Dual citizenship

01 September 2017


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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