Iatrogenic diseases pose a major threat to health throughout the world. According to a respected medical textbook, iatrogenic disease has become 'one of the most prevalent conditions facing modern health services, occupying countless hospital beds all over the Western world.'1 This view is strongly borne out by scientific research, as evidenced by many thousands of articles on the harmful effects of modern medicine published in medical journals over the past two decades. For example:

The horrifying side-effects of 'disaster drugs' such as practolol, clioquinol, phenylbutazone, benoxaprofen and, above all, thalidomide have so dominated medical and public thinking about iatrogenic disease that they have overshadowed the more insidious but ultimately much greater damage done by agents considered safe enough for widespread use. This point is clearly expressed in the following excerpt from a chapter entitled 'Two decades of drug-induced disasters' in a major medical textbook on iatrogenic disease:

High heap of scientific research papers on the hazards of modern medicine. The hazards of modern medicine have been documented by thousands of articles published in medical journals. Utilising the complete knowledge of Natural Law, the Natural Law Party offers a complete health care programme that will eliminate these hazards and create a disease-free society.

'The thalidomide tragedy looms so ponderously over the history of side-effects that any inclusion of it in a general discussion all too easily distorts the entire picture, causing other events to pale into insignificance and suggesting that since 1961 we have solved the worst of our problems. That is most certainly not true. The number of patients gravely injured or killed in epidemics of drug-induced disease since then is a vast multiple of the number of thalidomide victims; the range of injuries produced is also so wide that no simple solution to the problem seems likely to emerge.'7

Thus, while extreme cases of drug toxicity may be terminated by withdrawal of the offending agent, the creeping destruction wrought by many drugs with 'acceptable' safety records goes on unchecked. Magnified through massive use, the hazards of such agents have become a much greater source of morbidity and mortality than any of the much more publicized drug disasters. A prime example is provided by the non-steroidal anti-inflammatory drugs (NSAIDs), which are among the most widely prescribed of all pharmaceuticals. A study published in the journal Drug Safety indicates that NSAIDs claim around 3000 lives per year in the UK alone.8

Of great concern is the fact that most adverse drug reactions go unrecorded. A recent article in US News and World Report quoted David Kessler, M.D., Chief of the United States Food and Drug Administration, who believes that 'only one percent of all serious drug reactions are reported'.9

Another recent news article quotes Roy Schwarz, M.D., Group Vice-President of Scientific Education and Practice Standards at the American Medical Association, who summed up the current state of medicine as follows: 'We should make people aware of the uncertainties of medicine. Not everybody will be cured and in some cases disasters will occur. That's reality. ...Medical practice, by necessity, always will be based on trial and error.'10

The intrinsic toxicity of modern pharmaceuticals is especially dangerous in the elderly, who are by far the largest consumers of medical drugs, most likely to suffer side-effects and adverse reactions, and most easily harmed by the common practice of prescribing multiple drugs with consequent risk of complicated and potentially fatal interactions.11,12 Drugs cause or aggravate many common medical problems of the elderly, including dementia, confusional states, depression, Parkinsonism, falls (and associated fractures), loss of mobility, incontinence, heart failure, and many other conditions that drastically diminish the quality of life and independence of older people. In one study, 51 percent of new cases of Parkinsonism in elderly patients were found to be due to prescribed drugs.13

The toxicity of drugs is especially disturbing in light of serious doubts about the effectiveness and appropriateness of much drug use. Surveys have shown that a majority of prescriptions are for agents which have been defined as being of marginal therapeutic value. Nevertheless, these drugs still have substantial toxicity and pose a threat to health.14 For example, researchers at Yale University School of Medicine reviewed studies showing that between 24 and 66 percent of antibiotics prescribed in American hospitals are inappropriate.15 In another study, from Harvard Medical School, it was found that nearly 25 percent of older people were prescribed potentially inappropriate medications, placing them at risk of adverse effects. The authors suggest that their findings represent only 'the tip of the iceberg.'16

Modern medicine currently fails to prevent the majority of illnesses and its treatments are often directed only to the symptoms and advanced manifestations of disease, rather than addressing the root cause of the disorder. Overall, despite vast and continuously expanding expenditure on medical research and treatment services, modern medicine appears to be producing increasingly marginal advances.

In developed nations, these limitations are evident in the continuing high incidence of chronic disorders, including cardiovascular diseases, cancer, neurological degenerations (including Alzheimer's disease), diabetes, obstructive lung diseases (including asthma), arthritis, and psychiatric disorders. They are also reflected in the vast amount of resources consumed in trying to contain these problems and their complications, and the comparatively minuscule efforts and expenditure devoted to true primary prevention.

