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14 June 1999

Why doctors should admit their ignorance

Experts say too little milk, too much milk and a smart wife all make you ill. Don't listen, advises

By James Le Fanu

Everyone needs a lucky break, and mine came one Saturday afternoon in 1986 in Fleet Street’s famous watering hole, El Vino, where I was enjoying a lunchtime drink with a friend from university days. Conrad Black had just bought the Telegraph titles from the last of the old press barons, Lord Hartwell, and there was much speculation about the future. Suddenly the door burst open, and the new arrival announced in a loud voice: “Perry’s got the Sunday and Max has the Daily.”

As we mulled over the full implication of Conrad Black’s choice of Peregrine Worsthorne and Max Hastings, I found myself sitting next to Graham Paterson, news editor of the Sunday Telegraph. On hearing that I was a doctor, he promptly hired me as medical correspondent, on a retainer of £30 a week.

My new job, I soon found, was not very arduous. While my fellow journalists might take a week digging up a good story, I had only to do a quick trawl through the latest medical and scientific journals to turn up more than enough to write about and, as my impeccable sources were scientific papers from peer review journals, I did not have to worry about the veracity of what I was recycling for my readers.

It was not long before I had acquired a broad understanding of the major medical issues of the day, at which point I became suspicious that perhaps my sources were not quite as objective and authoritative as they appeared. The problem was not deliberate fraud – as in fabrication of results – but a subtler deception in which the selective presentation of data and the exclusion of important facts could prove just as misleading.

This was particularly striking in two matters of considerable public concern. The first consisted of speculation that the Aids epidemic would soon break out of the well-recognised at-risk groups, to pose a major threat to everyone enjoying the pleasures of casual heterosexual intercourse. The number of new cases, the experts predicted, would rapidly increase from a few hundred to as many as 30,000 a year. This was scary stuff and more than enough justification for the millions of pounds allocated to warning the public that “Aids does not discriminate”.

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Crystal-ball gazing can never be an accurate science. Nonetheless this prodigious miscalculation of the future scale of the epidemic would have been avoided had the experts taken into account the pattern of spread of another virus – hepatitis B – whose main modes of transmission, via contaminated blood products and dirty needles or following anal intercourse, are similar in every way to those of the HIV virus.

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The only difference is that hepatitis B is 100 times more infectious and has been around since the 1850s, if not longer, the first recorded outbreak having been in a group of shipbuilders in Bremen, following a smallpox vaccination programme.

One hundred and fifty years on, hepatitis B, even though it is so much more infectious, remains almost exclusively a disease of the same at-risk groups. It has never broken through to cause a heterosexual epidemic, and there was absolutely no reason for the HIV virus to behave any differently. Furthermore hepatitis B is, interestingly, much more widespread in the Far East and Africa.

This straightforward analogy with hepatitis B should have tempered the experts’ predictions. In fact it has never been invoked in the copious articles and reports anticipating the future pattern of the Aids epidemic.

The second example involved an even more surprising omission. The late eighties were the heyday of claims that the western diet was the main culprit in many common illnesses. Those unfortunate enough to be struck down by heart attacks, strokes or cancer really had only themselves to blame for continuing, in the face of expert advice, to have a cooked breakfast in the morning and to add salt to their potatoes. The imagery was certainly powerful enough, and virtually every month saw the publication of yet another “expert” report which, having ostensibly examined the entrails of the scientific evidence, would come to precisely the same conclusion.

This was all very well, but these claims about the benefits of switching to a so-called healthier diet had already been tested at the beginning of the decade in the largest and costliest experiment ever conducted in the history of medicine: 60,000 men had been divided up into an “intervention” group and a “control” group, the former being encouraged by every conceivable means to quit smoking and make substantial changes in their pattern of food consumption.

But when, ten years and millions of pounds later, investigators had totted up the number of heart attacks in each group, there was absolutely no difference. Now there could be good reasons for this failure to produce the “correct” result, but clearly any judgement as to the validity of the dietary explanation for disease had at least to take it into account. Yet reports on the subject somehow managed to avoid mentioning the results of this experiment or, if they did mention them, failed to explain why the negative results did not alter their verdict.

