In 1982 I attended the Spring Meeting of the Royal College of General Practitioners and the College of Family Physicians of Canada, in Dublin. Ivan Illich, Catholic priest and anti-establishment philosopher, gave the opening address entitled ‘Medicalisation and primary care’. His theme was that, by undermining people's self-reliance, we GPs were more part of the problem than the solution. He left us all feeling confused, browbeaten and angry. Questions were asked, but the answers came only in the form of stories. We dispersed to our small groups, where Illich's ghost haunted every discussion. ‘Are we medicalising yet another human problem?’ was the recurring question. It coloured my thinking for the rest of my career as a GP. Much of Illich's classic book ‘Medical Nemesis’1 now seems dated and rather opaque, but its premise is more important than ever.
The vogue for preventive medicine epitomises the argument. It pleases the government, who are seen to be doing something that sounds good; it gives power (and QOF points) to the GP; and it makes big money for big Pharma. But is it good for the patient? Apart from its obvious medical side effects, misplaced preventive medicine turns people into patients and may permanently damage their self-confidence. Are morbidity statistics really a good enough reason for the elderly to take statins, given the evidence that such interventions merely change the mode of death but not its timing, after a life made anxious by the knowledge that one is ill? Is a heart attack more to be feared than cancer, say, or Alzheimer's?
Freud once remarked that the most we could expect from psychoanalysis was ‘to change abject misery into everyday unhappiness’.2 But now there is a reverse pressure to convert life's problems into diseases, which not only recruits people into the sick role and generates more demands on medicine, but also removes the incentive to tackle the causes of the problem, be they familial, social, or political. More recently, we find low libido in women labelled as a ‘dysfunction’ which needs tablets to ‘cure’ it. It's ironic, too, that the government is mounting a campaign to get people off long-term sickness benefit while we doctors medicalise job stress and poor working conditions into ‘anxiety states’.
At 81 I remain a non-patient. I don't know my blood pressure, cholesterol level, prostate specific antigen, or whether I am depressed. But I am lucky to have good genes, a large garden and a loving wife who is a good cook. I know what — and who — does more for my health and wellbeing.
- © British Journal of General Practice, 2007.
