IT WAS A LONG time ago that I was at med school at Otago although sometimes it seems I am not such a different person now to who I was then. I was a ‘mature student’ and perhaps more worldly than others but I was also unsure. I felt like I was from another world, already questioning why things were the way they were. I had been a student before. I had a degree from Victoria University in Wellington, rich in smatterings from Lloyd Geering’s Comparative Religion class—I liked him. I liked the way he asked questions and thought for himself and I admired his courage in taking on the church through seeing the crucifixion of Christ in symbolic rather than literal terms. I took Classics too, featuring the fabulous sculptor Praxiteles famous for his languid S-curve seen in his magnificent statues—men so beautifully muscled and women with a real life softness and elegance—despite being sculpted from Carrara marble. At the opposite end of the spectrum were the stiff, freeze-dried, dead octopus, starfish and jellyfish of my Zoology class. Back then I had no idea what to do but I really enjoyed myself, gaining experience in living.
Then, still unclear of my future, together with other lost but intriguing souls I took up a job driving buses in Wellington. The buses were big and red, some diesel, the majority electric and all fun.
The induction programme for new drivers stretched over a six-week period. In my group was a bohemian ex-junkie, his literate girlfriend, a close friend from school and university, and me. Our instructor was a Yorkshire man who had a penchant for cream buns, especially the ones from the Seatoun cake shop.
Every day we would meet at the Courtenay Place depot, now a New World supermarket, for the bus-drivers’ equivalent of the ICU morning huddle. A plan was made, the route to Seatoun decided, one of us allocated to drive, and off we went.
Once we reached Seatoun the huddle reconvened as we discussed road rules—we only gave way to concrete mixers—and common pitfalls that we might encounter in our new career.
The trolley buses were dangerous beasts—silent and lethal. At the command of your foot, surges of electricity descended down from the overhead wires, through those pesky poles, and into the heart of the beast. At first attempt, driving the trolley was like taming a wild horse—all raw power and scarily unpredictable. Slowly, with patience, practice and a soft foot, the power could be reined in.
The next challenge was how to change tracks, off the main line to another destination. Like trains pulling in and out of platforms at a station, trolley buses needed to do the same to get to where their passengers were waiting and, from there, to where the passengers wanted to go. That took some skill because changing tracks requires power to be applied as you cross the switch in the lines above. With power comes speed and with speed the embarrassment of your poles falling down. I say embarrassment because that was the prevailing sentiment among our group when our poles would drop—apart from at that well known spot at James Smith corner when all of us, at one time or another, deliberately brought our poles down changing from the number 3 to the number 2 route through the Mt Victoria bus tunnel. So notorious was this spot that if approached at exactly 15 kilometres per hour, not only would the poles come down but invariably one of the ropes holding them in place would break. A broken rope was a morning off and, from time to time, all of us needed one of those.
We wore a uniform; it was grey and made out of polyester. We ate often and badly, and we sat for long periods on red vinyl seats. At worst, it was a recipe for an early death. At best, the road to a bad case of haemorrhoids. I did it for a while but soon realised I couldn’t keep driving buses forever.
More for fear of haemorrhoids than an early death, compounded by the profound sense of disappointment I felt in letting my father down, I started to look for an alternate career.
During my adolescence my father drove a series of flash cars, staring out as he did between the dashboard and steering wheel, his hat the one part of him visible to oncoming motorists. He never took public transport, nor did my mother, who rode in taxis when not with my father. What a surprise it was then when one morning at about 10.30 Dad made his way to the bus stop at the bottom of the Wadestown hill and waited for a ride home with his son. I was surprised and perhaps a little embarrassed because I knew what he thought of me doing this and not following a professional or academic career. He was really sweet and I think he enjoyed the ride and seeing me sitting up there. I suspect he was also a little reassured by the selection of books I had stacked up on the dash in front of me, perhaps thinking my choice right then was not necessarily wrong or a waste of time.
In those days there were many students in the same position as me. We’d all been to university and were looking around, wondering what to do and what career to follow—spending time in each other’s company, solving the problems of the world and having a ball. That was a luxury and an investment enjoyed by many of my age including many of those now responsible for denying that same opportunity to the students of today. Who knows what might have happened to me if I had been forced into some other kind of employment or career before I was ready.
