Trick or Treatment (5 page)

Florence and her sister were born during an extended and very productive two-year-long Italian honeymoon taken by their parents William and Frances Nightingale. Florence’s older sister was born in 1819 and named Parthenope after the city of her birth – Parthenope being the Greek name for Naples. Then Florence was born in the spring of 1820, and she too was named after the city of her birth. It was expected that Florence Nightingale would grow up to live the life of a privileged English Victorian lady, but as a teenager she regularly claimed to hear God’s voice guiding her. Hence, it seems that her desire to become a nurse was the result of a ‘divine calling’. This distressed her parents, because nurses were generally viewed as being poorly educated, promiscuous and often drunk, but these were exactly the prejudices that Florence was determined to crush.

The prospect of Florence nursing in Britain was already shocking enough, so her parents would have been doubly terrified by her subsequent decision to work in the hospitals of the Crimean War. Florence had read scandalous reports in newspapers such as
The Times
, which highlighted the large number of soldiers who were succumbing to cholera and malaria. She volunteered her services, and by November 1854 Florence was running the Scutari Hospital in Turkey, which was notorious for its filthy wards, dirty beds, blocked sewers and rotten food. It soon became clear to her that the main cause of death was not the wounds suffered by the soldiers, but rather the diseases that ran rife under such squalid conditions. As one official report admitted, ‘The wind blew sewer air up the pipes of numerous open privies into the corridors and wards where the sick were lying.’

Nightingale set about transforming the hospital by providing decent food, clean linen, clearing out the drains and opening the windows to let in fresh air. In just one week she removed 215 handcarts of filth, flushed the sewers nineteen times and buried the carcasses of two horses, a cow and four dogs which had been found in the hospital grounds. The officers and doctors who had previously run the institution felt that these changes were an insult to their professionalism and fought her every step of the way, but she pushed ahead regardless. The results seemed to vindicate her methods: in February 1855 the death rate for all admitted soldiers was 43 per cent, but after her reforms it fell dramatically to just 2 per cent in June 1855. When she returned to Britain in the summer of 1856, Nightingale was greeted as a hero, in large part due to
The Times
’s support:

However, there were still many sceptics. The principal medical officer of the army argued that Nightingale’s higher survival rates were not necessarily due to her improved hygiene. He pointed out that her apparent success might have been due to treating soldiers with less serious wounds, or maybe they were treated during a period of milder weather, or maybe there was some other factor that had not been taken into account.

Fortunately, as well as being an exceptionally dedicated military nurse, Nightingale was also a brilliant statistician. Her father, William Nightingale, had been broadminded enough to believe that women should be properly educated, so Florence had studied Italian, Latin, Greek, history, and particularly mathematics. In fact, she had received tutoring from some of Britain’s finest mathematicians, such as James Sylvester and Arthur Cayley.

So, when she was challenged by the British establishment, she drew upon this mathematical training and used statistical arguments to back her claim that improved hygiene led to higher survival rates. Nightingale had scrupulously compiled detailed records of her patients throughout her time in the Crimea, so she was able to trawl through them and find all sorts of evidence that proved that she was right about the importance of hygiene in healthcare.

For example, to show that the filth at Scutari Hospital had been killing soldiers, she used her records to compare a group of soldiers treated at Scutari in the early unhygienic days with a control group of injured soldiers who at the same time were being kept at their own army camp. If the camp-based control group fared better than the Scutari group, then this would indicate that the conditions that Nightingale encountered when she arrived at Scutari were indeed doing more harm than good. Sure enough, the camp-based soldiers had a mortality rate of 27 deaths per 1,000 c ompared with 427 per 1,000 a t Scutari. This was only one set of statistics, but when put alongside other comparisons it helped Nightingale to win her argument about the importance of hygiene.

Nightingale was convinced that all other major medical decisions ought to be based on similar sorts of evidence, so she fought for the establishment of a Royal Commission on the Health of the Army, to which she herself submitted several hundred pages of detailed statistics. At a time when it was considered radical merely to include data tables, she also drew multicoloured diagrams that would not look out of place in a modern boardroom presentation. She even invented an elaborate version of the pie chart, known as the polar area chart, which helped to illustrate her data. She realized that illustrating her statistics would be enormously helpful in selling her argument to politicians, who were usually not well versed in mathematics.

In due course, Nightingale’s statistical studies spearheaded a revolution in army hospitals, because the Royal Commission’s report led to the establishment of an Army Medical School and a system of collecting medical records. In turn, this resulted in a careful monitoring of which conditions and treatments did and did not benefit patients.

Today, Florence Nightingale is best known as the founder of modern nursing, having established a curriculum and training college for nurses. However, it can be argued that her lifelong campaigning for health reforms based on statistical evidence had an even more significant impact on healthcare. She was elected the first female member of the Royal Statistical Society in 1858, and went on to become an honorary member of the American Statistical Association.

Nightingale’s passion for statistics enabled her to persuade the government of the importance of a whole series of health reforms. For example, many people had argued that training nurses was a waste of time, because patients cared for by trained nurses actually had a higher mortality rate than those treated by untrained staff. Nightingale, however, pointed out that this was only because more serious cases were being sent to those wards with trained nurses. If the intention is to compare the results from two groups, then it is essential (as discussed earlier) to assign patients randomly to the two groups. Sure enough, when Nightingale set up trials in which patients were randomly assigned to trained and untrained nurses, it became clear that the cohort of patients treated by trained nurses fared much better than their counterparts in wards with untrained nurses. Furthermore, Nightingale used statistics to show that home births were safer than hospital births, presumably because British homes were cleaner than Victorian hospitals. Her interests also ranged overseas, because she also used mathematics to study the influence of sanitation on healthcare in rural India.

