BMJ  2005;330 (23 April), doi:10.1136/bmj.330.7497.0-f

Editor's choice

Preventive medicine makes us miserable

The old adage—prevention is better than cure—is one we have heard so often that it's hard to shift from our minds. It is intuitively powerful. It just seems to make sense. But shift it we must, for it fuels what Iona Heath, in her cogent article this week (p 954), calls "the excessive self confidence of preventive medicine," which is making us ill and miserable.

Paradoxically, says Heath, the more people are exposed to doctors and contemporary health care, including the rhetoric of preventive care, the sicker they seem to feel. Meanwhile the developing world is starved of affordable treatments. Heath's solution? A tax on preventive drugs sold in rich countries to fund treatments in poor countries, helping both sides to a better balance.

More than two thirds of people in the UK now take medicines to treat or prevent ill health or to enhance wellbeing. Heath asks us to consider the opportunity cost even within a developed country of directing vast sums of money to health promotion rather than to providing better care for those who are actually ill. Of course, there's more money to be made from selling interventions for the healthy majority than for the sick minority, and it helps if you can turn a risk factor (high blood pressure, osteopenia) into a disease.

Whether or not preventive medicines work, they bring with them their share of iatrogenic harms. Heath asks, are we sure that the balance sheet of preventive activity offers more good than harm? Attempting to answer this question for women invited to attend mammography breast screening, Barratt and colleagues (p 936) have created a balance sheet of benefits and harms for women in different age groups.

As Paul Taylor explains in his accompanying editorial (p 915), the main potential harm is overdiagnosis—causing unnecessary anxiety and intervention for those who might otherwise have lived and died (of some other cause) without ever having had their cancer detected. Barratt et al estimate that between 2% and 30% of invasive cancers fall into this category. The benefits and harms for mammography are finely balanced. The decision to be screened is, they say, a gamble, with only a small chance of benefit but a great deal at stake. These kinds of data are being used in patient decision aids in Australia and should be tested more widely.

Because it is acted on healthy people, preventive medicine needs even stronger supporting evidence on benefits and harms than therapeutic interventions. And, for a new age, we need new adages. But will they have the same ring to them? Prevention may not be better than cure. A stitch in time may in some cases be unnecessary and even harmful. All better ideas to bmj.com.

Fiona Godlee, editor

(fgodlee{at}bmj.com)

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Relevant Articles

Who needs health care?: Preventive medicine has potentially big role
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BMJ 2005 330: 1331. [Extract] [Full Text]

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