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on 6 December 2001
Other pundits have proposed the misanthropic ideas of the end of history, of politics, of industry and of class. Now James Le Fanu, the Daily Telegraph's medical columnist, pronounces the end of medicine.
He claims that medicine's golden age from 1945 to 1980 was due to the chance discovery of drugs, advances in clinical science and innovative technology. He believes that medical progress is now exhausted, and laments that the vacuum is being filled by what he thinks are the dead ends of New Genetics, epidemiology and social medicine.
However, it is perhaps bad timing to write off genetics when the Human Genome Project offers such exciting possibilities, and when epidemiology and social medicine have proven the social determinants of so many diseases. He rejects all social and economic explanations of illness. But lifestyle changes - losing weight, improving diet and exercising more - do, for instance, prevent diabetes and promote health and well being (British Medical Journal, 14 July 2001, page 63.)
But he usefully calls for more research into the causes of disease, and rightly rejects idealist explanations. He recounts how doctors used to blame peptic ulcers on 'stress' or 'personality factors', but in 1984, Barry Marshall, a young Australian doctor, identified the bacterium that triggered them. A seven-day course of antibiotics could cure them. The same organism caused two-thirds of stomach cancer cases. In 1986, Thomas Grayston discovered that the bacterium chlamydia caused heart disease. Le Fanu speculates that bacteria as yet undiscovered may cause arthritis, schizophrenia, leukaemia, MS, diabetes and ME.
Le Fanu shows that doctors' seclusion of tuberculosis patients in sanatoria dramatically reduced the infection's incidence, proving that the influential historian of medicine, Thomas McKeown, was wrong to deny doctors the credit for its decline.
He has a brilliant chapter on how the use of new drugs refuted Freudianism and psychoanalysis, as chlorpromazine effectively relieved schizophrenia's symptoms, lithium mania's, prozac depression's and Valium anxiety's.
This is a provocative and infuriating book, full of ideas and prejudices. All who work on improving people's health will naturally make their own judgements about the continuing value of their work.
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on 25 July 2011
The first 186 pages of Le Fanu's book are a brilliant history of the twelve major moments of post-war medicine. In a gripping narrative Le Fanu manages to present a well-researched, thorough and insightful journey from Penicillin to Heliobacteria - the reader never loses track of where they are thanks to the author's ability to seamlessly weave context and science together.

After page 186 things radically change. Le Fanu now argues for a certain interpretation of modern day medicine - one where statistics and clinical medicine have slowed medical breakthroughs to a halt and are strangling the spontaneity and freedom which (he argues) were the hallmark of the 1940's to 1970's which produced almost all twelve major moments. From here the diatribe begins - whilst he pulls out major themes and changes there is a distinct lack of counter arguments. In fact his evidence is so one-sided that the reader starts to wonder what is not being shown to them.

However it is a convincing argument in places, but not uniformly so. One might question whether the style of argument Le Fanu deploys is little different to the style of argument that the clinical scientists use in reaching their (by now) ridiculed conclusions - the conclusion comes first the evidence second, and counter arguments are ignored in order to present seemingly clear correlations.

Overall, an interesting read. The long 'prologue' is excellent, but the next few hundred pages are frustrating. More balance is required in order to give weight to Le Fanu's arguments.
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on 24 August 2012
This book factually destroys many myths about medicine and health care peddled by interest groups and financially interested parties. It raises big questions about priorities for public sector expenditure and charitable expenditure in the next few decades, as the rate of new discoveries slows down and treatments become more routine. It should be read by everyone who thinks about health care priorities.
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As you have probably already guessed by its title, this is a book of two halves.

The first half is the uplifting bit, the history of modern medicine's stunning advances which lasted roughly from the end of the Second World War until the 1970s/1980s when innovations started to peter out, a decline that neither the breakthroughs in mapping the human genome nor the enormous research outlays of pharmaceutical corporations have done anything to reverse.

Before the 1930s, doctors were all but powerless: they could diagnose what was wrong but the cupboard of specific remedies was all but bare. This was to change dramatically over the next few decades. As Le Fanu writes:

`The newly qualified doctor setting up practice in the 1930s had a dozen or so proven remedies ... to treat the multiplicity of different diseases he encountered every day ... Thirty years later, when the same doctor would have been approaching retirement, these dozen remedies had grown to over 2000 ... (p. 234).

