A great loss to medicine

Medical Matters:The pre-medical year in the early 1980s was a somewhat arid affair. As its name suggests, the purpose of our first year in medical school was to ensure that we were up to speed on the basic sciences of physics, chemistry and biology before embarking on "real" medical subjects such as anatomy, physiology and biochemistry.

But there was one oasis in the desert. A short course called "Man and his environment" offered a glimpse into our future lives as doctors. As part of the course, we visited GPs' patients in their homes to elicit how the environment affected people's lives.

I went to see a woman in her late 50s who lived in a flat off the North Circular Road. She had quite severe rheumatoid arthritis and was unable to work as a result.

I can still picture her huddled in her upstairs flat, trying to keep warm in front of a single-bar electric heater.

Her arthritis pains were worse in the cold; the stairs were a challenge and restricted her ability to go out to the shops; and as a single woman unable to work, she was not in a position to move to more suitable accommodation.

It was an eye-opening experience for a callow youth: how such basic factors as housing, heat, solitude and money could have a significant influence on a person's health.

The man responsible for this course, who died earlier this month, was James McCormick, a GP and professor emeritus of community health at Trinity College Dublin.

At the time, "Man and his environment" was a groundbreaking initiative in Irish medical schools. It was also shrewdly designed to expose medical students early in their studies to the world of health outside hospitals.

With this, and later medical school courses, James McCormick had a profound influence on several generations of doctors.

A highly original thinker, he excelled at questioning everything he read and heard. He made his students think, a rare gift.

In two books and many original articles, McCormick laid out his stall as a sceptic. He did not agree with the World Health Organization (WHO) definition of health as "not merely the absence of disease but a state of complete physical mental and social wellbeing".

Rather, "health is the ability to live autonomously: health is successfully coping with the slings and arrows or outrageous fortune". He argued that this view allowed health to those with a disability and even opened up the possibility of dying healthy.

McCormick was especially critical of health promotion and health screening.

"Health promotion mixes the obvious and widely known with the questionable and unproven," he wrote.

Along with his late colleague, Dr Peter Skrabanek, he wrote Follies and fallacies in medicine which set out to question errors of medical doctrine of the kind that set obstacles in the path of rational thought and inquiry.

They famously labelled themselves "the abominable no-men".

Referring to the enthusiasm among some doctors for behavioural change designed to promote health, they noted: "The language of this debate is often more like the language of the hustings than that of academia and those who express doubts have been dubbed 'the abominable no-men'.

"We are happy to be numbered among them," they said.

Both were advocates of hedonism, arguing that individual patients had a right to harm themselves in the pursuit of happiness, provided they did not harm others in the process.

Noting the growing evidence for the protective effect of a moderate alcohol intake in the prevention of coronary heart disease, they said: "What is perhaps surprising is that those who are enthusiasts for prevention and health promotion have never encouraged people to drink, presumably because of the danger that we would all become drunks."

In his 1978 book, The Doctor: Father Figure or Plumber, McCormick argued that doctors should follow a course between paternalism and human plumbing.

"It is possible to combine technical competence with knowledge of its limitations: possible to recognise human needs and to allow to every man his autonomy and his right to human dignity.

"The doctor can still aspire as his forefathers did to mediate between the patient and his illness . . . this demands more than knowledge of disease, it demands concern and awareness of people as individual, unique, human beings."

McCormick would have approved of the results of last week's poll in the British Medical Journal, which voted sanitation as the greatest medical milestone since 1840, having once said: "Improvement in health of any considerable degree still depends not upon doctors, but upon having enough to eat and proper drains."

His challenging voice will be missed in the corridors of medicine.

Dr Muiris Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets that he cannot answer individual queries.