Public Health: Corporate hospitals pushed house physicians out but failed to replace them

Goliath, holds the Biblical tale, was a gigantic warrior equipped with state-of-the-art gear for combat. He epitomized strength backed by unlimited wealth. David on the other hand was a lowly shepherd boy carrying a stick and a sling. In the contest between the two, to the amazement of all, David brought down the clumsy, groping Goliath with a sharp stone shot from his sling.

People down the ages assumed that Goliath, given his size and heavy armour, had the advantage in this unequal combat and David’s victory was just a fluke. Recently Malcolm Gladwell has reinterpreted this biblical tale in his book ‘David and Goliath: Underdogs, Misfits, and the Art of Battling Giants’. He affirms that we get this famous legend often wrong as we misunderstand who had the upper hand in this uneven match.

A peer reviewed paper by Dierdee Donnelly and Patrick Morrison titled, ‘Hereditary Gigantism – the biblical Goliath and his brothers’ published in the Ulster Medical Journal, after studying the description of Goliath in original Hebrew theological texts, concluded that Goliath suffered from a tumour of the pituitary gland at the base of the brain. This condition increases the secretion of the growth hormone which leads to gigantism.

The tumour also presses on the optic nerve which carries visual images from the eyes to the brain and can lead to double vision and severe near-sightedness. That Goliath was almost blind is evident in the biblical narrative where he has to be led by hand to the contest. The big lumbering giant is also weighed down by his cumbersome heavy armour, making his movements clumsy and slow. David, with the advantage of speed and flexibility, got the better of his mighty foe.

Gladwell says lessons from this ancient tale are applicable to big monolithic organisations. The very things which make these organisations formidable, such as size, huge resources, state of the art technology, often also weigh down these companies and limit their vision, leading to unexpected failures. After a period of growth, size is no longer an advantage. Conflicts of interests, absent in times of Goliath, deprives them of autonomy.

Parallels can be drawn to the gigantic heights reached by medicine and public health in recent decades. Remarkable advances in genomics, precision medicine and biotechnology have transformed medicine to “gigantic” heights! The costs of sustaining technology have made individual practice give way to corporate hospitals.Medicine has been transformed from a calling to big business, propped up by pharmaceutical giants.

Medical advances have led to remarkable improvements in health and wellness of people. But like in the case of Goliath, the vision and flexibility of this growing and faceless industry have diminished. It should be a matter of concern. Fall of this medical giant can be catastrophic for humankind.

The response of this medical Goliath to the present pandemic brought these limitations to the fore. Faced with a nimble, fast-spreading and adaptable foe in the form of SARS-CoV-2, it tottered clumsily to vanquish the invisible enemy. The clumsy visionless movements of this giant trampled upon lives and livelihoods across the globe. Prolonged restrictive measures like lockdowns destroyed businesses and fractured society.

While the initial awkward and uncoordinated response in face of many unknowns was understandable, the giant failed to adapt itself to accumulating evidence. It kept on persisting with restrictive measures for all even when data indicated that the novel virus is lethal mostly for the frail, the elderly or for people with co-morbidities. Schools and educational institutions continue to remain closed in several countries despite evidence that risks to young people and children are minimal.

Just as Goliath flung blindly at David without making any impact, the mainstay of the Covid-19 response continues to depend on blind chase of the virus by contact tracing and quarantine, even when the virus has silently spread through communities and although these resource intensive measures have not made any dent. In this present crisis, many would be missing the “Davids” of medicine, i.e. the general practitioners of a bygone era, with a stethoscope, symbolic of the sling. They would wonder whether these Davids would have performed better with their flexible and customised approach, instead of the costly “state of the art” armour of RT-PCR tests and chest scans with a host of costly and useless repurposed drugs

They would also wonder whether David would have coerced them to get vaccinated from a growing choice of rapidly developed vaccines.

The combat between the giant and the nimble virus is continuing so it would be inappropriate to predict or pass judgment on who will win or what is the right approach.

Posterity will hopefully judge.

(The writer is Professor & Head, Community Medicine and Clinical Epidemiologist at Dr DY Patil medical college, Pune. Views are personal)