Jacob Stegenga, Medical Nihilism, Oxford; Oxford University Press; 2018, Hardcover, pp. 226, price: $39.95. ISBN: 978-0-19-874704-8

In 1976, the Croatian-Austrian philosopher, historian and Catholic priest, Ivan Illich, later to be defrocked for his radical views, shocked the medical world with his publication Medical nemesis: The expropriation of health (1). Illich argued that modern medicine was one of the greatest dangers to health, pointing to ever increasing rates of iatrogenesis, that is, illness, disease or death due to medical treatment. His dire forebodings were prophetic. As Stegenga reveals “a recent study estimated the number of preventable hospital-caused deaths in the United States to be over 400,000 per year (p 180). It is well known that iatrogenesis is one of the ten leading causes of death in the US.

Since Illich’s publication, the reach and spread of the medico-industrial empire has vastly increased. More people have access to bio-medicine than ever before. The drugs and pharmaceutical industry is only behind the armaments industry in the profits it generates. While life expectancy has improved over these years, we also know that curative medicine in particular, while possibly easing suffering, contributes little to public health. As the epidemiologist and historian, Thomas McKeown, revealed, coincidentally in the same year as Illich’s publication, even preventive medicine played a guest role in the improvements in health that took place in 19th century England and Wales (2). What did play the key roles in health improvements were adequacy of food, improvements in real wages, and so on. In other words, how wealth and power are distributed in the real world also determine how health is distributed, as Stegenga concludes.

Taking off from where Illich left us, Jacob Stegenga, the philosopher of science, has come up with a path-breaking and, and indeed revolutionary work, in these counter-revolutionary times.

Philosophers have to deal with real world problems through abstractions. That is their avocation and training. Which is why their works are so much more compelling than those dealing only with the empirical. Facts have to be understood as facts, but also interpreted. This is where ideologies, and therefore values, creep in. There is no neutral social science.

This is also the reason why philosophers and historians and social scientists are being derided today: they raise questions about many things, including the role of finance capital in everything ─ education, health, culture ─ and, in this book, we learn of how the ideas of science and the institutions that emerged, have been systematically undermined.

Medical nihilism is a book that demolishes the many myths that surround the medical -industrial complex which dominates the world. The author, writing in an amazingly clear manner that even those uninitiated in philosophy can understand, has done the most extraordinary: questioned the claims of medical science, conceptually, methodologically and empirically.

The book makes the argument that more often than not, medical interventions have not helped, if they have not harmed. “Medical nihilism is the view that we should have little confidence in the effectiveness of medical interventions” (p 1), a view traced back to Hippocrates. By “medical interventions”, Stegenga makes it clear he is referring to drugs and pharmaceuticals alone. In other words, he is not discussing here the technologies of investigation or surgery. So he does not comment, for example, on the fact that ultrasound is now ubiquitous in normal pregnancy, although not scientifically warranted, and known to cause foetal problems. Nor does he draw attention to the fact that the National Health Service in the UK has stopped mammograms to identify cancer of the breast since it produced high rates of false positives, and women who did not have breast cancer were being wrongly diagnosed with the disease, thanks to this technology.

But first the caveats. There are a lot of anti-science and other movements around the world, critical of bio-medicine. These include alternative medical systems like homeopathy, Ayurveda, anti-vaccine movements and so on, that he rejects most unequivocally as utterly unscientific. What he is asking in this book is whether scientific medicine is doing the scientific thing, which he finds it is not. What medical nihilism shares most with is social epidemiology, which looks at the broader determinants of health.

Stegenga points out that medical nihilism was the pervasive attitude to medicine throughout history. And this is not surprising, given the medical practices of the past. It was the discovery of medical “magic bullets” like antibiotics and insulin that changed this perception. Over the last few decades, as more and more funds have been poured into medical research, there have been no magic bullets and none are in the making. On the contrary, there is increasing evidence that it is medical nihilism that is indeed warranted, and not the misplaced optimism of infinite progress – promised by the medical-industrial complex.

The book is divided into three substantial sections. In the first, the author examines various theories of what is a disease. Till recently, homosexuality was a disease. Now, it is not. What has changed? Perhaps no disease is fundamentally biological, but is also imbued with the social and political.

What, then, are the definitions of a disease? How do we assess the efficacy of interventions? Stegenga takes us through many definitions of disease and of interventions. These are important, because as he shows us, more and more situations or conditions, not considered disease, are now being labelled as such. This is frequently led by a drug manufacturer, finding a new disease to use for a drug that is ending its patent life cycle. Called ever-greening, this is extensively commented upon in literature (3). This is also led by patient groups and doctors anxious to garner attention and attract funds to one particular condition.

The methodological chapters of the book argue that the gold standard of research, the randomised control trial and meta-analysis, do not always live up to the claims they make, for a number of reasons. For example, “all randomized trials on the effectiveness of antidepressants use one of very few scales for measuring the severity of depression and such scales are systematically biased towards overestimating the benefits and underestimating the harms of antidepressants” (p.90). Problems have also arisen with meta-analysis, as the sordid story of the Cochrane Collaboration reveals. The Cochrane reviews considered the gold standard of scientific honesty and integrity, recently hounded out the distinguished Danish scientist, Peter C Gotzsche, allegedly at the instance of pharmaceutical companies, for pointing out that psychiatric drugs produce more harm than good (4). There have been profound problems with the meta-analysis of statins, the anti-cholesterol medication, Statins retain a huge global market, despite a majority of studies showing they are really of no use to patients for whom they are prescribed.

It is not fraud, although fraudulent research and reporting does take place; it is not conspiracy involving drug companies and researchers, although such conspiracies do exist and Stegenga documents them. It is, instead, a structural problem in the system. Stegenga highlights the biases and the conflict of interests that haunt the system. For example, “Joseph Biederman is a professor of pediatric psychiatry at Harvard who received 1.6 million dollars in consulting and speaking fees from pharmaceutical companies that manufacture drugs that he promotes” (p. 161). In the U.S, this is perfectly legal. Indeed, the FDA, meant to monitor and regulate drugs, is chronically under-funded, under-staffed and dependent on funding from the very industry it is to regulate.

Stegenga makes an impassioned plea for what he calls a “gentle medicine”, cautious in intervention, allowing nature and the body to heal. He cites sufficient evidence to show why this might be more healthy. For instance, many countries have given up routine screening for prostatic cancer and thyroid cancer, as most people with these cancers die of other natural causes.

What is revolutionary in Stegenga’s prescriptions is his call to abandon the patent system and treat the industry as a public good. He gives us sufficient evidence and reasons as to why this should be so. But decisions in this world are rarely made in the interests of the people’s health. It is finance capital that shapes these decisions: new free trade agreements are being negotiated that will further curtail the production of generic drugs and give even more power to patents. This was indeed on the agenda of the Indian Prime Minister’s recent visit to the USA and the much-hyped meeting with President Trump.

This dazzling book must be very widely read, not just by health activists and public health scholars; but also by policymakers. Could it be on the curricula of medical colleges?