It was at an impromptu get-together that I met my fellow driver Jim. He was the son of a prominent physician from not far away. He really was the subject of his father’s disappointment. We were in the depot. It was payday. The sun was shining down through the skylights, cutting hazy spotlights through the cigarette smoke onto the card players and conversationalists. I was at a table with Elias, on the run from the coup in Chile, Leota, the original laughing Samoan, and Jim, who had already been a bus driver for three years. Jim was smart and had been accepted to med school after his final year at school but he didn’t know what to do so opted out for a bit. We laughed about ‘a lifetime with haemorrhoids’ and that’s when he told me he’d decided to reapply for med school. It was then that I decided to do the same.
Without telling anyone, I got the papers, wrote my application, and started to get in the groove. I had an okay degree, although I’d never get a look-in these days. That said, I was reasonably confident that if I got an interview I might just swing it and persuade them to let me in. I put a lot of thought and time into my application, making much of the broader experiences that I’d had since leaving school. Strangely, it went as planned. I got the call, flew to Dunedin and enjoyed the interview.
The deep dashboard of my trolley bus was my bookcase. I was a big reader in those days and just before my med school interview I’d just finished reading The Summing Up by Somerset Maugham—it was a great read and of course I talked about it in my interview. I remember quoting a fabulous observation made about judges, ‘I have wished that beside his bunch of flowers at the Old Bailey, his lordship had a packet of toilet paper. It would remind him that he was a man like any other.’
I was interested in the world and used to looking outwards. Once I got to med school, such were the workload and the hours, many students drifted away from real life and, despite explicit warnings from some of our professors, the gaze of many turned inwards. Down into the most fascinating of worlds, people tumbled, emerging periodically for air at a funeral, a wedding or occasionally at a good party.
I was single, still relatively young and discovering the potential of good conversation and charm in making new friends. I had a ball. Perhaps saved by my already well-entrenched bad habits, ‘everything in moderation including excess’, my gaze remained firmly outward.
I have never been a science type—50 per cent in School Certificate physics—nor am I particularly academic. I just scraped an A bursary and got an okay bachelor’s degree. But when I hit med school I did really well. Maybe I was better balanced—I really don’t know—but the work was fascinating and came easy, and I loved the people. I made lots of new friends, many from the corner bar at the Captain Cook where the emphasis was more on conversation than drinking. My friends there were artists, poets, lecturers from the English department and a steady stream of students like me who enjoyed a bit of excess in moderation.
Even back then I knew what mattered and what made the world go around—it was people. Throughout my career in medicine that hasn’t changed. When I look for purpose in my work, it’s about people and life. When I look for purpose in the provision of healthcare services, whether they be to an individual, a family or a population, nothing changes—it’s also about people and life. I didn’t learn that at med school, I learned it at the corner bar of the Captain Cook Tavern. Sadly, that is no more. There are new and more bankrupt lessons we are asking our young people to learn—the inherent value of many social services has been replaced by their cost and saleable value. Wind back the clock I say, remake the corner bar of the Captain Cook Tavern and bring back the conversation; send the grey men of government there for 10 years of reprogramming until they know full well the value of people and the sanctity of the world we live in.
I am no scholar of the history of medicine but I often think about what we do today and how that will be judged tomorrow. Looking back provides a degree of humility about what we understand and what more we have to learn. I see no end to that journey in the near future—we have evolved over many millions of years so to think otherwise smacks of arrogance. No matter where we are on that journey it is unlikely that our accumulation of knowledge will be matched by our ability to use it appropriately or even equitably. These are the skills that probably need researching, addressing and promoting more than scientific knowledge itself.
My friend Professor Sir Muir Gray is a Glaswegian public health doctor who lives in the English city of Oxford. He has a brain that is both big and agile, and I am a pupil of his in many ways. Although an intensivist, I am a public health doctor too. I know full well that the outcomes from what I do, so long as I do it well, are more determined by the patient than by me. Was the patient a rusty Skoda or a new Lexus before the disastrous crash? You get my drift.
