A MEDICAL MANIFESTO - THE RELATIONSHIP OF MEDICINE WITH POLITICS AND MODERN SOCIETY
There is a strong relationship between medicine and politics. It has always existed. Politics, being the art of exertion of power and social reform, attracts men and women of all professions, and medical professionals are not immune to that seduction. This has especially been the case in nations where medical changes are implemented by governmental plans. This, of course, is ultimately symbolized in something like the NHS, which was born 60 years ago following the famous remark of Sir John Hawton, “The British Government have announced that they intend to establish a comprehensive Health Service for everyone in the country.” As a result, there are quite a few medical professionals working at the highest levels of the British government.
But it has been a recurring theme in all other times, and many other nations. For instance, the founder of modern republican China, Sun Yat-Sen, was a physician. So was the Georges Clemenceau, the man who led France in the First World War. In modern times, the president of Chile, Verónica Michelle Bachelet Jeria is “a surgeon, pediatrician and epidemiologist”, a medical professional like former Chilean president Salvador Allende. The current president of Syria, of course, is the ophthalmologist Bashar Al-Asad, who had it not been for the interruption of his residency at the prestigious Western Eye Hospital in London by the death of his brother, would have been spending his life removing cataracts and, like Jesus Christ (PBUH) bringing back sight to the blind! Quite a few of those in the current Iraqi parliament are physicians, such as Ibrahim Al-Jaafari and Iyad Allawi.
Besides the desire for power, medical professionals get involved in politics for a far more important reason, as explained by Rudolf Virchow:
“Medicine is a social science and politics is nothing but medicine writ large…Should medicine ever fulfill its great ends, it must enter into the large political and social life of our time; it must indicate the barriers which obstruct the normal completion of the life-cycle and remove them…If disease is an expression of individual life under unfavourable circumstances, then epidemics must be indicative of mass disturbance”.
It is an extension of their caring self. They wanted to be involved in politics to help prevent problems caused by social problems. Virchow himself believed that, “The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them”, and as he stated, “my politics were those of prophylaxis, my opponents preferred those of palliation.”
Nevertheless, the relationship between politics and medicine has not always been a positive one. This is evident to all those who have worked in the NHS, a political product, and to all those who have reflected upon the possible future of the profession. Because of this intermingling, the possibility of the death of the profession, as it has been regarded for thousands of years, is something entertained by many of its prominent thinkers. It is a time when the patient is regarded as a customer, “who is always right”, and the medical profession merely as a service provider, to support the goals of politicians. This has been a triggered by the GMC, the government, and of course by patients themselves. James E Parker, a retired pediatrician writing in the BMJ a few years ago, said:
“Now that the GMC has extended the precedent of consent for diagnosis by the patient to other conditions in the name of patient autonomy, we can expect the philosophy of the market place to prevail. 'The customer is always right'. Whether or not this serves the greater good of society is quite another matter.”
David Haslam, a Hertfordshire based GP also wrote about how the government has affected and will likely affect his profession in the future, in a pessimistic BMJ article aptly entitled, ‘The Beginning of the End’:
“British general practice is part of the fabric of our society. It is effective, precious, and threatened. It is not only possible but likely that within a few years the central feature of general practice- personal continuing care-will exist only in nostalgic memories.
Absurd? Let me explain. To reach this unhappy conclusion you have only to look at some of the apparently separate strands of recent government thinking to be able to see the type of cloth that it is weaving.”
He concludes, if things are not sorted out now, that general practice may well become, “the medical equivalent of an out of town hypermarket. Open 24 hours, efficient, cheap, reliable, and totally without a soul.”
Politics is a reflection of society; I firmly believe that “as you are, you will be led”. If society is in a mess, so will be the politicians, for the simple reason that politicians do not come out of a vacuum. They are the products of their own community and society. No man is evil or good, but his environment makes him so. Anyone conversant with the lives of the dictators of the world, whether it’s Adolf Hitler, Joseph Stalin, or Saddam Hussein (or others) cannot help but feel sorry for them in their early years. It is only very rarely that we see a man revolt against his own community, and aspire for greater things. Great examples of this are the great prophets Ibrahim and Muhammad (PBUH). But they are such rare men; they were prophets, who after the prophet Muhammad are rarer than hen’s teeth – for they do not exist anymore.
Because we live in a very corrupt age, politics, and ultimately the medicine it influences logically become corrupt.
We are living in a time when the patient’s chief interest lies, for example (in many instances) not in treatment in hospital by a caring doctor, but the opinion of a lawyer and the verdict of a judge in court. We are living in the age of ‘litigation’ or ‘compensation’ neurosis, when patients “adapt or exaggerate their symptoms, and physical signs if they are present, in an effort to increase the possibility of compensation - or to gain in some other manner.” An age described brilliantly by Philip K Howard, an American lawyer, who said in his book, ‘The Collapse of the Common Good: How America's Lawsuit Culture Undermines Our Freedom’:
“A schizophrenic strain has crept into the society, with people edging around the baseboards, looking this way and that before doing anything in the common realm, but then, when they can, aggressively using law to gain a personal advantage. There's a "litigation neurosis," Chief Justice Warren Burger noted almost 20 years ago, developing "in otherwise normal, well adjusted people." Like savages, rather than citizens of a great civilization, we pounce when there's an opening and cower in our caves the rest of the time”
It is an age when every medical professional is expected to attend court at some stage, an age when the number of biscuits and spoons of sugar that the patient had in his tea is ‘documented’ in his notes, when the doctor’s documentation is the most important of all his or her work day duties. If more time is spent helping patients out, and less in ‘prophylactic’ documentation, everyone would benefit, except of course the lawyers who relish every case of litigation. And this will remain the case until our current medical culture changes.
