Wel, Heather Ashton is always a hard act to follow, but I'm going to go further than that, and risk presenting you with 12 very wordy slides, even in the light of what Nigel Meadow says.
Meadow said about the impact that words make, as opposed to body language. 7%, I think he said, was the take-up rate. I'm going to talk about Farmergeddon, I'm not going to talk about what's beyond, I'm going to talk about what's behind.
But I'm also going to address the main theme, or the other main theme in this conference, which is what's our responsibility. And the approach I took to this was to respond to another of Millie's requests, she makes many, but bless her for organising this conference.
She asked all of the speakers to put together their 10 golden rules for survival, but she didn't specify survival from what, and so I decided that I would talk about my personal 10 golden rules for averting rather than surviving Farmergeddon.
I don't be intimidated by the word Farmergeddon, I simply think that we need a word to describe the malign end point of health climate change. Health climate change is happening the whole time for reasons and in ways which I will explain.
And Farmergeddon simply represents a notional end point, the point at which it has all become really too bad to bear. And I have the feeling that if we haven't already passed a tipping point, we're certainly heading in that direction.
So that's what I'm going to talk about, although there is in fact a formal ish definition of Farmergeddon, three of the principal authors of the definition you can see on the screen are in fact attending this conference.
So my first rule, and I ought to say even before I start, that when I'm talking about my own capacity to survive in clinical situations, this happens to be rule number 10.
So I have a completely different order. What I'm trying to do today is elucidate my rules for surviving Farmergeddon. So although this deals with my personal responsibility and perhaps to some extent yours, the order is rather different.
If I said to you that the purpose of or the natural output of the media is truth and fact or the natural output of the banks is economic progress or wisdom and learning the natural output of universities, nutrition, the natural output of the food industry, I hope you would shout me down.
I'm sure you would shout me down and yet we somehow take for granted that good intent produces good effects and it doesn't.
So this is my first rule that we need, as several other speakers have emphasised already, we need to be thoroughly critical about the way in which medicine works or the effects of medicines and medical intervention and Peter, I'd love some water.
Thanks.
Medical and pharmaceutical endeavour clearly does produce great health returns, but having dipped into what Hippocrates started, at least in the tradition of Western medicine 2,000 years ago, I do increasingly regard medicine as a dreadful disappointment, a disappointment in the sense that its potential is increasingly less fulfilled.
We live in a world in which the potential of medicine could be so much better used and it simply isn't. Health inequalities between nations and within nations and the second point here is we proceed on the basis that good will result because good is intended, it doesn't.
We have only the flimsiest idea of the relationship between harms and benefits of medicines and the reason is very simple, we do not investigate health outcomes, health outcomes and therefore we're really not entitled to expect them.
I have focused my attention on the regulators because the regulators are the people who should be responsible to us for controlling this situation. In fact, my impression having studied them for the best part of 30 years is that they act in effect as a first line of defence for the pharmaceutical industry.
There are all kinds of things wrong which I can't really go into now, but the confusion of science and politics is clearly one, the confusion between scientific, between commercial and health imperatives is another and so on and so forth.
Far from acting in a way in which they make it obvious that they are aware of their limitations, the regulators produce exactly the opposite. They are stuck in a world of tick box accountability which is actually perpetuating the situation I dread.
I won't mention dishonest and irrelevant scientific inquiry because first of all because it's been referred to by several other speakers but also because Ben Goldacre is going to talk about the limitations of clinical trials.
The two great changes that have occurred in driving the health climate change that I think we should be attending to are first of all globalisation and secondly and the two are obviously related commercialisation.
The climate, certainly in my lifetime, I was a war baby, I benefited from a very young age from the national health service. Health was basically a quiet endeavour until about the 1980s.
We regarded ourselves as pretty robust, unfortunate if we got ill, but there were good enough services to look after us if that happened.
Now the quest for health has become shrill and I happen to think that it is dangerous and damaging.
My second golden rule is to remember that my health depends overwhelmingly on the health of people around me.
Nothing surprising about this, it does reflect my bias as somebody who's been privileged enough to have health care through the national health service, but the point I'm trying to make here is that no one is an island.
You cannot exist as an island of sanity in a sea of madness and this was the way I put it in the book I co-authored with Anitha Hardan.
My health is really the consequence of the example set by other people, not only in my upbringing but at school or wherever. If I'm surrounded by people who are generally obese, I shall probably follow suit.
If I'm surrounded by people who smoke, I will probably join them, I certainly, there is no prospect of ever beating them and so on and so forth.
I point to the example in the United States, which is the United States that existed before the pretty encouraging result of the election.
