Dual citizenship

01 September 2017

ISTOCK

IN HER famous essay Illness as Metaphor, Susan Sontag wrote about “the kingdom of the well” and “the kingdom of the sick”. We each possess a passport between the two regions, but must, at some point, resign ourselves to the inevitable journey into that darker realm.

When and how we pack our bags, however, is not a simple question; and it is made more difficult by the ubiquity in today’s medicine of early screening for seri­ous illness. This was the subject of Dr Margaret McCartney’s sub­vers­­ive document­ary Too Much Medicine? The problem of over-treat­­­ment (Radio 4, Tuesday of last week).

To take a homelier metaphor, coined by Dr Gilbert Welch of the Dartmouth Institute for Health Po­licy and Clinical Research: physio­logical malfunctions (and, in particular, cancers) might be likened to birds, rabbits, and tortoises. Birds represent the aggressive form of a disease, the type that cannot be contained; rabbits are energetic and wayward, but might, given enough fencing, be kept under control; tortoises are going nowhere, anyway.

The point that Dr Welch makes is that screening for a particular con­dition might pick up any or all of these species, but there is only one kind — the rabbit — for which the screen­ing is of any value. Mass-screening programmes will find birds, rabbits, and tortoises in abund­­ance, but will that change the number of people who die from the condition?

The evidence from South Korea, where a mass screening for thyroid cancer was initiated in 2000, sug­gests not. The number of people who, after screening, have had their thyroids removed has increased; but the number of people dying from thyroid cancer has not reduced. The same, it has been argued, goes for the breast-screening boom that followed Kylie Minogue’s revelation that she had breast cancer. “The Kylie effect” meant that more wo­­men were screened, but there was no corresponding increase in the treatment of breast cancer.

On the basis of “Better safe than sorry”, this might not be a bad thing. But, as clinicians argued in this programme, when a good deal of GP time is spent engaged in screening, and when screening leads to a greater number of revenue-yielding surgeries, then it is time to take a harder look at the problem.

Those of us currently engaged in the campaign to save the Music­ians’ Church in London from the censure of a new Evangelical regime might listen to Music in Peril (Radio 3, Thursday of last week) and acknow­ledge our manifold blessings.

Lopa Kothari’s survey of Sufi music-making in Pakistan described a situation in which musicians rarely now perform in public, after a series of bomb attacks by al-Qaeda. The last, in February 2017, at the shrine of Lal Shahbaz Qalandar, in Karachi, killed 80 people.

Kothari’s excellent programme included interviews with Sufi prac­titioners and opponents alike, but its main strength was the generous dol­lops of music which were served; for Sufi music flourishes in Pakistan, despite the op­­pression.

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