The medical-industrial complex

Twenty years ago, our task was to establish the exact nature of the environmental problems that confronted us and to work out how best they could be solved. This task has now been largely achieved. We do not know everything, but we know enough about them to determine how we should set about solving them. What remains to be established however is what exactly are the special interests that are preventing us from doing so, and how their utterly irresponsible activities can be counteracted.

This book provides valuable information on this subject. Its basic thesis is that strategies for dealing with our mounting health problems have not been adopted because they are effective but because they are those that best satisfy the requirements of an alliance of commercial interests, national governments and state bureaucracies. The author also shows convincingly how the scientific worldview, in terms of which we see the world - reductionistically and mechanistically - is designed above all to rationalise such strategies.

Such an alliance, he notes, is often referred to as the "iron triangle". Hall sees it as "a three-cornered alliance" that promotes a special interest at the expense of the common good. President Eisenhower was the first to refer to it, as it operates in the military sector, as the "military industrial complex". He warned the American people that this complex would distort military and social policy because of its strong bias towards producing ever more elaborate and expensive military equipment. Military policy, in fact, was becoming dictated very much more by the needs of this complex than by the defence needs of the country.

Today the same can be said for America's health policy. If anything, the 'medical industrial complex' as it is increasingly referred to, is even bigger and more powerful than the military industrial complex. Its turnover is massive. A small group of companies that make medically-related machines and drugs and sell health services, is responsible for fully a third of the $600 billion spent on the nation's health in 1989.

Their influence on decision-making is obviously enormous, exerted in such a way as to ensure health policies are no longer necessarily taken in the interest of improving the nation's health but "in the interest of increasing sales, maximising efficiency and containing costs". To satisfy these requirements the accent is on maximising expenditure on technological interventions, regardless of their ineffectiveness.

Not surprisingly, the cost of medical care in the US goes up from year to year. Today it adds up to almost 12 percent of the gross national product. By the year 2000 on current trends, some 15 percent of gross national product will be spent on high-tech medical care. The fact that it goes on increasing in this way suggests that it is very ineffective and that, in spite of the billions spent on it, the health of the nation continues to deteriorate.

This is the conclusion of a number of studies. Trevor Hancock, [1] a Public Health physician with the Toronto Board of Health, cites several, conducted by the Canadian and United States governments, that come to the conclusion that "the health care system plays a minor role in determining our state of health".

Aaron Wildavsky of the Graduate School of Public Policy, University of California, considers that "the medical system (doctors, drugs, hospitals) affects about 10 percent of the usual indices for measuring health". This means, as Ross Hume Hall notes, that "90 percent of all illness is unaffected by high-tech. medicine".

The problem is what Aaron Wildavsky [2] calls "the great medical equation: medical care equals health". The truth of the matter is the best way to assure the health of a nation is not by spending money on high technology health care but by creating those social and ecological conditions in which the incidence of disease is minimised. In the 19th century the accent was on prevention and it was very effective. As Ross Hume Hall notes,

"the engineering of sanitary sewers and public water mains were the major factor in wiping out tuberculosis, cholera and typhoid, the major causes of death in the 19th century."

But prevention does little to satisfy the short-term economic requirements of the medical industrial complex. Consider the way it deals today with the growing incidence of angina pectoris. Its favourite strategy is the coronary artery bypass. It was introduced some 20 years ago and is enormously popular with surgeons and patients.

In 1987 there were 230,000 such operations performed in the United States - a 50 percent increase over 1982. They cost on average $30,000 each, and now provide the basis of a massive health care enterprise worth about 6 billion dollars a year. Significantly the efficacy of these operations is very much in doubt. As Ross Hume Hall notes, these operations do not address the real causes of the problem.

"Plugged coronary arteries are only symptoms of the basic disease, atherosclerosis. Arterial degeneration is not corrected by the operation and the plaques continue their relentless build-up."

As noted in The Lancet, [3] 20 percent of newly bypassed arteries become plugged up again within a year. Pain, in most patients, is relieved to begin with but returns within a few years.

Reports now coming in suggest that the disease can be arrested and even reversed by a combination of drugs, dietary changes and exercise. This approach has all sorts of advantages. To begin with it addresses the real causes of the problem rather than its symptoms. It avoids the traumatic, often dangerous, effects of a chest operation, and it is also relatively inexpensive.

Three studies have been undertaken to compare the effects of these two approaches. One conducted in Europe suggests that the life of the patients can be lengthened by a bypass operation. The other two studies done in the US, conclude on the contrary, that there is no difference in the longevity of the patients treated in these two different ways.

The situation with regards to the treatment of hypertension is very similar. The conventional treatment today is drug therapy, the physician having all sorts of drugs in his armoury, such as Alpha-Agonists, which interfere with the normal release of the hormone Noradrenaline by the brain, which causes the heart to slow down.

