The UK doesn't provide enough medical care for some – and too much for others

Doctors and patients need to question unnecessary procedures, writes Dr Margaret McCartney.

Earlier this year, I was in Washington listening to the reasons why the "Choosing Wisely" campaign was set up. This is the country which spends the most per head on healthcare in the world. The doctor on the podium was not happy. We are doing too many tests, too many procedures, and prescribing too many medicines, he said. Doctors needed to wisen up and stop doing do much stuff. “Basically; what we're saying is; don’t be stupid.”

Choosing Wisely is a campaign backed by the full force of the American medical hierarchy – from the American College of Surgeons to the Society of Critical Care Medicine. Each learned institution has come up with “Five Things Physicians and Patients Should Question.” So the American Academy of Paediatrics says that CT scans for minor head injuries aren’t necessary (when, currently, 50 per cent of children attending in these circumstances are being sent to the CT scanner.) The College of Physicians says that you shouldn’t do X-rays in straightforward low back pain. Elsewhere: don’t use high dose antacid drugs when you can use them at low dose – or not at all. Don’t use feeding tubes for people with dementia – concentrate on helping the person feed by mouth. They are pledges to do better medicine, but also, crucially, to do fewer tests and procedures, and prescribe fewer pills. And to be "less stupid" - stop doing things that the evidence tells us doesn’t work.

This is a volte-face for American doctors. But it's also a contrast to the UK, where the more-is-more philosophy has been gathering pace amongst medics. The contract which GPs work to is in many cases a payment per intervention: We check blood pressures and cholesterols because when patients come in to see us, there are small boxes on the computer screen which tell us they are due (we are paid when we hit the target); campaigns from the Department of Health urge us to achieve more ‘early” diagnosis; health secretary Jeremy Hunt has been vocal in criticising GPs for not diagnosing dementia as often as we apparently should.

The message is that faster diagnosis and more medicine is better. The US still advocates multiple non-evidence-based interventions, in vastly greater quantity than the UK: for example, breast and internal examinations are routine for a straightforward prescription of the contraceptive pill.

Even so, we still have an awful lot of treatment of conditions that would never have brought the patient to any harm. For example, for a patient who has never had a heart attack or stroke, treating cholesterol with statins for 5 years will stop 1.6 per cent of people having a heart attack, and 0.4 per cent from having a stroke. This means that the other 98 per cent get no benefit – but they still get the harms. The risk of developing diabetes caused by the statins is 1.5 per cent. And the cost of overtreatment is not just financial cost, or side effects, but also of making perfectly healthy citizens into patients.

Now the US is keen to talk about doing less. Quite right: it is unsustainable to spend as much as they do on tests, procedures or medications and afford it. But the twin of cost is effectiveness; using less unnecessary medicine saves money, but also reduces harm. During the last US election, when some US commentators accused the National Institute of Clinical Excellence’s judgements as being that of a “death panel” they failed to see the point: not all medicine is good for us. Some of it is decidedly bad for us. Some of it simply doesn’t work.

Jeremy Hunt’s idea of "early diagnosis" for dementia is a case in point. He wants people who have concerns about their memory to be rapidly assessed for dementia. The problem is that most people will have experienced problems with their memory, and the vast majority do not have dementia. Many memory problems in older people can be low grade and not particularly medically concerning. Known as MCI, moderate cognitive impairment, it progresses to dementia in only a minority of cases. But because the psychological testing and the brain scans are not highly specific for dementia, it means false positives are common – some people will be told they have dementia when they don’t.

Meantime, the people who really do have problems with not just memory but their ability to function because of it are less likely to see their doctor to discuss it – and more likely to have a serious underlying cause. The paradox is that the most healthy get tests they don’t need, and diagnoses they don’t benefit from, while the most ill get least care – as usual.

This is the real crunch, and the prize. The Inverse Care Law – that most healthcare goes to the people who benefit least from it – was described by GP Julian Tudor Hart in 1971. We have progressed very little with reversing it. Perhaps we can, now. More and more of the medical establishment can see that we have a problem: too much medicine for some, but not enough medical care for others. Facing up to the stupidly of the current status quo is a start.

Photograph: Getty Images

Margaret McCartney is a GP in Glasgow who broadcasts for Radio 4's Inside Health and is author of The Patient Paradox: Why Sexed-Up Medicine is Bad for Your Health.

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The view from Google Earth is magnificent - but there's a problem

Google Earth is spectacular - but it can give a misleading impression of the planet and the threats we face from climate change. 

 

Google Earth wants you to “get lost” in its updated interactive map. Collaborations with new media partners mean you can now climb Mount Everest, swim with sharks or visit Afghanistan with Zari the purple muppet. No, really:


Source: Google Earth

Yet as Trump slashes support for the science behind satellite imaging, is Google’s emphasis on spectacle leading us down the wrong path?