In the United States, the Centers for Disease Control estimates that only 3% of the population lead a normal and healthy lifestyle.
In spite of the fact this is the richest and most medicated country on earth. That is the direction I think we are heading in.
My third rule is to take into account the relationship between my demand for health services and my access to them and the same for other people.
At micro level, this means that if I join a queue, you fall behind or vice versa, but at macro level it means that excessive mass demand for medicines and medical treatment by some populations inevitably imposes deprivations on others.
I should have added that there is no need to make notes, I have these 12 slides on a handout and everything you see on the screen will be on the handout.
What has happened in this age of marketing that really began from about the 1980s, globalization say from about the 1990s, is that what used to be the mainstay of the big farmers,
the ability to innovate useful new drugs has pretty much come to an end.
In order to survive, even in the, I would say, obese states that they now exist, in order to survive they rely overwhelmingly on marketing and marketing is producing a degree of over medication.
The point I want to make is that the world is now divisible between societies where over medication is or is becoming the norm and other countries where under medication is and is being maintained as the norm and the two things are clearly related.
Point four, the treatment I get is the product of a system in which the doctor plays an increasingly marginal part.
Now this is a hard thing to say or even believe when I'm in front of my doctor needing treatment.
The doctor is of course focal and is of course critical, but the fact is that the doctor is the end product or the end user, or I'm the end user, the doctor is the penultimate end user in a system upon which the doctor is hugely dependent for information about drugs and so on.
I included here the Hippocratic Oath or a segment of it because it emphasises here how the doctor will use his or her, it was actually his, his judgment in deciding what you needed and how to treat you.
Those days have passed, the doctor is now on the receiving end of, or the doctor's understanding of treatment modalities and most important of treatment outcomes, the doctor is dependent on information that is overwhelmingly guided by market forces.
The reference there to FSA standards is a snide comment on the financial services agency and a reflection on its total blindness to the financial crisis that we are now in.
And I'd like to suggest, or I am suggesting by implication that the medicines and whatever it is, healthcare products, regulatory agencies, the MHRA is in pretty much the same boat.
They do a wonderful job looking at the detail of this and that, but their overview of the situation and their propensity to look at evidence of health outcomes simply isn't there.
And it isn't there because they're obeying a law which says they don't need to look at these things.
They've just got to look at safety and efficacy which may be measured in all kinds of strange ways which have nothing to do with health at all.
So what I'd suggest is that the doctor has actually been left behind and is increasingly being left behind and really out of touch with expert and honest opinion.
Sorry to be rattling through these, I can only barely see the clock but I think I'm roughly on time.
Now this is a complicated bit, the paradox of progress and the conspiracy of goodwill. What is a paradox of progress?
Well, in the, really throughout the second half of the 20th century, all of us have enjoyed the most extraordinary benefits of this energy consuming device and another.
Cars, aeroplane flights, washing machines, you name it, computers, but now we're on the brink of ecological disaster.
It was never meant to be like this, we've enjoyed huge benefits but now there is the prospect of something really quite terrifying in the form of environmental climate change which is a direct consequence of this.
Is there an analogy with medicines? Yes, and I think it's even stronger.
Let us suppose that antidepressants or anxiolytics or similar drugs actually worked wonderfully well, which they do not, they clearly do not, but let us suppose that they did.
Let us suppose total efficacy and marginal or minimal or zero side effects. What would be the consequence for generations to come?
Well, let's take antidepressants. You can say for certain that the 3% of people who are treated now who are indeed severely depressed would benefit enormously because depression is a ghastly state to be in.
But you could also make some other predictions with absolute certainty. One is that you would certainly not be able to control the distribution of those drugs.
They would be available absolutely everywhere. Everybody would have access to them, everybody would take them, and there would no longer then be any depression because there would then no longer be any excuse for depression.
Society would thereby deprive itself of any feedback mechanism whatsoever for defining conditions, whether in working relationships or the workplace. Society would deprive itself of the opportunity of defining the difference between depressing and healthy conditions.
So that is a paradox of progress. The conspiracy of goodwill, well, it's a seemingly mutually advantageous collaboration such as we now have between professionals, commerce, government and consumers.
It is a seemingly advantageous collaboration that in fact works to disastrous effect, and the downside of that conspiracy is certainly health deprivation, the growth of unsustainable demand, the growth of unmet need, disappointed expectations, destructive dependencies, corrupt practice and far-fetched official denials of failure.
I'm going to jump to rule number six.
Deny the emphasis on counting and classifying adverse drug reactions. We've heard a lot about that this morning as any adequate response to my atrogenesis. Sorry to use that word. I'll come on to that in a minute.
