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Death in the pavilion
DISSECTING ROOM
The Refractory Patients’ choice: David and Goliath s it too obvious to state that clinical research should provide patients and physicians with evidence that will help direct choice of medical intervention? Each patient is different, both in presentation of disease and in personal circumstances. But evidence in randomised clinical trials is provided by data from adequately large cohorts of participants, equally diverse, ideally comparable to the mass of future patients who will benefit from the intervention. However, manifestations of “the same” disease in different cultures, or in different socioeconomic populations, or in countries with different systems of health provision, will produce inherently different cohorts of research participants and different populations to be treated. Surely this ought to be borne in mind by international
I
research collaborations and those trying to achieve more equitable global health provision? The current ratio of research on simple inexpensive options able to ameliorate the lives of many people worldwide to expensive, scientifically driven research on minute refinements of interventions that address advanced biomedical questions is morally unacceptable. How has this come about? Who has the power to see that research questions actually address the greatest needs of patients in all their misery and diversity? Why aren’t the most relevant questions being asked? Who is currently setting the questions? Who should be? Who shall direct this prioritisation?
Death in the pavilion Silence of the Heart: Cricket Suicides David Frith. Edinburgh: Mainstream, 2001. Pp 255. £15.99. ISBN 184018406X. he rules of cricket were first drawn up at an artillery ground in London. The very early pitches could be disablingly irregular, but for a long time batsmen scorned the wearing of gloves. The legs were often unprotected too. Indeed the preface to Lord’s and the MCC (1914) notes: “When leg-pads were first introduced they were worn under the trousers, as though the hardy cricketer was ashamed of his cowardice in wearing them”. Men were men, in other words—or pretended to be. Today’s cricketer may pack kitbags as if going to war (and even the prepubertal buy “boxes”), but this summer game is seldom associated with the risks of long-bone fracture and spinal injury of some other sports. How about away from the field of play? You might think that boredom or, in England anyway, pneumonia was the greatest hazard to a cricketer’s health. David Frith makes the case for suicide. Silence of the Heart: Cricket Suicides is a follow-up to Frith’s By his Own Hand, and he begins with some simple, even simplistic, epidemiology. For 1998 the Office for National Statistics reported that 1·07% of male deaths were suicides. Frith identifies six suicides among 339 English international (test) cricketers who had
T
768
died; when figures for Australia, New Zealand, and South Africa are added, the frequency is 2·70%. I do wonder how well these “deadly statistics” (the author) and cricketers’ “unduly” high suicide rate (the publisher) would stand up to more sophisticated scrutiny. However, Frith’s research goes far beyond the statistical, and beyond the test level too—to include spectators, cricket writers, and one woman. Having done so much for women’s cricket in her younger days, Miss Marjorie Pollard, 82 and lonely, shot herself. The trouble with many of Frith’s suicides, especially those happening years after the playing days is that they may have had nothing to do with cricket at all. Others surely did. The death by hanging of David Bairstow in 1998 will have shocked even non-cricketers; the open verdict was compassionate. In July, 1893, a few days after the former England batsman William Scotton had cut his throat, two men, Andrew Stoddart and Arthur Shrewsbury, walked out to open the England innings, passing as they did so the Australian fielder, Billy Bruce. In 1925, Bruce drowned himself while Stoddart (1915) and Shrewsbury (1903) used revolvers. This may be an extreme coincidence,
Patients are best able to identify the health topics most relevant to them to inform their comfort, care, and quality of life, as well as its quantity. The patients are the David, who must load their slings against the Goliaths of the pharmaceutical companies who need evidence to market goods and make profits, and trialists who are driven by curiosity, the need to secure research money, professional acclaim, and career development. Profit, scientific inquiry, grant money, and research papers are acceptable only if the central motivation is the good of patients. Independent patients and organisations that advocate good quality research should ready their sling, carefully choose their stone, take aim, and conquer. Refractor e-mail: [email protected]
but as Frith’s tragedies mount it does seem almost inescapable that there is something gloomy about the game of cricket or the people who choose to play it. At one point in the 1990s the English cricket authorities offered the team spiritual guidance in the form of a chaplain, but the idea—targeted, as I recall, more at improving performance on the field than survival off it—did not catch on. But for every cricket suicide there will, just as in the real world, be dozens of players who had moments of glory later marred by disgrace, drink, an irregular love life, or poverty, yet survived to a ripe old age; my greatgrandfather (Bobby Peel [1857–1941], Yorkshire and England) was one. In the end Frith, reluctantly, talks himself out of finding cricket itself guilty. On the other hand, former England captain Michael Brearley, in his preface, is persuaded away from his own theory, one that only a psychoanalyst (Brearley’s current profession) could have come up with in the first place. That previously reassuring notion is that the game actually helps people to “work through the experience of loss by forcing its participants to come to terms with symbolic deaths on a daily basis”. Too much analysis, statistical or psychological, could spoil Frith’s well-researched stories of personal tragedy, told in these pages with honesty and sometimes with humour, but humour never out of place. David Sharp c/o The Lancet, London, UK
THE LANCET • Vol 358 • September 1, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
The Refractory Patients’ choice: David and Goliath s it too obvious to state that clinical research should provide patients and physicians with evidence that will help direct choice of medical intervention? Each patient is different, both in presentation of disease and in personal circumstances. But evidence in randomised clinical trials is provided by data from adequately large cohorts of participants, equally diverse, ideally comparable to the mass of future patients who will benefit from the intervention. However, manifestations of “the same” disease in different cultures, or in different socioeconomic populations, or in countries with different systems of health provision, will produce inherently different cohorts of research participants and different populations to be treated. Surely this ought to be borne in mind by international
I
research collaborations and those trying to achieve more equitable global health provision? The current ratio of research on simple inexpensive options able to ameliorate the lives of many people worldwide to expensive, scientifically driven research on minute refinements of interventions that address advanced biomedical questions is morally unacceptable. How has this come about? Who has the power to see that research questions actually address the greatest needs of patients in all their misery and diversity? Why aren’t the most relevant questions being asked? Who is currently setting the questions? Who should be? Who shall direct this prioritisation?
