by Dr Raj Persaud and
Dr Peter Bruggen
14 May 2012
Dr Raj Persaud is a
Consultant Psychiatrist and Consultant Editor of 'The
Mind: A Users Guide' published by Bantam press.
Dr Peter Bruggen is a retired Consultant Psychiatrist and author
of Who Cares?: True Stories of the NHS Reforms published
by Jon Carpenter.
As doctors start voting from today on whether to strike in the UK,
what's the likely impact of withdrawing medical care on the health
of the nation?
The doctor's union, the British Medical
Association, seems to be gambling that the government doesn't want
to alarm the electorate. But when doctors strike, the scientific
research evidence finds that patients stop dying.
The most comprehensive review of the medical impact of doctors'
strikes is published in the prestigious academic journal Social
Science and Medicine.
A team lead by Solveig Cunningham
and Salim Yusuf at Emory and Georgetown Universities in the
USA and McMaster University in Canada, analyzed five physician
strikes around the world, all between 1976 and 2003.
Doctors withdrew their labour, in the different strikes analyzed,
from between nine days and 17 weeks. Yet all the different studies
report population mortality either stays the same, or even
decreases, during medical strikes. Not a single study found death
rates increased during the weeks of the strikes, compared to other
For example, in a strike in Los Angeles County, California in
January 1976, doctors went on strike in protest over soaring medical
malpractice insurance premiums.
For five weeks, approximately 50% of
doctors in the county reduced their practice and withheld care for
anything but emergencies.
One analysis, quoted by Cunningham and
colleagues, found the strike may have actually prevented more deaths
than it caused.
It's the fact that elective, or non-emergency surgery, tends to stop
during a doctors' strike, which seems to be the key factor.
It looks like a surprising amount of
mortality occurs following this kind of procedure which disappears
when elective surgery ceases due to doctors withdrawing their labour.
Mortality declined steadily from week one (21 deaths/100,000
population) to weeks six (13 deaths) and seven (14 deaths), when
mortality rates were lower than the averages of the previous five
However, as soon as elective surgery resumed, there was a rise in
There were 90 more deaths associated
with surgery for the two weeks following the strike in 1976 (i.e.
when doctors went back to work) than there had been during the same
period in 1975.
But, unlike Los Angeles, what about the impact of doctors'
industrial action where the majority of doctors participate, and the
strike lasts several months?
Cunningham and colleagues report on a strike in Jerusalem from 2
March to 26 June 1983 due to a salary dispute between the government
and the Israel Medical Association (see 'Doctors'
Strike in Israel May Be Good for Health').
8000 of Jerusalem's 11,000 physicians
refused to treat patients inside hospitals, though many of them set
up separate aid stations where they treated emergency cases for a
One analysis examined death certificates from several months
surrounding the strike period, 16 February-3 September 1983, and
from a control period the previous year, 17 February-3 September
1982. Mortality did not increase during or after the strike, even
when elective surgery resumed.
The pre-strike deaths for the control period and the strike period
were identical at 89; there were six fewer deaths during the strike
than during the control period, while in the ten weeks following the
strike, there were seven more deaths than there had been in 1982.
In an intriguing example of how a doctor's strike can backfire, the
authors of this particular mortality analysis argued this apparent
lack of impact of the strike on mortality suggests that there was an
over-supply of doctors in Jerusalem at the time.
The problem with drawing conclusions
remains that the strike did not involve the whole scale deprivation
of medical services.
Cunningham and colleagues point out in their review paper that
striking physicians opened aid stations, supplementing medical care
and preventing people from mobbing the hospitals.
While physicians were technically on
strike during the four months of the dispute, most did not in fact
adhere to the industrial action regulations. In truth, most doctors
in Jerusalem provided care in a private or partially private
context, so, while participating in spirit, they did not actually
Another intriguing study analyzed changes in mortality by studying
the Jerusalem Post's newspaper reports of funerals during another
Jerusalem doctors' strike, this time between March and June of 2000.
This one arose from the Israel Medical Association's conflict with
the government's proposed wages.
The hospitals in the area cancelled all
elective admissions and surgeries, but kept emergency rooms and
other vital departments, such as dialysis units and oncology
The funeral study found a decline in the number of funerals during
the three months of the strike, compared with the same months of the
previous three years. One burial society reported 93 funerals during
one month of the strike (May 2000) compared with 153 in May 1999,
133 in May of 1998, and 139 in May 1997.
Cunningham and colleagues summarize their review of research
assessing the effects of doctors' strikes on mortality, finding that
four of the seven studies report mortality dropped as a result of
medical industrial action, and three observed no significant change
in mortality during the strike or in the period following.
There are several possible interpretations for this surprising
One is that as its elective or
non-emergency surgery which is usually most effected in a
doctor's strike, it could be the mortality findings reflect
an impact of elective surgery. The findings might be
important because they perhaps illuminate the relatively
high risks of elective surgeries, which may actually
increase mortality. If it wasn't for doctor's strikes, this
might be a finding, ironically never otherwise properly
Another sobering possible
conclusion is that the public, and perhaps doctors
themselves, overestimate the ability of medicine to stave
off or have an impact on mortality.