There is no difficulty in working out the reason behind these two deceptions. The imminent threat of a heterosexual Aids epidemic or the promise of preventing thousands of deaths a year from heart disease was much the best way of continuing the free flow of government and research funds. And it was all so easy. They did not have to tell any deliberate fibs – they had simply to omit a few relevant observations that would have allowed the public to put a different gloss on what they were being told.

It could be said that there is nothing new in all this. Dr Alex Comfort, in his famous book The Anxiety Makers, carefully documents the many instances in which doctors invoking the authority of expertise have “retailed their patients with a flood of misinformation – moralistic intention as well as content”.

Thus at the turn of the century most doctors, strongly influenced by the writings of the venereologist William Acton, were convinced that sexual excess was a prime cause of physical degeneracy. “The wear and tear of the nervous system arising from the incessant excitement of sexual thoughts and a large expenditure of semen” was implicated as the cause of a whole host of illnesses, from cataracts and nasal catarrh all the way through to “consumption, loss of memory, fatuity and death”.

Helpful as it may be to see contemporary anxiety-mongering as part of a historical pattern, there are still enormous qualitative differences.

Its methods are, or at least appear to be, much more sophisticated and scientific than anything Acton could have come up with. The numerous reports on the harmfulness of the western diet come packed with graphs and tables of statistics, references and appendices. It all looks so impressive that it is hard to imagine it can be anything other than balanced and objective.

The more sophisticated the anxiety-mongering, the more potent a force it becomes in undermining the authority of medicine as a source of reliable knowledge. If it is true that buttering your toast can be lethal, there is little reason to doubt any of the hundreds of hazards of everyday life that have been identified by doctors and scientists over the past decade – that consumption of alcohol increases the risk of breast cancer, that drinking coffee increases the chance of succumbing to cancer of the pancreas or that the chemicals in your baby’s plastic duck are carcinogenic.

The reason for this panoply of pseudo-explanations is scientific ignorance. For, despite the extraordinary technological and therapeutic innovations that distinguish contemporary medicine from that practised in Acton’s day, the cause of most illnesses remains obscure. This is as true for those that seem to strike out of the blue, such as multiple sclerosis, diabetes or arthritis, as for the chronic degenerative diseases of later life, such as cancer and strokes.

This vacuum of ignorance can be filled only too readily by statistical sophistry. Take one group of people with a disease and another without and compare their lives. Any statistically significant difference that emerges is then proposed as being the cause.

In this way multiple sclerosis has been associated with keeping cats, diabetes with eating barbecued meat and Alzheimer’s with the use of aluminium saucepans. So profligate are these explanations that for heart disease alone there are no less than 240, often contradictory, risk factors, which include both alcoholism and total abstinence, having an intelligent and having an unloving wife, drinking too much milk and too little.

In the past the antidote to such quackery would be the reasoned judgement of the scientific expert, whose practical knowledge and scrupulous evaluation of the evidence would have produced a good opinion. But no more. The result is intellectual anarchy, where anything can be harmful and the currency of the expert has been devalued.

This phenomenon has grown and flourished in ways I could never have imagined when I joined the Sunday Telegraph 13 years ago. There is no obvious way of countering it, though the sensible should operate on the principle that whatever the latest health scare may be, it is unlikely to be true – for the following reason.

The human organism is, as it has to be, remarkably robust, capable of repairing itself and impervious to changes in the external world. There are myriad feedback mechanisms to ensure that the essential physiological functions – core temperature, blood pressure, glucose level and much else besides – are kept within very narrow limits and can be modified only by really substantial threats or challenges.

It is thus staggeringly unlikely that subtle alterations in the pattern of foods consumed, scarcely detectable levels of pollutants in the air and water or any of the other alleged hazards about which we read every day in the paper can pose a significant threat to health.

Beware of experts. Or at least, before giving up your cooked breakfast and divorcing your wife, take a pinch of salt.

“The Rise and Fall of Modern Medicine” by James Le Fanu has just been published by Little, Brown, £20