at a slower pace than everyone hoped. In animal models, transplants of fetal nigral dopaminergic neurones into the putamen have been shown not only to survive but to form synaptic connections, exhibit normal firing patterns, and improve motor function. In patients with Parkinson’s disease, too, positron emission scanning and postmortem studies indicate that grafts survive and reinnervate the striatum. But the extent to which motor activity benefits is more controversial. A big problem, of course, is the difficulty of carrying out an objective evaluation of this sort of intervention. The ethics of carrying out a trial of fetal nigral transplantation in Parkinson’s disease in which the placebo control group receive a sham operation are currently being debated. This programme isn’t concerned with anything so mundane as clinical trials. It is about miracle cures. Humans have always found the idea of eternal youth beguiling, Demographic entrapment Before the advent of the world wide web, awkward WEBSITE OF THE WEEK Douglas Carnall BMJ dcarnall@ bmj.com voices from offbeat angles could be silenced with a two line rejection letter. Now that authors are freed from the constraint of seeking the approval of a publisher, we can get direct access to authors’ ideas without intermediaries. This week’s special issue on population studies provides an opportunity to evaluate an interesting example of such “disintermediation.” We have in the past presented Maurice King’s ideas on “demographic entrapment” (www.bmj.com/cgi/content/full/315/7120/1441#R2). He, after rejections from other journals that obviously still rankle, also publishes an extensive website to develop his ideas further (www.leeds.ac.uk/demographic.disentrapment/). Although visually amateurish, it is readable, and there is a lot of it. Comparing his and the BMJ’s versions provides a straightforward measure of editorial value added. King believes that much of the world is trapped—that many communities exceed the capacity of their land to support them, their capacity for migration to other regions, and the economic development needed for them to buy sufficient extra food. Such apocalyptic views cannot sit easily in the bureaucratic policy forums of the World Health Organisation and the World Bank, and, possibly, of most learned journals. His emphasis on equity of consumption of resources is an uncomfortable reminder of the West’s hypocrisy when it lectures the developing world on “population control.” King’s website illustrates both the strengths and weaknesses of self published material. Whether it is effective rhetoric remains open to question: the site lacks links to other relevant web resources, which suggests that, on the internet at least, King’s communication settings are more write than read. If you want links a good place to start is demography.anu.edu.au/VirtualLibrary/. For a jolt from complacency, consider the “Estimated World Population” counter at www.unfpa.org/modules/6billion/en/index.htm, which ticks up and up—a truly modern rhetorical device. CHANNEL FOUR reviews Cured or incurable? and stem cell transplants promise a lot more than can be achieved by wrinkle removing creams or liposuction. For a vision of the future, we are taken to Sun City, Florida, where the minimum age of the residents is 55 and centenarians are commonplace, and elderly women of terrifying sprightliness ride round in golf buggies. We eavesdrop on a conversation about death. They spoke of it in the careless way that only the truly healthy can manage. These people weren’t candidates for stem cell treatment. They were there to show us what old age could be like for everybody if the treatment worked. The widespread application of stem cell transplantation is no more than a glint in the venture capitalist’s eye at the moment. But the companies who are developing the techniques are already thinking about the market. Cross-cut from the Florida retirement community to a rainy street scene in a nameless industrial city. It’s the seedy people living here whom they have in mind. They want stem cells to be medicine for the masses and their greatest anxiety is whether their treatment will be reimbursed by the insurance companies. They marshalled a demographic argument that it should be. With a rapidly ageing population, the number of elderly people in need of expensive long term care for chronic disease is rising fast. The proportion of the population who are working, and therefore footing the bill for this care, is decreasing. Unless new treatments for the degenerative diseases of old age are developed and made available to everyone, the tax burden on working people must rise intolerably. The demographics may well be right. But scientifically educated viewers will have been frustrated by the programme’s failure to answer obvious questions about the underlying cell biology. They will have wanted to know how stem cells were identified, separated and cloned, what factors triggered their differentiation, what was going to stop them proliferating uncontrollably after transplantation, and why they wouldn’t be rejected. Clinicians, wearily sceptical of miracle cures, will have wanted to see some indication that patients benefited. On the evidence presented, it was hard to believe that stem cells were better than snake oil. Chris Martyn BMJ 1012 BMJ VOLUME 319 9 OCTOBER 1999 www.bmj.com reviews PERSONAL VIEW SOUNDINGS Both sides Oracles I Sometimes it seems as if you are blessed with the answer to every conceivable problem and everyone knows it—it’s just that someone forgot to tell you. These are the days when your patients, their relatives, and even your colleagues start to ask you for advice, not just about treatment, but also about their children, business, studies—as this is a university hospital about a quarter of my patients are postgraduate students— relationships, and so on. They come to you along the corridors. “Excuse me, Doctor, but I’d like your advice about . . . .” And there you are, like the hopeless fish on a fishing hook. The worst part is not your total ignorance of the subject, or the fear that you’ll ruin their lives with the wrong answer, or that you’ll appear unconcerned and uncaring if you refuse