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The Man Who Shocked the The subjects in Milgram’s original series of tests believed that they were part of an World: The Life and experiment dealing with the relation Legacy of Stanley Milgram between punishment and learning. An Thomas Blass experimenter—who used no coercive powers beyond a stern aura of mechanical Basic Books, £15.50/$26/$C40, pp 360 and vacant eyed efficiency—instructed par- ISBN 0 7382 0399 8 ticipants to shock a learner by pressing a Due for publication in lever on a machine each time the learner paperback next month made a mistake on a word matching task. Each subsequent error led to an increase in Rating: ★★★★ the intensity of the shock in 15 volt increments, from 15 to 450 volts. Actually the shock box was a well crafted prop and the learner an actor who did not receive shocks. Most of the subjects contin- ued to obey to the end—believing that they were delivering life threatening 450 volt shocks—simply because the experimenter he late Stanley Milgram fairly lays commanded them to. Although subjects claim to be one of the greatest were told about the deception afterward, the behavioural scientists of the 20th experience was a real and powerful one for T Milgram: groundshaking experiments century. He derives his renown from of a them during the laboratory hour itself. series of experiments on obedience to These groundbreaking and controver- authority, which he conducted at Yale sial experiments had—and continue to University in 1961-2. Milgram found, have—longlasting significance. The media although the subject performs the action, he surprisingly, that 65% of his subjects, have been obsessed with them since, repeat- allows authority to define its meaning.” ordinary residents of New Haven, were will- edly “re-discovering” them and re-reporting We did not need Milgram to tell us that ing to give apparently harmful electric them as if they were amazing news. we have a tendency to obey orders. But what shocks—up to 450 volts—to a pitifully Milgram’s study demonstrated with we did not know before Milgram’s experi- protesting victim, simply because a scien- brutal clarity that ordinary individuals could ments was just how powerful this tendency tific, lab coated authority commanded them be induced to act destructively, even in the is. And having been enlightened about our to, and despite the fact that the victim did absence of physical coercion, and humans extreme readiness to obey authorities, we nothing to deserve such punishment. The need not be innately evil or aberrant to act can try to take steps to guard against unwel- victim was, in reality, a good actor who did in ways that are reprehensible and inhu- come or reprehensible commands. not actually receive shocks, a fact that was mane. While we would like to believe that Many professions have taken heed of revealed to the subjects at the end of the when confronted with a moral dilemma we Milgram’s work. The US army, for example, experiment. will act as our conscience dictates, Milgram’s now incorporates his findings into its educa- Milgram’s interest in the study of obedi- obedience experiments teach us that, in a tion of officers in order to illuminate the ence partly emerged out of a deep concern concrete situation with powerful social issue of following unethical orders. How- with the suffering of fellow Jews at the hands constraints, our moral sense can all too ever, it is not clear that medicine has truly of the Nazis and an attempt to fathom how easily be overwhelmed. understood the implications of Milgram’s the Holocaust could have happened. His The research was also conducted with work. How often are doctors or medical stu- researches, like Freud’s, led to profound amazing verve and subtlety—for example, dents in the position of having to obey revisions in some of the fundamental Milgram ensured that the “experimenter” “orders” or implicit expectations in hospitals assumptions about human nature. wear a grey lab coat rather than a white one, Milgram’s experiments suggested that it or clinics, when they are uneasy about the precisely because he did not want subjects to was not necessary to invoke “evil” as a ethics of doing so? think that the “experimenter” was a medical concept to explain why so many ordinary What is perhaps most intriguing about doctor and thereby limit the implications people do terrible things. Instead his work, this book is not so much the dramatic impli- of his findings to the power of physician and that of other social psychologists, cations of Milgram’s work, but instead the authority. suggested that much of what we do, we do insight that Blass gives us into the kind of The nuance of Milgram’s conclusions automatically. Evil often occurs simply unconventional mind required to devise has often been obscured by the superficial because we do not question our acts groundshaking experiments that will con- reporting of his work, which Blass, a US psy- enough; instead our rationale arises from tinue to echo through the corridors of chology professor, goes to some lengths in our trust in authority figures who are in history long after much more mundane this important book to rectify. Milgram “charge.” work currently dominating learned journals believed the true explanation of evil such as is forgotten. the Holocaust was linked to his experiments Items reviewed are rated on a 4 star scale by their demonstration of “a propensity for Raj Persaud Gresham professor for public (4=excellent) people to accept definitions of action understanding of psychiatry and consultant provided by legitimate authority. That is, psychiatrist, Maudsley Hospital, London