It is an age when the junior doctor especially, but also all doctors at all levels of the hierarchy, are treated as slaves of different types to the hospital managers and medical directors, who often are not doctors, but highly qualified accountants who occupy the biggest and most plush offices in the hospital. We are living in an age when these hospital managers and non-medical professionals are in control of hospital fate, at least here in England.
Because of the fact that we live in an increasingly litigious world, all such doctors, from the house officer to the consultant, have become, in the majority of cases, over-investigative screeners, costing a great deal of money, effort and time, much of it unfortunately going to waste, unless of course the waste all these things is documented on a solicitor’s report in the future, in which case it is all ‘well spent’. We are living in the age of ‘cover yourself’; to use the favourite line of health professionals today, the age of defensive medicine, where the patient and his or her relatives are attacking from one side, forcing doctors to act against all their wishes, for fear of being taken to court. This is a natural outcome of conceding too much power to patients.
No one has described the problems of such defensive medicine better than Raymond Tallis. Writing in his aforementioned book, he says:
“The term ‘defensive medicine’ is a desperate euphemism for a profound corruption of the patient-doctor relationship that will make the much-derided notion of a grateful, trusting patient and doctors doing their best and ‘giving over the odds’ seem quite attractive. An obstetrician, who has a low threshold for performing Caesarian sections to avoid litigation, and personal ruin and disgrace, has lost his or her professional soul. Where he or she ignores the evidence pointing to the safety of a lower operative rate for fear of being outsmarted by a claims lawyer, the first plank of professionalism – the knowledge base – has been abandoned.
Yet this is what is happening; it is becoming almost impossible to live with uncertainty (the essence of good clinical-decision-making) because uncertainty will be trumped by the certainties of the courts and the media, who will not hesitate to deploy the superior wisdom of hindsight. The doctor who informs a patient of every possible risk, however remote, of a treatment or investigation and gets the patient to sign that he has understood all of these risks, and leads the patient to expect the worst, may be acting in the new spirit of transparency and partnership, but is more likely to be giving his own fears priority over those of the patient. The doctor who always eschews reassurance in case it might be false and chases down every symptom with a battery of tests he does not really believe in may have abandoned paternalism for something worse – inhumanity….Evidence-based medicine (EBM), the glory of the profession, will give way to LPM (lawyer-proof medicine) or GRM (grievance-resistant medicine).
As I suggested earlier, the fundamental injunction of Hippocrates – ‘First do no harm’, will, since optimal care informed by the intention to do no harm will not necessary prevent harm from being done, be displaced by one yet more fundamental: ‘First cover your ass and damn the harm’. Ironically, the principle of informed consent will be undermined, because the patient will not truly know the primary reason for the investigation of intervention”
Tallis concludes saying that all these changes “are liable to make medicine an unnattractive career option”. And indeed, most people who enter medical, or any type of college for that matter, these days do not enter it because of any real attraction to it, or any deep seated desire to help others. Medicine is studied for different reasons. As explained on an encyclopedia article on consumerism:
“Beginning in the 1990’s the most frequent reason given for attending college had changed to making a lot of money, outranking reasons such as becoming an authority in a field or helping others in difficulty. This statement directly correlates with the rise of materialism, specifically the technological aspect. At this time compact disc players, digital media, personal computers, and cellular phones, all began to integrate into the affluent American’s everyday lifestyle. A large change in American culture has subsequently occurred – “a shift away from values of community, spirituality, and integrity, and toward competition, materialism and disconnection.”
Companies and corporations have realized that rich consumers are the most attractive targets for marketing their products. The upper class' tastes, lifestyles, and preferences, trickle down to become the standard which all consumers seek to emulate. The not so well off consumers can “purchase something new that will speak of their place in the tradition of affluence”. A consumer can have the instant gratification of purchasing a high-ticket item that will help improve their social status.
Emulation is also a core component of 21st century consumerism. As a general trend, regular consumers seek to emulate those who are above them on the social hierarchy. The poor strive to imitate the rich and the rich imitate celebrities and other icons. One needs to look no further than the celebrity endorsement of products to dissuade the notion that the American population makes its own decisions and models itself as a group of individualists.”
In my opinion, medicine is one of the two things in our world that have endured the greatest injustices of our time (the other is the idea of God). Medicine has become a victim of all that is ugly and wrong with our society – excessive materialism, consumerism, and in short, inhumanity. Professor Raymond Tallis raised the possibility that in the future, medicine may become “a business, its practitioners tradesmen, and health care just another industry”. He predicts a world where:
“The patient as client or customer in the shopping mall of medical care will see the doctor as a vendor rather than as a professional. There will be an increasing emphasis on the accoutrements that make the first experience, or the first encounter, customer friendly. The key to doctor-as-salesman will be the emphasis on those aspects of customer care that give the patient the feeling of ‘enpowerment’ – only weakly correlated with the actual empowerment that comes from effective evidence-based medicine. The almost robotic standardisation of the way doctors are taught to interact with patients – even down to when doctors should move from open to closed questions, when and how often they should use techniques to indicate they are listening, and the bodily postures that should be adopted – will make the professional, with a depp compassion and the ability to makes and stick by difficult unpopular advice, an ever-rarer bird. The doctors of the future will be easy-going and friendly conformists, relentlessly because, as George Bernard Shaw said, “The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man””
This, I believe, is already the case. The human side of medicine is disappearing. Far from developing the vision that the great William Osler had for it, who described it as “an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish”, it has become the exact opposite. Most junior doctors these days show, as Tallis explains, “an expressed unwillingness to work long hours and in particular, to do the unpaid work that earlier generations accepted as the norm”. Unlike previous generations, where “many, perhaps most of those who worked in the NHS….assumed that their job would be a way of life: it was going to be hard, rarely fun and sometimes a sheer grind. It was, however, serious and deeply worthwhile. This was what a calling was about. The notion of ‘creative fun’ had not yet taken hold in the collective consciousness. Doctors in the 1950s found working all hours an improvement on war-time service – working all hours and being shot at. The notion of a life-work balance had not entered their vocabulary”, medicine, to most people nowadays is merely a means to a living, and as John Saunders explains, “As the practice of medicine becomes more like just another industry, it is easy to narrow the concept of service to that of personal convenience”.
