 Mae'r ffordd hefyd yn ymwyfyr yma yn ymwyfyr yn ymwyfyr yma yn ei gwirionedd ydy'r ddodol, ac mae'r lleol erbyn yn cael ei ddodol, yn ymwyfyr, yn ymwyfyr yn ymwyfyr, yn ymwyfyr yn ymwyfyr. Mae ydych yn gweld â'r hwn yn ymwyfyr yn ymwyfyr yn yr ysgrifennu'r hynny. You need to see a doctor. Now I don't think in a world in which the government is expected to secure the health of a population, its scope for interference in our lives is much restricted by that definition and it can do almost anything in the name of health. In the 1980s, the World Health Organisation coined a slogan to encapsulate its then goals. Namely, health for all by the year 2000. Now either it didn't take its own definition of health seriously, or perhaps it forgot it, or it was indulging in terrible utopian and totalitarian fantasies. And here I hope you'll forgive me if I tell you an anecdote. The late Professor Michael Shepard, who was a distinguished professor at the Maudsley Hospital in London, was once a member of the British delegation to the World Health Assembly, which is a kind of supposed parliament that meets regularly under the auspices of the World Health Organisation, in which the delegations of the various national members of the organisation discuss matters of public health and can put forward official resolutions about world health. Well, Professor Shepard was a bit fed up with all the resolutions such as mothers should love their children and things like that. So he decided on a very simple resolution and he put forward the resolution war is bad for health. And as he expected chaos broke out immediately. Which war was he talking about? And as there were several wars raging in the world at that time, the delegates of the countries that participated or supported one side or another were unanimous that their particular war was actually good for health and had no difficulty improving it because of course if their side won and only if their side won, then the health of the population would improve out of all recognition. Now this idea of course was possibly false. There's been an enormous improvement in the health of the population almost of the entire world irrespective of the government in power. And I think that everyone in this room must have heard justifications for regimes such as that of Fidel Castro, in particular the regime of Fidel Castro on the grounds that the population's health has improved enormously under that regime. Has anyone not heard that argument about Fidel Castro? Is there anyone in this room who hasn't heard that argument? No, good. But at the same time the health of the population improved very greatly under the military dictatorships in Guatemala and a few people would use that fact as a justification or propaganda on behalf of those dictatorships in my view quite rightly. Now good health if one defines it more narrowly as the absence of disease is clearly a desirable state in some rather special circumstances for example being a soldier in a front line in the war where illness of course means being removed from danger or and this is the other great example being unemployed in a welfare state where illness confers not only slightly higher monetary income but also absolves you from the task of looking for a job. And we have in fact created a system in which being ill confers economic advantages on millions of people. They may be small advantages but the marginal importance of those advantages is great. Now it might seem obvious that no one could take seriously or literally the World Health Organization's definition of health which obviously would justify endless interference in the most intimate details of everyone's life. But there's little doubt that whether or not anyone does take that definition seriously the scope of ill health so called has been expanding and the desirability of health pretty broadly conceived has been used as such an important disorder atom that it justifies almost anything. A recent editorial in the British Medical Journal for example suggested that all legislation whatsoever all of it should consider its effect on the health of the population and most often of course that was by regulation. Now we may be sure that when they say all they don't actually mean quite all because the largest single cause of personal injury in western countries is sport and it's very unlikely that anyone would consider banning sport in a regime of bread and circuses. But the health benefits of sport could be obtained of course by other means like risk walking the park. And not long ago there was an article in the British Medical Journal that suggested that fences should be put around all swimming pools in the entire world to prevent children from falling in and drowning and no doubt after that it would be rivers and oceans. The tendency of illness to expand is illustrated very well by the latest edition of the Diagnostic and Statistical Manual of the American Psychiatric Association which is used in my view completely unjustifiably all around the world to diagnose so called psychiatric disorders. Not only has the number of illnesses tripled and all of them practically are without biological markers but when you add up the prevalences that are given in the Diagnostic and Statistical Manual you add up the prevalence of all the diseases or disorders that are given in that manual you find that the average American suffers at least two and a half psychiatric disorders each year. Now that of course might seem a very small number to you but it does seem that psychiatrists will not be unemployed for quite a long time. And there's been an inexorable tendency for the scope of illness to expand and medicine has made one of the greatest discoveries of all time that you don't have to feel ill to be ill. In the eyes of