And throughout her long career, Nightingale’s commitment to working with soldiers never waned. In one of her later studies, she observed that soldiers based in Britain in peacetime had an annual mortality rate of 20 per 1,000, nearly twice that of civilians, which she suspected was due to poor conditions in their barracks. She calculated the death toll across the whole British army due to poor accommodation and then made a comment that highlighted how this was such a needless waste of young lives: ‘You might as well take 1,100 men every year out upon Salisbury Plain and shoot them.’

The lesson to be learned from Florence Nightingale’s medical triumphs is that scientific testing is not just the best way to establish truth in medicine, but it is also the best mechanism for having that truth recognized. The results from scientific tests are so powerful that they even enable a relative unknown such as Nightingale – a young woman, not part of the establishment, without a great reputation – to prove that she is right and that those in power are wrong. Without medical testing, lone visionaries such as Nightingale would be ignored, while doctors would continue to operate according to a corrupt body of medical knowledge based merely on tradition, dogma, fashion, politics, marketing and anecdote.

A stroke of genius

Before applying an evidence-based approach to evaluating alternative medicine, it is worth re-emphasizing that it provides extraordinarily powerful and persuasive conclusions. Indeed, it is not just the medical establishment that has to tug its forelock in the face of evidence-based medicine, because governments can also be forced to change their policies and corporations may have to alter their products according to what the scientific evidence shows. One final story illustrates exactly how scientific evidence can make the world sit up, listen and act regarding health issues – it concerns the research that dramatically revealed the previously unknown dangers of smoking.

This research was conducted by Sir Austin Bradford Hill and Sir Richard Doll, who had curiously mirrored each other in their backgrounds. Hill had wanted to follow in his father’s footsteps and become a doctor, but a bout of tuberculosis made this impossible, so instead he pursued a more mathematical career. Doll’s ambition was to study mathematics at Cambridge, but he got drunk on three pints of Trinity Audit Ale (8 per cent alcohol) the night before his entrance exam and underperformed, so instead he pursued a career in medicine. The result was a pair of men with strong interests in both healthcare and statistics.

Hill’s career had involved research into a wide variety of health issues. In the 1940s, for instance, he demonstrated a link between arsenic and cancer in chemical workers by examining death certificates, and he went on to prove that rubella during pregnancy could lead to deformities in babies. He also conducted important research into the effectiveness of antibiotics against tuberculosis, the disease that had ended his hopes of becoming a doctor. Then, in 1948, Hill’s interest turned towards lung cancer, because there had been a sixfold increase in cases of the disease in just two decades. Experts were divided as to what was behind this health crisis, with some of them dismissing it as a consequence of better diagnosis, while others suggested that lung cancer was being triggered by industrial pollution, car fumes or perhaps smoking.

With no consensus in sight, Hill teamed up with Doll and decided to investigate one of the proposed causes of lung cancer, namely smoking. However, they faced an obvious problem – they could not conduct a randomized clinical trial in this particular context. For instance, it would have been unethical, impractical and pointless to take 100 teenagers, persuade half of them to smoke for a week, and then look for signs of lung cancer.

Instead, Hill and Doll decided that it would be necessary to devise a
prospective cohort study
or an
observational study
, which means that a group of healthy individuals is initially identified and then their subsequent health is monitored while they carry on their day-to-day lives. This is a much less interventionist approach than a randomized clinical trial, which is why a prospective cohort study is preferable for exploring long-term health issues.

To spot any link between smoking and lung cancer in their prospective cohort study, Hill and Doll worked out that they would need to recruit volunteers who fulfilled three important criteria. First, the participants had to be established smokers or vehement non-smokers, because this increased the likelihood that the pattern of behaviour of any individual would continue throughout the study, which would last several years. Second, the participants had to be reliable and dedicated, inasmuch as they would have to commit to the project and submit regular updates on their health and smoking habits during the course of the prospective cohort study. Third, in order to control for other factors, it would help if all the participants were similar in terms of their backgrounds, income and working conditions. Also, the number of participants had to be large, possibly several thousand, because this would lead to more accurate conclusions.

Finding a group of participants that met these demanding requirements was not a trivial task, but Hill eventually thought of a solution while playing golf. This prompted his friend Dr Wynne Griffith to comment, ‘I don’t know what kind of golfer he [is], but that was a stroke of genius.’ Hill’s brilliant idea was to use doctors as his guinea pigs. Doctors fitted the bill perfectly: there were lots of them, many were heavy smokers, they were perfectly able to monitor their health and report back, and they were a relatively homogenous subset of the population.

When the smoking study commenced in 1951, the plan was to monitor more than 30,000 British doctors over the course of five decades, but a clear pattern was already emerging by 1954. There had been thirty-seven deaths from lung cancer and every single one of them was a smoker. As the data accumulated, the study implied that smoking increased the risk of lung cancer by a factor of twenty, and moreover it was linked to a range of other health problems, including heart attacks.

The British Doctors Study, as it was known, was giving rise to such shocking results that some medical researchers were initially reluctant to accept the findings. Similarly, the cigarette industry questioned the research methodology, arguing that there must be a flaw in the way that the information was being gathered or analysed. Fortunately, British doctors were less sceptical about Hill and Doll’s emerging conclusions, because they themselves had been so involved in the study. Hence, they were not slow in advising the public against smoking.