These are concerns that many of us don’t think about until how we have lived our lives catches up with us, physically and spiritually. I am not saying we need to obsess about every little thing but at least we can be a bit more sensible and not smoke, drink or eat ourselves to an early grave.
I care because I reckon if I met you I would like you. I care too because when it’s you at death’s door, it might be me in the middle of the night trying to get you working again. I care one more time because I am probably paying for your care and if I am paying for your care, someone else is missing out. That is still our world. Despite efforts by some to deny it, human beings in New Zealand are communal in their thinking, values, beliefs and behaviours, and long may that continue.
Like Muir Gray, I too am a revolutionary and see progress in modern medicine over the past 150 years through a revolutionary lens. We recognise the extraordinary events of 1854 London as emblematic of the first revolution in modern medicine. John Snow, a practising physician, became aware of and interested in an outbreak of disease causing diarrhoea, dehydration and subsequently death for many folk living in London—it was cholera.
Although not that long ago, the theories of disease in 1854 were very different from what they are now. Back then it was a commonly held belief that disease was caused and spread by bad air or ‘miasma’. While many diseases are spread by things in the air, there was no knowledge then about what those things might be. There was no formal recognition or description of bacteria or viruses. Snow, now recognised as the world’s first epidemiologist, meticulously identified all the cases of cholera. He recognised that all were associated with their close proximity to the Broad St pump in Soho. By disabling the pump by removing its handle, the epidemic was halted.
Later it was found that the Broad St water supply came from a well dug very close to an old sewer or cesspit from where the contamination arose. Snow’s act to protect the public was emblematic of our first revolution in healthcare—the importance of public health.
Although traditionally the domain of public health practitioners, responsibility for interventions like this—recognising and providing clean water, immunisation, prevention of disease, stewardship of our environment—fall on all of us. As such, these are too important for us to allow them to be traded away by the grey-faced ideologues, hell bent on short-term gains.
Not long after, in 1890, at the request of sugar merchant and philanthropist Sir Henry Tate, Luke Fildes painted a now famous work called ‘The Doctor’. It hangs in Tate’s eponymous gallery in London. This is the description of the work written by Simon Wilson in Tate Gallery: An Illustrated Companion:
In the final version of The Doctor, Fildes paints a young child in a rustic interior lying across two chairs, his pale face illuminated by the glass lamp on the table. The doctor, dressed in a tailored suit, sits beside the makeshift bed looking down at his patient anxiously. The boy’s father, standing in the background with his hand on the shoulder of his wife whose hands are clasped as if in prayer, looks in to the grave face of the doctor. Their humble lifestyle is evident from the pewter, the scrap of carpet on the stone floor and their ragged clothing. The extent of the youth’s illness can be seen by the half empty medicine bottle on the table, and the bowl and jug, used to relieve the boy’s temperature, on the bench. The bits of paper on the floor could be prescriptions made out by the doctor for medicine now already taken. Fildes described the shaft of daylight as signifying the imminent recovery of the child. He wrote: ‘At the cottage window the dawn begins to steal in—the dawn that is the critical time of all deadly illnesses—and with it the parents again take hope into their hearts, the mother hiding her face to escape giving vent to her emotion, the father laying his hand on the shoulder of his wife in encouragement of the first glimmerings of the joy which is to follow.’5
This painting is rich in its imagery and has become a favourite for many in the profession, especially family doctors. In it there is so much about the relationship between the parties, the devotion of the doctor and, in particular, the anxiety and hope that is associated with someone becoming critically ill. This is made all the more poignant because the patient is a child.
‘The Doctor’ was painted well before the era of antibiotics, at a time when survival from infectious disease, particularly pneumonia, was in the lap of the gods. Back then the role of the physician was to offer symptomatic relief, prognostication and reassurance.
All that changed with the discovery of penicillin in 1928. Since then, we have witnessed a second revolution in healthcare—the rise of personal health services, characterised by the discovery of more pharmaceuticals and technologies to improve the quality and quantity of the lives of individual patients. This is perhaps best personified by the total hip joint replacement, voted by the British Medical Journal as the operation of the twentieth century, perhaps because it is both so effective and ubiquitous.
