What is the focus of medical care?
B. M. HEGDE
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An inseparable marriage between the pharmaceutical lobby and the medical profession
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On October 3, 2008, as usual on any Friday, I received the new British Medical Journal with an editorial on the need to have a broad perspective on management of killer diseases like heart attack, stroke, and their risks. I was a bit confused by the editorial and the connected articles in that issue. Fiona Godlee, the editor, and her authors of the cited articles were advocating a broad perspective to preventing cardiovascular disease, and rightly so. At
the same time they were forgetting the most important aspect of the risk factors for CVS diseases — the mind of the victim.
While all the contributors and the editor seemed to be totally engrossed in and obsessed with some of the questionable risks like cholesterol, raised sugar and arterial pressure, and even that evanescent homocycteine the whole gamut of the vital role of the human mind seemed to have slipped away.
All the components of the poly-pill, advocated in the editorial as the panacea for the prevention of all diseases if every one above the age of 55 years were to receive them in society, when tested individually even in adequate doses, did not significantly reduce the end results of stroke or heart attack and death. While there were significant relative risk reductions, the absolute risk reductions were negligible and the number needed to treat was prohibitively high with dangerous (even fatal) adverse drug reactions (ADR). Ebrahim Shah and GD Smith went one step further to show that the pooled effect of multiple risk factors interventions on mortality were insignificant and very small. Professor Michael Oliver, FRS, had shown that drug use for risk reduction was almost useless. Smith and Eggar ask a very pertinent question as to “who benefits from medical interventions” in this scenario? These all add up to the case of the missing evidence of Sherlock Holmes.
Did not Hippocrates warn his progeny to study the patient in greater detail compared to the disease? Sun light is more powerful than the poly-pill to lower many of those risks mentioned, especially cholesterol. Nobody seems to advocate sun bathing. In our efforts we seem not to be concerned with the apparently “well” human beings that we are targeting for the poly-pill!
Lack of awareness
Every one seems to swear by epidemiology. The latter’s capacity to forecast the future has been questioned by some of the leading epidemiologists of the U.K. like Ebrahim Shah and others. Reminds me of what Albert Einstein wrote in his essays on religion: “With absence of perspective of history or philosophy in academia, we have started making technicians of science in tons, who pride themselves as scientists, and in medical science making health care vending dispensers on assembly line, who pride in calling themselves doctors.” Mary Tinnetti, professor of medicine at Yale University, had written that our obsession with the “disease” concept is our undoing. She adds “that the time has come to abandon disease as the focus of medical care. The changed spectrum of health, the complex interplay of biological and non-biological factors, the aging population, and the inter-individual variability in health priorities render medical care that is centred on the diagnosis and treatment of individual diseases at best out of date and at worst harmful.”
All these efforts to use drugs at the drop of a hat are due to the inseparable marriage between the pharmaceutical lobby and the medical profession. In the words of one of the leaders in the field, Marcia Angell, a former editor of the famous New England Journal of Medicine, says that “the ties between clinical research and industry include not only grant support, but also a host of other financial arrangements. Researchers serve as consultants to companies whose products they are studying, join the advisory boards, and the speakers’ bureaus, enter into patent and royalty arrangements, agree to be listed authors of articles ghost written by interested companies, promote drugs and devices at company sponsored symposia, and allow themselves to be plied with expensive gifts. Many also have equity interest in companies. Academic medical institutions are themselves growing increasingly beholden to industry.”
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