Death in the pavilion Silence of the Heart: Cricket Suicides David Frith. Edinburgh: Mainstream, 2001. Pp 255. £15.99. ISBN 184018406X. he rules of cricket were first drawn up at an artillery ground in London. The very early pitches could be disablingly irregular, but for a long time batsmen scorned the wearing of gloves. The legs were often unprotected too. Indeed the preface to Lord’s and the MCC (1914) notes: “When leg-pads were first introduced they were worn under the trousers, as though the hardy cricketer was ashamed of his cowardice in wearing them”. Men were men, in other words—or pretended to be. Today’s cricketer may pack kitbags as if going to war (and even the prepubertal buy “boxes”), but this summer game is seldom associated with the risks of long-bone fracture and spinal injury of some other sports. How about away from the field of play? You might think that boredom or, in England anyway, pneumonia was the greatest hazard to a cricketer’s health. David Frith makes the case for suicide. Silence of the Heart: Cricket Suicides is a follow-up to Frith’s By his Own Hand, and he begins with some simple, even simplistic, epidemiology. For 1998 the Office for National Statistics reported that 1·07% of male deaths were suicides. Frith identifies six suicides among 339 English international (test) cricketers who had
T
768
died; when figures for Australia, New Zealand, and South Africa are added, the frequency is 2·70%. I do wonder how well these “deadly statistics” (the author) and cricketers’ “unduly” high suicide rate (the publisher) would stand up to more sophisticated scrutiny. However, Frith’s research goes far beyond the statistical, and beyond the test level too—to include spectators, cricket writers, and one woman. Having done so much for women’s cricket in her younger days, Miss Marjorie Pollard, 82 and lonely, shot herself. The trouble with many of Frith’s suicides, especially those happening years after the playing days is that they may have had nothing to do with cricket at all. Others surely did. The death by hanging of David Bairstow in 1998 will have shocked even non-cricketers; the open verdict was compassionate. In July, 1893, a few days after the former England batsman William Scotton had cut his throat, two men, Andrew Stoddart and Arthur Shrewsbury, walked out to open the England innings, passing as they did so the Australian fielder, Billy Bruce. In 1925, Bruce drowned himself while Stoddart (1915) and Shrewsbury (1903) used revolvers. This may be an extreme coincidence,
Patients are best able to identify the health topics most relevant to them to inform their comfort, care, and quality of life, as well as its quantity. The patients are the David, who must load their slings against the Goliaths of the pharmaceutical companies who need evidence to market goods and make profits, and trialists who are driven by curiosity, the need to secure research money, professional acclaim, and career development. Profit, scientific inquiry, grant money, and research papers are acceptable only if the central motivation is the good of patients. Independent patients and organisations that advocate good quality research should ready their sling, carefully choose their stone, take aim, and conquer. Refractor e-mail: [email protected]
but as Frith’s tragedies mount it does seem almost inescapable that there is something gloomy about the game of cricket or the people who choose to play it. At one point in the 1990s the English cricket authorities offered the team spiritual guidance in the form of a chaplain, but the idea—targeted, as I recall, more at improving performance on the field than survival off it—did not catch on. But for every cricket suicide there will, just as in the real world, be dozens of players who had moments of glory later marred by disgrace, drink, an irregular love life, or poverty, yet survived to a ripe old age; my greatgrandfather (Bobby Peel [1857–1941], Yorkshire and England) was one. In the end Frith, reluctantly, talks himself out of finding cricket itself guilty. On the other hand, former England captain Michael Brearley, in his preface, is persuaded away from his own theory, one that only a psychoanalyst (Brearley’s current profession) could have come up with in the first place. That previously reassuring notion is that the game actually helps people to “work through the experience of loss by forcing its participants to come to terms with symbolic deaths on a daily basis”. Too much analysis, statistical or psychological, could spoil Frith’s well-researched stories of personal tragedy, told in these pages with honesty and sometimes with humour, but humour never out of place. David Sharp c/o The Lancet, London, UK
THE LANCET • Vol 358 • September 1, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.