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More medicine is not necessarily good medicine

December 10, 1999

"It is intrinsic to training and experience in all branches of engineering that cost matters as well as effectiveness," says Feachem. "Not so in medicine. Doctors are trained to believe that the best interest of the patient is paramount and that cost is either not a consideration or a very subsidiary one." He believes this view has been fuelled by healthcare systems where doctors simply did not know the costs they were dealing with. "This was the case in the pre-reform British NHS," he says, "and in insurance-based systems, like the USA prior to 1990, doctors and patients conspired to spend someone else's money - the insurer's."

Feachem welcomes the recent rapid changes in both the UK and the USA. "In Britain, GPs now have strong incentives to use their funds carefully and to be cost-conscious, and hospital management has increasingly involved doctors, as well as managers and accountants in cost-containment," he says. But he claims there is still a long way to go before cost management is second-nature to medics. "The Channel Tunnel notwithstanding," he says, "where would we be if civil engineers were commissioned to build things irrespective of cost?"

Feachem thinks an engineering mindset is a great benefit when looking at health issues, enabling people to challenge established wisdom and work with the world as it is, as well as dealing with cost issues. "As we enter a new century we need to deal with health systems as they are and not as we wish them to be," he says. But many public health professionals are too idealistic, and continue to work with governments in low-income countries to strengthen their frail public health systems while ignoring the large and unregulated private systems. Unfortunately, the government services, while nominally free, are often so poor or inaccessible that sick people actually prefer to pay to go to a private clinic.

"Tubercolosis is a good illustration," says Feachem. "In India, for example, most people with TB symptoms go to a private doctor or quack, where they will probably be wrongly diagnosed and incorrectly treated. The result is unnecessary deaths and an increasing number of antibiotic-resistant TB strains. So TB control programmes must strengthen the response of both public and private doctors - this is seldom the case."

Some of Feachem's own work at the London School of Hygiene and Tropical Medicine discredited the medical view up to the 1970s that cholera was an exclusively waterborne disease. His team proved that Vibrio cholerae, the cholera bacterium, has a reservoir in saline water and can be transmitted to people via contaminated fish. With other work showing how widespread faecal contamination of poverty-stricken homes can be, they showed that simply providing clean drinking water would not protect people from diarrhoeal diseases.

ends

Royal Academy of Engineering

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