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Beyond Depression: A New activities and decreased energy, and rather politicians have found that depression is a vaguely differentiated from normal mood convenient packaging of society’s ills, which Approach to Understanding changes by the duration and severity of might otherwise require more fundamental and Management symptoms. WHO reports that worldwide 121 solutions and a more equal allocation of Christopher Dowrick million people currently have depression and hope and opportunity. I suspect that there that an estimated 5.8% of men and 9.5% of are few general practitioners who have not Oxford University Press, women experience a depressive episode in prescribed antidepressant medication when £19.95, pp 238 ISBN 0 19 852632 6 any given year. These prevalences are rising what is needed is a home that is not every year and depression is predicted to be overcrowded, damp, and squalid. Rating: ★★★★ the world’s second commonest cause of disa- In an increasingly medicalised world bling disease by 2020. Christopher Dowrick obsessed with disease taxonomies, depres- asks whether there is an unprecedented sion has become a procrustean label that epidemic of sadness and misery sweeping the fails to acknowledge the diversity of indi- world or whether, alternatively, we are in vidual experience and further disables the the process of altering our interpretation of labelled. In A Fortunate Man, John Berger our physical and emotional experiences and asked, “What can the word ‘depressed’ mean our understanding of the human condition. to the depressed? It is no more than an echo Dowrick explores the many and diverse of the patient’s own voice.” ways in which human culture and language Dowrick proposes systematic avoidance pening my review copy of this have responded to the experience of suffer- of the label and argues that this opens up book I was amazed to find my ing and distress and, in this context, finds the many more opportunities for restitution. He Oname in the acknowledgments and modern concept of depression to be stultify- prefers to agree with his patient that “some- myself immediately encumbered with an ing in the narrowness of its vision and disa- thing bad has happened” and, in so doing, to obvious conflict of interest. It is a generous bling in its allocation of a passive sick role to normalise distressing experience and acknowledgment as my only contribution the sufferer. Set alongside this persuasive oppose the increasingly pervasive expecta- was a peripatetic meeting with the author analysis is the knowledge that depression tion of a continuous state of happiness and that combined a conversation about life, the operates to the advantage of many powerful contentment. With less diagnosis and more universe, and everything with demonstrat- interests: pharmaceutical companies have understanding, fewer prescriptions and ing against the presence of President Bush made huge profits from the manufacture more listening, it may be possible to locate in London in November 2003. and promotion of antidepressant medica- renewed meaning within the patient’s life At a time when many well meaning, but tion with an ever wider range of indications; story and so find a way forward. surely misguided, people are pushing for mental health professionals and academics How I wish that Dowrick’s understanding financial incentives to be offered for the have built careers on creating and analysing was shared by more mental heath profession- medical management of depression within an evermore complex classification of als, policy makers, and politicians, and that a the UK general practitioner contract, this is a depression; general practitioners have copy of this challenging book was open on book that is both brave and timely. sought refuge in the label as a means of con- health secretary Patricia Hewitt’s desk. The World Health Organization describes trolling uncertainty in the consulting room depression as a common mental disorder and diverting attention from the causes, Iona Heath general practitioner, London characterised by sadness, loss of interest in nature, and extent of human suffering; and [email protected]

