BMJ  2004;329 (11 December), doi:10.1136/bmj.329.7479.0-g

Editor's choice

Public health's Holy Grail

A television company once approached us proposing a fly on the wall documentary of life at the BMJ. Viewers, we reasoned, would find it hard to be mesmerised by editors staring at computer screens or discussing sample sizes and the finer points of nested case control studies.

Were we wrong? Reality television manages to sex up most professions, and medical editing can be almost as exciting as hairdressing, dog walking, or proper doctoring. "I'm a manuscript, get me out of here," would be discussed in tabloids and on digital channels. The editor with the "X Factor" might—thanks to the public phoning premium rate numbers and pressing coloured buttons on remote controls—be elevated to the editorship of the BMJ, and the loser to the editorship of the Lancet.

The international outbreak of reality television might even be good for public health if it was legislated to carry public health warnings as advertisements. So promotion of beer, fizzy drinks, and salty foods would be out, and gruesome footage of people with end stage respiratory failure, severe peripheral vascular disease, and morbid obesity would be mandatory. Governments talk about the Holy Grail of delivering public health messages into people's living rooms—what could be better? This is an important hypothesis that needs further investigation.

Another important hypothesis that requires exploration is the finding of this week's research pointer. Folate supplements in pregnancy are advised to prevent neural tube defects in infants, supported by a reasonable evidence base, and widely used—either through personal choice or fortification of food. But what do we know about harms? Not much, argue Deborah Charles and colleagues, who completed over 30 years of follow up of a supplementation trial to find that higher doses of folate may double the risk of maternal breast cancer and hasten death (p 1375).

The result is not statistically significant—and may be the play of chance—but troublesome enough for the authors to propose further study. Clearly, nobody should avoid folate supplements on the strength of this work (p 1376), and many readers will consider the study to be sensationalist and meaningless. Journals, though, have a role in asking uncomfortable questions that may produce uncertain answers.

For those seeking succour in rigour, Ian Colman and colleagues show that parenteral metoclopramide is an effective treatment for migraine headache, and propose it as primary therapy in emergency departments (p 1369). A randomised controlled trial indicates that targeted occupational therapy at home increases mobility in people after stroke (p 1372). And two papers describe the benefits of spinal manipulation for back pain (p 1377, p 1381).

That's where the reality of 2004 almost draws to a close, except for our seasonal double issue that hits your doormats and browsers next week, asking uncomfortable questions such as is democracy good for people's health, is Gollum schizophrenic, and is a polimeal safer—and tastier—than the polypill?