WHO Cares?

by Theodore Dalrymple (Aug. 2006)

Public affairs, said Doctor Johnson, vex no man: by which, I suppose, he meant that, if we are honest, only those matters which touch us directly and personally have the power genuinely to move us. The rest is ersatz or assumed emotion that we fake or exaggerate in order to appear more concerned with public affairs than we really are; and true it is that an argument with my wife causes me more genuine upset than a distant war, however bloody, though I am perfectly aware that in the scale of human history the war weighs a million, or a trillion, times more heavily.

This means, or ought to mean, that I should by now have reached such a state of serenity that even the weekly arrival of the medical journals should not upset me. After all, my personal situation is about as satisfactory as it will ever be. I please myself, more or less, what I do; my work is also my pleasure. I am indeed fortunate.

And yet The Lancet in particular, once one of the world’s greatest medical journals, never fails to irritate me. Its sanctimony makes Elmer Gantry seem like a self-doubter. It propounds abject nonsense with the self-conceit of the assuredly saved preaching to the assuredly damned. Dickens would have loved to satirise it.

For example, it published a paper at the end of July entitled, “Is access to essential medicines as part of the fulfillment of the right to health enforceable through the courts?” The paper discussed whether, if individuals were denied access to important medicines, they could seek redress via the courts, particularly in Latin America, on the grounds that their rights were being denied.

The right to health was accepted in this paper as if it were a straightforward natural fact, like the roundness of the earth, for example, and no more disputable than the roundness of the earth. Yet the notion of a right to health is plainly ridiculous, at least until man becomes immortal. A man who is dying of incurable cancer is unfortunate, but his rights are not being infringed.

Perhaps the authors of the paper meant by the “right to health the “right to health care.” But this is scarcely any better. A right to a material benefit implies someone else’s duty to provide it, irrespective of whether he wants to do so or indeed is actually able to do so. This is not to say, of course, that the world would not be a better place if everyone who needed it were able to obtain health care; but the world would not be a better place because everyone’s rights had been observed or complied with, but because avoidable suffering had been avoided. There are more and better reasons, after all, to treat people medically than that they have a right to such treatment.

I could not help but notice that among the drugs deemed so essential that not to make them freely available to people who need them amounts to a breach of their rights was buprenorphine, a drug prescribed by doctors to opiate-addicts in the hope that they, the addicts, will thereafter stop talking opiates of their own, and take those of the doctor instead. In a way this was odd, because there was an item in the very same edition of The Lancet entitled “Designer drug Subutex [buprenorphine] takes its toll in Tbilisi [the capital of Georgia].” There, at least, there was no danger that the people’s right to burenorphine was being infringed.

The article starts with the following dramatic paragraph:

“Crushed on pavements, tossed by the road, or in the corners of apartment-block entrance halls, the used syringes tell a story of rising addiction. The needles seen across Tbilisi are discarded by the addicts of Subutex, a treatment for opiate abuse that has ironically become the country’s mostpopular drug.”

 The drug is manufactured in Britain and exported to France, where gullible doctors prescribe it to addicts who pretend to need it, and who then sell it on to dealers who smuggle it into Georgia at a profit of 600 per cent. Seven tablets in France cost $20, and $120 in Georgia. Among the smugglers of buprenorphine was the honorary consul of the Cote d’Ivoire in Georgia, who brought it into the country in his diplomatic bag. According to The Lancet, the problem is not a small one: 39 per cent of addicts treated in clinics in Georgia were addicted to buprenorphine, and the total number of drug addicts in Georgia was 250,000, which is to say one in twenty of the entire population. This represents an 80 per cent increase since 2003, and is largely due to the importation of buprenorphine.

Five pages later in The Lancet, the very same author wrote an admiring, even hagiographical article, about Dr Vladimir Mendelevich, a doctor who is trying to introduce the treatment of drug addicts in Russia, Georgia’s neighbour and historical suzerain, with yes, you’ve guessed it, buprenorphine (among other drugs). Dr Mendelevich is described as a hero by the author without any hint of irony, or even of awareness of what he had written only five pages previously, or that to introduce yet another drug into a country notorious for its corruption and administrative chaos, contiguous with Georgia, is an idea that needs very careful consideration.

Just how essential is buprenorphine that, not to make it available to all who feel they need it constitutes an attack on their fundamental human rights? This question was in part answered by a paper in the New England Journal of Medicine that appeared in the same week as The Lancet that I have cited. The authors, who practised at Yale, wanted to establish whether extra counselling had any effect on the abstention of addicts who were prescribed a tablet containing both burpenorphine and naloxone.