Part of the blame has to be put on the politics of it all. But also a lot must be put on the shoulders of materialism of the modern world, which may have spread itself to doctors. This is what Tallis himself believes, “We reflect the values of the society in which we have grown up. Doctors reared in a consumerist society will be consumers too”.
The selfishness and greed that predominates our world is also reflected in modern medicine. Tallis explains:
“Social attitudes have changed dramatically. One could grossly oversimplify the sequence of events by dividing the changes into two phases: the 1960s and the 1970s said that it was perfectly OK to be selfish: Thatcher’s children in the 1980s learned that it was almost a responsibility to be selfish. A more recent generation, perhaps, has build on this with the notion that it is more important to be cool and successful than to be truly useful and to help people in grave need. The tabloidisation of the national consciousness has inculcated an ethos which accepts as role models empty characters in whom surface is more important than substance…it seems the emergent social ethos is hardly compatible with a life of caring for and worrying over others, especially in public service where it may be rewarded by low status, continuing criticism, and the possibility of public execration”. He further predicts, “Consumerism in patients who see the doctor as addressing their customer rights, and in cynical self-protecting doctors who want a life but who do no want to antagonize their customers, will push the profession from a calling to a business”.
Society expects those same doctors, inculcated with those beliefs, to be the most perfect and virtuous humans. Society needs to realise that, as Sir Maurice Shock put it, “society is changing – gone are the ‘social contract’ and the ‘rights of man’; instead we have ‘the sales contract’ and the ‘rights of the consumer’”, and an environment like this is hardly conducive to the production of those angels. As Tallis says, “Dying, terrified, depressed patients will not get the doctors they need because a society whose overriding values are consumerist will not produce them.”
Instead of those angels, society has succeeded in producing doctors like Harold Shipman, who has killed more people than any other doctor – possibly over 200 patients, a man who was a drug addict as a junior doctor, who was “in 1976, fined £600 on drugs and - significantly for the future - forgery charges, but although he had a warning letter from the General Medical Council, he was not struck off. He accepted psychiatric treatment, and appeared to have rounded a difficult personal corner.”
Enter any medical school nowadays, and witness the corruption therein. I have, in my time as a student, encountered many colleagues who resorted to all sorts of drugs, and have continued this habit to their working days. As explained by one recent ‘Anaesthetics’ journal editorial, “Physician substance abuse is a significant societal problem that affects all aspects of medical care. Previous studies of addiction, which have included alcohol abuse, have projected that 10%–14% of physicians may become chemically dependent at some point in their careers”. Professor Roger Cicala, an American anesthesiologist states, “The impact of the problem is severe. Chemical impairment has been shown to be a major risk factor for medical malpractice and negligence lawsuits, the development of physical and psychological illness, and adverse effects on the substance abuser's family. Left untreated, the mortality rate of substance abuse among physicians has been reported as high as 17%”. A recent study, ‘Drink and drugs: from medical students to doctors’ in the journal ‘Drug and Alcohol Dependence’, showed that in recent years, “Mean alcohol consumption had increased significantly (P<0.015) over the three time points; 15.2–16.0–18.8 units/week…Experimentation with illicit drugs had increased from 50 to 63 to 65%”. Another article concluded, “The present heavy drinking and drug taking behaviour among medical students and doctors could damage the responsible and caring image of the profession”. This brings me nicely to another problem – the drinking culture of the medical profession.
Medical students seem to have a passion for drinking unlike any other group of students. Of course, it is a major problem in all college students, but seems especially dominant among ‘medics’. Jonathan Chick, a senior lecturer in psychiatry in Edinburgh University writes in the student BMJ, “When doctors who have recovered from alcohol dependence reflect on the route they took, they often recall a period when drinking was very positive: as a student enjoying newly gained independence (for instance, freshers' week), the good company, and their liking for the buzz or the relaxation that alcohol gave them. They share this experience of alcohol with many of their year. Indeed `heavy' drinking is common in UK medical schools,( 2 3) with over 20% of students who drink consuming more than 21 units - 170g - per week, comparable with their age group in the general population.” This habit unfortunately continues into their working days.
Under the headline, ‘Intoxication 'rife among doctors'’, the BBC reported in June 2005, that “over the last 10 years 750 hospital staff in England had been disciplined over alcohol and drug-related incidents”. It revealed some other fascinating facts, that:
“At Maidstone and Tunbridge Wells NHS Trust, three consultants in three years had been referred to the General Medical Council for alcohol problems…At East Kent NHS Trust, seven doctors and two nurses had been disciplined over drink and drugs in the last 10 years…The biggest figure came from the University of Leicester NHS Trust where 17 clinical staff, including one consultant, four nurses and two operating theatre practitioners were disciplined over the past decade…The British Association of Oral and Maxillofacial Surgeons said a survey of 150 consultant surgeons revealed more than a fifth said they knew a colleague who they believed to be impaired by alcohol while on call.”