Those personal health services include new generations of drugs that more effectively treat and cure people with cancer and a wide range of other previously crippling diseases like rheumatoid arthritis and other autoimmune diseases. These surgical and medical treatments are expensive but can be effective if used wisely. As a result, all countries are struggling to pay for them.
In New Zealand, although access to the newest medications might be delayed, the government drug buying agency Pharmac has kept the cost of pharmaceuticals down while improving access to most medications. Their bulk-buying approach, cost benefit analyses, and how they negotiate and trade with individual pharmaceutical firms is masterful. Despite their enormous profits, the shrinking cartel of increasingly wealthy and powerful drug companies continue to lobby governments around the world to disenfranchise Pharmac and prevent its approach spreading more widely. Their lobbying usually takes place on the quiet and behind the scenes, perhaps even on the golf courses of Hawai’i, but would probably have been most intense in the negotiations leading up to the recent signing of the Trans Pacific Partnership. Occasionally it can spill over into overt outrage and anger. This happened a few years ago at a meeting of the Commonwealth Fund—a private US foundation that is focused on providing a better healthcare system, especially for society’s most vulnerable—in Washington. The then administrator of the Medicare and Medicaid services in the United States, Mark McClellan—brother of President George Bush’s White House spokesman, Scott McClellan—launched an outright attack on New Zealand’s approach to buying pharmaceuticals. This occurred at a dinner attended by our health minister, me as her advisor, and a small group of our best and brightest mid-career health practitioners and researchers who had been awarded Harkness Fellowships by the Commonwealth Fund.
In short, McClellan’s argument was that countries like New Zealand were happy to reap the benefits of the investments made by drug companies but not pay the real costs. In that lies the core difference between how our two countries view health services—New Zealanders see them as a public good, while the United States view them as a series of profit-driven businesses. A little embarrassed by the brazen nature of this man’s comments, we were unsure how to respond until, almost as one, we Kiwis began to hiss loudly while he droned on.
Whatever your position on this argument, we seem to have become victims of our own success with healthcare costs and affordability, now critical issues for all governments around the world.
That’s not the only legacy of this explosion of knowledge and technology. We still have real and unsolved issues related to patient harm, waste, maximising value from what we spend our money on, health inequalities and inequities, and our ongoing failure to prevent disease.
Greater awareness of these problems towards the end of the last century brought on a third revolution in healthcare with the rise and rise of the quality improvement movement.
Up until that time, quality had been one of those motherhood and apple pie terms—hard to define but usually something we recognise when it is either present or starkly absent in our interaction with the health services. As helpful as that might be, without a clearer definition of what we are talking about and appropriate measures to know if we are any good, quality of care is hard to improve.
From the 1990s, healthcare providers agreed on a definition of quality across a range of domains including safety and timelines; equality of access and equity of outcomes; and effectiveness of treatments and their cost effectiveness. This began the journey to better understand and meet the real needs and wants of patients.
Behind each of those domains lie a cascade of evidence-based actions and measures that were developed to improve patient care and in many places, Middlemore included, experts in improvement were specifically employed to help clinicians like me improve our performance.
Here is a recent example of a quality improvement initiative that has enhanced patient outcomes, reduced hospital costs and engaged clinical staff to do even more.
Patients in intensive care are extraordinarily vulnerable and at great risk of being harmed by the very people and interventions meant to help them. One of those risks is from a commonly occurring and potentially very dangerous blood stream infection associated with the use of large-bore intravenous catheters necessary to infuse drugs to treat patients with shock. Using an evidence-based set of interventions to standardise the insertion and maintenance of these lines, this infection has been largely eliminated. In New Zealand, this work was initiated by staff in my own intensive care unit at Middlemore Hospital then spread to all other ICUs in the country in an improvement effort led by Ko Awatea. As a result patient harm has been reduced and the estimated cost per infection of greater than NZ$20,000 saved. A secondary gain, and perhaps a more important one, was the engagement of clinical staff who have become enthused and more willing than ever before to embrace the ethos of ‘we have two jobs, to do our job and to improve’. This resulted from the way this work was carried out, thereby fostering better teamwork within intensive care units and allowing staff to find their own solutions to ensure reliability of their processes.
