Una dosis de pruebas empiricas

A dose of empirical evidence

Ivan Illich: Medicalization and primary care

York history professor David Wootton talks to John Crace about his radical new version of the development of medicine

Tuesday April 29, 2008
The Guardian

David Wootton
Photograph: Sarah Lee

You can’t help seeing it as a kind of back-handed compliment. No sooner had his daughter announced that she intended to train to be a doctor than David Wootton decided to start work on Bad Medicine, a book that comes with the catchy subtitle Doctors Doing Harm Since Hippocrates. Wootton smiles, unfazed by the association. “It’s true that my daughter’s career choice did spark my interest in the history of medicine,” he says, “but the title is somewhat misleading. My working title was Death Deferred and the main thesis is that it’s only in the last 150 years that doctors have started to do any good.”Just as the title got lost somewhere in translation, so too did the book. What Wootton, anniversary professor of history at York University, originally intended to write was a rather esoteric Foucaultian exploration of the ways we inhabit the body, but he rapidly became diverted into the 2,000-year Hippocratic tradition of western medicine and how it had failed to progress for so long while keeping its reputation largely intact. True, there had always been a few quacks, but then – as now – doctors were, for the most part, well-paid, highly educated practitioners who were respected within the community – even when they were killing more patients than they were curing by practising therapies such as blood-letting, which we now know had worse results than allowing the illness to take its natural course.

Professional delusion

“You can only see it as some kind of mass professional delusion,” Wootton says. “Even in the late 17th century, when doctors no longer believed that the body was made up of the four humours, they continued to practise the same therapies. They managed to convince themselves that the treatments they had always practised were effective, and it was their belief systems about why they worked that needed to change. And patients colluded because they were desperate; doing something was perceived as better than doing nothing.”

So far, Bad Medicine has received what publicists refer to as a “mixed reaction”. Doctors in the UK, with an interest in how medicine became effective, have largely given the book the thumbs-up, while those in the US – where evidence-based medicine still plays second fiddle to clinical judgment – have been lukewarm. But it is from the medical historians that Wootton has copped the heaviest flak. His crime? Writing a history in terms of progression.

“It is almost an article of faith for historians that notions of progress are relative and illusory,” says Wootton “And it makes perfect sense when you are studying something like 18th-century politics, because notions of taking sides between good guys and bad guys are to some extent meaningless, because people are a product of a particular social and cultural construct. But it doesn’t make so much sense when you are talking about science, because progress is something than can be clearly measured and quantified.”

This is more than some slightly recherche academic squabble over postmodernism. For in writing Bad Medicine, Wootton has completely redrawn the received version of medical history which states that it was only with the building of large hospitals in the 19th century – and the accompanying increased mortality rate due to the proximity of patients to one another – that doctors began to grasp germ theory. Rather than trading in the standard “what if?” counterfactuals that have become the staple diet for many historians, Wootton has trawled through the archives to create a parallel, virtual history of medicine that raises serious questions about how the actual one evolved.

“There were physicians in the 17th century who had come up with relatively sophisticated ideas of germ theory,” says Wootton. “They understood there were little things that were buzzing around and that some people must develop resistance to them. They could even see them in microscopes. I’d always previously assumed that their microscopes weren’t powerful enough, but that was incorrect. They could see microbes, but the medical establishment did nothing. It was Pasteur who got the credit for germ theory, but he was really only running experiments other scientists had run 30 years before.

Progressive breakthroughs

“It may sound as if I’m using hindsight to condemn doctors for failing to break free from the prevailing belief systems, but that’s not true. Contemporaries were asking themselves the same kind of questions; when anaesthetics were first introduced, countless doctors asked themselves why on earth they hadn’t started using them earlier, as the science was already well-understood. Medical history is littered with these anomalies. Penicillin was actually first successfully used to treat eye infections in the late 19th century, but no one made the right connections about its antibiotic properties until the 1920s and 30s. So it makes sense to think of medicine as a series of progressive breakthroughs and it is legitimate to ask why progress has often been so slow when the necessary evidence is available. Even now, we’re making the same mistakes. It’s only in the past 25 years that we’ve finally accepted that ulcers are caused by bacteria rather than stress.”

Wootton is a curious mix of the radical and the old school. He might have cut his teeth on Foucault and Levi-Strauss several years ago, when he came across their work piled up in a sleepy bookshop in Poitiers where he was studying on a pre-Cambridge scholarship; and he still lives an agreeably bohemian life, dividing his time between his north London flat, a cottage in Leicestershire and a longboat in York. But, not far beneath the surface, there is a committed rationalist whose beliefs – and interests – are firmly rooted in the Enlightenment. And it’s a rationalism he values, all the more for the fight it took to get it.

His parents were both missionaries and he spent his early life near Lahore in Pakistan, where his father was having limited success converting Muslims to Christianity. It was a peculiar, alienated existence. He was home-schooled and the only English speakers he came across were Americans, so when he returned to this country, he found England to be just as strange a land. “I spoke with an American accent,” Wootton points out. “My father was a committed Christian working for the British and Foreign Bible Society and I had no understanding of British culture. So I felt completely disconnected.”

He won a scholarship to the City of London school and his daily commute from Blackheath gave him a rare sense of normality away from the doctrinal formality of the family home. These days he chooses his words carefully when describing his relationship with his father, but he does concede it wasn’t easy. “My father was an extremely religious man,” he says, “and it upset him greatly that I did not share his beliefs.” Wootton wanted to become a mathematician – “It was soon made clear to me I didn’t have the talent for it” – so he ended up going to Cambridge to read history. And hating it.

