Fifty thousand people were followed for thirty years. Half received annual stool-card screening for colon cancer; half did not. In the screened group, two per cent died of colon cancer. In the unscreened group, three per cent did. The thirty-three per cent reduction in colon-cancer-specific mortality is one of the most-cited screening results in the literature. The same paper carried a second graph, this one measuring deaths from any cause. The two curves sat directly on top of each other. Seventy-one per cent of the screened group had died by year thirty. Seventy-one per cent of the unscreened group had died. Screening did not help anyone live longer. H. Gilbert Welch’s Less Medicine, More Health (2015) is organised around what follows from numbers like these, collected across cardiology, cancer medicine, orthopaedics, and the diagnostic clinic, and from the question his Dartmouth colleagues have asked for forty years: what is medical care actually doing for the people who are not acutely sick or injured, and how do its practitioners know?
Welch is a general internist at the White River Junction VA in Vermont, a professor at the Dartmouth Institute for Health Policy and Clinical Practice, and the author of two prior books on the same subject, Should I Be Tested for Cancer? (2004) and Overdiagnosed: Making People Sick in the Pursuit of Health (2011). Royalties from all three have gone to local charities in New Hampshire and Vermont. He is not an outsider. His career was built inside the system he examines. He has published in the New England Journal, JAMA, and the BMJ. His conclusions have drawn hard pushback from the specialty societies whose practices he scrutinises; the orthopaedic surgeons’ lobby nearly destroyed the small federal agency that funded spine-surgery research after a Dartmouth colleague of his reviewed the evidence for spinal fusion surgery and concluded there was none of benefit, and substantial evidence of harm. Welch records that episode and keeps writing. His authority rests on having done the primary epidemiological work, published it where the critics could read it, and remained a working clinician throughout.
Less Medicine, More Health appeared at a particular moment in American medical practice. The Affordable Care Act had been in effect five years. The debate about medical costs was constant and politically charged. The question of whether screening programmes delivered what they promised was no longer confined to specialist journals. The US Preventive Services Task Force had downgraded its recommendation for routine PSA screening in 2012 and moved mammography from annual to biennial for women aged fifty to seventy-four in 2009, both decisions prompting widespread denunciation. The COURAGE trial had been in print since 2007, showing that balloon angioplasty for stable angina offered no mortality or heart-attack benefit over drug therapy. The DePuy ASR XL metal-on-metal hip had been recalled in 2010 after the pattern of early failures became undeniable in the national joint registries. Welch’s 2011 book Overdiagnosed had carried the word into mainstream health reporting. The evidence was accumulating. The practice was changing slowly, when it changed at all. The book was written for the patient sitting in the examining room being offered interventions that the trials had already assessed and the data had already answered.
The book is a convergent-witness document for the terrain reader. Welch operates fully within mainstream clinical epistemology, accepts germ theory and conventional immunology without question, and does not challenge the ontology of what medicine calls cancer. What he reaches from inside the system, through randomised trials and large registries and the discipline of all-cause mortality as the test that matters, converges on conclusions terrain writers reach by a different route: that the body heals when left alone, that most intervention in the well produces net harm, that the manufacture of patients from asymptomatic populations is the central modern pathology of institutional medicine, and that less is often more. The full summary walks the arithmetic. The thirty questions unpack why, for every thousand patients given balloon angioplasty for stable angina, approximately two will die from the procedure, twenty-eight will have a procedural heart attack caused by the procedure itself, and eight hundred will see neither harm nor benefit; why arthroscopic knee surgery for chronic knee pain performed no better than sham surgery in randomised trials at the VA, in Canada, at Harvard, Washington University, the Mayo Clinic, the Cleveland Clinic, the Hospital for Special Surgery, and in Finland; why the DePuy metal-on-metal hip fails at twenty per cent within nine years while the stainless-steel Charnley hip from 1970 takes twenty-five years to reach the same failure rate; and why Mr Nadeau, aged eighty-five and in excellent health, spent a week in hospital bleeding through ten units of blood from a biopsy that chased a problem that was not there. The healthiest person who walks into a modern clinic will walk out with something to worry about, if the testing is thorough enough.
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