Although marked improvements in health standards have of course occurred in developed nations over the past century, these have resulted primarily from better nutrition, housing, and sanitation rather than from advances in modern medical technology. Moreover where major diseases are declining today - such as coronary heart disease in a number of developed nations - it is clear that these gains have little to do with expensive and sophisticated technologies such as drugs, surgery, and hospital care.

Indeed, Dr. Alexander Leaf, until recently Chairman of the Department of Preventive Medicine at Harvard Medical School, describes the current response to coronary heart disease as 'inadequate, despite massive efforts to apply costly treatments after the disease is clinically manifest...Doctors are too preoccupied with measures that only lessen symptoms and which will do nothing for the next generation of 30-, 40-, or 50-year-olds, dooming them to the same heart disease.'17

Doubts have also been raised about the current approach to cancer. According to research published in the New England Journal of Medicine in 1986, both crude and age-adjusted mortality rates from cancer in the United States have risen over three decades. The authors of this research conclude that, according to this evidence, 'we are losing the war against cancer'.18 Similar concerns were expressed in a 1993 editorial in The Lancet, which calls for a major rethink in the prevention and treatment of breast cancer, the commonest fatal cancer in women: 'To sustain the incentive for progress we must eschew complacency and recognize the dangers of a mindless race down familiar pathways when, in all truth, we lost our way several leagues ago along this very route.'19 Public concern over the lack of progress against cancer is also rising: a recent article in The Times discussing official British cancer figures observes that: 'More and more people are suffering from cancer, in spite of the huge resources pitted against the disease...'.20

Meanwhile, in developing countries, growing expenditure on drugs and expensive diagnostic and therapeutic facilities has drawn resources away from vital basic public health measures. As a result, many infectious scourges continue to rage, while disorders prevalent in industrialized societies - like coronary heart disease, diabetes, and lung cancer - are increasing at an alarming rate. Moreover, although the iatrogenic epidemic has reached enormous proportions in developed nations, pharmaceutical toxicity presents an even greater threat to people in developing countries, where controls on drugs are often grossly inadequate.

Throughout the world, increasing concern about the hazards and limitations of the current approach to health is intensifying the search for new developments that can solve the current crisis in health care and take medicine forward towards its ultimate goal - the creation of a disease-free society.

References

1 Butterfield, Sir John. (1986). Foreword. In D'Arcy, P.F. and Griffen, J.P. (eds). Iatrogenic Disease, 3rd edition. Oxford University Press.

2 Leape, L.L. (1994). Error in medicine. Journal of the American Medical Association 272: 1851-1857.

3 Brennan, T.A., Leape L.L., Laird, N.M., et al. (1991). Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. New England Journal of Medicine 324: 370-376.

4 Zinn, C. (1995). 14,000 preventable deaths in Australian hospitals. British Medical Journal 310: 1487.

5 Steel, K., Gartman, P.M., Crescenzi, C., and Anderson, J. (1981). Iatrogenic illness on a general medical service at a university hospital. New England Journal of Medicine 304: 638-642.

6 Isselbacher, K., Braunwald, E., Wilson, J.D., et al. (eds). (1994). Harrison's Principles of Internal Medicine, 13th edition. New York: McGraw-Hill.

7 Dukes, M.N.G. (1986). Two decades of drug-induced disasters. In D'Arcy, P.F. and Griffen, J.P. (eds). Iatrogenic Disease, 3rd edition. Oxford University Press.

8 Hayllar J., Macpherson A., Bjarnason I. (1992). Gastroprotection and non-steroidal anti-inflammatory drugs (NSAIDs). Rationale and clinical implications. Drug Safety 7(2): 86-105.

9 Podolsky, D. and Loeb, P. Drug Alert! US News and World Report, 9 January 1995.

10 USA Today, 13 September 1995.

11 Patterson, C. (1986). Iatrogenic disease in late life. Clinics in Geriatric Medicine 2(1): 121-136.

12 Editorial. (1988). Need we poison the elderly so often? Lancet 2: 8061.

13 Stephen, P.J. and Williamson, J. (1984). Drug-induced parkinsonism in the elderly. 2(2): 1082-1083.

14 Melmon, J.R. (1971). Preventable drug reactions: causes and cures. New England Journal of Medicine 284: 24.

15 Frieden, T.R. and Mangi, R.J. (1990). Inappropriate use of oral ciprofloxacin. Journal of the American Medical Association 264:1438-1440.

16 Gurwitz, J. (1994). Suboptimal medication use in the elderly: the tip of the iceberg. Journal of the American Medical Association 272: 316-317.

17 Leaf, A. (1993). Preventive medicine for our ailing health care system. Journal of the American Medical Association 269: 616-619

18 Bailar, J.C. and Smith, E.M. (1986). Progress against cancer? New England Journal of Medicine 314: 1226-1232.

19 Editorial. (1993). Breast cancer: have we lost our way? Lancet 341: 343-344.

20 The Times, 31 July 1995.

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