Although well established as ‘business as usual’ in many industries, especially those in the private sector, healthcare and many other areas of the public service have been slow to capitalise on this kind of progressive thinking. The reasons for this are complex but perhaps partially lie in a generalised lack of knowledge by health professionals about what’s possible, absent leadership in this area, a lack of clarity about expectations and goals, little expertise in improvement and, most importantly, a belief that doctors know best.
By way of example consider the difference between subject matter expertise—being a doctor or a judge—and delivery expertise—providing a service that meets the quality standards discussed above. Clearly some doctors and judges will have these complementary skills but it is wrong to assume that just because I am a good intensive care doctor I can run a good intensive care service, let alone a hospital or a health service. In fact, many doctors are hopeless at this. In the same way, just because someone has been on the bench as a judge for 30 years does not mean that they can fix the problems of a system that they have been a part of for so long. As Albert Einstein said: ‘We cannot solve our problems with the same thinking we used when we created them.’
Changing the way health services are planned and delivered requires a range of different and complementary skills, including those of doctors, people with improvement expertise, as well as patients and their families. There is also a place for production engineers to problem solve and improve the flow of people through our organisations. We also need experts from other industries to teach us about customer service and much more.
This kind of open thinking brings other benefits by challenging us to think more deeply about what we mean by ‘health’. ‘Health for what?’ I commonly ask. Surely health for life, for being happy, for creating a sense of self-reliance, and for being productive as individuals, families and communities.
In the past the state and other healthcare funders obsessed about cost and volume. That view has changed to embrace quality and, more recently, the concept of value, defined simply as what we get for what we spend.
The practical application for this is called the ‘Triple Aim’. It is made up of three key imperatives within the health system: managing costs and getting value for money; improving the quality of care and experience of care for individuals and families; and improving the overall health of our population.
Shifts in thinking like this are incredibly important. They open up the potential for new approaches to address debilitating legacy issues, and allow us to think about health through a broader lens in order to make more informed judgements about how policies in one area might affect another. A simple example of that is the impact of housing policy on the health of children.
As a result, while still acknowledging the value of important individual programmes like immunisation and vaccination, we can redefine population health more broadly to also consider the impact of climate change, housing, levels of employment and the minimum wage, our diet and more on our health and who we want to be as individuals and a nation.
Inconveniently complex, you might say. Yes, you’re right, but at least it’s real! Only when we embrace this complexity and the interdependence of so many factors necessary to produce the outcomes we want will we actually have a show of getting there. There is a term used for this kind of thinking—it’s called transformation, a word many find easy to say but difficult to action. To date there has been little official interest in dealing with the root causes of the complex mix of issues bleeding our social services dry. But as I sit here there are signs that the conversation might be changing, with some asking for help and quietly speaking to those who know better.
When I was young and handsome, I fell in love with a fabulous woman, not just because she was beautiful but because she was smart, funny and in her own unique way amusingly quirky. We first met over an orange. She was peeling it carefully with a knife and managed to skin the whole thing such that the entire peel came off in one piece. I thought that was impressive but more was to come. She then spent a lot of time meticulously peeling the pith from around the skinned orange before separating out the individual segments then, piece by piece, we ate it. When I asked about her technique, especially the care she took in removing the pith, she replied, ‘Don’t you know? If you eat the pith, it layers around your heart.’
‘From a medical family?’ I asked.
There is a lovely naivety and innocence about this. Whether or not her belief has changed, she continues to do it the same way today.
In its own way, modern medicine is a belief system too but one based on the scientific method or at the very least cumulative anecdote and expert opinion. Crucially, though, it must be open to scrutiny and review. Like other belief systems modern medicine has its own creation story, history and tradition. One book of that gospel, the birth of modern anaesthesia, now elevated to biblical status in the minds of all anaesthetists, is permanently etched on my brain. Here is a snippet:
The father of modern anaesthesia is credited as
W.T.G Morton who gave ether to a patient in Boston,
Massachusetts in October 1846.