What I mean is that our attempts to measure the true relationship between the benefits and the harms done by drugs, we make a mockery of that measurement by pretending that counting adverse drug reactions is the answer.
It clearly isn't. This is just the tip of an iceberg. It is essential work, but it is wholly insufficient to what we ought to be doing. Ivan Ilych defined atrogenesis in its widest sense saying, we're not only talking about ADRs, clinical atrogenesis.
What about social and cultural atrogenesis, and he used this wonderful expression, the paralysis of healthy response. We're absolutely in the grip of this now, if I'm right, about the nature of health climate change.
It really is happening right now, and it's certainly not hard to see what is meant by the expropriation of health.
However, we need a new word for atrogenesis that follows from what I've said. First of all, because it's a long and cumbersome word, it's meaning barely known.
But secondly, because it too much lays the door, lays the blame at the door of the doctor. Not fair, because as I said, the doctor operates really as part of a system rather than on his or her own.
How am I doing for time, Peter? Oh, that's encouraging. Thank you.
I made up my mind that I was going to take this at leisure and not be embarrassed if I ended with rule number six, because you'll have the handouts anyway, but I will come on to them.
Rule number seven, this is a very personal thing. A great American doctor, Lewis Thomas, is wonderfully worth reading, has certainly had a decisive influence on the way I think about medicines.
One of the reasons why, and I did know him slightly, indeed we've even enjoyed a quiet smoke together. It's a long time since I did that with a doctor. A hugely humane and wise and sensible man, and if he wanted the odd cigarette, that was absolutely fine.
He was averse to health obsession, and what he wrote here was, in the next clip I'll show you, what he wrote was in fact written in 1980, which makes it all the more wonderful.
It was a warning, a warning of what actually would happen, and he said, we are in real life a reasonably healthy people, far from being ineptly put together, we are amazingly tough, durable organisms, full of health and ready for all contingencies.
The new danger to our well-being, if we continue to listen to all the talk, is in becoming a nation of healthy hypochondriacs, living gingerly and worrying ourselves half to death.
Now, if he's right, and there's clearly much more evidence now than then to support that view, if he's right, we have not only to worry about the people, the individuals who are on the receiving end of this onslaught of health messaging.
We are also doing something which is certainly one of the most precious elements in my health package, and that is we are destroying the possibility of an effective national health service.
Thomas anticipated this, by saying that the demand will be totally unsustainable, and we will make any healthcare system, however efficient, totally unworkable.
Just remember what I said about Lewis Thomas writing that in 1980, that was before the madness of direct-to-consumer advertising, and direct-to-consumer promotion that masquerades as honest information, and what I call the dictatorship of patient choice.
My eighth rule, consider the etiology and nature of other crises before dismissing the threat of Farmergeddon.
I included BSE, I think for sort of rather symbolic reasons, but also because it was an accident waiting to happen, dead cow mixed with cattle feed.
Really not a very good idea. The other two crises, of course, much slower to unfold, and the danger with what I call Farmergeddon is that it actually is behaving like a rather slow virus, an infection in the body of medicine that threatens in the end to overwhelm it.
The thing I'm just about to put up, you're really not meant to read. You could, if you got out one of those handouts, you could use a magnifying glass and do so, and I don't think I'm going to enumerate them now.
But these are some of the common denominators that I thought existed between the three crises that I've mentioned. But the point I want to make, or the overall point I want to make, is that history still rules and that crisis conditions and strict compliance still happily co-exist.
Now this is pretty near the top of the list that I present to myself when I undergo treatment. The best of medicine is completely wonderful. It's absolutely stunning. Great doctors are absolutely wonderful.
But the best of medicine is so profoundly unrepresentative of the whole. You've got also to be hugely critical, hence the reference to the utmost discrimination.
And I'm not going to talk about that last line, but I've written a book about it and there are at least four copies left outside. This happened once to my father. He actually dropped all his papers while he was shuffling them as I'm doing now.
He dropped them all over the floor and wasn't in a position to pick them up. He was quite disabled by that time and my mother rushed up to the podium and sorted the papers and plonked them back in front of him.
And at that point he said, oh, I see what you mean. Nine comes after ten, or sorry, ten comes after nine. I'm coming on to my rule number ten. And this has actually been mentioned obliquely or otherwise by other people.
Trust your own judgement, notwithstanding your own levels of ignorance and the professed wisdoms of the media and the drug establishment.
And one of the reasons I say that and feel it with considerable confidence is the certainty that if we were all capable of knowing, understanding, distilling and processing all the information there was to be had about a particular treatment or intervention, we would probably stop dead what we're doing.