I leave the last revelation with regards to alcohol consumption with Chick:
“Ten year comparisons between occupational groups in the UK suggested that the excessive death rate among doctors from alcoholic cirrhosis was falling in the 1970s. Predictions were falsely optimistic; the 1980s once more showed doctors to have three times the alcoholic cirrhosis of the general population, second only to publicans and bar staff. Doctors also have higher than average rates for other alcohol related deaths including suicide, alcohol-related cancers, and accidents.”
Sexually transmitted diseases, and other problems of our modern society, are affecting doctors just like the rest of the population. Doctors do not exist in a vacuum; they are expected to participate in the hedonism of the age like everyone else. If not they are regarded as ‘deviants’ or ‘sad’. In the presence of so much indecent behaviour, a recent NEJM article rightly said, “Medical students are reflective of society at large. Lack of professionalism among medical students is hardly surprising when high schools and colleges seem rife with unethical behavior that seems to be tolerated by society”. And until society is sorted, this will be an escalating problem, and the words of William Osler, that “In the records of no other profession is there to be found so large a number of men who have combined intellectual pre-eminence with nobility of character”, will become a distant memory or even a myth.
GOVERNMENTS AND MEDICINE
On the other side we have the government, with its obsession with ‘governmental targets’ and what are referred to as ‘QOF points’ (Quality and Outcomes Framework), and its indirect belief that achieving them is more important than the patient’s welfare. Our current practice of medicine is akin to the way the great totalitarian that is Plato would have liked. As Karl Popper explains, “Plato interprets medicine as a form of politics, or as he puts it himself, he ‘regards Aesculapius, the god of medicine, as a politician’. Medical art, he explains, must not consider the prolongation of life as its aim, but only the interest of the state.”
Medicine is directly affected by the political beliefs of its practitioners; this is a fact we cannot deny. And any attempts that ignore this fact are doomed to failure. Which is why, as I emphasize in the essay on ‘Medicine and Ethics’, only a belief in God, the unwritten oath, can spare us the crimes that may be initiated by politicians (who may be physicians themselves, as I have mentioned above) but are perpetuated by physicians, who remain powerless in the face of political pressure.
And their political beliefs are influenced by religious factors. Politics and religion, despite all that is being said of our living in a secular age (which believes “Give to Caesar what is Caesar's, and to God what is God's") are completely intertwined; is America not a nation governed by a bunch of Christian evangelists and pentacostalists who support nations like Israel based entirely on religious belief. Are not Israel and Saudi Arabia two countries governed by religion (whatever we may think of their religious beliefs is not the issue here).
Any oath that ignores these things will inevitably fail; an oath that says, “I will exercise my professional judgment as independently as possible, uninfluenced by political pressure or the social standing of my patient”, or “I will oppose policies which breach internationally accepted standards of human rights. I will strive to change laws that are contrary to patients’ interests or to my professional ethics”, as the ‘New Hippocratic Oath’ devised by the BMA in 2004 does – is unrealistic and cannot succeed. For the simple reason that it ignores the greater oath – the unwritten oath that submission to God teaches - the unity of humanity.
Had the oath been realistic, we would not have had doctors like François Duvalier (also known as Papa Doc), a dictator not unlike the dictators of the West, who ruled over Haiti from 1957, making himself ‘President for Life’ in 1964, ruling over it until his death in 1971, “in a regime marked by autocracy, corruption, and state-sponsored terrorism through his private militia known as Tonton Macoutes. He was estimated to have caused the deaths of 30,000 and exile of thousands more”. Or Hastings Kamuzu Banda, former president and dictator of Malawi, a man who supported the Apartheid, oppressed his people and accumulated so much wealth while they suffered in silence.
What proportion of Israel’s doctors I wonder have spoken out against their government’s policies, or “oppose policies which breach internationally accepted standards of human rights. I will strive to change laws that are contrary to patients’ interests or to my professional ethics”, a government that deprives Palestinians of basic human rights, like clean water, medicine, food and hygiene, that expects Palestinian women to deliver at checkpoints (and many of them end up dying there), old men are expected to be searched inside out lest they be carrying missiles (in truth, it is just a form of humiliation and oppression), and even a quadriplegic man is not spared from murder. As far as I know, no one in their medical establishment has spoken out against these crimes, which are inextricably connected with the ugly politics of the Zionist state.
How many doctors, I wonder spoke out against the crimes of the American government in Hiroshima and Nagasaki, leading the health of the Japanese people to a jeopardy that remains with them to this day. Very few, and many prefer to ignore this fact.
Where are the brave doctors, who are prepared to give up their lives for humanity or stand up in the face of evil, when, thanks to the very humane American government again, “Iraqi Red Crescent vehicles attempting to deliver medical supplies (were) besieged and wounded Iraqis (to be) turned back”.
Where are the doctors, who ought to speak out against all that contravenes human rights when the Americans destroyed the hospitals of Falluja? As Noam Chomsky elaborates:
“One of the first acts in the conquest of Falluja was to take over the general hospital, which was a major war crime. And they gave a reason. The reason is the hospital was a "center of propaganda against allied forces" because it was producing "inflated civilian casualty figures." First of all, how do we know they were inflated? Because our dear leader said so. Secondly, the idea that you take over a hospital because it's publishing casualty figures is obscene. The Geneva Conventions could not be more clear. The wording says explicitly and clearly that "Medical and religious personnel shall be respected and protected and shall be granted all available help for the performance of their duties.... Medical units and transports shall be respected and protected at all times and shall not be the object of attack.” In the attack on Falluja General Hospital, patients were kicked out of their beds and doctors and patients were forced to lie on the floor, handcuffed. This is a grave breach of the Geneva Conventions. In fact the entire political leadership should face the death penalty under U.S. law for these actions. They're all eligible for the death penalty, according to the War Crimes Act passed by the 1996 Republican Congress.”
