For some time, I have been concerned about the harm that may occur as a result of medical treatment such as adverse effects of drugs or damage caused by exposure to radiation. I have just come across a paper entitled “Death by Medicine” (1), which presents a picture that is absolutely horrendous. Although it deals with the USA and was published in 2004, the information is almost certainly still relevant and is applicable in many countries.

Deaths

It was estimated that the annual death rate in the USA attributed to medicine is 783,936. This figure is higher than the 699,697 deaths caused by heart disease and 553,252 due to cancer in 2001. Hence the medical system is the leading cause of death. The specific causes and the number of related deaths are shown in Table 1.

Table 1. Annual mortality and economic cost of medical intervention

Condition Number of deaths Cost, B$
Adverse drug reactions 106,000 12
Medical error  98,000 2
Bedsores 115,000 55
Infection   88,000 5
Malnutrition 108,800 —-
Outpatients 199,000 77
Unnecessary procedures  37,136 122
Surgery-related  32,000 9
Total 783,936 282

 

The above values are based on conservative assumptions, which may provide an under-estimate of what actually happens in practice. In reality there may be as many as one million deaths per year.

As long ago as 1994, Lucian Leape published a paper in the Journal of the American Medical Association (2), in which he made the following points:

  • Many medical errors are not reported. A UK study found that in two obstetrical units only about one-quarter of adverse incidents were ever reported, to protect staff, preserve reputations, or for fear of reprisals, including lawsuits;
  • Only about 6% of adverse drug reactions are identified properly;
  • Information from the American College of Surgeons estimates that surgical incident reports routinely capture only 5-30% of adverse events.

All of this strongly suggests that whatever information is available represents only a fraction of what is happening in the real world. Even more important it clearly demonstrates a definite lack of interest in facing up to these issues on the part of the medical profession.

Adverse drug reactions

Later studies indicate that the incidence of adverse drug reactions may be increasing. In 2003, an investigation that followed 400 patients after discharge from hospital care found that 76 patients (19%) had adverse events. In two thirds of these, drugs were involved, while 17% of them had injuries related to the procedures they had experienced.

A study conducted in four primary care practices in Boston found that one quarter of outpatients had adverse drug events during a three-month period (3). Of these events, 13% were serious, 39% were either ameliorable or preventable, and 6% were serious and preventable or ameliorable. Ameliorable adverse drug events were attributed to poor communication: the physician’s failure to respond to symptoms reported by the patient or the patient’s failure to report symptoms to the physician. Preventable adverse drug events were due to prescribing errors, one third of which could have been prevented by the use of advanced computerized systems of prescribing medications. The characteristics of the patients were not significantly associated with adverse events, except for the number of medications taken. One of the doctors who produced the study was interviewed by Reuters and commented:

“With these 10-minute appointments, it’s hard for the doctor to get into whether the symptoms are bothering the patients.”

An editorial commenting on the issue said:

“… given the increasing number of powerful drugs available to care for the aging population, the problem will only get worse.”

Based on records for prescribed medications for 33 million US hospital admissions in 1994, it has been estimated that there are 2.2 million serious injuries in the USA due to prescribed drugs; 2.1% of inpatients experienced a serious adverse drug reaction, 4.7% of all hospital admissions were due to a serious adverse drug reaction, and fatal adverse drug reactions occurred in 0.19% of inpatients and 0.13% of admissions. The authors estimated that 106,000 deaths occur annually due to adverse drug reactions (4).

Antibiotics

In the USA, about 10,000 tonnes of antibiotics are used in the productions of farm animals such as pigs and poultry. About 90% of this is used for disease prevention and growth promotion. The remaining 10% is used to treat specific infections. As a consequence, measurable concentrations are found in food. In addition, the seepage from farms results in the presence of antibiotics in the waterways. This is certainly contributing to the development of pathogens that are resistant to treatment with antibiotics.

It is highly relevant to note that in Denmark, the use antibiotics for growth promotion in farm animals was banned in 1999. As a result, the usage was reduced by well over 50% and significantly, there was little impact on the costs of production.

Unnecessary surgical procedures

It is difficult to obtain reliable information on the extent of surgical operations that are not necessary. Leape has suggested as much as 30% of controversial surgeries, which include caesarean section, tonsillectomy, appendectomy, hysterectomy, gastrectomy for obesity, breast implants, and elective breast implants, could not be justified. A committee of the US Congress found that 17.6% of recommendations for surgery were not confirmed by a second opinion. A study in Spain declares that 20-25% of total surgical practice represents unnecessary operations. Studies in the USA indicated that about one fifth of all back surgeries were unnecessary. Another study found the following significant levels of inappropriate surgery: 17% of coronary angiography procedures, 32% of carotid endarterectomy procedures, and 17% of upper gastrointestinal tract endoscopy procedures.

Conclusion

In this blog, I have only covered a few of the issues raised in “Death by Medicine” but it is clear that the reality is much greater than anything I or most other people have imagined. What has happened to the axiom “First, do no harm”? Although this information is primarily from the USA, there is no doubt that similar approaches and attitudes apply here in the UK and in many other countries. Even if the numbers are much smaller, the picture that emerges is catastrophic. It is unacceptable that patients being treated should be exposed to such risks. In a recent blog, I compared the safety standards in the airline industry with those being treated medically (5). We can be confident that if we travel by scheduled airlines in most countries passenger safety will be paramount. Regrettably, the same is not true for hospitals but it ought to be so. It really is time that the medical profession got its act together. The fundamental problem is that the drive to make money overrides the need to protect the patients, especially in the USA. On top of this, the medical profession is extremely hierarchical so that it is dominated by the senior members who invariable will not admit to mistakes or tolerate criticism from any quarter, especially from other staff.

As with so many other issues, if there is to be progress it will probably only be achieved if there is pressure from the public. So hopefully, those who read this will be alarmed by the content and take positive steps for a radical change in the basic philosophy that permeates the medical and healthcare professions.

References

  1. http://www.webdc.com/pdfs/deathbymedicine.pdf
  2. http://jamanetwork.com/journals/jama/article-abstract/384554
  3. http://www.nejm.org/doi/full/10.1056/NEJMsa020703#t=article
  4. http://jamanetwork.com/journals/jama/article-abstract/187436
  5. http://vernerwheelock.com/263-no-way-to-run-an-airline/