Prior to this, techniques for anaesthesia included,
alcohol, opium, cannabis and hypnosis. Nitrous oxide
(laughing gas) was first used in 1844 by Horace Wells.
Before anaesthesia was introduced surgery was a last
resort and operations able to be performed were few.
Most patients were held down, or if lucky, fainted.
Many died.
Anaesthesia developed rapidly with the introduction of
many new and safer drugs, allowing come complex and
longer operations.
Professor James Young Simpson introduced chloroform
in 1847 and this was given successfully to Queen
Victoria by John Snow for the birth of Prince
Leopold …
And so it goes.
Other cultures have different belief systems to cure and to heal that are as influential in those places as modern medicine is in the west. Take Samoa, for example—a small, proud, independent nation in the middle of the Pacific Ocean, where a largely homogenous population has lived for over three thousand years. The Samoan people have a powerful, impressive and deeply rooted set of values and beliefs. Central in that is the place of traditional healers, while the impact and reach of western medicine remains limited because of a lack of accessible primary care, poorly developed systems and limited local capabilities.
At the age of seventeen, Tina gave birth to her first child whom she breastfed. When the baby was two weeks old, Tina had a minor breast infection that was treated with the application of leaves by a local healer. Tina’s breast got better quite quickly but she didn’t. Over the next six weeks she became increasingly tired, had sweats, backache and recurrent fevers. During this time, she consulted three other healers and saw a traditional massage therapist twice a week.
One morning she woke with a painful dusky blue foot. She was treated for this with more traditional medicines and massage. Another two weeks later, at death’s door, she arrived at the hospital. Tina was lethargic and feverish, struggling with her breathing and with signs of heart and kidney failure.
Examining her more closely, she had the classic findings of advanced infective bacterial endocarditis, a bacterial infection of the heart valves. Her symptoms included finger clubbing, a strange deformity that leaves the finger tips looking like the end of drumsticks; splinter haemorrhages, tiny blood clots that run vertically under the nails; small haemorrhages in the conjunctivae of her eyes; and, most obviously, a cold black leg that was now clearly gangrenous. Listening to her heart, she had a raging murmur consistent with a leaky mitral valve.
A cardiac echo confirmed the problem and identified a massive 10-millimetre infected clot, adherent to the posterior leaflet of her mitral valve. We could see it flapping backwards and forward with each beat of Tina’s heart, and with each beat the chances of more infected debris dislodging and flying off increased. Already some had lodged in her fingernails, others were in her eyes, and a bigger one was blocking the blood flow in her leg. The echo also showed that Tina had thickened abnormal heart valves caused by undiagnosed rheumatic heart disease. This explained why she had become so ill following such a minor infection in the first place. What a tragedy. If she had been diagnosed and then treated with the monthly penicillin injections that kept so many others like her safe, she would now be well and at home with her baby. Instead, here she was needing an above-knee amputation of her leg. Then, if she survived that, her life would only be saved by an operation to replace her mitral valve.
That became impossible. The next day, her left leg now gone and her place on a theatre list in an Auckland hospital four hours’ flight away assured, debris from that huge clot on her mitral valve worked itself loose. Carried at pace through the left ventricle and out through the aortic valve into the aorta, like a pooh stick in a river, it followed the current up into her carotid artery and from there into her left middle cerebral artery where it became stuck, effectively blocking blood flow to the entire left hemisphere of her brain. A similar pooh stick took another route into the left vertebral artery to block the posterior inferior cerebellar artery, knocking off a large part of the posterior part of her brain. These things just happened—there was no song and dance, no obvious signal. It was just that she didn’t wake up in the ICU and, although moving abnormally to a painful stimulus applied to her left hand and foot, she had no motor response to a painful stimulus on the right side of her body.
Later that morning, we scanned her brain and saw it—the dark areas of cerebral infarction or stroke in the territories of those vessels now blocked. Strokes often leave focal deficits causing a spastic paralysis or weakness of parts of the body—typically a weakness or paralysis of one arm and leg—but if large territories of the brain lose blood supply the swelling that accompanies these catastrophes can cause damage from which there is a loss of consciousness and no realistic hope of recovery. Sadly this was the case for Tina, so later that day we removed her from the ventilator and she died several hours later surrounded by her family.
