IELTS Academic Reading Practice Test 334

At the end of the nineteenth century a blood transfusion was still a dangerous gamble. Doctors in Europe and North America had attempted the procedure since the early 1800s, when the London obstetrician James Blundell transferred blood from one person to another, and some patients benefited. Many others, however, suffered a violent reaction and died, and nobody could explain why. The same operation that saved one patient might kill the next. It was this puzzle, rather than any interest in surgery, that occupied a young Austrian physician named Karl Landsteiner at the start of the twentieth century.

Landsteiner was born in 1868 in Baden, a small town near Vienna, the son of a journalist who died when Karl was six. He studied medicine at the University of Vienna and qualified in 1891, but his real enthusiasm was chemistry, which he continued to study after taking his degree. In 1896 he became an assistant at the city's Institute of Hygiene, and the following year he moved to the Institute of Pathological Anatomy, directed by the bacteriologist Anton Weichselbaum. There he remained for more than a decade, studying the chemistry of the immune response.

The question Landsteiner asked was simple. If human blood were everywhere the same, why should one person's blood sometimes destroy another's? He suspected that individuals differ in some chemical feature of their red cells, and that the serum of one person might react with the cells of another. To test the idea he took samples of blood from himself and from colleagues in the laboratory, separated the pale yellow serum from the red cells, and mixed serum from one person with cells from another. The results were striking. In many combinations nothing happened, but in others the red cells clumped together in visible clusters, a reaction he called agglutination.

Landsteiner reported his first observations in 1900 and set out his conclusions in a paper published in 1901. Human blood, he suggested, could be sorted into three groups according to how the sera and cells of different people reacted together. What mattered was which substances, later called antigens, were present on the surface of the red cells and which antibodies were present in the serum. A year later two of his colleagues, Alfred von Decastello and Adriano Sturli, identified a fourth group, in which the cells carried both of the relevant antigens and the serum reacted against neither.

Landsteiner's paper attracted little attention at first. The letters A, B, AB and O, still used today, were introduced by other researchers a few years later. The practical value of the discovery lay in prediction. Once a patient's group and a donor's group were known, a doctor could tell in advance whether the two samples of blood were likely to be compatible, and the disastrous reactions could be avoided. Hospitals began to apply the new knowledge in the years before the First World War, and in 1907 the New York surgeon Reuben Ottenberg described the systematic matching of donor and recipient.

Transfusion remained awkward, however, because blood clots within minutes of leaving the body. Everything depended on connecting the donor's artery to the recipient's vein and completing the transfer before the blood clotted. The solution came in 1914, when Albert Hustin in Belgium and Luis Agote in Argentina independently showed that a small quantity of sodium citrate prevented clotting without harming the patient, and Richard Lewisohn in New York later worked out a suitable dose. Citrated blood could be stored in bottles for a short time, and during the First World War the American physician Oswald Robertson organised the first blood depot, supplying stored blood to casualty stations in France.

Landsteiner himself had moved on. In 1908 he became head of pathology at the Wilhelminenspital in Vienna, and in 1919, with conditions in post-war Austria difficult, he left for a laboratory in the Netherlands. In 1922 he accepted an invitation to join the Rockefeller Institute for Medical Research in New York, where he spent the rest of his working life. His interests ranged widely. With Erwin Popper he had shown in 1909 that poliomyelitis could be transmitted to monkeys by injecting material from the spinal cord of a patient, work that helped to establish that the disease was caused by a virus.

Landsteiner's work on blood groups brought him the Nobel Prize in Physiology or Medicine in 1930. He was then sixty-two and continued to work for another decade. In 1940, with Alexander Wiener, he reported another antigen, found in the blood of rhesus monkeys and in a large majority of people, which became known as the Rh factor. Its importance was quickly recognised in pregnancy, where an incompatibility between mother and fetus could damage the newborn child, and in transfusion, where it could cause serious reactions.

Landsteiner died in New York in 1943. The system of blood groups he described remains the foundation of transfusion medicine, and A, B, AB and O are among the first letters a medical student learns. More than forty other blood group systems have since been discovered, several of them by Landsteiner himself, but none has the practical importance of the ABO system. Group O blood lacks both antigens and can be given to patients of any group, which makes it valuable in emergencies. Incompatible transfusions still occur, but most often because of a clerical error in identifying a sample rather than any gap in the science.