We would probably stop dead in our tracks. Looking back at the history of medicine and you really don't have to have to look back very far, it is blindingly clear that mistakes are absolutely routine.
That's the A and the B is that the medical establishment in general and doctors in particular are actually very, very bad at learning from them. Lack of accountability is the reason and I'm going to end on the note on the point made by Lewis Thomas.
Probably more true today than it was when he said it then because of the huge complexity of medicines and medical intervention. The plain fact of the matter is that we do not know enough about the facts of the matter and we should be much more open about our ignorance.
Thank you. Thank you Charles. I'm having to peer into the lights.
Hello, yes. I was interested in knowing what can be done about very obstructive preemptive laws discouraging litigation in favor of big pharma. What can be done about this because it seems that governmental officials are coming out now in the US with those preemptive laws and also
capping compensation for those who have suffered life threatening and very nasty side effects from drugs.
I rather wish you'd asked me about what is the secret of life instead. It's honestly impossible to give you a sensible answer to that question.
But I wholly agree with the intent of your question that there is an awful lot that needs to be done. The obvious thing is that we should institute proper enquiries to establish causation if not negligence when drug disasters happen.
If I crash my car, a policeman will turn up on the scene and will make such an assessment. This does not happen in the case of medical mishaps, medical accidents and so on.
Or if there is a plane crash or a train crash or a fire in a stadium, the legal establishment is galvanized to establish what went wrong and we don't have this system in the body of medicine and it is gravely bad not only for us but for the progress of medical and pharmaceutical endeavour.
Thank you. Thank you. Just behind. Hello, I'm Jerome Byrne journalist. I've heard an awful lot about the dangers of drugs and I think we all agree that there are huge problems and difficulties.
That still leaves people I feel very unempowered because if you are faced with somebody who has psychological problems or difficulties with dealing with other people or the kind of things we've been talking about here, if you can't use any of the drugs and very good cases for being enormously careful of them, you're kind of left without anything else.
I just thought I'd mentioned very briefly, I went to a conference a couple of weeks ago which was about the links between nutrition and vitamins and so on and mental conditions and this seems to me to be an area that could quite usefully be explored and awful lot more.
There isn't very much money, it's a problem, there's a same old problem with evidence and the rest of it but I've heard a huge amount about the problems and clearly the forces keeping those problems in place are enormous and very powerful but maybe some more consideration of where else you might go to find relief, comfort, help and so on would be useful.
Drugs were the problem with my daughter and the drugs offered as a solution were also the problem and the way the NHS is structured you cannot change your GP easily and if you are being treated by an NHS psychiatrist you will find that you are under extreme pressure to conform to what that psychiatrist says and prescribes.
Now I absolutely agree with you that each individual needs to take responsibility for their own health and I agree that we are a healthy society but it is extremely difficult to get any kind of treatment if you don't submit to the views of the GPs and the psychiatrists.
Yeah well of course, well you know the applause is almost a sufficient answer because what you say is absolutely true.
The anything I can say is perhaps emphasising the distinction between on the one hand a personal responsibility where in your experience as indeed in mine, frustration at the hands of medical experts has sometimes been appalling.
On the other hand the collective responsibility we have and I do lay this in a democracy there is really no choice but to do so.
In some sense we get the system we deserve, we join in this conspiracy of goodwill and the only other thing I would add to that is that I think well no I do think doctors are victims.
I think actually I could argue a case for drug companies being victims, I mean victims of pernicious desire admittedly but victims nonetheless.
But you raise a critically important point and forgive me if I didn't you know it wasn't something I covered in what wasn't really meant to be a clinical appraisal.
It was more a sort of overview and I should have said at the outset I am a layman, I don't have clinical qualifications of any kind whatever to some extent an advantage I may say.
And that would you know really have precluded me you know touching on the area in which you exist but stay for the rest of the conference because there are some very good speakers to come who I hope will deal with the points you've made.
I would agree with that but I really feel very strongly that our society is not set up to empower people to think for themselves.
If you think just in terms of medical journalism daily there will be things in the press saying what's dangerous and what's good and in a sense it's disempowering people.
And so we're supposed to listen to these experts all the time and as I say you're stuck with a GP, you're stuck with a psychiatrist and you have very little freedom to move.
Yeah we have in common a huge impatience and all I can leave you with is what Heather who's sitting in front of you left you with which was Margaret Mead's adage about what a small band of individuals can do.
Indeed you know to do what needs to be done. I try to number myself among that band but there we go.
Thank you very much Charles.