the exhibition aims to stimulate our thinking and to manipulate other electronic gadgets. about our sense of touch and how we use it. Julia Leihener’s Thups, glass or plastic cups Several of the innovative products are hooked over drinkers’ thumbs rather than witty. Rather than flicking a switch, visitors held, provide a further, light hearted use for can activate an electric lamp called the Watt? these previously neglected digits. Light by drawing a line with a lead pencil, to A new area of research highlighted in the complete a circuit printed on a sheet of exhibition is the development of tactons or Touch Me paper. The light is extinguished by rubbing “tactile icons,” like the vibrations already used out the line with an eraser. Whether the to alert mobile phone users to incoming calls. additional tactile experience provided In the future, vibrations of differing duration, An exhibition at the Victoria and Albert would be worth the hassle on a daily basis is frequency, or strength could be used to pro- Museum, London SW7, until 29 August debatable; however, Paul Cocksedge’s design vide more information about the caller www.vam.ac.uk/vastatic/microsites/1376_ is certainly thought provoking. touch_me/ Although using our thumbs in place of or type of call, providing that we can learn to differentiate new tactile stimuli. Rating: ★★>> fingers looks awkward, we use them increas- ingly, to text messages on mobile phones Although Touch Me provides many opportunities for interaction, which engage useums usually instruct us not to adults and children alike, the curators touch their displays; however, the opposite is the case at this exhibi- acknowledge that the exhibition raises more M questions than it answers. Even its central tion, developed in collaboration with the Wellcome Trust, where visitors are encour- hypothesis, that we are becoming dissoci- aged to handle many of the objects. ated from our sense of touch in the modern Touch Me explores aspects of how we world, is not proven. Ultimately, the exhibi- relate to each other, and to the objects we use tion’s open ended conjectures appear as every day, through touch, which the curators muddled thinking, from which it is difficult argue is a neglected sense. Partly resembling a to draw meaningful conclusions. degree show for a design course with an emphasis on improving the tactile quality of Colin Martin independent consultant in healthcare products and partly like an amusement communication, London arcade featuring quasi-scientific experiments, Getting the thumbs up: Thups [email protected]

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PERSONAL VIEWS Let the buyer beware

he Roxy market in the Adjamé The second category is the drugs found district of Abidjan in Côte d’Ivoire is only in the illegal street markets. These are T well known among the city’s poor drugs that have escaped government regula- people. With hundreds of vendors, it is a vast tion and are essentially those smuggled into expanse of shelters and parasols under the country past customs agents (or with which all kinds of drugs in all sorts of their connivance). They are usually not forms—pills, syrups, powder, suppositories, registered in Côte d’Ivoire and mostly come injectables, ointments—are displayed in a from Ghana, Nigeria, and India. Also in this jumble on tables or in baskets. The drugs are category are the illicit Chinese traditional constantly exposed to dust, sun, and changes medicines, a burgeoning market throughout in weather that can affect their quality. It is the country. They are distributed by young common to find drugs sold without their jobless Ivorians, under the guidance of a original packaging and repackaged in Chinese boss. The vendors, unable to read plastic bags with no men- the Chinese characters, give tion of the drug’s name, the medicines their own active ingredients, or expiry The substandard designations to identify the date. Nearly all the vendors drugs are often product. Of course the are women, and more than accompanying leaflets, if a third are illiterate. None those in high any, are likewise illegible to has knowledge of drugs or demand for AIDS the consumers. any medical training—but The few studies that this does not mean they and malaria have looked into the prob- aren’t ready to quickly diag- lems caused by the spread nose an illness or try to decipher a prescrip- of illegitimate channels of drug distribution tion so they can provide a drug, though their in less developed countries have all found choice is more likely to be determined by that a large proportion of the drugs are of what they have in stock than the actual cause low quality. This is partly because the drugs of the illness. are sold after the expiry date or stored in The drugs in the market can be divided bad conditions but mostly because the active into two broad categories. The first is drugs ingredients are lacking or even wrong, that can also be found in legal pharmacies owing to irregularities in the manufacturing and street markets. They find their way to process, whether intentional (in the case of ISSOUF SANOGO/AFP/GETTY Roxy from legal wholesalers and pharma- counterfeit drugs) or not (substandard drugs). Pile them high, sell them cheap cists. Indeed, the legal pharmaceutical Up to 25% of the drugs consumed in sector supplies about 48% of the stocks poor countries are counterfeit or substandard of drugs in the country’s illegal street (Journal of Advanced Nursing 2004;46:338-9). The paradox is that these illegal vendors markets (www.remed.org/fichiers/ReMeD22. Because of the absence of controls in pay daily fees to the city council to occupy pdf). Some wholesalers have set up a supply markets like Roxy, the proportion of poor space on the pavement or the street. system to the illegal