medicine you're never healthy, you're at best pre-ill. And a development internal to medicine widens the scope for governmental interference in everyday life enormously. What is now often treated is not illness in the old fashioned or obvious sense but risk factors for developing illness at some unspecified time in the future for example high blood pressure. The higher your blood pressure the greater your chance of suffering a stroke or a heart attack. But the relationship which no doubt has a physiological explanation in fact does have a physiological explanation is principally a statistical one. So when someone is treated for blood pressure and of course there has been a tendency for lower and lower pressures to be treated he is treated not as an individual but as a member of a group. The logic is as follows if you take X number of people with blood pressure Y and treat them with drugs to lower their blood pressure then a certain proportion of them will fail to have a heart attack or stroke one five or ten years later a chance that they would otherwise have had. Now in my experience very few patients actually understand this. They suppose that the tablets that you the doctor give them are actually going to do them some good and this is a reasonable supposition. But in fact it is statistically only statistically likely to do them some good and in fact the chances of them doing them some harm are actually greater than of doing them good. The harm is slight and the good is important. The problem here of course is that some risks are great enough to justify treating groups in this way but there are other risks that are not worth treating in this way at least not in the opinion of the people running the risks. But in health systems such as the British health system and increasingly this will be so in other systems what should be done for the patients is decided centrally at least in part and doctors are rewarded or penalized according to the proportion of patients with high blood pressure whom they treat. And as the number of risk factors for the development of diseases expands so the number of patients treated on a statistical rather than on individual grounds increases and they won't necessarily know it. Most people going to the doctor think that the doctor is treating them as an individual and there's no discussion of this. In effect doctors must hide from the patients the basis of their treatment of them. Now it's easy and perhaps inevitable for doctors to concentrate their minds on the good that they do rather than the harms that they do. Most of them are benevolently intentioned. They want to save the lives of their patients or at least make them better. But a paper in this week's British Medical Journal examined the 57 experiments done on screening that is you look at a healthy population and you find some factor which you look at which predicts disease. 57 experiments conducted on 3,419,036 people and these people of course complained of nothing when they entered the experiment. The purpose of such population screening is to detect disease early on the supposition that if you do detect it early it will be easier to treat or to prevent it altogether from occurring. What the researchers found was that almost no attention was paid in these experiments on screening procedures to the possible harms that such procedures brought with them both physical and psychological. Yet it is upon such experiments that screening procedures of whole populations are undertaken. The harms done by screening are not necessarily trivial and actually can be quite extensive. There is for example the problem of over diagnosis. The procedure may diagnose and often does diagnose people having a disease that they do not in fact have. If the diagnosis brings in its wake surgical operation then unnecessary operations will be performed which is a harm in itself. But it also brings complications including death. If the numbers of complications are large enough then the harm done by screening may outweigh the benefits. This is not a mere theoretical possibility. A professor of surgery in London calculated that for every life saved by breast screening in women under the age of 50 three women died as a result of unnecessary surgical operation provoked by that screening. Now not everyone agrees with his calculations and indeed the whole question is one of formidable and perhaps insuperable complexity because the technique of mammography is constantly being refined as is that of treatment and maybe even the nature of the disease itself is changing. So in a sense the statistics are constantly trying to hit a moving target. But the main point of the paper that I've cited in the British Medical Journal is that promoters of screening procedures affecting millions of people have an inherent bias against considering the harms that their favoured procedures might do and these procedures are often mandated by governments. And doctors are performing in effect large numbers of experiments on huge numbers of people without knowing the effects of all the effects of those experiments. And the people of course cannot give their informed consent because the information doesn't exist upon which they could base such an informed consent. Now decisions based on epidemiological ideas may be good or they may be disastrous and when disastrous they affect millions of people. According to one theory of the modern epidemic of obesity and type 2 diabetes that is now affecting the entire western world but especially in United States and Great Britain with its great culinary tradition. This epidemic was caused by the decision taken by the Nixon administration in the 1970s to tell food companies to put less fat in their products. And this idea was based on the theory that it was