A story (after Candide)

Peter Davies

Once upon a time a 50-year-old man went to his GP with a sore knee and, while there, had his blood pressure checked. The doctor, being a fervent and justified believer in opportunistic health promotion, was pleased that he had discovered the fact that this patient was suffering from the dreaded disease of hypertension. This was the best type of medicine, and damned be those who could not see just how important incidentalomas might be.

He explained fully about the illness to the man and, after the statutory three blood pressure readings were all raised, the man gave his informed consent to take some bendroflumethiazide. The man fully understood the seriousness of hypertension and made the attainment of normotension his top priority. He was delighted with the service provided by this best of all possible health services and he had every faith in Dr Pangloss (and his illustrious line of forebears). All would be well but, as he had a disease, he would now have to take extra care of himself. The fact that he already was well, and had had no symptoms except for a bruised knee did not strike this man as odd.

Some 3 weeks later it was not his knee, but his big toe, that was sore. The doctor diagnosed gout and treated it with an anti-inflammatory agent, having counselled him that it was necessary, but might make his blood pressure rise a little — although not as much as the pain from gout would. He gave the man a sick note and his employer sacked him on the spot. ‘Still’, said the man, ‘this must be for the best, for surely work stress is a major cause of hypertension and without work my blood pressure will surely be lower!’

A week later the man started vomiting blood. So he contacted his GP who arranged for him to be admitted to hospital. As he was admitted his blood pressure was found to be normal and the man rejoiced for the attainment of normotension was now his mission and his public duty. He was not sure that he was keen on transfusion for that might take his blood pressure up again although, with a haemoglobin level of 6.3 g/dl, the hospital doctor's arguments became persuasive.

As he recovered, the hospital doctor saw his concern for normotension and so gave him atenolol to help him in his quest. The man's GP followed him up and was delighted by the improvement in his blood pressure. The shared understanding and continuity of care was deeply gratifying for both parties and represented the best of all possible health care to both doctor and patient.

Some months later the patient was normotensive but depressed. Depression was a small price to pay for normotension. The doctor prescribed some fluoxetine for the depression saying, ‘There there, it will soon be all better, in this best of all possible worlds’.

The man came back for follow-up, with joy and full concordance with his own and his doctor's wishes exactly 4 weeks later. The man was normotensive, but he now mentioned that he was suffering from impotence, and had lost his libido. His wife had accused him of being unmanly, but what did he care about that as he had achieved his top goal of normotension, and his secondary goal of not being depressed. And now he had done this he must not grumble, as there was nothing to grumble about in this best of all possible healthcare systems in this best of all possible worlds.

His wife divorced him on grounds of non-consummation of marriage; this was for the best as ‘without a nagging wife my blood pressure will surely go lower still now’. He had the consolation of an ongoing therapeutic relationship with the best of all possible GPs and, better still, normotension.

The man was continuously grateful to have the best of all possible blood pressures, which meant he had the best of all possible health from the best of all possible health systems. The fact that he had lost his wife and his job were clearly the actions of divine providence, and all was for the best. He was so much more empowered to lead a good life now that he had been so empowered, even if he had not been empowered to know what empowerment meant! Still, at least Derrida told him that it meant whatever it meant to him, and who was he to argue with the French version of Humpty Dumpty?1

The man still said all was for the best as they wheeled him into the stroke unit where he died the best of all possible deaths, as the crash team tried to resurrect him.

The epidemiologists counted the death in their statistics and showed that he had died in the best of all possible ways for, although his cardiac risk had been reduced from 30% to 15%, it had never been eliminated entirely and, although his treatment had not benefited him much, by his compliance with treatment he had reduced the population rate of stroke by at least 0.0000001%. He had done his best as a citizen to reduce the risks of illness in this best of all possible worlds, in which everything was for the best, even though people still kept eating too much and drinking too much and having unprotected sex too much. But even these vices were all for the best too as, without these, who would the public health folk have left to chide, and without a public health department how could the people be healthy?

The GP audited his performance in a self-reflective learning journal and congratulated himself on his great consultation skills, his great continuity of care, and his compliance with the approved guidelines. He surely was the best of all possible GPs for doing this, and he had the best of all possible patients, all of whom he helped and empowered to lead healthy lives characterised by normotension.

He never read any of these dangerous Frenchmen (‘filthy foreign muck’) who said that, ‘Doctors give pills of which they know little to patients, of whom they know less’. They clearly had not had the benefit of the best of all possible health care from the best of all possible healthcare systems.

A visiting Martian physician saw the madness unleashed by the best of all possible healthcare systems and bought shares in pharmaceuticals so that, from these best of all possible systems, he could get the best of all possible returns!