The problem with interpreting the data,
as Cunningham and colleagues point out in their review paper, in all
medical strikes studied so far, not all doctors down tools.
In the 1976 Los Angeles strike only 50%
of physicians were involved. So doctors' strikes don't necessarily
drastically reduce access to health care.
Given the purpose of most strikes is to
deprive management of the worker's labour, and it's benefits, this
raises the sobering question of how effective a doctors' strike can
ever be in comparison to other occupations.
The very difficulty in getting physicians to withdraw their labour
in the way other occupations can do, hints at a fundamental
difference between what it is to be a doctor, compared to pursuing
other ways of making a living. A doctor, the research on strikes
illuminates, isn't something you do, it's something you are.
This issue of identity is why it's so
much more difficult for doctors to simply discontinue practicing
medicine. It's a character flaw prone to exploitation by governments
and employers, effectively frustrating standard union tactics.
Another theory as to why patients live longer when doctors go on
strike, is that the profession finally shakes off the shackles of
its employer's restrictive practices, and returns, albeit
temporarily, to practicing medicine freely, as it would really like
And perhaps, British Medical Association take note, that's actually
the most effective sort of industrial action doctors can ever take.
Doctors are The Third Leading Cause
of Death in the US...
Killing 225,000 People Every Year
by Joseph M. Mercola
July 30, 2000
This article in the Journal of the American Medical Association (JAMA)
is the best article I have ever seen written in the published
literature documenting the tragedy of the traditional medical
This information is
a follow-up of the Institute of
Medicine report (To
Err Is Human - Building a Safer Health System) which hit
the papers in November of last year (1999), but the data was hard to
reference as it was not in peer-reviewed journal.
Now it is published in JAMA which is the
most widely circulated medical periodical in the world.
The author is Dr. Barbara Starfield of the Johns Hopkins
School of Hygiene and Public Health and she describes how the US
health care system may contribute to poor health.
ALL THESE ARE
DEATHS PER YEAR
12,000 - unnecessary
medication errors in hospitals
20,000 - other errors in
80,000 - infections in
106,000 - non-error, negative
effects of drugs
These total to 225,000 deaths per year
from iatrogenic causes!!
What does the word iatrogenic mean? This term is defined as induced
in a patient by a physician's activity, manner, or therapy. Used
especially of a complication of treatment.
Dr. Starfield offers several warnings in interpreting these numbers:
First, most of the data are
derived from studies in hospitalized patients.
Second, these estimates are for
deaths only and do not include negative effects that are
associated with disability or discomfort.
Third, the estimates of death
due to error are lower than those in the IOM report.
If the higher estimates are used, the
deaths due to iatrogenic causes would range from 230,000 to 284,000.
In any case, 225,000 deaths per year constitutes the third leading
cause of death in the United States, after deaths from heart disease
Even if these figures are overestimated,
there is a wide margin between these numbers of deaths and the next
leading cause of death (cerebrovascular disease).
Another analysis concluded that between 4% and 18% of consecutive
patients experience negative effects in outpatient settings, with:
116 million (US$) extra
77 million extra
17 million emergency
3 million long-term
199,000 additional deaths
77 billion in extra costs
The high cost of the health care system
is considered to be a deficit, but seems to be tolerated under the
assumption that better health results from more expensive care.
However, evidence from a few studies indicates that as many as 20%
to 30% of patients receive inappropriate care.
An estimated 44,000 to 98,000 among them die each year as a result
of medical errors.
This might be tolerated if it resulted in better health, but does
it? Of 13 countries in a recent comparison, the United States ranks
an average of 12th (second from the bottom) for 16 available health
More specifically, the ranking of the US
on several indicators was:
13th (last) for low-birth-weight
13th for neonatal mortality and
infant mortality overall
11th for postneonatal mortality
13th for years of potential life
lost (excluding external causes)
11th for life expectancy at 1
year for females, 12th for males
10th for life expectancy at 15
years for females, 12th for males
10th for life expectancy at 40
years for females, 9th for males
7th for life expectancy at 65
years for females, 7th for males
3rd for life expectancy at 80
years for females, 3rd for males
10th for age-adjusted mortality
The poor performance of the US was
recently confirmed by a World Health Organization study, which used
different data and ranked the United States as 15th among 25
There is a perception that the American public,
"behaves badly by smoking, drinking,
and perpetrating violence."
However the data does not support this
The proportion of females who
smoke ranges from 14% in Japan to 41% in Denmark; in the
United States, it is 24% (fifth best). For males, the range
is from 26% in Sweden to 61% in Japan; it is 28% in the
United States (third best).
The US ranks fifth best for
alcoholic beverage consumption.
