First do no harm: I hope it is still the case that all medical students have heard these words from one or other of their teachers. Sometimes the admonition used to be given in Latin, Primum non nocere, and paradoxically attributed to the Greek Hippocrates. However, the concept was probably introduced to medical teaching by Auguste-François Chomel, who succeeded his teacher, René Laënnec, as professor of Medicine in Paris in 1836.
At that time, medicine was undergoing a transformation as great as the one from the extraordinary increase in understanding of molecular biology and imaging that we have witnessed over my lifetime. At the time of Laennec (who is best known for his invention of the stethoscope and explaining its value) and Chomel, medicine was exploring the human body and the changes in it associated with disease, the science that became known as pathology. Old traditions and the efficacy of treatments were being questioned, and Chomel was central to this. His teaching referred to the possibility that medical management of illness could do harm as well as good; 'first do no harm' was recognition of the controversial concepts of nosocomial (hospital-caused) and iatrogenic (treatment-caused) diseases.
The period of Chomel's life was difficult. He was born in Paris, one of a line of doctors going back to the late 17th century, including an ancestor who was physician to Louis XIV. He himself was physician to King Louis-Phillipe until the king was exiled after the 1848 Revolution, and then lost his job by refusing to swear allegiance to Napoleon III in 1852.
But in spite of Terrors and Revolutions, Paris was the centre of the modern medical world throughout and Chomel’s writings made an important contribution to this. Ambitious young doctors flocked to Paris to learn from the masters and brought the lessons on clinical examination back to the major cities of Europe and USA, including London and Edinburgh. It was the period when medical and scientific works were being written in the vernacular, although formal lectures were still often given in Latin. Remarkably, translation of a Latin text was a part of the examination for membership of the London Royal College of Physicians until the 1930s and some use of Latin phrases persisted in medicine to the 1950s. Less remarkably, translation from French and German in this examination continued as an optional extra into the 1960s when I took it.
The 19th century also saw the introduction of numerical methods into medicine by a colleague of Chomel's, Pierre Louis. The concept that doctors and surgeons could actually harm their patients must have been apparent to their many victims from botched surgery and from blood-letting. There had been earlier examples of doctors investigating this; in the 16th century the French surgeon Ambroise Paré wrote of the healing power of nature (vis medicatrix naturae) in an attempt to stop unnecessary and dangerous interference with war wounds, and the alchemist and physician Theophrastus von Hohenheim (Paracelsus) had commented that all drugs were poisons and the difference between a poison and a medicine lay in the dose.
In the 17th century, pioneering investigation of the efficacy of foxglove extract in heart failure by William Withering had demonstrated the importance of dose in causing side effects, while the Scottish naval surgeon James Lind had carried out a small comparison of the efficacy of citrus fruits and other dietary measures in preventing scurvy. But Louis' numerical demonstration that blood-letting didn't work led eventually to what we hear about frequently in these COVID-19 days: the controlled clinical trial.
The concept of medicine doing harm is now very familiar. If you have the misfortune to require invasive investigations or some powerful treatment like chemotherapy, your doctor will read out to you the list of possible harmful effects as well as the benefits of the treatment. The decision as to whether to proceed or not is notionally yours, but it can be complex, as there is often a fine balance between possible benefits and adverse consequences. General practitioners are usually best placed to advise on this, and an enormous body of knowledge of the efficacy and harmfulness of medicines is now available to all doctors quite readily, owing to the randomised controlled trial. In these often huge studies, different treatments are compared with each other or new treatments are compared with no active treatment (usually a so-called placebo, Latin for
I shall please, which curiously it often does, such is the potency of suggestion), which brings me to COVID-19.
Almost as soon as the pandemic started, doctors went to work designing controlled trials of a number of drugs that might be beneficial, although no drug was known to be active against the new virus. These included anti-viral and anti-malarial drugs and corticosteroids, but also a range of other new medicines specially synthesised from theoretical considerations of their actions. The success of this depended on detailed planning and administration and is a triumph of collaboration across the UK using the facilities of the NHS.
At the same time, many groups of scientists collaborated in designing and making candidate vaccines and as these became available another major effort allowed them to be tested in many centres round the world as the pandemic reached them. This extraordinary collaboration between basic university scientists, pharmaceutical companies and thousands of doctors, nurses and technicians worldwide is a wonderful example of what mankind can achieve when petty rivalries are set aside in a common endeavour.
What has been achieved has been the discovery within a year of a very effective drug, dexamethasone, fortuitously cheap and readily available, that reduces the risks of death in a good proportion of cases. Dexamethasone has many known side effects if used for prolonged periods, but in the case of COVID-19 only a few days are required and as a lifesaver it is being used with confidence by doctors in hospital. Some other drugs show promise on which the jury is still out. Very hopeful is the recent announcement of likely efficacy of at least three vaccines. We still await regulatory approval of the vaccines and must remember that this is a scrupulous and painstaking process designed to examine their efficacy and safety and thus reassure the public.
For the moment, we can ignore the percentage efficacy numbers, released prematurely by enthusiastic vaccine scientists, until the trials have reached their final goals. There are several reasons for thinking that early results may overestimate their efficacy. For example, they may have been tested predominantly on younger people and at a time when many might have had mild infection and have been already immune. This explains why the results require detailed scrutiny before release; sometimes further research is needed. However, it does look as though we may well have one or more vaccines approved during this winter. Plans are being prepared for their delivery and priorities on a worldwide basis.
This is all good news, and the UK and NHS can be proud of the leading role we have played in this research. We should be less proud of the fact that we have been among the hardest hit countries in the world, something few of us suspected at the start. This was not just bad luck; it was bad management, a consequence of unpreparedness political hubris, and delays in reacting to the scientific evidence. I think it can be traced back a long way, to a rejection in the 1980s of the post-war political consensus, over-centralisation of power, ideological damage to the public health infrastructure, and a more recent anti-science attitude in government, even leading to denigration of people with expert knowledge.
There has also been, particularly in England, a failure of politicians to understand the implications of the science and thus to get a clear message to the people on how important a part we all play in looking after each others' safety. This pandemic has, I hope, taught us some sharp political lessons. Politics and economics are not sciences but, like medicine, they both need science to test their ideologies and theories.
The history of medicine shows how our care of the people has improved with this application of scientific evidence from the time of Chomel and Louis. Good governance aims for the welfare of the people and bad governments can do harm. So, indeed, can a cloth-eared public. We now have plenty of evidence on which to plan a path out of this pandemic and on how to prevent the worst of the next one. The admonition, first do no harm, applies as much to political and economic thinkers as to drugs and public health interventions in medicine. It also applies to every one of us.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own
