Harmful effects, which can be serious and even lethal, are associated
with every facet of modern medicine...
Injury from medical treatment in the U.S. accounts for more deaths than
all other accidents combined.
Iatrogenic illness--disease produced as a result of medical treatment--is
now recognized as a health hazard of global proportions. MEDLINE (the computerized
medical research database of the United States National Library of Medicine)
includes over 7,000 articles, reports, and scientific research papers since 1966
that show a substantial number of patients suffer treatment-caused disorders and
adverse drug reactions. These harmful effects, which can be serious and even lethal,
are associated with every facet of modern medicine including drugs, other medical
therapies, diagnostic procedures, and surgery.
Detrimental effects have become so extensive as to prompt the use of the term
"iatroepidemic2". Reporting in the Journal
of the American Medical Association, Dr. Lucien Leape of Harvard School of Public
Health, has calculated that "180,000 people die in the U.S. each year partly as
a result of iatrogenic injury, the equivalent of three jumbo-jet crashes every
two days3". In another issue, the Journal
of the American Medical Association points out that injury from medical treatment
in the U.S. "dwarfs the annual automobile accident mortality of 45,000 and accounts
for more deaths than all other accidents combined
Medication- caused disorders costs are nearly twice that spent on diabetes
treatment and near the amount for cardiovascular disease.
Fifteen per cent of hospital days are devoted to the treatment of drug side
Every medication, including those that are sold over the counter without
a prescription, has an associated side effect.
Medication-caused disorders produce a substantial economic drain.
For example, the Archives of Internal Medicine reported a cost to the U.S.
economy of $76 billion in 1995. This amount is nearly twice that spent on
diabetes treatment and near the amount for cardiovascular disease
Iatrogenic disease can be due to many factors. These include: errors in
prescribing or administering drugs and other treatments; accidents; inappropriate
use of diagnostic or therapeutic measures; and the intrinsic potential for harm
and side effects associated with medications, surgery, and other procedures.
The hospital environment is especially conducive to medical hazards.
tudies including those conducted at Harvard Medical School show that as
many as 36 per cent of patients admitted to hospitals suffered iatrogenic
injury with up to 25 per cent of those being serious or fatal. Up to half
of these injuries were related to the use of medication
The results of an analysis of cardiac arrests at a teaching hospital
found that 64 per cent were preventable. Inappropriate use of drugs was
the leading cause7.
In addition to treatment-caused disorders, hospitals foster life-threatening
nosocomial infections involving rare or drug-resistant microorganisms, which are o
ften difficult to treat.
Fifteen per cent of hospital days are devoted to the treatment of drug side
effects8. Every medication, including
those that are sold over the counter without a prescription, has an associated
side effect. Commonly used drugs have been found to affect every system.
Frequent reactions include skin rashes, nausea, headaches, dizziness, lethargy,
diarrhea, and gastric bleeding in a significant number of people. More severe
reactions that can be fatal or severely debilitating include deafness,
depression, abnormal heart rhythms, angina, bronchospasm, electrolyte
disturbances, immune system dysfunction, serious blood disorders such as
aplastic anemia, liver or kidney toxicity, Stevens-Johnson syndrome, or
anaphylactic shock. These occur in a statistically significant proportion of
the population. Despite what is known about adverse drug effects, Dr. David
Kessler, Chief of the U.S. Food and Drug Administration, believes that "only
one per cent of all serious drug reactions are reported
The problem escalates to public health proportions when large numbers
receive a treatment and experience its attendant side effect.
Many drugs have side effects serious enough to cause a secondary
disease warranting its own intensive therapy.
The problem escalates to public health proportions when large numbers receive a
treatment and experience its attendant side effect. The New England Journal of
Medicine makes this point in discussing the link between breast cancer and
menopausal hormone replacement therapy: "because of the high incidence of breast
cancer even a slight increase in risk will yield a substantial increase in the
number of cancers10". The scale of use causes
drugs which are considered safe to end up producing significant damage. In this
regard, the widely used non-steroidal anti-inflammatory drugs cause over 3,300 deaths
per year and 41,000 hospitalizations.
Many drugs have side effects serious enough to cause a secondary disease
warranting its own intensive therapy. An example is Parkinsonism caused by the
neurological side effects of anti-depressants or anti-psychotic medication. A
Harvard Medical School study showed that drugs were the real cause of the
original symptoms in 37 per cent of elderly patients who were treated for
Parkinson's disease. L-dopa, the medication used in treating these patients
has its own severe side effects, that often require the use of additional drugs
to control11. Other examples of new diseases
caused by medications include collagen vascular disease produced by blood pressure
medications, and Cushing's syndrome produced by prolonged cortico-steroid use. The
New England Journal of Medicine has published several studies linking cancer
chemotherapy to the later appearance of new malignancies
12. Many drugs are classified as teratogens
and cause birth defects when taken during pregnancy. Others can cause diseases in
offspring in later life.
Unfortunately, these effects may not become apparent until many thousands of
women have taken a drug which had been enthusiastically introduced and promoted,
the classic example being the tragic epidemic of birth defects in Europe due to
thalidomide, or cancer in the children of mothers who took diethylstilbestrol.
