IJE vol.32 no.6 © International Epidemiological Association 2003; all rights reserved. International Journal of Epidemiology 2003;32:918–919 DOI: 10.1093/ije/dyg262 Commentary: Bernard Shaw’s dilemma: marked by mortality

Sally Peters

By the time of his death in 1950, Bernard Shaw had attained an advance of the 19th century. For Shaw, even the instruments of unprecedented celebrity, much of which revolved around the fighting infection were suspect. Acutely sensitive to odour, he Downloaded from https://academic.oup.com/ije/article/32/6/918/775140 by guest on 27 September 2021 man as well as the artist. Even as the Nobel laureate and Oscar- called the stench of carbolic acid permeating London a poison winning playwright was revered as a visionary and prophet, masquerading as a cure. Even more profoundly, Shaw had a he amused with his seeming quirks and eccentricities. But the horror of those invisible microbes. Similarly, he shuddered at vegetarian parading in knee breeches was also a hypochondriac the thought of underground creatures, even rabbits, and the who longed for another mode of existence—bodiless, in a spot- whole rank subterranean world of decay and death symbolized less ethereal world. As he obsessively envisioned the human for him by the cesspool. Out of his own revulsion came his insist- body plagued by pestilence, he sought to protect himself from ence that sanitation, ventilation, and sunshine could both prevent internal and external contamination, converting private concerns and cure disease. His views resembled those of pythogenesis, into public campaigns. the outdated notion that disease is generated spontaneously The 100-page 1911 Preface to The Doctor’s Dilemma is part of from filth and spread by a vile gas. the lifelong battle he waged against the medical profession. His Meanwhile, like Schopenhauer, he believed that sickness writings on the subject range from an 1887 book review attack- was a sign of infirm will, an intolerable thought for him as he ing vivisection through the 1931 collection of articles comprising sought to control every aspect of his personal, private, and social Doctors’ Delusions to the 1944 summary comments in Everybody’s worlds. Not for him that mind/body harmony dependent on Political What’s What? As Shaw declared doctors fair game, physiological health that Victorians called mens sana in corpore he portrayed more than 20 physicians in his dramatic works, sano. Adamantly believing in the power of mind and individual although they are more likely to be fools than the knaves found will, he reversed the aphorism. ‘It is the mind that makes in Molière. Throughout, the controlling theme is victimization the body and not the body the mind’, the Lamarckian vitalist as Shaw’s suspicions set the doctor against the patient. proclaims in the Preface to The Doctor’s Dilemma. While the nature of his attack was peculiar, the underlying As Shaw longed to transcend his body, he exercised a reasons were rooted in biography. In 1881 despite being vac- rigorous asceticism in personal habits, including ritualistic body cinated, Shaw caught smallpox. He claimed to be unblemished cleansing, wearing hygienic wool, and following a stringent but his chin and jaw were pockmarked, marks concealed by vegetarian diet. The onset of some of those habits can be traced growing the famous beard. Psychologically marked as well by to his early life. Influential in the Shaw household was George his encounter with the dread disease, he proceeded to attack Vandeleur Lee, who formed part of what Shaw insisted was an doctors and the vaccination that failed to protect him. For him, innocent ménage à trois. Lee—mesmeric musician, charlatan, vaccination was Edward Jenner’s stunt, a stunt that managed to and genius—sought the secret of bel canto by vivisecting human kill one baby a week. In addition to Jenner, Shaw specifically cadavers and birds. Whether or not the boy witnessed Lee’s attacked Louis Pasteur and Joseph Lister. The three men had experiments, Shaw, outraged and shamed by Lee’s position in one thing in common: their fame rested on controlling micro- the family, became a militant anti-vivisectionist decrying amoral organisms. Shaw denounced the trio as murderers posing as science. Yet from Lee, he learned to value such practices as saviours of mankind. dietary abstention and sleeping with the window open. From Despite his animus, Shaw counted physicians among his his father, George Carr Shaw, a miserable alcoholic, Shaw learned friends, including controversial bacteriologist Sir Almroth Wright, to hate alcohol, tobacco, alimentary excess, and failure. the model for Sir Colenso Ridgeon in The Doctor’s Dilemma. In his drama Shaw triumphed over the materials of his life, Ridgeon’s dilemma, the morality of saving one life over another, transforming the virulent into the playful. In Too True To Be Good was one that Shaw had discussed with Wright. Additionally, (1931), Shaw satirizes the doctor who admits he cures no Shaw listened to Wright’s latest theories on vaccine therapy, disease while blaming the microbe. Shaw’s microbe comedically including Wright’s belief that microbes are vehicles of disease appears on stage as a character who laments that he has caught but not the cause, a belief which earned him the label Almroth measles from the patient while being blamed for infecting Wrong from his colleagues. humans. In The Philanderer (1893), Dr Paramore is a vivisector Undeterred, Shaw also refused to accept the germ theory of whose reputation rests on discovering a microbe in the liver disease, labelling as superstition the most spectacular medical that means certain death. When his discovery cannot be con- firmed, he is inconsolable, even though it means perfect health for his misdiagnosed patient. While intellectually Shaw might University of California, Los Angeles, Writers’ Extension Program, Los wonder, like his character Blanco Posnet (The Shewing-Up of Angeles, CA 90024. E-mail: [email protected] Blanco Posnet, 1909), whether the croup bacillus was an early THE DOCTOR’S DILEMMA 919 attempt to create a higher being, the personal meaning to him lit, clean, deodorized, incorporeal world, the only world his psyche was the threat of being metamorphosed into a breeding ground could tolerate. for bacilli. On the subject of doctors and medicine Shaw put forth a dazzling display of partial truths, the clear prose giving a seem- Note ing lucidity to his arguments. The incessant repetition declares For a fuller explanation of the ideas in this commentary, see what he needed to believe. In extolling the purifying properties my biography of George Bernard Shaw. Peters S. Bernard of sunshine and fresh air, he moved the theatre of action from Shaw: The Ascent of the Superman. New Haven: Yale University a dark crawling world of unseen organisms upward to a brightly Press, 1996.

