First, Do No Harm

Around 400 BC, the physician Hippocrates gave his students a simple rule: "As to diseases, make a habit of two things: to help, or at least to do no harm." His medicine was built on diet, rest, fresh air, movement and what he called vis medicatrix naturae, the healing power of nature. (See Vital Force.) Two and a half thousand years later, many of us leave a ten-minute appointment with a prescription, and no one has asked what we eat, how we sleep or what is happening in our lives. How did we get here?

Let's be clear from the start: modern medicine is one of humanity's greatest achievements. Antibiotics, vaccines, insulin, anaesthetics and emergency surgery save countless lives every day, and most doctors, nurses and scientists are dedicated, caring people. This article isn't about them. It's about a system in which profit has quietly shaped what medicine studies, what it prescribes and what it leaves out.

When profit shapes the evidence

We trust medicines because we trust the research behind them. But much of that research is funded, designed and reported by the companies that sell the products, and the public record shows what can happen when commercial interests come first:

• The opioid crisis. Purdue Pharma marketed its painkiller OxyContin as having a low risk of addiction. The company pleaded guilty to federal criminal charges in the United States in 2007 and again in 2020, over a crisis that has claimed hundreds of thousands of lives.¹
• Vioxx. Merck's arthritis drug was withdrawn in 2004 after it was found to raise the risk of heart attack and stroke. Researchers estimated it may have caused between 88,000 and 140,000 extra cases of serious heart disease in the US alone.²
• Record fines. In 2012, GlaxoSmithKline agreed to pay $3 billion, then the largest healthcare fraud settlement in US history, partly for promoting the antidepressant Paxil for children and for failing to report safety data on the diabetes drug Avandia.³ In 2009, Pfizer paid $2.3 billion over the illegal promotion of several medicines.⁴
• The missing trials. When researchers compared published antidepressant trials with the full set held by the US regulator, 94% of the published trials looked positive, but only about half of all the trials actually were. Many of the disappointing results had simply never been published.⁵
• Ghostwriting. A famous 2001 study reported that Paxil was safe and effective for teenagers. When independent researchers re-analysed the original data in 2015, they found it was neither effective nor safe for this age group.⁶

Closer to home, the UK's own independent review of medicines safety, led by Baroness Cumberlege and tellingly titled First Do No Harm, investigated the pregnancy test drug Primodos, the epilepsy medicine sodium valproate and pelvic mesh implants. It found a healthcare system that was "disjointed, siloed, unresponsive and defensive", and patients, mostly women, who had been dismissed for years when they reported harm.⁷

To help, or at least to do no harm.

Selling sickness

The surest way to grow a market is to make more people feel they need the product. Researchers have described this as "disease mongering": widening the definitions of conditions, turning ordinary life experiences into medical problems, and promoting the idea that a medicine is the natural answer.⁸ Normal ups and downs of mood, sleep, shyness, menopause and ageing can all be reframed as conditions to be treated for life.

There is also a quieter problem: you can't patent a plant. A company that spends hundreds of millions of pounds on a clinical trial needs a product it can own. Nobody can own turmeric, magnesium, a walk in the woods or a bowl of lentils, so these rarely receive the large trials that would bring them into medical guidelines. The lack of big trials is then taken as a lack of evidence. (See The Inner Life of Plants.)

A pill for every ill

Medicines save lives every day. But every medicine also carries risk, and the scale of harm from medicines, most of them taken exactly as prescribed, is staggering and rarely spoken about:

• In the UK, a study of hospital admissions in Liverpool found that around 1 in 6 were caused or made worse by a reaction to a medicine.⁹ Across England, adverse drug reactions have been estimated to cause up to 5,700 deaths a year in hospital alone.¹⁰ On top of this, around 237 million medication errors are thought to happen in England every year.¹¹
• In the United States, a landmark analysis estimated that more than 2 million hospital patients a year suffer a serious reaction to a medicine and over 100,000 die, placing properly prescribed medicines among the leading causes of death in the country.¹² Reactions to medicines also lead to well over a million emergency department visits every year.¹³
• In Europe, the European Commission has estimated that adverse drug reactions cause around 197,000 deaths a year across the EU.¹⁴
• Worldwide, around 1 in 20 patients suffers harm in healthcare that could have been prevented, and medicines are the single largest cause, accounting for about a quarter of it.¹⁵ To put that in context, on any given day around 95,000 people are in an NHS general hospital bed in England: 1 in 20 would be nearly 5,000 people, over 1,000 of them harmed by medicines. The World Health Organization estimates that medication errors alone cost US$42 billion a year.¹⁶

Why do so many people die?

Most of this harm doesn't come from rare or exotic drugs, but from everyday medicines. In the large English study, the most common culprits were anti-inflammatory painkillers (including low-dose aspirin), water tablets, the blood thinner warfarin, blood pressure medicines, antidepressants and opioids, and the most common harm was bleeding from the stomach.¹⁰ The main ways medicines injure and kill include:

• Bleeding, especially from the stomach and gut, caused by blood thinners and anti-inflammatory painkillers.
• Falls and fractures, as sleeping tablets, sedatives, some antidepressants and blood pressure medicines cause dizziness, drowsiness and sudden drops in blood pressure. For an older person, a broken hip can be life-threatening.
• Kidney and liver damage. Paracetamol overdose is one of the leading causes of sudden liver failure in the UK and US.¹⁷
• Dangerous interactions between medicines, and with some herbs, foods and supplements, which become far more likely as the list of medicines grows. (See When Plants Meet Pills.)
• Infections, such as the serious gut infection C. difficile, which can follow antibiotics and long-term acid-reducing medicines.
• Dependence and overdose, most tragically with opioid painkillers.