The Vietnamese too are still suffering medically from the effects of the American invasion in the 1960s, whose government, as Noam Chomsky explains:
“…"cannot afford to repair many of the roads, hospitals and sewage drains destroyed 20 years ago by U.S. bombers, John Stackhouse reports from the shattered city. In 1991, the children's hospital was forced to close 50 of 250 beds and to ask patients to provide medicines. Doctors perform surgical operations on a table donated by Poland, largely without equipment. At the Vinh Medical Center, where the hospital's pharmacy remains "a pile of rubble," a doctor states the obvious: "the problems here are a consequence of the American war, and the embargo has made it worse."”
Where are our Oaths when those things happen, or are the Iraqis, Vietnamese, and Palestinians not human beings.
And among the worst things I recall to have happened in recent years, showing the ugly impact of politics on medicine, and the sheer powerlessness (not to say cowardice) of medical professionals in the face of all this is what Bill Clinton, former US president did to a Sudanese pharmaceutical company in August 1998 to divert the world’s attention from his various personal scandals, with Monica Lewinsky and others, an event described by Chomsky as “one little footnote in the record of state terror, quickly forgotten”. I would like to recount the memory of this, and find no better analysis of the event than that of Chomsky himself in his book, ‘9-11’ which I quote here in full:
“Though it is merely a footnote, the Sudan case is nonetheless highly instructive. One interesting aspect is the reaction when someone dares to mention it. I have in the past, and did so again in response to queries from journalists shortly after 9-11 atrocities. I mentioned that the toll of the "horrendous crime" of 9-11, committed with "wickedness and awesome cruelty" (quoting Robert Fisk), may be comparable to the consequences of Clinton's bombing of the Al-Shifa plant in August 1998. That plausible conclusion elicited an extraordinary reaction, filling many web sites and journals with feverish and fanciful condemnations, which I'll ignore. The only important aspect is that that single sentence- which, on a closer look, appears to be an understatement- was regarded by some commentators as utterly scandalous. It is difficult to avoid the conclusion that at some deep level, however they may deny it to themselves; they regard our crimes against the weak to be as normal as the air we breathe. Our crimes, for which we are responsible: as taxpayers, for failing to provide massive reparations, for granting refuge and immunity to the perpetrators, and for allowing the terrible facts to be sunk deep in the memory hole. All of this is of great significance, as it has been in the past.
About the consequences of the destruction of the Al-Shifa plant, we have only estimates. Sudan sought a UN inquiry into the justifications for the bombing, but even that was blocked by Washington, and few seem to have tried to investigate beyond. But we surely should. Perhaps we should begin by recalling some virtual truisms, at least among those with a minimal concern for human rights. When we estimate the human toll of a crime, we count not only those who were literally murdered on the spot but those who died as a result…In this case, we count the number who died as a consequence of the crime, not just those killed in Khartoum by cruise missiles; and we do not consider the crime to be mitigated by the fact that it reflects the normal functioning of policymaking and ideological institutions-as it did, even if there is some validity to the (to my mind, dubious) speculations about Clinton's personal problems, which are irrelevant to this question anyway, for the reasons that everyone takes for granted when considering the crimes of official enemies.
With these truisms in mind, let's have a look at some of the material that was readily available in the mainstream press. I disregard the extensive analysis of the validity of Washington's pretexts, of little moral significance in comparison to the question of consequences. A year after the attack, "without the lifesaving medicine [the destroyed facilities] produced, Sudan's death toll from the bombing has continued, quietly, to rise... Thus, tens of thousands of people-many of them children- have suffered and died from malaria, tuberculosis, and other treatable diseases... [Al-Shifa] provided affordable medicine for humans and all the locally available veterinary medicine in Sudan. It produced 90 percent of Sudan's major pharmaceutical products... Sanctions against the Sudan make it impossible to import adequate amounts of medicines required to cover the serious gap left by the plant's destruction... [T]he action taken by Washington on August 20, 1998, continues to deprive the people of Sudan of needed medicine. Millions must wonder how the International Court of Justice in The Hague will celebrate this anniversary" (Jonathan Belke, Boston Globe, August 22, 1999).
Germany Ambassador to Sudan writes that "It is difficult to assess how many people in this poor African country died as a consequence of the destruction of the Al-Shifa factory, but several tens of thousands seems a reasonable guess" (Werner Daum, "Universalism and the West," Harvard International Review, Summer 2001). "[T]he loss of this factory is a tragedy for the rural communities who need these medicines" (Tom Carnaffin, technical manager with "intimate knowledge" of the destroyed plant, quoted in Ed Vulliamy, Henry McDonald, Shyam Bhatia, and Martin Bright, London Observer, August 23, 1998, lead story, page 1). Al-Shifa "provided 50 percent of Sudan's medicines, and its destruction has left the country with no supplies of chloroquine, the standard treatment for malaria," but months later, the British Labour government refused requests "to resupply chloroquine in emergency relief until such time as the Sudanese can rebuild their pharmaceutical production" (Patrick Wintour, Observer, December 20, 1998).
