Children, doctors, trials: a survival game
Authors: Kamran Abbasi
Journal: Journal of the Royal Society of Medicine (2007)

Journals have placed themselves on the frontline of the battle against manufactured diseases. They have waged war on the wickedness of pharmaceutical companies and the cancer of hidden competing interests. They have condemned war and climate change. Few, though, have questioned the value of saving children—not that this journal does either as a matter of policy.

But Imre Loefler, a doctor working in Nairobi, wonders whether children are treated preferentially (p. 110). Loefler's argument is an uncomfortable one and it is one that many readers will strongly disagree with: ‘The saving of children has become a matter of morality—and a characteristic of postmodernism—without regard to the question whether it retains any survival value, is economically sound and ecologically sustainable, and what the global consequences may be.’

Demographers have argued that we require a one-child world to prevent a Malthusian apocalypse, where population will outrun food supply. Loefler perhaps takes us beyond what we might find acceptable but it is a view to be debated and probably refuted. What kind of society have we created if it cannot discriminate positively, to counter Loefler, in favour of those who are disadvantaged and those who are vulnerable?

John Braithwaite picks up the theme of contemplating the deeper meanings of our existence with his exploration of the species and sub-species that are passionate about health reform (pp. 78-80). Homo commandus controlus, says Braithwaite, is a zealous health reformer with a mechanistic, linear perception of the world, in which organizational life is characterised by tangible, cause and effect terms. This top-down controlling subspecies contrasts sharply with the bottom-up, elastic subspecies. Homo extremus flexibilitus, meanwhile, believes the world is continuously uncertain and that health systems are emergent, fragile, indefinite, fragmented and at times chaotic. Early identification of these subspecies will allow you to understand events and reduce fall-out damage to yourself. Survival is the name of the game, argues Braithwaite, which in a difficult kind of way is exactly the point of Loefler's piece.

Elsewhere, Rustam Ali-Shahi Salman and colleagues question the survival of clinical trials. Their attempt to uncover the impediments to research governance approval in the UK reveals a sorry system that incurs unacceptably long and costly delays for clinical trials (pp. 101-104). The delays resulted in 108 patients missing the opportunity to be included in clinical trials. The authors call for urgent reform that will speed up trial design and implementation of ‘bureaucracy busting’ measures. Indeed, the Department of Health has promised all of this in its five-year vision of a ‘vibrant health research system,’ as spelt out in Best Research for Better Health. Yet it seems that the department has been flapping around like H. extremus flexibilitus instead of taking action in the style of H. commandus controlus. But, then again, might it be a predicament to which the ruthless logic of Imre Loefler might be better applied?