Google Earth's new look all starts well enough. Opening the new site on your browser takes you to an image of a blue earth floating through the blackness of space. Back in the 1970s, similar images taken from the Apollo space missions helped kickstart the modern environmental movement. As the astronomer Sir Fred Hoyle put it: “Once a photograph of the Earth, taken from the outside, is available, a new idea as powerful as any in history will be let loose.”


Source: GETTY and Google Earth

And it gets better. Enter a destination in the search bar and you are greeted with the option to link directly out to the Wikipedia page: nerds of the world, rejoice! 

A guided tour from NASAearth is also on hand for anyone whose nerdery is in need of a prompt: “Geostationary satellites in geosynchronous orbits. Greenhouse gases and global warming. Glaciers... going, going, gone,” says the Bob Dylan-esque entry on its "ABCs from Space".

You can then choose to orbit your landmark of choice in 3D. And let’s face it - who doesn’t want to glide around the top of Mont Blanc, pretending to be an eagle? It’s almost as good as the BBC’s actual eagle-cam

But then it hits you. This is no soaring eagle, buffeted by wind currents and having to constantly adjust its flightpath in the face of real-world obstacles. This is a world surveyed at a safe and sanitising distance. Tourism for the Trump age – focused on providing “a consumption experience”. Certainly it is the opposite of “getting lost”.

In fact if anything has been lost or downplayed, it is the principles of scientific enquiry. The program is littered with human choices. Local versions of Google Maps, for instance, have shown different national borders depending on where in the world you log in. And while new, open-data imagery from America's Landsat 8 program is helping bring many regions up to date, other high-resolution imagery comes from commercial providers, such as Digital Globe. And as this Google 'help' page implies, there are issues of time-lag to face. 

You can’t even be sure what you’re looking at still exists. In 2015, Bolivia’s second largest lake vanished - a combination of climate change, El Nino, and irrigation withdrawal caused 2,700 square kilometres of water to evaporate into a dry salt pan. (It has not recovered, and seems unlikely to do so.) Yet on the new version of Google Earth the lake is still a healthy green:


Source: GoogleEarth

The much lauded film clips from the BBC’s Planet Earth II are similarly short on context. As I've argued before, David Attenborough's latest TV series did little to explain the stories behind the spectacle – there was no mention, for instance, of the arctic anthrax outbreak which caused thousands of reindeer to be culled, nor the role of climate change in worsening locust swarms. 

Finally, the new update actually shows you less of the world than it did before. Gone is the “Historical Imagery” tool that allowed you to see how a place had changed through time. Now, the Citadel of Aleppo in Syria is only visible as a bombed-out ruin. A surreal street-view reveals two women cheerily taking a selfie – with debris all around and their legs spliced out of shot:


Source: GoogleEarth

So why do these omissions matter? Because they take users further away from the evidence-based approach of earth science. It turns out that satellite images on their own are of limited use when it comes to quantifying change. Instead researchers must turn the raw pixels into numbers, which can then variously represent everything from forests to cities, glaciers and farms.

As Dr France Gerard at the UK’s Centre for Hydrology and Ecology explains, this process enables us to live in a better managed environment – be that by measuring air pollution or the impact of fertiliser on soil. The centre's landcover map, for instance, has been mapping British land use since 1990. Similar methods allow Sam Lavender’s company to provide Ugandans with a Drought and Flood Mitigation service, as part of the UK Space Agency’s International Partnership Programme.

Sadly, the need for public engagement has never been more urgent. Brexit and austerity have cast doubt over important projects in the UK. While in Donald Trump’s America, funds for earth monitoring are set to be slashed. Two missions already under the knife are PACE, a spacecraft set to track global ocean health, and CLARREO, which would have produced highly accurate climate records. Trump has also called for the earth-viewing instruments on the DSCOVR satellite to be turned off. Phil Larson, a former space advisor to President Obama, describes this decision as “baffling”.

So what can be done to reverse this trend? Experts I spoke to believe that collaboration is key. With government programs being squeezed, the earth monitoring industry may come to rely increasingly on the trend towards smaller, commercial satellites. These are great for increasing the quantity of data available but their accuracy needs to be constantly checked against the data from the larger and more reliable state-launched equipment.

There’s also still more data out there to share. As Bronwyn Agrios from Astro Digital points out, many countries have been gathering region-specific data – which could, in future, be made open source. “The neat thing about space is that there’s no border,” she concludes.

To help this process, Google Earth could do far more to raise public awareness of the science behind its special effects. Yet at least in one way it is already on the right path: its own new range of collaborations is impressively large. As well as the BBC, you can take interactive tours with The Ocean Agency, the Wildscreen Arkive, and the Jane Goodall Institute – all of whom put conservation up front. The Goodall journey to Tanzania’s Gombe National Park even describes the use of satellite imagery to measure conservation success.

 

More links with other citizen science projects around the world could turn the program into something truly ground-breaking. If it can incorporate these, then desktop-tourism may yet save the planet from Trump. 

India Bourke is an environment writer and editorial assistant at the New Statesman.

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