The Al-Shifa facility was "the only one producing TB drugs- for more than 100,000 patients, at about 1 British pound a month. Costlier imported versions are not an option for most of them- or for their husbands, wives and children, who will have been infected since. Al-Shifa was also the only factory making veterinary drugs in this vast, mostly pastoralist, country. Its specialty was drugs to kill the parasites which pass from herds to herders, one of the Sudan's principal causes of infant mortality" (James Astill, Guardian, October 2, 100).
The silent death toll continues to mount. These accounts are by respected journalists writing in leading journals. The one exception is the most knowledgeable of the sources just cited, Jonathan Belke, regional program manager for the Near East Foundation, who writes on the basis of field experience in Sudan. The Foundation is a respected development institution dating back to World War I. It provides technical assistance to poor countries in the Middle East and Africa, emphasizing grassroots locally-run development projects, and operates with close connections to major universities, charitable organizations, and the State Department, including well known Middle East diplomats and prominent figures in Middle East educational and developmental affairs. According to credible analyses readily available to us, then, proportional to population, the destruction of Al-Shifa is as if the bin Laden network, in a single attack on the U.S. caused "hundreds of thousands of people-many of them children-to suffer and die from easily treatable diseases," though the analogy, as noted, is unfair. Sudan is "one of the least developed areas in the world. Its harsh climate, scattered populations, health hazards and crumbling infrastructure combine to make life for many Sudanese a struggle for survival"; a country with endemic malaria, tuberculosis, and many other diseases, where "periodic outbreaks of meningitis or cholera are not uncommon," so affordable medicines are a dire necessity (Jonathan Belke and Kamal El-Faki, technical reports from the field for the Near East Foundation). It is, furthermore, a country with limited arable land, a chronic shortage of potable water, a huge death rate, little industry, an unserviceable debt, wracked with AIDS, devastated by a vicious and destructive internal war, and under severe sanctions. What is happening within is largely speculation, including Belke's (quite plausible) estimate that within a year tens of thousands had already "suffered and died" as the result of the destruction of the major facilities for producing affordable drugs and veterinary medicines. This only scratches the surface.”
Interestingly, because of politics, many nations of the world have been deprived of medical care in previous times too; it is not a feature of just the more recent American politicians. And I can see very little done on the part of medical professionals to speak out against these atrocities. For example following the Cyclone Flora that devastated Cuba and the Caribbean during a time of political embargo in October 1963, and although, “Theoretically, medicines and some food were exempt from the embargo … food and medical aid were denied …Standard procedure, incidentally”. Also:
“Consider Carter's refusal to allow aid to any West Indian country struck by the August 1980 hurricane unless Grenada was excluded (West Indians refused, and received no aid). Or the US reaction when Nicaragua was fortuitously devastated by a hurricane in October 1988. Washington could scarcely conceal its glee over the welcome prospects of widespread starvation and vast ecological damage, and naturally refused aid, even to the demolished Atlantic Coast area with longstanding links to the US and deep resentment against the Sandinistas; its people too must starve in the ruins of their shacks, to satisfy our blood-lust. US allies timidly followed orders, justifying their cowardice with the usual hypocrisy”.
However, I don’t think I am mistaken in saying that the poor American people themselves have actually been the first victims, medically speaking, of their current socio-political establishment. As Chomsky explains:
“You'd think that in a rich country like this, these wouldn't be big issues, but they are for a lot of the population. Lancet, the British medical journal -- the most prestigious medical journal in the world -- recently pointed out that 40% of children in New York City live below the poverty line. They suffer from malnutrition and other poor conditions that cause very high mortality rates -- and, if they survive, they have very severe health problems all through their lives. The New England Journal of Medicine pointed out a couple of years ago that black males in Harlem have about the same mortality rate as people in Bangladesh. That's essentially because of the extreme deterioration of the most elementary public health conditions, and social conditions.”
He elaborates elsewhere, that in the USA, “medical care is rationed by wealth. If you're rich, the system is working just right. The insurance companies, the health maintenance organizations, the pharmaceutical corporations are doing just great. Wealthy people are doing fine. If most of the population can't get decent medical care, that's not our problem. If health care costs are astronomical, too bad.” Our NHS is paradise compared to America’s health care system. In fact, there is no comparison. Gore Vidal explains:
“We are not actually people in the eyes of the national ownership: we are simply unreliable consumers comprising an overworked, underpaid labor force not in the best of health: The World Health Organization rates our healthcare system (sic—or sick?) as 37th-best in the world, far behind even Saudi Arabia, role model for the Texans. Our infant mortality rate is satisfyingly high, precluding a First World educational system.”
American politicians have also ruined the health of nations indirectly, through their cultural imperialism, leading to all the illnesses that are associated with it. But I shall not delve into this any further now.
American imperialism is one of the most important, if not the most important direct and indirect cause and fuel for terrorism. The American government, as we mentioned above, is the initiator of ‘radiation terrorism’, and the only government to have hit another nation with nuclear warfare (the Japanese army may have been at fault, but the victims of Hiroshima and Nagasaki were certainly innocent), and its crimes in many places have led to an unprecedented rise in extremism, and the threat of terrorism (including bioterrorism). This has led to a new problem in medicine, never seen before by our elders.
