Heroes Not Zombies

Iona Heath writing in the Public Library of Health Medicine journal nails the issue of disease mongering.

There are a number of issues to consider in relation to the problem of disease mongering. She particularly focuses on the use of pharmaceuticals for preventitive medicine reasons.

The first step has to be a genuine disentanglement of the medical profession from the pharmaceutical industry—there really is no such thing as a free lunch

Sadly, there is an enormous, unhealthy, amount of pharmaceutical industry influence on not only individual doctors, but on regulatory bodies, governments and the publication of so-called evidence on which policies and protocols are based. Until we tackle this influence, disease mongering will continue to grow apace.

Beyond this, there is a need for better science that has the integrity to demand more explicit acknowledgment of the limits of medical knowledge, less extrapolation beyond research findings, and much more responsible use of statistics, so that the true extent of the benefits and harms of proposed treatments can be properly understood.

There’s a terrible tendency these days for people to claim knowledge which enables them to make predictions about treatments with certainty. Human life is not certain, and, as human beings can be considered as complex adaptive systems, it is impossible to predict outcomes in detail in any individual case. Research trials and statistics are not the whole truth, and they never will be.

Most variables are distributed across a continuum, but despite this, the medical tradition has been to dichotomise the continuum into normal and abnormal

It is irrational to divide human phenomena into two discreet categories – normal and abnormal. It isn’t scientific to do that, and it certainly isn’t realistic. There is no such thing as some drugs which work and others which don’t. No drug has the same effects on everyone who takes it.

When doctors treat patients with diseases, progress can be assessed and the outcome is measurable. This means that if the patient responds to treatment, it can be continued; if not, the treatment can be stopped. When doctors treat people who are merely at risk of disease, the outcome is probabilistic, so whether disease is prevented or was never going to develop, the treatment continues indefinitely

I’m not sure it’s always so clear that a patient has responded to treatment, or at least, responded sufficiently to treatment. After all, who is to judge the “sufficiently”. However, I do agree with Dr Heath’s point that if you prescribe drugs to reduce risks you can never stop prescribing them. You are condemning those “at risk” to a lifetime of treatment as if they had a disease.

Part of the rationale for expenditure on the treatment of health risks is that it will reduce health costs in the long run, but such arguments do not stand up to close scrutiny. The costs of health care are highest during the year before death, regardless of the age at which death occurs. Everyone must die and be cared for while dying, and no amount of preventive pharmaceuticals can reduce the cost of providing this crucial end-of-life care

You don’t make people healthier by prescribing drugs, and you never achieve immortality. We all die, and the last year of life is the year we receive most health care.

Dr Heath’s final sentence is this –

Ultimately, the only way of combating disease mongering is to value the manner of our living above the timing of our dying.

Couldn’t put it better. We need to focus on health more than disease, and on living, more than dying.