Saving young Tina’s life would have happened if her rheumatic fever had been diagnosed. Saving young Tina’s life would have happened if the traditional healers and modern medical practitioners had more respect for each other, and she had been seen at the hospital earlier. Saving Tina’s young life was totally possible but just didn’t happen because things are the way they are. Sadly, in that place there are many Tinas and there will be more until these fundamental issues are addressed.
Despite mature health systems in the better resourced nations of the world, strongly held belief systems like the one just described abound there too. A few years ago much of the world was affected and terrified by an outbreak of a swine flu virus for which there was no specific treatment apart from symptom control and organ support. Historians and experts in the field remembered the devastating effects of the influenza epidemic of 1919, estimated to have killed between 50 and 100 million people worldwide, including one quarter of the population of Samoa much to the shame of the New Zealand administration at the time.
The young, the elderly and pregnant women seemed most vulnerable to this latest strain of flu but clearly many others became ill too. One of those was a farmer from the Waikato. So ill did he become that he ended up on an extra corporeal membrane oxygen machine to do the work of his failing lungs as well as needing renal dialysis to temporise for his failed kidneys. Believe me, no one gets sicker than this. In the end Alan survived—to some it was thanks to a miracle from G-d, to others it was because of exceptionally good care, and to some it was all put down to the high doses of intravenous vitamin C he received at the behest of his family. His case became a cause célèbre for the vitamin C lobby—yes, there is one—and he became the subject of a 60 Minutes documentary. This clip is available on YouTube, accompanied by this introduction written by the proponents of vitamin C:
Doctors treating Auckland farmer Alan Smith had decided it was time to turn his life support machine off, until a timely intervention by his family and vitamin C saved his life.
A simple google search of vitamin C will reveal a foundation established to promote its efficacy in all things including (but not restricted to) curing cancer and being an antidote to all known toxins. The same foundation diss the use of conventional treatments for many life-threatening conditions which they are convinced vitamin C alone will assuredly cure. Following the publicity about Alan’s case, it was no surprise that the families of other patients with swine flu in our ICUs began to demand the same treatment. Medical staff around the country, supported by their peer group, the College of Intensive Care Medicine, resolutely refused. As a result, battlelines were drawn and the parties were at war.
I too appeared in that 60 Minutes documentary, I suspect portrayed as a demonic unbeliever in the eyes of some. Cheekily, I was sceptical of the cause and effect relationship between Alan receiving vitamin C and his eventual recovery. We have very few magic bullets in medicine and I simply cannot accept that we had one there. For their part, the vitamin C lobby cannot believe that I cannot believe. Some of them went further to say that proponents of western medicine like me are peddling deceit and corruption.
I know only too well that modern medicine does not hold a monopoly on the truth nor does it have explanations for many of the mysteries we witness in everyday life—even though some in my profession might pretend it does. Perhaps it’s partly because of this, and the patronising approach of many modern medical practitioners toward their patients in general, that huge swathes of society believe in and take advantage of alternative and complementary treatments.
In fact, when families ask me whether they can bring complementary medicines into the ICU, so long as I am satisfied that they won’t cause harm, I usually say yes because I define benefit more broadly. Although there is little to no evidence of improvement from most of these treatments, if they allow the family to feel as though they are actively contributing to their loved one’s care and that promotes a sense of trust in me and what my team are doing, I see a benefit to their use.
That was not the case here though. While there is a small potential for harm to the critically ill when high-dose vitamin C is given intravenously, my main objection to its use was because of how the vitamin C lobby groups responded in the case of Alan Smith by attributing all benefit—even his survival—to it alone. They then use that to actively promote vitamin C as a universal cure-all when clearly there is no credible evidence for this. On the face of it, its proponents seem remarkably similar to the snake-oil salespeople of the 1800s preying on the desperate and, in so doing, promising false hope and it is this behaviour that I find so unacceptable. When we are doing our best to help the critically ill, there may well be a place for some traditional and complementary forms of treatment but there is no place for outright dishonesty.