“I went to Peterhouse College in 1969 and it felt as if I was going back to the 1930s,” he says. “It was as if the new intellectual world I’d discovered in France just didn’t exist. History was reduced to the stultifying empiricism of the establishment of facts.” Things started to look up in his third year when the first English translations of Foucault started to appear, and Wootton found himself in the vanguard of the student radicals. “It was a heady, exciting time,” he says. “We genuinely felt that the world could be changed through freedom, equality and participation.”

Pessimism – or realism – has long since blunted some of his idealism, yet even in his student days he never allowed his enthusiasm for the new isms of postmodernism and structuralism to completely destroy his faith in the old ism of empiricism. For just as Bad Medicine is grounded in evidence, so too was his doctoral thesis on Paolo Sarpi, a minor Venetian theolgian and contemporary of Galileo. And just as with Bad Medicine, his work on Sarpi caught him on the wrong side of the historical thought police.

“I came across a notebook that no one had read since Lord Acton in the 19th century,” Wootton says. “And it clearly showed that, contrary to what everyone had hitherto believed, Sarpi believed religion to be completely false and merely a means for the inculcation of social order. I presented my findings to my supervisor, Hugh Trevor-Roper, and he told me to forget them, as the examiners would reject them because no one would accept that atheism existed in the 17th century. He didn’t say I was wrong; just that it wouldn’t be accepted. I was amazed as I thought the evidence would speak for itself. But apparently not.”

Battle for acceptance

Wootton resolved the situation by resorting to a peculiarly quaint Oxbridge tradition. “I discovered that if a Cambridge graduate could persuade the University Press to publish their book, it would count as a Phd. So I got a contract from CUP, sacked Trevor-Roper as my supervisor, and wrote the book. Twenty years or so on, my work on Sarpi’s atheism is now accepted in historical circles. But it’s been a battle.”

Once the Sarpi opus was published, Wootton upped sticks and moved to Canada, taking jobs in Montreal, Nova Scotia and Victoria, and he rather imagined he might see out his career on that side of the Atlantic. But that all changed when – on a year’s sabbatical to the UK – his 16-year-old daughter told him she had no intention of going back to Canada as the maths teaching there was crap. “She did rather force my hand,” he smiles, “so I applied for a job teaching politics at Brunel.” From there he moved to Queen Mary, University of London, and then to York.

But his taste for controversy – evidence-based, of course – is undiminished. Earlier this month, he delivered the prestigious Raleigh lecture to the British Academy in which he suggested that Queen Elizabeth I had been instructed into a quasi-religious, virtual psychotherapeutic group, the Family of Love, by one of her courtiers, Robert Seal. And you would put odds on the biography of Galileo that he’s currently writing upsetting a few of the old canards. Still. You can’t help feeling that one of the Enlightenment’s leading figures wouldn’t have expected any less.

Curriculum vitae

Age: 56

Job: Anniversary professor of history, York University

Likes: Dogwalking

Dislikes: Sitting in libraries

Married, two children

· Bad Medicine is published by Oxford University Press. To order a copy for £9.99 with free UK p&p go to guardian.co.uk/bookshop or call 0870 836 0875

El mito del progreso

W. SACHS (editor), Diccionario del desarrollo. Una guía del conocimiento como poder, PRATEC, Perú, 1996 (primera edición en inglés en 1992), 399 pp.

El mito del progreso ha impregnado profundamente a nuestras sociedad. Mientras los paises ricos propugnan esta idea, planteada por EEUU en 1949, no parece ser una realidad ni una solucion para los paises sumergidos.

Una nueva sociedad se encuentra inaugurando la era de la informacion, a la vez que sufriendo las consecuencias de una universalizacion de estas ideas, que devino en globalización. Otros aspiran a ser paises industriales, y varios paises de Africa apenas piden sobrevivir.

Este escrito fue hecho antes del 2001, un hito en donde el nuevo orden mundial se expreso violentamente tras el ataque del 11S. Nada mas funcional a ésta idea que aquel ataque. Pero las consecuencias del mismo lejos de repensar los modelos sociales, ha profundizado el mito del progreso, y aún lo ha subordinado a estrategias militares.

Con claridad, este capitulo, en un libro con multiples autores coordinado por Ivan Illich, se planteaba ya que pasaria si China decidiera entrar en la era industrial. Pues bien, lo hizo, al igual que la India. Y, cual profecia, mas de uno plantea hoy hipotesis de conflictos basada en la apropiacion de los recursos naturales que de por si estan agotados. Y el medio ambiente sigue siendo agredido a pesar de las señales que mostró en el año 2005. Chernobyl tras 25 años sigue provocando efectos que se ocultan, ya que gran parte de la Europa quedó contaminada por sus efectos, pero afirmar esto significa problemas para sus economias subsidiadas por el estado. Y oculta el hecho que el cofre en donde se encuentra el Reactor 4 , que habia sido calculado. El mismo progreso no ha alcanzado a todos por igual, y Paris se subleva con Franceses hijos de una migracion tras la guerra con Algeria, que piden tan solo ser reconocidos como Franceses que son, y los mismos estudiantes de la Sorbona protestaron contra modelos de exclusion social, como la flexibilizacion laboral que quiso imponerse, pero que será inevitable si el nuevo orden sigue presente. Vale entonces leer este capitulo de ese libro. Que elegi el de tecnologias.

Medio Ambiente