In forty years medicine banished a range of maladies that had afflicted humankind for millennia. The victories were not just against the perennial killers of the body such as polio and TB but also of the mind, like schizophrenia. These advances were reinforced and complemented by technological innovations, leading to the wonders of open-heart surgery, organ transplants and hip replacement operations. The alleviation of suffering and distress these advances entailed was truly phenomenal.

What was the basis of this success? Le Fanu confesses that he doesn't know: these discoveries were fortuitous, serendipitous, and accidental. Had Alexander Fleming not been at the right place, at the right time, we might never have discovered penicillin. `It could not have happened any other way, as scientific understanding of disease was much too limited to provide an intellectual basis for the purposive design of drugs. Regrettably, it is simply not possible to describe in any detail the way in which this cornucopia of new drugs transformed every aspect of medicine' (p. 244)

So what went wrong in the last quarter of the 20th Century? In brief, medicine has become a victim of its own success. People live longer but the diseases of ageing (like cancer) are harder to beat: the war on cancer might as well be a war on ageing. The emphasis on doing more, such as preemptive medication to ward off theoretical risk of harm, means medicine is doing more but for less return. Taking statins to prevent heart disease may be offset by the harmful side effects the drugs produce. Screening for the early signs of prostate cancer may trigger premature and superfluous intervention, causing greater harm while doing so than simply doing nothing. Pharmaceutical companies spend masses of money on research on remedies that are no longer innovative but mere marginal increments of improvements on existing therapies - the so-called `me too' drugs.

The mapping of the human genome has not provided the medical panaceas expected in its wake. The relationship between disease and genetics is too complex to yield any magic bullets. If he is sceptical about the `new genetics', he is downright scornful of the `social theory of disease' and all but writes off epidemiology as a scientific discipline - other than smoking and drinking too much alcohol, it has not managed to prove any significant link between lifestyle and disease. Those of us who like bacon and eggs for breakfast in the morning will be heartily reassured by such sentiments.

As a medical layperson I find the overall thesis hard to fault, although I would approach the polemical second half of the book with caution. Issues around the relationship between genes and health, and the environment and health, are dismissed far too peremptorily in these pages for my liking. He seems to be dismissing both nature (genes) and nurture (the social theory) as factors that influence the cause and pattern of diseases.

From a lay perspective, my principal objection is how he characterises the innovations he describes in the first half of the book, as some sort of mystical gift from a higher power. He seems to suggest that if you sit in a lab long enough and just happen to be in the right place at the right time, serendipity will mysterious intervene and deliver the solution to the problem that has eluded you for so long. He is wont to use question-begging phrases too often, frequently describing for instance pharmacological innovations as `a gift of nature.' If the cluster of innovations that came so thick and fast in the thirty to forty years after 1945 was a mere fluke then the obvious corollary is that they could have happened at any time. But we know that this cannot possibly be the case: a certain degree of scientific knowledge was an essential prerequisite. They could not have occurred in the 18th Century, say. If this observation is valid, then it could not have happened at anytime. Therefore Le Fanu's explanation is a cop-out.

This edition brings the book up to date and qualifies some of the assertions he made in the earlier edition: the development of keyhole surgery in the 12 years since the book was first published indicates that technological innovation does not appear to have slowed down. But the broad challenge is that the successes of medicine means we live longer than we ever did before, which means that the cost of medicine in advanced societies soars ever upwards. There will be tough decisions to make regarding the prioritisation and allocation of healthcare. Further innovations in themselves will not resolve these dilemmas. Indeed they may compound them.