increased consumption of fats that caused the development of atheroma that led to heart attacks and strokes. Actually it is now recognized that the epidemiological evidence for that was deeply flawed. Anyway it is no longer accepted in this simple way but the decision to reduce fats in prepared foods was taken. And the food companies responded by increasing the sugar content of their products. In particular by means of corn syrup the production of which instantly is federally subsidized in the United States. And in the last 40 years then food has become sweeter and sweeter and especially in countries such as United States and Britain. And you can see this even in things like the taste for sugar grows with the consumption so that even grapefruit now are sweeter than they were 20 years ago. It doesn't absolve individuals from responsibility for what they eat of course. A book by Professor Lustig who's a pediatrician in the United States about the role of sugar in the production of gross obesity and type 2 diabetes. And this obesity instantly is threatening according to some people to reverse the rise in life expectancy that has been more or less continuous since the middle of the 19th century. He begins his book by telling the story of an Hispanic mother in America with a hugely obese young child, a child really vast. And Lustig discovered that she had been giving a gallon that's to say more than four litres of orange juice per day to her child. Apparently because she thought that the government had told her that orange juice was healthy for children. And she concluded that the more of it the healthier the child. Now against such stupidity perhaps there is no defence. Though it may be wondered whether a population that looks to official advice on such matters as how to feed its own children is more susceptible to such stupidity. Now one of the greatest health disasters in the world in the last half century was produced by a centralized decision taken with the best of intentions no doubt by a government. But in conjunction with a quasi governmental institution the United Nations Children's and Educational Fund UNICEF. On the correct theory that contaminated water is one of the greatest causes of diarrheal diseases that cause a high infant mortality rate in countries like Bangladesh. It was decided there to sink pipe wells to use supposedly uncontaminated ground water. And unfortunately the decision was taken to supply these wells to everyone at the same time. And so that more than a million such wells were sunk. But unfortunately it was discovered a few years later that while the ground water was not bacteriologically contaminated it had a very high arsenic content. With the result that millions of Bangladeshis now suffer from chronic arsenic poisoning. Which is not a trivial condition it leads to quite a lot of health damage. And in fact this is the greatest mass poisoning in the whole of human history. By a neat but fatal irony the Bangladeshis were able in a way to extract some small revenge upon the world or at least upon a very vulnerable part of the world namely Haiti. Bangladeshi soldiers and policemen were sent there by the United Nations in order to keep the peace. And it is one of the theories of the cholera epidemic that started there soon after and was the largest cholera epidemic in the world for probably a century. That it was brought by those Bangladeshi peacekeepers. As Christ would have put it I come not to bring peace but diarrhea. On the other hand collective action has been very successful in all but eliminating many infectious diseases by means of immunisation. Epidemics of infectious disease require large numbers of people living in close contact who are not immune to them. And for most diseases about 90% of the population must be immune for the epidemics not to occur. In Britain and the United States measles returned after much publicity was given to research which turned out to be bogus and even fraudulent. That the combined vaccine of measles mumps and Rubello which is German measles caused autism which is a serious neuro developmental disorder. And in fact the chief researcher of that research so-called research was being paid by lawyers who hoped to make a large amount of money out of class action for the alleged but non-existent injury. However conspiracy theories always flourish and the rate of measles immunisation in Britain fell below the level that conferred what is known as herd immunity. And there were soon measles epidemics of a kind that had not been experienced for many years. Well unlike in the United States in Britain there was no element of compulsion in the immunisation of children and people chose whether or not to have their own children immunised. Similar epidemics or previously controlled diseases which are potentially dangerous such as hooping cough returned after there were scares that immunisation against them caused serious brain damage. So this is not an isolated phenomenon. Well eventually in such situations confidence returns and herd immunity is restored but in the meantime numbers of children suffer from the diseases and in a minority of cases also suffer permanent damage as a result of them. The ethical problem here is that parents are making decisions about immunisation not for themselves but for their children who may be seriously damaged by their decision. As we have seen in normal times parents are generally willing to immunise their children at least in such numbers on medical advice that will produce herd immunity. But once there is a panic many do not have their children immunised and put their children at risk and also other people's children at risk. Well the number of children who suffer devastating long term consequences of diseases such as measles are very