outlets so that all the products sold there must surely be higher, Sporadically the police mount raids and groups of drugs present in but we do not have any reli- arrest the vendors and confiscate their mer- the legal pharmacies can also able data. The substandard chandise, but usually the owners can get be found at cheaper prices Many visit the drugs are often those in their goods back by paying the police. in the illegal market. This high demand for life threat- The country needs a much stronger new business line is helped street vendors to ening conditions such as political will and enforcement of drug regu- by the fact that the street sell- avoid doctors’ AIDS and malaria. Inevita- lation to beat this rapidly expanding ers buy on a cash on delivery bility, their ineffectiveness problem. However, the country’s current basis, while the legal pharma- consultation fees leads to clinical aggrava- political and economic crisis makes this cists negotiate payments by tions and even death. The unlikely. Instead it is up to those in Côte credit. The delivery cars operate at night or situation is made worse by the encourage- d’Ivoire’s pharmaceutical sector to face up to their responsibilities and fight this dishon- early in the morning. Some drugs are ment of prompt self treatment for diseases ouring of their profession. stolen from pharmacies by employees and such as malaria. sold in the street market at a cheaper price. It Although the market’s customers Eboukél Aka research pharmacist is often possible to see drugs labelled “free may sometimes need a prescription, many sample, not for sale,” provided by medical visit the street vendors to avoid doctors’ Candice Legris Lavoisier research fellow in drug representatives who sell the samples intended consultation fees. Less than 10% of Côte management and policy, department of drug for doctors. d’Ivoire’s population has health insurance. management and policy, Graduate School of Natural Science and Technology, Kanazawa University, Japan Drugs donated to charities are also The exact proportion of people buying [email protected] often found in the street market. These medicines from the illicit outlets is drugs are often not suited to the needs of unknown, but estimates are that in some the receiving population and so will be sold African countries as many as 85% of by the organisations. In addition, some patients may visit these ignorant and We welcome submissions for the personal view drugs made in Europe are in the street dangerous bogus “doctor-pharmacists.” section. These should be no more than 850 words and should be sent electronically via our website. market—probably sold on by unscrupulous Occasionally the authorities publicise the For information on how to submit a personal view Europeans—even though domestic manu- dangers, but nothing concrete is being done online, see http://bmj.com/cgi/content/full/325/ facturers are licensed to make the same to eradicate the problem, by either the 7360/DC1/1 drugs. authorities or the pharmaceutical sector.

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SOUNDINGS Can Labour take the NHS to market? Be alert

ow that the Blair government’s third public aspect of the NHS will be defined The more things change, the more they term has started, its health policies only by its funding and control. stay the same—cynical old men are becoming clearer; ironically for Underpinning these developments is suckering gullible and vulnerable young N men into doing their dirty work for a Labour government, at their heart is a the rhetoric of fixed tariffs, supposed to market. allow variations based on quality and them. You’ve just experienced it in The Conservative government of the convenience, rather than price. The premise London, I saw it for years in Northern 1990s tried to introduce an “internal that variations in activity should not affect Ireland, and Siegfried Sassoon wrote market” in health care in which hospital price may sound reasonable, but it is unsus- about it in 1918: “If I were fierce and services were intended to be market tested tainable in the longer term, since costs vary bald and short of breath, I’d sit with to make them more efficient and to offer even if prices do not. Every business has scarlet Majors at the Base, And patients more choice. It could never really fixed costs, but once these are covered, doing speed glum heroes up the line to have succeeded at that time; a right wing more of the same becomes relatively death.” government, while being able to take for cheaper; offering suppliers the full price is You’ll get used to it. More visible granted support from its own followers, unnecessary, and distorts their profit. security, regular searches, frequent false would never have been able to convince Conversely, removing marginal activity alarms, delays on trains and buses—all more left wing voters to trust in a market at full price amplifies suppliers’ losses in a these things will gradually soften like philosophy. way that will eventually bankrupt them. In music into the background. Life has to Only a government able to gain the con- an open market, the three variables are go on, the anxiety will fade as you adjust fidence of more egalitarian