A cough is one of the most familiar sounds in human life, and almost everyone produces one from time to time. It is best understood not as a symptom in itself but as a reflex, a protective programme built into the nervous system. Its purpose is to keep the airways clear. Smoke, dust, a crumb of food, a drop of acid from the stomach or the mucus produced during an infection will all provoke it, and the reflex removes the intruder before it can reach the delicate surfaces deep in the lungs where oxygen passes into the blood.

The reflex begins when sensory nerve endings in the larynx, the trachea and the larger airways are stimulated. These endings send signals along the vagus nerve to a small region of the brainstem, sometimes called the cough centre, which coordinates the response. The muscles of inspiration first contract, drawing a deep breath into the lungs. The glottis, the opening between the vocal cords, then closes, and the muscles of the abdomen and chest contract forcefully against the closed airway. Pressure inside the chest rises sharply. A fraction of a second later the glottis opens and air is expelled explosively, carrying mucus and any trapped particles up towards the throat. From there the material is either coughed out or swallowed.

The airways are lined with a thin layer of mucus that traps particles, and with microscopic hairs called cilia that beat in a coordinated wave, sweeping the mucus upwards towards the throat. This mechanism is sometimes described as the mucociliary escalator. In healthy people it clears the airways without any conscious effort. A cough is what happens when the escalator is overwhelmed, or when the mucus becomes too thick to move, as it does in some chronic lung diseases. Smoking paralyses the cilia for a period and eventually destroys them, which is one reason why smokers cough.

Coughing also has a public dimension, because the droplets it produces can carry bacteria and viruses several metres through the air and deposit them on surfaces or in the airways of other people. Measles, influenza, tuberculosis and the viruses that cause the common cold all travel in this way. The recognition that coughs and sneezes spread respiratory infections transformed public health in the late nineteenth and early twentieth centuries, and simple measures such as covering the mouth remain among the cheapest defences available.

Clinicians classify coughs by how long they last. An acute cough, the kind that accompanies a cold, usually settles within three weeks. A subacute cough lasts between three and eight weeks and often persists after an infection has cleared. Anything longer is described as chronic, and chronic cough is one of the commonest reasons for consulting a doctor. Coughs are also divided into those that bring up phlegm, known as productive coughs, and dry coughs, which produce nothing; the distinction matters because a dry cough is often the more exhausting of the two.

Most acute coughs follow a viral infection of the upper respiratory tract, which is why antibiotics rarely help. Persistent coughs have a wider range of causes. Asthma commonly presents as a dry night-time cough; acid reflux from the stomach can irritate the throat; and a group of drugs known as ACE inhibitors, prescribed for high blood pressure, produces a tiresome dry cough in a proportion of patients. Smoking and exposure to air pollution are important contributors, and in some people no cause is ever found.

Whooping cough, or pertussis, is a different matter. It is caused by the bacterium Bordetella pertussis, which attaches to the lining of the airways and releases toxins that damage the cilia. The result is an illness of violent coughing fits, often ending in a desperate intake of breath that produces the characteristic whoop. Young infants are at greatest risk and may stop breathing altogether. Vaccination protects most children, but immunity wanes, so adolescents and adults can be infected and pass the bacterium to those too young to be immunised.

For all their frequency, coughs are poorly served by medicine. Systematic reviews have repeatedly found no good evidence that the cough syrups sold in pharmacies shorten an acute cough, and some contain ingredients that are not recommended for young children. In 2018 the National Institute for Health and Care Excellence, which advises the health service in England, suggested that honey might be offered to children over the age of one. For chronic cough, doctors try to identify and treat the underlying cause; where none can be found, speech and language therapy, which teaches patients to control the reflex, has shown some benefit.

Research in the past two decades has changed how specialists think about chronic cough that has no obvious explanation. Rather than being a sign of hidden disease, it may reflect a sensitised reflex: the nerve endings have become hypersensitive, so that ordinary stimuli such as cold air, perfume or talking trigger coughing. This concept, usually called cough hypersensitivity syndrome, has become the basis of new treatments.

