Dear Editor,
We are not often so vividly brought to confront and feel what practising Medicine and research is like in third-world places as we were by the report [1] and Opinion piece [2] in the BMJ online of 25th February 2021.
What is Medicine for? Why do doctors practice Medicine? Has the age-old reason `to help people` gone, or does it still drive some of today`s doctors? That we all have to die sometimes seems to be an unacceptable truth in many Western cultures, as `affecting mortality` so often seems to take precedence over `affecting morbidity` in the prevention, research and practice we see here today. `Saving lives` at all costs can so often result in years of increasing and sometimes extreme morbidity, but is so often applauded. Preventable death, and dying before one`s time, are quite different matters. Life is precious, each life is unique, but preserving life `at all costs` is one example of the way that Medicine in the `western world` has lost its way, [3] from cradle (neonates) to grave (with multi-morbidities and incapacities). Prevention methods have become excessive, `finding it early` [4][5] to the point of using minutiae [6] the stated aim.
Relieving suffering amongst the world`s millions of poor and disadvantaged, who die well before their three-score years-and-ten from disease, exhaustion and poverty in the low- and middle-income areas of the world, is less fashionable and so often out of sight and out of mind in more affluent places. The coronavirus pandemic has brought the well-off up close and personal to the reality of premature death, to people who forget that that is the norm for many who live in the slums of Mumbai and other similar places over the globe. This example of care and compassion, the persistence and passion to find low cost means to prevent the horror of palpable and visible breast cancer, demonstrate to me that `helping people` as a motivation for practicing Medicine is alive and well. There are many lessons to be learned from the history [1] and practice [2] of this cluster randomised trial undertaken in the shadow of the Tata Memorial Hospital in Mumbai to determine the effect of screening by clinical breast examination on breast cancer incidence and mortality. It has already brought great benefit in India. [7] The dedication of the doctors and the trained female primary care workers who showed tenacity and compassion (as well as curiosity in their research question), going into those slums to give care to these disadvantaged people is one such that we should bear in mind as we Westerners expend huge resources, both human and financial, on saving lives at all costs, in population screening programmes which bring more (iatrogenic) harm than benefit.
Prioritising health care, prioritising order for vaccination in this pandemic, currently preoccupy the thoughts (and media!) of the whole population. A painful experience for everyone. May lessons be learned from it as we struggle to `think global` and then, hopefully, to `act global`. May we come to learn to thoroughly observe what is happening, not just from the data [8] but from the experience of doing such research; find the route to practising better, more just Medicine through showing concern for all our fellow-travellers.
[1] Mittra I. The Story of the Mumbai breast screening study. BMJ Opinion, 25th February 2021. https://blogs.bmj.com/bmj/2021/02/24/the-story-of-the-mumbai-breast-scre...
[2] Mittra I, Mishra GA, Dikshit RP, Gupta S, Kukami V, et al. Effect of screening by clinical breast examination on breast cancer incidence and mortality after 20 years: prospective, cluster randomised controlled trial in Mumbai. BMJ 2021;372:n256
https://www.bmj.com/content/372/bmj.n256
[3] Richard Smith: The most devastating critique of medicine since Medical Nemesis by Ivan Illich in 1975. February 13, 2019. BMJ Opinion piece. https://blogs.bmj.com/bmj/2019/02/13/richard-smith-most-devastating-crit...
[4] Michael Baum rapid response to [2]
[5] Thornton H. Randomised clinical trials: the patient`s point of view. In `Ductal Carcinoma in Situ of the Breast`s. Ed: Melvin J. Silverstein. Williams and Williams. 1997. Page 434.
[6] Ismail Jatoi rapid response to [2]
[7] Manus P. Roy rapid response to [2]
[8] Greenhalgh T, Howick J, Maskrey N. Evidence based medicine: a movement in crisis?
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3725 (Published 13 June 2014) BMJ 2014;348:g3725 https://www.bmj.com/content/348/bmj.g3725
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Re: Effect of screening by clinical breast examination on breast cancer incidence and mortality after 20 years: prospective, cluster randomised controlled trial in Mumbai - The BMJ
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