Personal view: It's all in the mind, or rather, all in the pocket
By Theodore Dalrymple (Filed: 04/08/2003)
http://www.telegraph.co.uk/money/main.jhtml
Many people must have wondered about the paradox of health care: that the
healthier we grow, the graver the crisis in the health care system. The paradox
is not entirely explained by an aging population - for even the elderly these
days are growing healthier.
The peculiar thing is that the number of people
claiming to be sick, and in receipt of certificates from their doctor allegedly
to prove it, has also increased as we grow ever healthier. In Merthyr Tydfil,
a quarter of the adult population is on the sick.
Of course, the idea that health is a happy state
to be reached once and for all is naive. The framers of the National Health
Service believed that once the British people had been cured of all the ills
that the previous system left untreated, the cost of health care would decline.
O brave new world, that has such people in it!
The sick note paradox is easily explained. Doctors
conspire (unconsciously, no doubt) with the Government to keep the unemployment
rate down. The Government is interested in statistical propaganda, while the
doctor is interested in avoiding an unpleasant scene in his surgery if he
refuses to sign. Sickness rises to meet the politically desired decline in
unemployment.
Moreover, we doctors, ably assisted by litigation
lawyers, are able to make up whole new categories of illness. The means by
which this is done is made brilliantly clear in two new books, one from Canada
and one from Australia: Whiplash and Other Useful Illnesses by Andrew Malleson
(McGill Queen's University Press) and Constructing RSI by Yolande Lucire (University
of New South Wales Press).
A combination of bogus science, evangelical fervour
and moral cowardice on the part of doctors, and financial inducement to be
ill created by lawyers that is eagerly grasped by patients, is capable of
creating whole epidemics of previously unknown conditions.
In Australia, for example, a condition that came
to be known as Repetitive Strain Injury (RSI), or less respectfully as kangaroo
paw, suddenly afflicted thousands of workers, particularly women who used
the new computer technology of the early '80s. This had all been seen before
with the introduction of new technology: in the first decade of the last century,
telegraphists using Morse code developed a condition known telegraphists'
cramp.
As Dr Lucire makes clear, both the history and
the epidemiology of RSI prove beyond reasonable doubt that it is a psychogenic
condition. RSI was not discovered, it was created, made up out of whole cloth
- in this instance by unions, assisted by lawyers and a few misguided but
charismatic and campaigning doctors who thought they were doing their patients
a favour.
Between them, they created an industry, an industry
that manufactured cripples, medical reports and lawsuits. It is possible,
of course, that the RSI industry added to the GNP of the country, insofar
as the monetary output of the doctors and layers involved was probably greater
than that of the patient, had she remained at work.
This helps to explain why ceaseless activity,
all of it with a price attached, may not conduce to genuine productivity,
let alone human happiness. Dr Lucire is not without human sympathy for the
'victims' of RSI: she demonstrates that they merely seized the opportunity
presented to them to resolve problems in their personal predicament by means
of sickness while being financially rewarded for doing so.
Most victims of RSI had profoundly unsatisfactory
lives before they were encouraged by unions, doctors and lawyers to be sick,
and RSI came as a convenient scapegoat for all their previous dissatisfactions,
at the cost admittedly of crippling them for long periods and subjecting them
to wholly unnecessary treatments and even harmful operations.
As for Australian industry, it spent hundreds
of millions of dollars on ergonomic measures to avoid a sickness that did
not exist, except in the minds of those who promoted it and suffered from
it. Whether all this expenditure represented a net economic gain (after all,
someone must have made a lot of money from it) I leave it to economists to
work out.
Dr Malleson does for whiplash what Dr Lucire does
for RSI. The sums of money involved are even larger, running (in America)
into billions annually.
Insurance companies don't mind: they simply add
a percentage to the money they pay out. Doctors, physiotherapists and others
are supplied with paying patients who take ages to get better, if they get
better at all, and are therefore something of a licence to print money. Altogether,
it is a miracle of economic growth.
I believe that Dr Malleson is quite right. I recall
a patient who was a refugee from one of the world's viler dictatorships. His
early career was spent as a torturer in the dungeons of the regime, but as
the whirligig of time brings in its revenges, he subsequently became the tortured
rather than the torturer.
He eventually escaped to England, where everything
went well until he was involved in a rear-end collision in Melton Mowbray.
Someone went into his car at five miles an hour, and the wrench to his neck
ruined his life. Its effect upon him was incomparably greater than that of
having been both a torturer and tortured. There are no prizes for guessing
why.
Sickness, to an extent, is like all other commodities: it obeys the laws of
supply and demand. If you pay people to be ill, they will be ill.
Theodore Dalrymple is a doctor working in the National Health Service
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