to say anything. No, the real terror hidden in this situation is when you are forced, against your will, to give an opinion and they return, days or weeks later, and thank you with tears in their eyes, saying that you have changed their lives for the better. And you stand there desperately trying to remember what you had said. became too frightened to make a cup of tea, am a specialist registrar in accident and and I could not eat or sleep. emergency medicine and a patient with Drug side effects were a major problem. mental health problems, and I have The worst was developing urinary retention experienced both sides of psychiatric care. I and having a catheter. This felt like an realised that I was in the throes of a major assault and I continue to have problems depressive episode in January 1995. I was a dealing with this memory. I became increassenior house officer in medicine and had ingly agitated and over the course of the completed the membership examination of next year I was admitted to hospital on the Royal College of Physicians. Until this numerous occasions and made several failed point everything had progressed smoothly. I attempts to return to work. was a young and successful doctor; I had I gained invaluable insight into the completed all my postgraduate examinaattitude of the various professional groups tions and had the financial security of a in medicine. Nurses, junior doctors, and professional job. I had hardly had a day off paramedial staff, especially secretaries, were sick in four years. supportive. But consultants who had known But then I lost two and a half stones; my me before I was mentally ill sleep was disrupted; I had found it difficult to address early morning panic me or accept me with my attacks; and I noticed a I am not sure if I illness. It has not been easy marked deterioration in to get references. I have concentration and memory. will ever unite the experienced widespread The turning point came in a doctor and patient ignorance among doctors. lecture, given by a consult“Will you have to take drugs ant psychiatrist in depres- parts of me sion. I was horrified that I for the rest of your life?” fulfilled all the criteria for a major depressive Returning to work after a significant episode. The lecturer agreed to assess me period of sick leave is always difficult; mental and confirmed that I was clinically illness makes it harder. Sick doctors need depressed. She prescribed a standard antitheir colleagues and consultants to have a depressant and saw me regularly. greater understanding and less fear of The realisation that I, a doctor, had a psychiatric illness. The stigma of this area of mental health problem was too much and I medicine will not be removed until we dispel crumbled. Lithium augmented the standard it within our own ranks. antidepressant. I changed to accident and The insight I have gained from being ill emergency medicine, but I continued to has had a profound effect on how I practise struggle. My illness remained a secret from medicine. I frequently recognise in my my family, most friends, and work colpatients the intense despair, pain, isolation, leagues. and frustration that I have often felt. It is not A year after the diagnosis I took an overeasy; I frequently find the boundaries dose. I was taken to the casualty department blurring. It is easy to become too involved. It where I had worked for the previous three is often difficult to get the response you years, and I was assessed and treated by need from other doctors for your patient friends and colleagues, including the conwith psychiatric needs. There is a lack of sultant for whom I had first worked. funding, as patients with mental health Unfortunately, this event affected the problems are treated as a lower priority in relationship with my psychiatrist, who felt the health service. unable to continue to treat me as there had Fortunately, I have been lucky to have an been little improvement. I refused to see the understanding and compassionate general sector psychiatrist at the hospital, where practitioner, and although we rarely see eye until recently I had been reviewing patients to eye my psychiatrist has been a constant with medical problems. help in traumatic times and was always there Eventually, after three of what seemed to pick up the pieces. These two people, the longest weeks of my life, I was referred by together with many friends, have encourcourtesy of general practitioner fundholdaged and guided my stuttering return to ing to a private psychiatrist. My list of drugs work. tripled and I was admitted to hospital. This is I am not sure if I will ever unite the docan experience that has left scars that even tor and patient parts of me, but I am with psychotherapy and time will not heal. I determined to use the valuable insight that I was unable to leave the ward without a have gained into mental illness to dispel nurse, I was observed every 10 minutes, I some of the fear and increase understanding. It is a struggle but I hope with time the boundaries will sharpen, the pain will If you would like to submit a personal view please recede, and the control will return. send no more than 850 words to the Editor, BMJ, BMA House, Tavistock Square, London WC1H Belinda Brewer specialist registrar in accident and 9JR or email editor@bmj.com It’s so embarrassing to be seen as a guru, especially when deep inside you know that you’re an impostor, a con man taking advantage of your patients in their hour of need. When I ask my friends if they have been in the same situation they nod immediately. They feel just like me, impotent in the face of their patients’ faith in them. Perhaps the mythological factor— Apollo was the god of oracles and the curative arts—plays a part in this. Perhaps, despite their occasional dissatisfaction with medicine and the public health system, our patients see us above the common lot, wise, just, and as benevolent priests doing God’s (or the gods’) work. How awful! It’s a relief, then, when a patient complains about something I say. I whisper, “Thanks Apollo, I’m human after all.” Ricardo Silva psychiatrist, São Paulo, Brazil emergency medicine, West Sussex BMJ VOLUME 319 9 OCTOBER 1999 www.bmj.com 1013