Whatever your beliefs, these are unhelpful spats that should be overcome as we embrace the changes of the latest (and most welcome) of revolutions in healthcare—the revolution of people and of knowledge, of co-design, morality and respect.
Modern medicine, reluctant or not, will be forced to mature to a point where it can acknowledge that it does not have all the answers on its own and never will. Increasingly we are seeing healthcare professionals, organisations and whole health systems less interested in foisting treatments on people without a better understanding of what they value. They are also actively seeking to engage with their communities to redesign the services that were always supposed to be for the benefit of the people. Using the resources and power within teams and across organisations and social services to deliver meaningful outcomes for individuals, families and communities has the promise to radically change the equation such that one plus one might equal five or ten, but never just two.
New Zealand’s Alcohol and Other Drug Treatment Courts (AODTC) are an example of this kind of transformational thinking in action. Begun by a small group of judges, including my wife Ema, to address recidivist criminal offending which is fuelled by drug and alcohol addiction, it is a model of the kind of cooperation across multiple services that is increasingly necessary to address the real life problems that we have struggled with for ages.
Based on an American model and championed by the National Association of Drug Court Professionals (NADCP), the AODTC have an evidence base for success that is formidable.
In New Zealand, more than 80 per cent of all offences are committed under the influence of alcohol or drugs, and the cost of incarceration for one year is close to NZ$100,000. A significant number of prisoners reoffend due to a variety of issues, including drug and alcohol dependence, against a background of challenging social circumstances.
Our traditional approach to punishment has been to fine and imprison offenders but you cannot punish away addiction. The folly of that approach has now been accepted and a new approach, based on successful models in other jurisdictions, is being piloted in the Auckland and Waitakere district courts in New Zealand.
The programme is over halfway through its five-year pilot scheme dealing with high-risk, high-needs offenders, and from early on results are impressive. Reported back in July 2013, in the two years prior to entering the court, this cohort of offenders committed 900 offences. In the twelve months since entering the court, this number has dropped to only eleven.
Participants in the court are referred by lawyers and judges, and their acceptance into the court is predicated on them accepting responsibility for their offending, pleading guilty to their charges, and making a contractual commitment to abide by the rules of the court.
The intervention is a multidisciplinary one led by individual judges. The teams comprise of a judge, case managers, a court coordinator, a pou oranga (Māori cultural advisor), defence lawyers, police prosecutors, and peer support workers. The case manager works with others to identify the appropriate treatment for the individual, and liaises closely with the various providers.
Instead of taking up their usual adversarial roles, defence and prosecution lawyers and the other team members work to the same purpose: keeping the offender in treatment and drug and alcohol free; ensuring that the offender addresses other significant rehabilitative issues and does not reoffend; and ultimately to restore them to a productive life with a driver’s licence and a job.
Each sitting day, all of the AODTC team meet together in closed court to go through the issues for each of the participants before seeing them in open court later in the day. Despite being in open court, these appearances are like nothing else within the justice system—intimate, very personal, deeply challenging and exceptionally moving.
In New Zealand, one of the objectives in providing this alternative to imprisonment is to address the gross over-representation of Māori in the imprisoned population, with over half of the participants in the AODTC being Māori. Further, the court appears to be developing its own tikanga—or cultural practices—which has been greatly enhanced by the role of pou oranga. This can be seen in the opening and closing of the court and in the graduation ceremony.
Tikanga can be described as general behavioural guidelines for daily life and interaction in Māori culture. Tikanga is commonly based on experience and learning that has been handed down through generations. It is also based on logic and common sense associated with a Māori world view.
The principles that underpin tikanga-based practices are personal and can have a relevance to people from all cultures and therefore to all drug court participants.
As a result of the court’s interventions its participants can make and sustain meaningful and pro-social changes in their lives. They are also able to rediscover the simple kind of happiness and joy that comes with ordinary life experiences without the need for alcohol or drugs.
Alcohol and drug addiction is a chronic disease and the approach taken by the AODTC is perhaps the most effective chronic disease management model I know of. How ironic that it should have come from the judiciary rather than from the health system. This is the face of success and this is the looking glass we need to step through to help many people with other long-term conditions help themselves.