Despite its polemical and sometimes tendentious tone, this is still a thought-provoking book and anyone interested in medicine and scientific innovation would benefit by reading it.
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on 5 August 2001
The Telegraph's medical columnist claims that medicine's golden age was from 1945 to 1980, due to the chance discovery of drugs, advances in clinical science and innovative technology. He believes that it is now exhausted, and laments that the vacuum is being filled by what he thinks are the dead ends of New Genetics, epidemiology and social medicine. It is untimely to write off genetics when the Human Genome Project offers such exciting possibilities.
He calls for more research into the causes of disease, and rightly rejects idealist explanations. Doctors used to think that peptic ulcers were due to 'stress' or 'personality', but in 1984, Barry Marshall, a young Australian doctor, identified a type of bacterium that triggered them. A seven-day course of antibiotics was the cure. The same organism caused two-thirds of stomach cancer cases. In 1986, Thomas Grayston discovered that the bacterium chlamydia caused heart disease. Perhaps as yet undiscovered bacteria cause arthritis, schizophrenia, leukaemia, MS, diabetes and ME.
He has a brilliant chapter on how the use of new drugs refuted Freudianism, as chlorpromazine effectively relieved schizophrenia's symptoms, lithium mania's, prozac depression's and valium anxiety's.
Le Fanu shows that the influential historian of medicine Thomas McKeown wrongly denied doctors the credit for tuberculosis's decline. Doctors' seclusion of TB patients in sanatoria dramatically reduced the infection's incidence.
He argues against social medicine, rejecting all social and economic explanations of illness. But lifestyle changes - losing weight, improving diet and exercising more - do prevent diabetes and promote health and well-being (British Medical Journal, 14 July 2001, page 63.)
He claims that medicine has run its course. We have seen the misanthropic idea of the end of history, of politics, of industry and of class. Now Le Fanu pronounces the end of medicine. This is a provocative and infuriating book, full of ideas and prejudices. We need the tests of practice to see what he has got right.
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on 20 January 2012
Most of us take modern health care for granted without any thought as to how it developed in the latter half of the twentieth century. This book is a fascinating insight into those developments. The first half of the book deals with the rapid post war devopment of medicine. Key to many advancements was the persistence of dedicated individuals but as important, especially in the field of drug treatments was luck. Many of the drugs upon which medicine relies were discovered by chance without any understanding of how they worked.

The second half of the book traces the stagnation of medicine from the mid 1970s. Two prominent themes are examined - the concept of disease being the result of an unhealthy lifestyle and the development of genetic treatment for disease. Neither of these have lived up to their first promise so far.

The postwar period is styled as a golden age in medicine with a subsequent decline from the seventies onwards. The reasons for this decline are based on drug companies prohibiting individual research looking only to maintain profits, younger clinicians no longer seeIng research as the exciting option it once was, few new medicines are appearing on the market most just newer versions of older drugs. This sounds like a rather depressing scenario - the rise and now the fall, however despite the current stagnation in many fields of medicine I found the book ultimately optimistic.

This book is extremely well written and informed, with fascinating historical detail. I would recommend it.
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VINE VOICEon 25 August 2003
This is the best book I have read in ages- it manages to present the truth about medicine and science of yesterday and of today with a sometimes brutal but refreshing frankness. Le Fanu is not blinded by science nor is he scornful of it. He is a faithful reporter with a sprinkling of imagination thrown in for fun. What a wonderful read.
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on 27 November 2010
Given that we are all potential patients; this is a book that everyone should read. With painstaking research 'The Rise & Fall of Modern Medicine" describes both the beauty and the beast that is the medical profession and the pharmaceutical industry today. The book leads us through 12 of the most important developments in medicine over the last century but in many ways it is the 'fall' of the medical profession/pharmaceutical industry and especially it's attitude to 'preventing' illness that proves to be the real climax of this book. The history of medicine may sound like a heavy topic but Dr Le Fanu adds that personal touch which brings every chapter to life. Dr Le Fanu has a great gift for open mindedness and is never afraid to ask both the reader and the medical profession, why? Both patients and professionals would benefit from reading this book.
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on 3 June 2001
The first section (the twelve most important medical breakthroughs) is the best medical history I've read. His critique of social medicine and genetics is sound - too much is made of too little by 'epidemiologists' and genetics has promised much but delivered little despite huge claims being made for it (not what happened in heart surgery etc.)However, both genetics and epidemiology may prove more beneficial in the future. However this is not certain (which is not what you here from geneticists!
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on 17 September 2015
Dr Le Fanu's work is always a good read, and very accessible. This book should be compulsory reading for all doctors and medical practitioners, and indeed anyone doing science to A-level or beyond. Fascinating, eye-opening and alarming - would make a good documentary series in order to reach a wider audience!
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