The Pharmaceutical Journal
Vol 268 No 7201 p820
8 June 2002

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Quality, not quantity [more]
Living and learning [more]
Organising world health [more]

Quality, not quantity

I remember that my undergraduate studies involved perusing the works of that distinguished philosopher and essayist Michel Eyquem de Montaigne, who flourished in the 16th century. In his 'Essais' (1580), Montaigne wrote: "L'utilité du vivre n'est pas en l'espace, elle est en l'usage. ... Il gît en votre volonté, non au nombre des ans, que vous ayez assez vécu." (The value of life lies not in the length of days, but in the use you make of them. ... Whether you have lived enough depends not on the number of your years but on your will.) He goes on to comment: "La plus grande chose du mond, c'est de savoir être a soi." In other words, know how to be your true self.

Montaigne's sentiments crept back into my mind when I encountered the powerful arguments regarding the over-medication of people in recent years, expressed in the 13 April issue of the British Medical Journal (PJ, 20 April, p527). There it is asserted that rich western societies are investing in a range of expensive treatments, most of them preventive in intention, which can benefit only a minority of the population at risk. Cosmetic treatments that postpone the ravages of advancing age are vastly popular in rich communities, and they tend to elbow out other therapies that may be able to improve day-to-day existence for the many by relieving pain and distress.

Ivan Illich in 1976 criticised the tendency of doctors to strive to preserve life by every possible means, even if its quality is not evident. Yet death is as natural as being born, and with pain and sickness is all part of being human. "People are conditioned to get things rather than do them ... They want to be taught, moved, treated, or guided rather than to learn, to heal, and to find their own way."

The pharmaceutical industry has a vested interest in producing "a pill for every ill", and the cult of producing non-diseases with impressive names has resulted in much medication that is pointless and, for society, wasteful. Telling people that they are sick but can be cured by taking a new medication, is a mine of commercial profit. In many instances, if people could be guided to judge which of their harmful habits they could discard with improvement in health, and what new habits they could adopt to avert sickness, everyone would benefit.

The tendency to over-medication is part of the wider belief that "bigger and more" is the secret of a better society of humans. We think of quantity as the thing to be desired, not of quality as the measure of how life should be lived. It is simply a question of not how long but just how. As advisers in healthy practices and dissuaders from harmful habits, pharmacists have a part, however limited, in discouraging the current increase in demand for more and more medicines for more and more inappropriate living conditions. Let us first ameliorate those conditions, if we can find any politicians who might be prepared to help.

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Living and learning

There is a tradition which maintains that learning a language and facility in communication are critically affected by age. Yet whether the onset and nature of a language imposed on a child in early life has any effect on later language learning ability is largely unknown territory.

In a communication to Nature for 2 May from linguistics experts from schools of communication sciences and disorders in Canada, findings are reported which indicate that the age at which a child starts to learn communication skills makes a significant difference to his or her later ability to acquire tongues.

Data were obtained from two groups of adults, some of them deaf from an early age who had studied sign languages as a consequence. Both deaf and hearing subjects who were taught languages in infancy proved better able to learn a new language later in life, but those who had undergone negligible language experience while still infants showed a poorer uptake later, irrespective of whether their early teaching had been signed or spoken and whether their later-learning was achieved through either of these means.

Tests were performed on adults who had learned sign language between the ages of nine and 15 and had used it for over 20 years. Some had heard spoken English in infancy but had afterwards become profoundly deaf and had learned sign language after an accident. Others had been deaf since birth. Three more groups had learned English at school between the ages of four and 13 and had used it for more than 12 years. One group, born deaf, had had little experience of spoken English before training in sign language at school. Another had been born deaf but had received sign language from infancy. Yet a third, able to hear from birth, had listened to Urdu, French, German, Italian or Greek, but not English, during infancy. Whatever the language encountered in infancy, their experience of sign language or speech made them more proficient in learning English later on. Ability to learn a language, and therefore to communicate effectively, seems to depend on synergy between early brain development and acquaintance with language, whether spoken or signed, during early life.

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Organising world health

At the annual world health assembly on 13 May, the director general of the World Health Organization, Gro Harlem Brundtland, told her audience that WHO plans to step up its campaigns against poverty-related diseases and intensify attempts to tackle cardiovascular illnesses, obesity and other ailments of richer nations. The organisation has been criticised for doing too little to further its goal of health and medicines for all. Work on diet, food safety, with efforts to correct specific nutrient deficiencies, is in the forefront. More funding is needed for tackling the illnesses of poverty and increasing access to essential medicines and health care.

The director general was criticised by Médécins Sans Frontières for not having shown more courage in persuading the pharmaceutical giants of the world to lower the price of their medicines to poor countries, and for not taking a more prominent part in the arguments over free trade and patenting in relation to drugs. The drugs industry, it was argued, had shown a lack of interest in developing new drugs against leishmaniasis, Chagas disease and malaria, and should have been prompted by WHO.

Nevertheless, Dr Brundtland has been praised for advances made since the previous administration under Dr Hiroshi Nakajima, when WHO's credibility was sadly strained for a decade. Since her accession in 1998 the organisation has taken on new vitality, and her work has been warmly praised as that of someone whose quality of leadership is good, who has focused on a few priorities and is honest, energetic, committed and politically adept.

There are, nevertheless, severe criticisms from some observers, not least that Dr Brundtland has been influenced too strongly by the pharmaceutical industry giants. The recent needs of the people of Afghanistan have offered a challenge to WHO. Child health, immunisation and nutritional difficulties have been exacerbated by a high degree of mental instability, with 40 per cent of the population suffering from psychosocial problems. Care and rehabilitation, with provision of essential drugs and equipment, are urgent problems. WHO with its international structure must face the future in Afghanistan and elsewhere with greater determination than ever before.

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