None of this makes the cough less necessary. It is a defence that has persisted across mammals because it works, and suppressing it completely, particularly in a patient with pneumonia, would be unwise. The aim of treatment, where treatment is needed at all, is not silence but relief.

A family doctor in a busy surgery sees patients whose difficulties do not fit on a prescription pad. An elderly man whose wife has died; a young mother newly arrived in a strange town; a woman with diabetes whose real problem is that she cannot afford to eat properly. In each case the medical complaint is genuine, but it is tangled up with circumstances that no drug will alter. In its Long Term Plan, published in 2019, the health service in England undertook to fund a thousand link workers in general practices, whose task is to refer such patients to walking groups, arts workshops, gardening projects or advice services. The idea has a name: social prescribing.

The underlying argument is old. Since its constitution of 1948, the World Health Organization has treated health as more than the absence of disease: in its definition, social and mental well-being count as much as physical fitness. Sir Michael Marmot, whose studies of British civil servants in the Whitehall research showed that health follows social position, has spent decades arguing that the conditions in which people live and work shape their health more powerfully than the health service does. And Julianne Holt-Lunstad, whose analyses pool the results of many separate studies, has repeatedly found that people with few social connections are more likely to die within a given period than those with many.

On this view, a consultation about sleeplessness and low mood in a recently widowed man is not a nuisance that distracts from real medicine. It is medicine, and the appropriate treatment may be a weekly walking group rather than a tablet. Family doctors report that a substantial share of their consultations are driven mainly by problems that are social rather than clinical, and that they lack the time, the training and the contacts to address them. A link worker who knows what is happening in the local community is, in this account, a sensible use of resources, and versions of the idea have since appeared in several other countries, including the Netherlands and Canada.

The difficulty lies in the evidence. Reviews of social prescribing have repeatedly found that the studies are small, that few of them compare participants with anyone who did not take part, and that those who enrol are often motivated volunteers rather than typical patients. Reported improvements in mood and in confidence are encouraging, but they may owe as much to the enthusiasm of the people running a project as to the activity itself. Schemes also vary enormously: a referral to a choir, a referral to a debt adviser and a referral to a gym are not the same intervention, and lumping them together under a single label makes evaluation harder.

There are further misgivings. Some clinicians worry that social prescribing allows governments to present as generous a policy that is in reality an economy measure, transferring to unpaid volunteers and struggling charities work that salaried staff once did. Others object that it medicalises loneliness: a bereaved person who is referred by a doctor to a coffee morning may reasonably feel that a normal human experience has been turned into a diagnosis. Community organisations, for their part, point out that they cannot absorb a flood of referrals without secure funding.

None of these objections is decisive. The strongest argument for social prescribing is not that it saves money, which has never been demonstrated convincingly, but that the alternative is worse. A doctor who has nothing to offer but a prescription may issue one, and Britain's rising use of antidepressants for mild and moderate distress is a case in point. A society that has no way of responding to isolation except through the clinic is one in which the clinic will be asked to do work it cannot do. A referral can be made in a few minutes, whereas a course of psychological therapy may mean months on a waiting list, and for mild distress the wait itself may cause harm.

What, then, would make the policy defensible? The answer is the standard that the National Institute for Health and Care Excellence applies to any treatment: evidence of benefit and of cost. That means well-designed trials with control groups, clear descriptions of what is being offered, and follow-up long enough to show whether improvements last. It also means honest reporting of schemes that fail. At present the field is dominated by enthusiastic small projects whose results are published by the people who ran them.

Two conclusions follow. The first is that social prescribing should be funded and evaluated, and that the link worker model is a reasonable way of doing so. The second is that it should be prescribed with the medicine, not instead of it. Funding should follow the referral, so that the community groups receiving patients are not left to absorb the cost themselves. No responsible doctor would send a patient with severe depression to a gardening club in place of treatment, and no sensible policy would present community activity as a cheaper substitute for clinical care.

The question in the title, then, is badly framed. Social activities are not an alternative to medicine; they are part of what health care has always tried to do, which is to help people live well, provided that they are offered honestly and tested properly.