So much for politicians affecting medicine. But it is those same politicians who insist on making us believe that this is the best of times for medicine. I refuse to believe this. What we have achieved is – increasing the duration of one’s life, at the cost of increasing the duration of their misery, and this can hardly be regarded as a success. As explained by Alexis Carrel, the great French vascular surgeon and Nobel Prize winner:
“Nevertheless, in spite of the triumphs of medical science, the problem of disease is very far from solved. Modern man is delicate…Medicine is far from having decreased human sufferings as much as it endeavors to make us believe. Indeed, the number of deaths from infectious diseases has greatly diminished. But we still must die, and we die in a much larger proportion from degenerative diseases. The years of life which we have gained by the suppression of diphtheria, smallpox, typhoid fever, etc., are paid for by the long sufferings and the lingering deaths caused by chronic affections, and especially by cancer, diabetes, and heart disease. In addition, man is liable, as he was in former times, to chronic nephritis, brain tumors, arterial sclerosis, syphilis, cerebral hemorrhages, hypertension, and also to the intellectual, moral, and physiological decay determined by these maladies. He is equally subject to the organic and functional disorders brought in their train by excess of food, insufficient physical exercise, and overwork. The lack of equilibrium and the neuroses of the visceral nervous system bring about many affections of the stomach and the intestines. Heart diseases become more frequent. And also diabetes. The maladies of the central nervous system are innumerable. In the course of his life, every individual suffers from some attack of neurasthenia, of nervous depression, engendered by constant agitation, noise, and worries. Although modem hygiene has made human existence far safer, longer, and more pleasant, diseases have not been mastered. They have simply changed in nature.”
We are also living in an age where men like Carrel are running out. We are not in the age of heroes. Where are the outspoken physicians, like Carrel, who have the guts and integrity to stand up in the face of modern politicians and society, and see through all the masks and corruption that they display? I am yet to see anyone write anything like Carrel’s ‘Man the Unknown’, which says in its introduction:
“Newspapers, magazines, cinema, and radio ceaselessly spread news illustrating the growing contrast between material progress and social disorder. The triumphs of science in some fields mask its impotence in others. For the marvels of technology, such as featured, for example, in the New York World's Fair, create comfort, simplify our existence, increase the rapidity of communications, put at our disposal quantities of new materials, synthesize chemical products that cure dangerous diseases as if by magic. But they fail to bring us economic security, happiness, moral sense, and peace. These royal gifts of science have burst like a thunderstorm upon us while we are still too ignorant to use them wisely. And they may become highly destructive. Will they not make war an unprecedented catastrophe? For they will be responsible for the death of millions of men who are the flower of civilization, for the destruction of priceless treasures accumulated by centuries of culture on the soil of Europe, and for the ultimate weakening of the white race. Modern life has brought another danger, more subtle but still more formidable than war: the extinction of the best elements of the race.”
He wrote that in 1939, the year the Second World War began. He also wrote that:
“The premature wearing out of modern men is probably due to worries, lack of economic security, overwork, absence of moral discipline, and excesses of all sorts” and, “The brutal materialism of our civilization not only opposes the soaring of intelligence, but also crushes the affective, the gentle, the weak, the lonely, those who love beauty, who look for other things than money, whose sensibility does not stand the struggle of modern life”.
Thus, we can conclude, that the relationship between politics and medicine has not really been as smooth as Rudolf Virchow and others who believe in the common aims of the two wish. Perhaps Frank G. Slaughter was right, when he said in 1942 of the relationship of medicine to politics, that:
“Doctoring is one thing that politics has no business monkeying with. Me for the old family doc making his rounds and sending out bills when he happens to think of it and no [politician] interfering with him, in or out of the office”.
Or Napoleon Bonaparte before him, who remarked that, “A physician and a priest ought not to belong to any particular nation, and be divested of all political opinions”.
No one can deny that they share common goals, but in the face of the current corruption of the two, none will be able to achieve any of those goals without harm to the other. Perhaps we ought to return to the spirit of the Enlightenment, the first of which was the Enlightenment of Islam, led by the Prophet Muhammad (PBUH), and the second of which was the Enlightenment of the West. As Mike Fitzpatrick put it in article devoted to a review of the ideas of Raymond Tallis:
“The medical profession has offered little resistance to the drive to deprofessionalise doctors. While commitment and continuity of care have been undermined by trends towards shift working, part-time working, and the abandonment of out-of-hours responsibilities, doctors have appeared more concerned about their work–life balance than with defending professional autonomy. The dumbing down of medical education and training, and the intrusion of third parties — insurance companies, government agencies, lawyers — into the doctor–patient relationship have contributed to the degradation of the profession. As medicine is transformed from being a calling into a business, a new generation of doctors faces a future of slavishly following protocols, and a working life of clock-watching and box-ticking”
And only an enlightened spirit will take medicine forward:
“In the same spirit in which he has championed the ideas of the Enlightenment against theories that disparage reason and diminish human subjectivity, Tallis challenges today's doctors to take a stand against the current onslaught on professional values. Although a staunch opponent of pessimism, he warns that the cost of failure may be high: ‘The doctor as intellectual leader, as clinical pioneer, and as advocate for the patient and the service, as the midwife of the future as well as the servant of the present, may well become a thing of the past.”
I can only conclude by paraphrasing the last words of Karl Marx and Friedrich Engels ‘The Communist Manifesto’, arguably the most important political document to influence the 20th century – doctors of the world, unite.