Behind these lie deeper causes. Many people take several medicines that no one reviews together, and older bodies clear drugs more slowly, yet older people with several conditions are often left out of the trials that test new medicines.¹⁸ Side effects are also hugely under-reported: a review found that over 90% of adverse drug reactions never reach official reporting schemes such as the UK's Yellow Card,¹⁹ so the true toll is likely to be higher still. Most striking of all, around 70% of the reactions that led to hospital admission in England were judged avoidable or possibly avoidable.¹⁰

Older people and those taking several medicines at once carry the greatest risk. None of this is a reason to stop a medicine you've been prescribed. It is a reason to ask, every time, whether a medicine is truly needed, and whether the cause could be addressed instead.

Side effects can also be mistaken for a new condition and treated with yet another medicine, a pattern known as the prescribing cascade.²⁰ A blood pressure tablet causes ankle swelling, so a water tablet is added; an anti-inflammatory raises blood pressure, so a blood pressure tablet follows. Each step makes sense on its own. Together, they can leave a person on a long list of medicines, with no one looking at the whole picture.

Some common examples of long-term prescribing where the cause often goes unasked:

• Acid-reducing medicines (PPIs) are among the most prescribed drugs in the UK, and many people take them for years. Long-term use has been linked with low levels of vitamin B12 and magnesium, gut infections and fractures,²¹ and indigestion can have many causes, from diet and stress to, surprisingly, too little stomach acid. (See You Are What You Absorb.)
• Antidepressants were prescribed to around 8.6 million people in England in 2022–23, according to NHS figures. For some, they are genuinely life-saving. But the long-held idea that depression is simply a "chemical imbalance" of serotonin has been seriously challenged,²² stopping them can bring withdrawal effects that are more common and longer-lasting than once thought,²³ and low mood is often bound up with sleep, gut health, inflammation, nutrition, loneliness and life circumstances. (See Where Body Care Meets Mind.)
• Sleeping tablets for insomnia, when the body clock, stress hormones and evening light may lie at the root. (See The Art of Sleep.)
• The contraceptive pill for painful or irregular periods, acne or mood changes, which quiets the symptoms without exploring the hormonal imbalance behind them. (See The Hormone Web.)

Why lifestyle gets left out

Most GPs know that diet, sleep, stress and movement matter. So why are they so rarely the first prescription?

• Time. A typical GP appointment lasts around ten minutes, barely long enough to listen to symptoms, let alone explore someone's diet, sleep, stress and history.
• Training. A review of medical education around the world found that nutrition teaching is consistently inadequate, leaving doctors feeling unprepared to give dietary advice.²⁴
• Guidelines and targets are built largely around medicines and measurements, and the research behind them is shaped by what gets funded.
• Expectations. Many of us arrive hoping for a quick fix, and a prescription can feel like being taken seriously.

None of this makes GPs the villains. Most are caring, overstretched professionals doing their best in a system designed for speed rather than for finding causes. But it does mean that the most important questions, why is this happening, and what is driving it?, too often go unasked.

Lifestyle is medicine

The evidence that lifestyle can prevent, treat and even reverse common conditions is strong:

• Diabetes prevention. In a major US trial of people at high risk, lifestyle changes cut the risk of developing type 2 diabetes by 58%, almost twice as much as the drug metformin (31%).²⁵
• Diabetes remission. In the UK's DiRECT trial, almost half of people with type 2 diabetes put it into remission through diet and weight loss, coming off their diabetes medicines.²⁶ (See Balancing the Sugar Seesaw.)
• Heart disease. In the Lifestyle Heart Trial, a whole-food diet, exercise, stress management and group support began to reverse narrowed coronary arteries, while they continued to narrow in the usual care group.²⁷
• Depression. A large analysis in the BMJ found that exercise, including walking, yoga and strength training, was an effective treatment for depression, with benefits comparable to psychotherapy and medication.²⁸ (See Born to Move.)

The NHS is beginning to recognise this, with growing support for social prescribing, which connects people with activities, nature, community groups and practical help. It's an encouraging start.

Taking back your health

You have every right to understand and take part in decisions about your own body. These questions can help at any appointment:

• What do you think is causing this?
• What happens if I wait, or try lifestyle changes first?
• What are the benefits and the possible side effects?
• How long will I need to take it, and how will we know when to stop?
• Could any of my symptoms be side effects of medicines I already take?

If you take several medicines, you can ask your GP or pharmacist for a structured medication review, to check each one is still needed and working well together. And when you start any herb or supplement, check it with your GP or pharmacist for interactions. (See When Plants Meet Pills.)

At Rootwise, we return to the oldest principle in medicine: first, do no harm, then look for the cause. We take the time to understand your whole story, from digestion, blood sugar and hormones to sleep, stress and the life you live, and work alongside your doctor and any medicines you need, so that treating symptoms and healing their causes can go hand in hand.