The US has relatively low
consumption of animal fats (fifth lowest in men aged 55-64
years in 20 industrialized countries) and the third lowest
mean cholesterol concentrations among men aged 50 to 70
years among 13 industrialized countries.
These estimates of death due to error
are lower than those in a recent Institutes of Medicine report, and
if the higher estimates are used, the deaths due to iatrogenic
causes would range from 230,000 to 284,000.
Even at the lower estimate of 225,000 deaths per year, this
constitutes the third leading cause of death in the US, following
heart disease and cancer.
Lack of technology is certainly not a contributing factor to the
US's low ranking.
Among 29 countries, the United
States is second only to Japan in the availability of
magnetic resonance imaging units and computed tomography
scanners per million population.
Japan, however, ranks highest on
health, whereas the US ranks among the lowest.
It is possible that the high use
of technology in Japan is limited to diagnostic technology
not matched by high rates of treatment, whereas in the US,
high use of diagnostic technology may be linked to more
Supporting this possibility are
data showing that the number of employees per bed (full-time
equivalents) in the United States is highest among the
countries ranked, whereas they are very low in Japan, far
lower than can be accounted for by the common practice of
having family members rather than hospital staff provide the
amenities of hospital care.
1. Schuster M, McGlynn E, Brook R.
How good is the quality of health care in the United States?
Milbank Q. 1998;76:517-563.
2. Kohn L, ed, Corrigan J, ed, Donaldson M, ed. To Err Is Human:
Building a Safer Health System. Washington, DC: National Academy
3. Starfield B. Primary Care: Balancing Health Needs, Services,
and Technology. New York, NY: Oxford University Press; 1998.
4. World Health Report 2000. Accessed June 28, 2000.
5. Kunst A. Cross-national Comparisons of Socioeconomic
Differences in Mortality. Rotterdam, the Netherlands: Erasmus
6. Law M, Wald N. Why heart disease mortality is low in France:
the time lag explanation. BMJ. 1999;313:1471-1480.
7. Starfield B. Evaluating the State Children's Health Insurance
Program: critical considerations. Annu Rev Public Health.
8. Leape L.Unecessarsary surgery. Annu Rev Public Health.
9. Phillips D, Christenfeld N, Glynn L. Increase in US
medication-error deaths between 1983 and 1993. Lancet.
10. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug
reactions in hospitalized patients. JAMA. 1998;279:1200-1205.
11. Weingart SN, Wilson RM, Gibberd RW, Harrison B. Epidemiology
and medical error. BMJ. 2000;320:774-777.
12. Wilkinson R. Unhealthy Societies: The Afflictions of
Inequality. London, England: Routledge; 1996.
13. Evans R, Roos N. What is right about the Canadian health
system? Milbank Q. 1999;77:393-399.
14. Guyer B, Hoyert D, Martin J, Ventura S, MacDorman M,
Strobino D. Annual summary of vital statistics1998. Pediatrics.
15. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of
care, and outcomes of care for generalists and specialists. J
Gen Intern Med. 1999;14:499-511.
16. Donahoe MT. Comparing generalist and specialty care:
discrepancies, deficiencies, and excesses. Arch Intern Med.
17. Anderson G, Poullier J-P. Health Spending, Access, and
Outcomes: Trends in Industrialized Countries. New York, NY: The
Commonwealth Fund; 1999.
18. Mold J, Stein H. The cascade effect in the clinical care of
patients. N Engl J Med. 1986;314:512-514.
19. Shi L, Starfield B. Income inequality, primary care, and
health indicators. J Fam Pract.1999;48:275-284.
Death Rate Drops During Doctor Strike
June 10, 2000 issue of the
British Medical journal reports on an interesting statistic that
has occurred in Israel.
It seems that three months ago
physicians in public hospitals implemented a program of sanctions in
response to a labor dispute over a contract proposal by the
The article stated that the Israel
Medical Association began an action in March to protest against
the treasury's proposed imposition of a new four year wage contract
for doctors. Since then, the medical doctors have cancelled hundreds
of thousands of visits to outpatient clinics and have postponed tens
of thousands of elective operations.
To find out whether the industrial action was affecting deaths in
the country, the Jerusalem Post interviewed non-profit making Jewish
burial societies, which perform funerals for the vast majority of
Hananya Shahor, the veteran
director of Jerusalem's Kehilat Yerushalayim burial society said,
"The number of funerals we have
performed has fallen drastically."
Meir Adler, manager of the
Shamgar Funeral Parlour, which buries most other residents of
Jerusalem, declared with much more certainty:
"There definitely is a connection
between the doctors sanctions and fewer deaths. We saw the same
thing in 1983 when the Israel Medical Association applied
sanctions for four and a half months."
In response Avi Yisraeli,
director general of the Hadassah Medical Organization, offered his
"Mortality is not the only measure
of harm to health."
He goes on to say that,
"Elective surgery can bring about a
great improvement in a patients condition, but it can also mean
disability and death in the weakest patients."