IJE vol.32 no.6 © International Epidemiological Association 2003; all rights reserved. International Journal of Epidemiology 2003;32:919–921 Downloaded from https://academic.oup.com/ije/article/32/6/918/775140 by guest on 27 September 2021 DOI: 10.1093/ije/dyg323

Commentary: Shaw’s critique of health care is still valid

K Srinath Reddy

The preface provided by George Bernard Shaw to The Doctor’s controlled trial for evaluating medical interventions. He is Dilemma1 is a profoundly insightful and deliberately provocative particularly caustic about the ecological fallacies that arise from essay on the short-comings of health care, as provided by analyses that depend on time trends and do not take into account doctors who are deficient in scientific thought and are driven by the confounding effects of concomitant changes in other petty profit motives. It is also an eloquent espousal of an ideal determinants. The example he provides, of the relationship public health system, devoid of those flaws. Though Shaw was between disappearance of typhus and amputation of the little unduly harsh on Pasteur, improperly critical of the efforts to finger, is particularly telling. The clarity with which he identifies eliminate smallpox and his prototype of an underpaid doctor and describes confounding as a factor which bedevils ‘causal’ driven to malpractice no longer exists in many parts of the associations would do an epidemiologist proud. world, most of the ideas developed in the preface are of great He especially emphasizes the role of socioeconomic status as contemporary relevance. an important determinant of differences in the levels of health Shaw’s consistent demand for credible evidence is the and as a powerful confounder which influences the effect of hallmark of a truly scientific mind. He expresses despair, and interventions which aim to alter health. His socialist ideology even disgust, at the usual medical practitioner not applying the and scientific temper blend into a brilliantly incisive analytical methods of scientific enquiry and the principles of statistical tool as he dissects out the contributions of poverty and analysis to evaluate the efficacy and safety of the treatment deprivation to ill health and pours out his convictions in a methods which they espouse with ill-informed enthusiasm and passionate piece of advocacy urging greater attention to such willingly inflict on an unsuspecting public. The situation has not broader determinants of health. The adverse health implications improved greatly since Shaw’s time. Even as ‘evidence’ con- of a low socioeconomic status have now been widely docu- stantly accumulates in the pages of prolific research publica- mented in virtually all areas of health, from under-nutrition and tions, the average practitioner is often distanced from its message. infectious diseases to many of the non-communicable diseases. Even when a part of that message does reach him or her, While a Virchow, a McKeown, or a Marmot may call attention often through the pharmaceutical industry’s sales promoters to this from among the public health fraternity, it requires the or through the lay media, the aptitude and the ability to subject writing power of a Dickens or a Shaw to stir the conscience of that message to serious scientific scrutiny are severely deficient. the world to take heed and initiate action. Shaw protests against the incorrect use of statistics and the lack The issues related to ‘confidence intervals’ and ‘absolute risk’ of matched comparison groups. He argues convincingly that also come up in Shaw’s preface, although the specific terms are apparent benefits of interventions are easily demonstrable in the not used. He questions the validity of drawing conclusions from absence of a matched comparison group and cautions that such estimates based on a zero numerator and a denominator which is spurious interpretations ought not to guide medical practice. He very small (he uses a sample size of one in the smallpox vaccina- makes out a good case for employing the scientific design of a tion example). The need to estimate confidence intervals and use them for judging the possible range of the effect size associated All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, with an intervention has been emphasized often enough in India. E-mail: [email protected] statistics. Yet a substantial section of published research, and