Heroes Not Zombies

Iona Heath wrote an open letter to Gordon Brown in the BMJ this week. She quotes his recent statement on preventitive services in the NHS –

…..an NHS which:”Identifies your clinical needs earlier than before, is targeted to keeping you healthy and fit, and puts you far more in control of your own health and your own life. And in the long run a preventive service personal to your needs is beneficial not just to individuals but to all of us as we reduce the cost of disease.”

She reminds us that Beveridge said at the time of the setting up of the NHS that he –

envisaged “a health service which will diminish disease by prevention and cure.” He foresaw “development of the service and as a consequence of this development a reduction in the number of cases requiring it.”

It was nonsense then and it’s also nonsense now. Neither the disease-focussed treatments of the NHS, nor the screening and early intervention strategies proposed will lead to a healthier nation. Iona Heath writes –

Medical science does not save lives, it defers death. No one lives for ever and, on average, a quarter of a lifetime’s costs of health care are incurred in the last year of life, whenever death occurs. Preventive health care, when it lengthens lives, exposes people to other health risks and cannot reduce costs. You imply that preventive health screening is an entirely benign endeavour and you make absolutely no mention of the well recognised harms of screening. When those who consider themselves healthy submit themselves to screening, they confront the possibility of serious disease and inevitably this can cause a burden of anxiety that varies from the trivial to a severity amounting to disease in itself. Every screening test gives both false positives and false negatives: the one dangerously reassuring, the other leading inevitably to further investigations that become increasingly invasive and risky.

and

Your problem as the financial custodian of the health service is that much of the burgeoning pharmaceutical treatment of risk factors is futile. Once a risk has been identified and treatment initiated, there is no way of knowing whether the treatment is effective but, none the less, it must be continued. The outcomes are negative, can only be measured at the population level, and cannot be assessed in relation to the individual taking the medication. A health service based on need and the relief of suffering is affordable by a tax paying population; one based on treating every identifiable risk factor is not.

These excellent points are not heard often enough. Too often the drug treatment of a risk factor is promoted as being life saving. Even if it did what it claimed to do it would not save lives……it would change the cause of death and in doing so alter the life experience. This is not the way to help more people experience better health for more of their lives.

Dealing with poverty, the enormous and increase disparity in incomes, improving housing, education and the experience of work, have all been shown to be factors which help to improve the health of populations. These interventions don’t try to pick off risk factors one at a time, they improve quality of life and resilience overall.

Isn’t it time we started to take on board that health is not the mere absence of disease, and therefore to understand and promote what is genuinely healthy instead of focusing on disease avoidance?