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THE ballyhoo in federal politics when derogatory remarks were made about Prime Minister Julia Gillard at an anti-carbon-tax rally in Canberra made me think about some of the extreme views we often see in medicine.
A recent comment article in MJA InSight by Jane McCredie about circumcision inspired just the type of rhetoric Jane had described in the article.
Like human nature itself, any question relating to health services is rarely black or white. And yet, when opposing forces argue, they almost always take extreme positions.
Proponents of cultural circumcision described a practice that has lasted millennia, while opponents used language like “barbaric”.
Can they both be right? Whose advice should we give to patients?
Emotive areas of health care often involve babies or children. Childbirth is a case in point, with homebirth advocates vehemently opposed to the elective caesarean — or perhaps any kind of intervention at all.
To the “natural” childbirth movement, intervention represents assault. To some in the medical profession, independent homebirth midwives are irresponsible and dangerous.
Can they both be right? What advice should we give to patients?
The same heat is evident in the immunisation debate.
Many who have followed the New South Wales Health Care Complaints Commission’s investigation of complaints made against the vocal anti-vaccination group, the Australian Vaccination Network (AVN) and the exposure of discredited UK researcher Andrew Wakefield will consider the views of AVN and Wakefield irresponsible and dangerous.
The anti-vaccine brigade accuses doctors of being caught up in the web of drug company profits.
What tends to mark all these arguments, and to make their proponents vulnerable to criticism, is the extreme positions taken. For example, we all know that vaccines are not 100% effective and that some of the more recently developed vaccines may be for conditions that are rarely severe and much more rarely fatal.
We need to explain to the community ― and to recognise for ourselves ― that modern medicine is a science of diminishing returns.
The quantum gains in infectious diseases, child mortality and obstetric mortality have already been made. Polio and epiglottitis have almost disappeared.
We now have a society that is risk-averse and has high expectations, coupled with a medical system that wants to keep progressing.
However, we need to be honest about effectiveness and risk ― both to ourselves and to the community.
We can’t keep insisting that health care is in “crisis” and that every childhood illness has to be eliminated despite health outcomes being better than ever before.
If we do, we only give the zealot anti-vaccinationists and populist “natural” therapists more credibility when they say “too much medicine”.
Dr Ieraci is a specialist emergency physician with 25 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She also runs the health system consultancy SI-napse.
Posted 28 March 2011
JennyH – you have been very selective – and indeed misleading – in your quotes from my essay above. I have not said that doctors are “caught up in the web of drug company profits” – I said that anti-vaccinationists allege this, as part of their attempt to discredit the medical profession in general. This “straw man” argument is typical of the anti-vaccination movement. Another typical tactic is to quote anecdotal cases of alleged vaccine complications which have never been verified, as you have done above.
The crucial thing is not to deny that vaccines are effective, and many life-saving, but to recognise the range of vaccines and diseases that are targeted. Polio and smallpox have disappeared from our society due to vaccination. Tetanus is a very effective vaccine – clostridium tetani is still in the soil, but infection in our society is almost unheard of (not so in developing societies, unfortunately).
On the other hand, the whooping cough vaccine is known to be less effective, and varicella (chicken pox) is rarely fatal – and mostly when contracted in adulthood. Those are the truths to which I am referring.
The obligation to honesty and perspective applies to both sides of the debate.
Good to see this valiant attempt at balance and hype-avoidance, Sue. But I have a suggestion. If doctors are “caught up in the web of drug company profits”, if “some of the more recently developed vaccines may be for conditions that are rarely severe and much more rarely fatal”, and if our medical profession is not honest about effectiveness and risk in the area of immunization, then let’s not waste our ammunition on the anti-vaccinationists. Let us get on with changing the medical culture to more honesty about risk and effectiveness. And maybe, just maybe, see if the concerns of those questioning vaccines have validity. And, importantly, find out in a way that cannot be hijacked by drug company interests. Not easy!!!
Personally I have seen a child develop whooping cough within a week of their third booster. I have also seen immediate signs of brain damage (e.g. unable to smile) after routine childhood vaccinations. And a 20 year old epileptic who was fine until a childhood vaccine. Oft-quoted experts who don’t disclose their bias or links to pharmaceutical companies. A case of Polio after vaccination in Queensland kept quiet by Federal Health, and compensation after the flu vaccine. I have also seen thousands of children who have not shown any ill-effects. But no one will research to tell me if they would have been just as well off without vaccines. No wonder the anti-vaccinationists have an impact. There are a lot of questions that the medical establishment has still to answer.
Charles has hit the nail of the head. People are looking for “answers” and for certainty, but no longer put their trust in traditional “experts”. As a substitute, though, many people are putting their trust in people who do clain to provide certainty, but with very little evidence.
Charles is right to comment that “moderate” views do not provide good press. The other issue is that the press have developed an obsession for “balance”, even when the opposing views do not hold equal validity or credibility.
However, I believe it is our responsiblity not to resort to exaggeration and hyperbole, no matter how appealing that might be to the media.
As usual, Sue has opened an interesting debate. How does an individual, who is not an expert and cannot possibly invest the time and energy in gaining expertise in understanding all of the risks or threats that could possibly affect their quality of life or even survival, decide which way to go, which drug to take, whether to vaccinate or not? This task is made more difficult by the phenomenon that Sue describes, of hype, of arguing for extreme positions. In the past, we trusted recognised authorities, the doctor, the scientist, the expert. Of course, that trust was often misplaced because the experts simply could not know what we needed them to know. But now, we no longer trust the experts. We impune their motives. We see them as having conflicts of interest. The paradox is that we now turn to those who do have conflicts of interest, we give the extremists air time, we even encourage the debate, because it makes good theatre, good copy, good television. We give the floor to those with extreme views,and we are left even worse off, not knowing which way to turn. Of course there is no going back, nor would we wish to, in this information age. However, we do need to find a way of getting the balance right. The position of balance is not necessarily the ‘midpoint’ position between two extremes. The media have a responsibility for this. How often do we get the media debate on an issue being led by proponents of the extreme, because they are eager to speak and are available? Even more so do our political leaders need to take responsibility. They are incapable of debate without hyperbole! We need to address the crisis of confidence and trust, starting at the top (or the bottom, depending on your point of view).
I don’t have a problem with hype or opposing views be they extreme or otherwise. After all, this article is as much hype as the instances it was referring to.
It is the responsibility of the consumer to work out their ideals and wants based on the two opposite agendas. I can tell you that I had responses from people that had informed me that they had a perfectly normal healthy young child that now is autistic since having had their vaccination. Was the amount in the vaccination too much for those little bodies? Rather than argue, we should be looking into the reasons why it seems that autism is becoming such a big issue?
It has been argued that for the size of our population and the little impact we make on carbon emission, does not warrant a carbon tax. With the possible concerns that more manufacturing will be sent overseas where manufacturers will not have to pay the carbon tax will lose us jobs in Australia. Perhaps we are going a bit overboard here? To say that it is not an issue with the people would be saying they are all stupid and don’t know what they are talking about. I think the last election says otherwise.
We are currently looking at spending billions on a new American broadband system that won’t be complete for many years, yet I read an article in the New York Times that says that Japan is using a system that is 150 times faster than anything in the USA.
Could it be that people are able to better inform themselves and just aren’t as gullible as Dr Ieraci thinks, or that she feels the experts should have the power to make decisions based on their own opinions that are sometimes found to be wrong many years later?