Overuse of antibiotics has produced resistant strains of formerly susceptible
micro-organisms. Serious concern has been voiced about the potential for epidemics
which cannot be effectively contained due to drug resistance. An example of this is
the emergence of tuberculosis that is resistant to presently available drugs.
A U.S. Congress Subcommittee found that in one year unnecessary
operations were responsible for more than 12,000 deaths,
Dependency on high technology is a often a source of injury.
Only 15 Percent of medical therapies were found to be reliable, or
Studies also show substantial inappropriate and overuse of surgery, and
continued use of outmoded operations. A U.S. Congress Subcommittee on Oversight
and Investigations into Unnecessary Surgery found that in one year, there were
approximately two million unnecessary operations, responsible for more than 12,000
deaths, with an approximate cost wastage of $10 billion
Dependency on high technology both in diagnosis and treatment has been shown
to be a source of injury with machine failure or misapplication of technology.
For example, 36 per cent of iatrogenic problems in intensive care units were
associated with equipment malfunction14.
In addition, medical care is often based on much less scientific evidence than
assumed and undergoes radical reversals. The editor of the British Medical Journal
revealed that only 15 per cent of all medical therapies have a scientific basis or
have been demonstrated to be effective15. Yet
patients remain vulnerable. An example is the formerly common use of irradiation for
enlargement of the thymus in infancy, a condition now recognized to be normal. This
treatment has recently been shown to cause cancer in later life in those who received
Pharmaceutical companies push physicians to prescribe new drugs and
don't reveal scientific information that oppose the use of that drug.
Developing countries have had special problems with irrational drug
marketing by multinational and indigenous pharmaceutical companies.
Pharmaceutical marketing also puts great pressure on physicians to use new
products. The medical journal Hospital Practice pointed out that pharmaceutical
company competition "leads to very aggressive promotion and inundation of the
physician with data supporting the use of each new drug". Such marketing may
dilute opposing scientific information that is not as well publicized.
Ultimately drugs may be withdrawn, but only after substantial harm has been
done. For example, benoxaprofen, a non-steroidal anti-inflammatory agent (NSAID)
was introduced and heavily marketed in 1982, but then withdrawn after cases of
fatal liver toxicity were reported in Great Britain. Zomepirac sodium was also
"aggressively marketed as a safe analgesic", but withdrawn after a year and
numerous reports of fatal anaphylaxis17.
The cardiac drugs flecainide and encainide, heavily promoted to control
abnormal heart rhythms, were then withdrawn years later after scientific
studies showed they caused fatal arrythmias and that those treated with them
were two-and-one-half times as likely to die as were those taking a placebo.
Developing countries, which have less stringent controls and means of
surveillance, have had special problems with irrational drug marketing by
multinational and indigenous pharmaceutical companies that have been carefully
documented. These practices have been reviewed in the Journal of Clinical
Epidemiology by several authors including Dr. Philip Lee, the United States
Assistant Secretary of Health. According to Dr. Lee and his colleagues, "unjustified
claims of efficacy or safety continue to proliferate
18". In addition to side effects, the high
cost of pharmaceuticals are a significant hazard to the economy of developing
The wealth of data has made clear that fundamental deficiencies exist
in the current medical approach and that new knowledge is urgently needed.
Physicians and patients have come to accept medical hazards as a necessary price
to pay for modern diagnosis and therapy even though they may be seriously
debilitating or lethal. The same is true with medical errors. Studies have
shown errors to be so pervasive that mistakes are considered to be an inevitable
part of the medical system, giving rise to the term "necessary fallibility
19". The deplorable acceptance of disease
or medical error as a consequence of treatment reflects a deviation from the
most primary principle of medical ethics--primum non nocere--above all do no
harm. The wealth of data documenting the serious nature and extent of the hazards
associated with modern medicine has made clear that fundamental deficiencies exist
in the current medical approach and that new knowledge is urgently needed to
effectively address this problem.
1. USA Today. September 13, 1995.
2. Review of Respiratory Diseases. 1987; 135: 1152-1156.
3. Journal of the American Medical Association. 1994; 272: 1851-1857.
4. Journal of the American Medical Association. 1995; 274: 29-34.
5. Archives of Internal Medicine. 1995; 155: 1949-1956.
6. Annals of Internal Medicine. 1964; 60: 100-110. New England Journal of Medicine. 1981; 304: 638-642. New England Journal of Medicine. 1991; 324: 370-376.
7. Journal of the American Medical Association. 1991; 265: 2815-2820.
8. Harrison's Principles of Internal Medicine. 1994.
9. US News and World Report. January 9, 1995: 49-54.
10. New England Journal of Medicine. 1994; 330: 1062-1071.
11. American Journal of Medicine. 1995; 99: 48-54.
12. New England Journal of Medicine. 1990; 322: 1-6
13. USA Today. October 31, 1983.
14. Nursing Clinics of North America. 1993; 28: 459-473.
15. British Medical Journal. 1991; 303: 798-799.
16. New England Journal of Medicine. 1989; 321: 1281-1284.
17. Hospital Practice. 1989; January 30: 89-94.
18. Journal of Clinical Epidemiology. 1991; 44: 49S-55S.
19. Journal of the American Medical Association. 1989; 261: 1610-1617.
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