Anti-hypertensive drugs can indeed lower blood pressure but it is by no means certain that this always reduces the incidence of heart disease. A study by Michael H. Alderman [4] of the Albert Einstein College of Medicine, New York, found that for many patients with mild hypertension, drug therapy actually increased the risk of stroke or heart attack. As Ross Hume Hall points out,

"One reason for this is that hypertension is only a symptom of deep seated changes occurring in the patient's heart and arterial system. The drugs do not really redress these changes."

In any case, the patient will have to continue taking the drugs for the rest of his life, which is highly undesirable in view of their possible side-effects.

Once again, the only really serious approach to this problem is prevention. A study by Ross Stamler, of the Department of Community Health and Preventive Medicine at North-Western Medical School, Chicago, showed just how effective prevention can be. Patients were taken off the drugs and were put on a sensible diet, which reduced their salt and alcohol intake. Many of them lost up to 4.5 kilograms in weight. 40 percent of them were able to regain normal blood pressure, without the aid of any drugs, while others could do so with lower doses of anti-hypertensive drugs. The trouble is that, as Rene Dubos commented,

"men as a rule find it easier to depend on healers than to attempt a more difficult task of living wisely". [5]

Drug companies take advantage of this. The market is enormous, since 60 million Americans today have high blood pressure and they spent 4.3 billion dollars on anti-hypertensive drugs in 1987 alone - a figure that was expected to increase to 8.5 billion by 1992.

Another field in which prevention should play an essential role is that of prenatal care, which could drastically reduce the number of low-weight babies. This can cost no more than about $100 for each mother. It is a tremendous bargain if we consider that low birth weight babies are likely to suffer from all sorts of disabilities, which later in life no high-tech. medical services are likely to cure, even though they can cost up to $400,000 in the course of an individual's life.

Needless to say, prenatal services are of little interest to the medical industrial complex. Indeed, the less prenatal care is undertaken the greater will be the market for the high-tech, medical services it provides.

High-tech. medicine is also the medical-industrial complex's favourite strategy for dealing with the present cancer epidemic. Today, practically nothing is spent on prevention, for this would be against its economic interests. Thus, though the connection between smoking and lung cancer is now clearly established, the British Government has always opposed restrictions on smoking for reasons of economic expediency. Iain Macleod, when Minister of Health in 1966, declared quite openly that the government could not stand the loss of its tobacco revenue, which at that time was about a billion pounds a year - and which was to more than double during the next 20 years.

The suggestion by the National Cancer Institute that people reduce their intake of fat, including fatty beef, has met with fierce opposition from cattle producers. Governments have also refused to do anything about reducing exposure to carcinogenic chemicals. The chemical industry is too powerful. No government would dare undertake legislation that would reduce its sales, nor would it be willing to forego the tax revenue derived from it.

The excuse is that there is no hard evidence that chemicals are to blame. However, no effort is made to look for the evidence. As Samuel Epstein notes,

"no more than 12 percent of the National Cancer Institute's budget goes into research on ways to prevent cancer, and 88 percent is devoted to high-tech cures." [6]

The National Cancer Institute (NCI) insisted 40 years ago, that if it were given a billion dollars a year it would find a cure within ten years. Needless to say, no cure has been found. In any case, if a simple and inexpensive cure were discovered, that provided a replacement for chemotherapy, it is unlikely that it would be accepted as chemotherapy now provides the basis of a massive and ever-growing industry.

John Cairns, an Australian cancer specialist, sees cancer as necessarily related to the sort of society in which we live. For him, only preventive measures can control cancer, or any other serious disease for that matter.

"None of the important causes of death has been primarily controlled by treatment. The death rate from malaria, cholera, typhus, tuberculosis, scurvy, and other scourges of the past have dwindled in the US, mainly because humankind has learnt how to prevent these diseases, not simply because they can be treated. To put most of the effort into treatment is to deny all precedent." [7]

It is not only pressure from the medical-industrial complex that prevents us from dealing with the health problems which confront us, it is also the crude reductionistic and mechanistic scientific world view with which we seek to understand them.

Jacques Monod, winner of the 1965 Nobel Prize for physiology and medicine, insisted that

"anything can be reduced to simple, obvious mechanical interactions. The cell is a machine; the animal is a machine; man is a machine". [8]

Amazing as it sounds, this is still the view of modern science, and, as Hall notes, it directs our thinking to specific parts of the body, isolated from the rest of the body and - most importantly - isolated from the personal, social and ecological environment of the individual. In this way, it justifies the biomedical model with its accent on cure as opposed to prevention.

It must be realized that there can be no health in an unhealthy society or an unhealthy ecosystem. It is the total ecosystemic approach that is required and unfortunately it is not consistent with the mechanistic world view of mainstream science, still less with the interests of the medical-industrial complex.

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