minded voters quality, quantity, and price; if a healthcare to a different dynamic, you’ll go back to would stand a chance of implementing a market is to succeed, it will need to be no talking about football and the weather, market policy. That is what has happened: different. and patients will still want antibiotics for the New Labour government seems to have So much for technicality; what about colds and sore throats even as the made the notion of a healthcare market its culture and values? Can a health market sirens wail. Humans aren’t genetically own, only this time it’s real, not “internal.” succeed in a society that still holds egalitari- designed for absolute tranquillity, and a Markets work most effectively when sup- anism and equity so dear? It depends on the bit of uncertainty is probably good ply exceeds demand, so the government’s power of commissioning. In theory the for us. first task was to loosen the primary care trusts, prob- constraints of the “old” ably working in ways that NHS and begin to increase Can a health give them greater economy Humans aren’t designed the number of potential market succeed in of scale, could regulate the for absolute tranquillity service providers. This has market by marrying the been done in several ways: a society that holds healthcare needs of their Statistically the chances of being firstly, contracts between the egalitarianism and populations, the resources involved are slight. During the Troubles service commissioners (cur- available, and the range of about 3000 people were killed, and in rently the primary care equity so dear? services required. that same period the death toll on the trusts) and their providers This strategic role would roads was over 6000. But the increased have been made less structural and more inform the decision making of local threat does make you more alert to small functional, so that outputs (for example, purchasers, thus ensuring that the market things, a little bit more cautious and numbers of operations) have become more retained a degree of efficiency, and did not thoughtful. important than inputs (such as numbers of result in fragmented, inappropriate services. I remember once driving to a house hospital beds or consultants). If that could be made to work, something call when I noticed a cardboard box at the side of the road. I stopped the car Secondly, the number of providers is unique will have been created, a pluralistic and sat for a while, pondering. It was just being increased, ostensibly to overcome system of provision offering equitable a cardboard box on a small country long waiting times, but actually to produce services under the control of the public sec- road, almost certainly just a piece of stray some open competition to create choice tor. However, this can work only if the strate- litter; no wires, no traditional whiff of and, in the longer term, to drive down the gic commissioners learn to use powerful, cordite, no sound of merry gunfire in the cost of care. The independent sector has mature contracts based on partnership and distance, no sign of any “insurgents,” been persuaded to enter the fray, with interdependency rather than the simplistic nothing at all suspicious. explicit inducements available for the first “win/lose” contracts we generally have now. I got out of the car at a prudent few years at least. The current independent Finally, there are the politics; a secretary of state coming from the Department of distance, and looked sternly at the box; I range of models (mainly companies offering consider myself an alpha male. It looked specific surgical procedures) should be Trade and Industry may be assumed to favour trading models of health care, back at me, unblinking. Observing the expected to expand, and other patterns may conventions, it exuded a faint air of emerge: accredited general practices offer- particularly when backed by a prime minister so closely associated with market menace: “You’re alive, you’re dead,” it ing surgical procedures, pharmacy compa- mechanisms. But with a smallish majority of seemed to be saying, “it really doesn’t nies (or even hospitals) competing for MPs, prepared to show their disapproval of matter to me.” For a long moment primary care, overseas companies bidding non-traditional Labour policies, how would neither of us moved. for business, and so on. a different premier react, one whose faith in Then I turned around and made a The creation of foundation trusts is also the market was not so well established? detour which cost me 10 miles; fortune intended to harness the innovation that has The reality is probably pragmatic; the may favour the brave, but the devil hates not traditionally been encouraged in the market will survive and thrive only if it a coward. NHS, so that such organisations may begins to produce results, and soon. diversify and develop to meet the demands of the growing healthcare market. The Liam Farrell general practitioner, Crossmaglen, Jonathan Shapiro senior fellow, Health Services County Armagh distinction between public and private Management Centre, University of Birmingham supply is likely to become irrelevant; the [email protected]

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