small at least in developed societies, in undeveloped societies measles is a much more dangerous disease. And in most cases the disease is a harmless one and many of the older people here, in fact most of the older people here will have suffered from measles as a child. The question then is whether we prefer a society in which parents are completely the arbiters of how their children should be treated or whether there should be some kind of authority that tells them in this limited respect how to treat them. And the question of course cannot be answered solely by reference to the practical results. For example an estimate of the numbers of children permanently harmed or damaged if parents are left with the decision to immunise their children or not compared with those so damaged if immunisation is compulsory. For it's always open to accept that freedom has its costs even if it imposes its costs unfairly. And there could hardly be a better example of unfairness than that of starting out life, death, one of the possible consequences of having measles. And this because one's parents believed in an idiotic and fraudulent theory about the dangers of immunisation. Here you might be interested to know, I mean this is a historical parenthesis, that in the 19th and first third of the 20th century one of the largest social movements in Britain was the anti-vaccination movement which resisted the government's desire to make immunisation against smallpox compulsory and the movement produced mass circulation publications that lasted for 70 years, right until the 1930s. And much of the argumentation that it used was scientifically unsound in trying to preserve the freedom to choose it resorted to inaccurate or bogus science and statistics as did the opponents of course. And it defended the freedom to choose not principally on the virtues of freedom itself or on the illegitimacy of coercion but on the supposed bad health consequences of vaccination. They did not dare say that vaccination is good but we still want the freedom to choose. And it believed that freedom would make people healthier and that was the justification for the freedom. So in other words the freedom was not an end in itself and as Tocwil said he who seeks in freedom anything other than freedom itself is destined for despotism. Well let me end by saying I was somewhat pessimistic that I don't think we live in societies that value freedom above other desiderata for example health. At least certainly not if the medical journals are anything to go by. I've been reading them for about 40 years. I'm not obviously all of them I've been reading the Lancet and New England Journal and the British Medical Journal and on and off the Journal of the American Medical Association which are the most important general medical journals. And I don't record ever reading an editorial or an article that acknowledged that while a certain regulation might have a beneficial effect as far as the health of the population is concerned other considerations including those of freedom mean that the regulation should not be instituted. And of course it has logical consequence that it would stop all the vehicular traffic for example because if there were no vehicular traffic there would be no traffic accidents. And on the whole I think most people in our society actually agree with that. But I'll just end by giving you a flavour of the thinking of the medical journals and it's almost without exception. And I'll quote just to this week's issues of the New England Medical Journal and the Lancet which are probably the two most influential medical journals in the world. Well the New England Journal has an editorial titled High Value Healthcare a Sustainable Proposition. And a title that's a title whose opacity in itself suggests to me evasiveness and willful lack of clarity. And it describes a new series of articles that it is going to run in the near future. The collaborative publishing project between the journal that's the New England Medical Journal of Medicine and the Harvard Business Review comes at a turning point in American healthcare. Never before have the interests of the healthcare community and the business community been better aligned. Well where is the poor patient you might in this you might ask. And here it's concluded and one concludes from that quotation that healthcare is a matter of negotiation between the healthcare community which these days and these days all abstract collections of people are communities. I even read a book about the tattooed community. The business community and the government and the corporatism of this the sheer corporatism this hardly needs emphasis. Now I will turn to the Lancet which this week asks what the World Health Organization can do for world health. Other that is than cease to exist. The paragraph goes as follows now you'll be very pleased that I'm ending because you wouldn't want much of this stuff I can assure you but there's acres of it in the medical journals. Five years ago the most important international event in global health was still the World Health Assembly held in Geneva each May. At that gathering ministers of health meet and decide global priorities and strategies for improving the health and well-being of their peoples. WHO visibly expresses and demonstrates its leadership at the assembly with technical staff guiding ministers in their decision making and planning. The assembly is the platform from which global directors supreme intergovernmental authority, WHO's director general speaks to the world about its collective successes, challenges and opportunities. And I think if you take that paragraph you can see that actually Pravda was Shakespeare by comparison and the Lancet will last much longer than Pravda. Thank you very much.