 Rudolf Virchow is considered the most prominent German physician of the 19th century, the father of pathology, known to most medical students through his famous 'Virchow's triad', which describes the risk factors for thrombosis. His involvement in politics was best described by William Osler, as follows, "In this country doctors are, as a rule, bad citizens, taking little or no interest in civic, state or national politics. Let me...tell of one of us...who...has found time to serve this city and his country. For more than twenty years Virchow has sat in the Berlin City Council as an alderman, and to no feature in his extraordinary life does the Berliner point with more justifiable pride. It is a combination of qualities only too rare, when the learned professor can leave his laboratory and take his share in practical, municipal work"
 We are told about the story of Ibrahim (PBUH) in so many places. For example, “We bestowed aforetime on Abraham his rectitude of conduct, and well were We acquainted with him. Behold! He said to his father and his people, "What are these images, to which ye are (so assiduously) devoted?" They said, "We found our fathers worshipping them." He said, "Indeed ye have been in manifest error - ye and your fathers." They said, "Have you brought us the Truth, or are you one of those who jest?" He said, "Nay, your Lord is the Lord of the heavens and the earth, He Who created them (from nothing): and I am a witness to this (Truth).” (21:51-56). See also verses 26:70-82, 29:16-18 and 37:83-98. The story of the prophet Muhammad and his rebellion against the corrupt Quraishite society, who “Truly…took this Qur'an for just foolish nonsense" (25:30) is well known to all.
 I have not talked here about problems such as plagiarism, dishonesty and other such aspects of medical students and doctors. But there are plenty of recent studies illustrating this, such as a recent BMJ study which involved 667 Dundee University medical students, which showed that, “The proportion of students reporting that they had engaged in or would consider engaging in the scenarios varied from 2% for copying answers in a degree examination to 56% (51-61%) for copying directly from published text and only listing it as a reference. About a third of students reported that they had engaged in or would consider engaging in the behaviour described in four of the scenarios: chatting about an objective structured clinical examination, writing “nervous system examination normal” when this hadn't been performed, lending work to others to look at, and copying text directly from published sources and simply listing the source in a reference list.”
 The Arab world is increasingly afflicted by diabetes and its ills, which can be explained by the thrifty genotype hypothesis. As explained by Raz et al (2008), “This phenomenon of shifting disease patterns, termed epidemiological transition, initially occurred in developed countries and subsequently spread to developing nations. Arthur Koestler coined the term 'Coca- colonization' to describe the impact of the lifestyle of Western societies on developing countries. The devastating results of intrusion by Western society into the lives of traditional living indigenous communities can now be seen across the globe”.
 May I just turn the reader’s attention to three quotes. The first from Noam Chomsky, writing in an article on ‘The Responsibility of Intellectuals’, “To what extent are the British or American people responsible for the vicious terror bombings of civilians, perfected as a technique of warfare by the Western democracies and reaching their culmination in Hiroshima and Nagasaki, surely among the most unspeakable crimes in history”. The second is from a BBC criticism website, which could have equally come out of the pen of the great Gore Vidal, “The Hiroshima bombing came at a time when the Japanese were negotiating peace with the USA. The United States however wanted to test its new weapon: demonstrating its power to the world, especially to the Soviets”. The third is from John Pilger, writing very recently in the ‘Guardian’, “The most enduring lie is that the atomic bomb was dropped to end the war in the Pacific and save lives. "Even without the atomic bombing attacks," concluded the United States Strategic Bombing Survey of 1946, "air supremacy over Japan could have exerted sufficient pressure to bring about unconditional surrender and obviate the need for invasion. Based on a detailed investigation of all the facts, and supported by the testimony of the surviving Japanese leaders involved, it is the Survey's opinion that ... Japan would have surrendered even if the atomic bombs had not been dropped, even if Russia had not entered the war and even if no invasion had been planned or contemplated."
The National Archives in Washington contain US government documents that chart Japanese peace overtures as early as 1943. None was pursued. A cable sent on May 5, 1945 by the German ambassador in Tokyo and intercepted by the US dispels any doubt that the Japanese were desperate to sue for peace, including "capitulation even if the terms were hard". Instead, the US secretary of war, Henry Stimson, told President Truman he was "fearful" that the US air force would have Japan so "bombed out" that the new weapon would not be able "to show its strength". He later admitted that "no effort was made, and none was seriously considered, to achieve surrender merely in order not to have to use the bomb". His foreign policy colleagues were eager "to browbeat the Russians with the bomb held rather ostentatiously on our hip". General Leslie Groves, director of the Manhattan Project that made the bomb, testified: "There was never any illusion on my part that Russia was our enemy, and that the project was conducted on that basis." The day after Hiroshima was obliterated, President Truman voiced his satisfaction with the "overwhelming success" of "the experiment"
 It is interesting to note that this may not be the case, as explained in ‘Harrison’s Principles of Internal Medicine’, “Descriptions of the use of microbial pathogens as potential weapons of war or terrorism date from ancient times. Among the most frequently cited of such episodes are the poisoning of water supplies in the sixth century B.C. with the fungus Calviceps purpurea (rye ergot) by the Assyrians, the hurling of the dead bodies of plague victims over the walls of the city of Kaffa by the Tartar army in 1346, and the spreading of smallpox via contaminated blankets by the British to the native American population loyal to the French in 1767”
 I am left rather bemused by how our media can be so skewed even in our supposedly neutral medical textbooks. Harrison’s has three chapters in the section on bioterrorism; the microbial bioterrorism and chemical bioterrorism sections begin with mention of “the tragic events of September 11, 2001” and “The use of sulfur mustard and nerve agents by Iraq against the Iranian military and Kurdish civilians, the sarin attacks in 1994–1995in Japan, and the terrorist strikes of September 11, 2001” respectively. The radiation bioterrorism section, written by Zelig A. Tochner, Ofer Lehavi and Eli Glatstein however, begins as follows, “Terror attacks using nuclear or radiation-related devices are an unequivocal threat in the twenty-first century and are capable of unique medical and psychological effects.” There is no mention of the great American crimes on the Japanese people. The message is clear; we will explore this further in the media section later.