This tablet is an extremely clever one. Naloxone when taken by mouth has no effect, but when taken by injection acts as an antagonist to opiates, and precipitates withdrawal symptoms. Thus its inclusion with buprenorphine discourages buprenorphine abuse (though I have little doubt that, before long, addicts and their acolytes will devise something to circumvent this precaution).

The researchers recruited 497 addicts for their study, but excluded 296 of them because (as addicts in real life tend to do) they took alcohol or other drugs as well as opiates, or behaved in a dangerous and antisocial way. A further 35 dropped out at preliminary stages, leaving only 166 of the original 497 for the experiment.

The 166 were divided, like Gaul, into three: those who received the drug on a once weekly basis, those who received it on a three-times weekly basis, and those who received it on a three-times weekly basis plus extra counselling. In the event, there was no difference in the outcomes between these three groups at 24 weeks.

What was most striking was that only 75 continued the experiment to the 24^th week, which is to say that 422 addicts of the original addicts did not get that far: and 24 weeks is not exactly an eternity. The average maximum duration of abstinence from illicit opiates among the 166 sterling citizens who were treated was between five and six weeks. More than half their urine specimens tested positive for the presence of illicit opiates.

Nor is this all. It is well known that the results of clinical trials are better than results obtained in a “natural” environment, that is to say you cannot expect the same degree of success when you transfer a treatment that has been tried experimentally to normal, everyday practice. This is for several reasons, among them the enthusiasm and dedication of the staff involved in the trial, enthusiasm that often communicates itself to the patients who are therefore more optimistic and compliant with treatment than they would otherwise be.

It might well be that the very low compliance rate of the patients was caused by an awareness of the presence of naloxone in the tablets they received. It was precisely because the medication could not be abused, at least until someone devised a method of abusing it, that the compliance rate was so very low. But if so, it must cast in doubt on the motives of the addicts for seeking and accepting treatment in the first place. And it should be borne in mind that the patients were selected among 479 addicts for their relatively “good” behaviour: namely, their absence of additional substance abuse and lack of threatening, violent and criminal conduct. In other words, their prognosis was already better than average among the addicts.

Had the patients been prescribed buprenorphine alone, I think they might well have “complied” with treatment better, but only because it would have had some economic or abuse value to them. The criteria for completion of the study were not exactly stringent: those who did not miss more than three counselling sessions or missed their medication for more than a week were deemed to have completed it.

In short, the whole business was an elaborate and sordid farce, from which the authors drew the conclusion that there is “a need both to measure adherence in future research and to monitor and encourage adherence in practice in order to reduce the potential misuse of the medication and to improve the treatment outcomes.” The idea that the whole notion of treatment in a voluntary condition such as addiction might be inappropriate was quite beyond the authors.

But let us return briefly to the question of the supposed right to health. Can it be the right of anyone to obtain a treatment that is marginally effective, if it is effective at all? In fact, this is often the case in modern medical treatment. The chances of anti-hypertensive treatment doing you good rather than harm are small, though the harm it can do you is slight and the good it can do you is enormous. How certain does the good that treatment does you have to be before it becomes a right enshrined in, and actionable at, law?

I am astonished at how quickly the doctrine of rights has colonised minds, like bacteria on a Petri dish. Not long ago, I asked a young patient what she was going to do with her life (I am sufficiently interested in my patients to ask such things). She said she wanted to study law. Any particular branch, I asked, thinking she might want to do criminal law, which is the most interesting, if least lucrative, branch?

“I want to go into human rights,” she said, with that semi-beatified smile with which a girl of her age might once have claimed to have a vocation.

“Oh yes,” I said, “and where do human rights come from?”

“What do you mean?” she asked.

“I mean, are they just there, like America, waiting to be discovered by someone going out and looking for them, or are they conferred by mere human agency, in which case they can be repealed at the drop of a law?”

She looked appalled, as if I were a deeply wicked man who had suggested that, for example, racial discrimination was just the thing.

 “You can’t ask that,” she said.

I didn’t explore the question of why not, because a medical consultation is not a dialogue by Plato. But after that, I did begin to think that there was something to Richard Dawkins’ conception of a meme, namely an idea that enters minds and spreads from mind to mind as a gene favourable to survival in a population.

The problem with memes, of course, is that they don’t have to be good ideas, only ideas that are in someone’s, or some group’s, advantage. And the ever-expanding concept of human rights is of advantage to regulatory bureaucracies, of course, for how can positive rights be enforced without them? Not coincidentally, the paper in The Lancet with which I began this article emerged from that bureaucracy of bureaucracies, that meta-bureaucracy, the World Health Organization in Geneva.     

[Dr. Dalrymple’s most recent  book is  Romancing Opiates ]

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