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Rapid Responses: Rapid Responses published:
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A case of Schrodinger's medical cat
- Vadakkuppattu D Ramanathan (22 April 2005)
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preventive medicine within individual
- Vaidyanathan Gowri (22 April 2005)
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Preventive Medicine: we can act today, if we will it
- Sergio Stagnaro (22 April 2005)
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preventative????
- benjamin dean (22 April 2005)
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Gaite' de coeur-SHEER WANTONNESS.
- BM HEGDE (23 April 2005)
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Are we talking about the same issue?
- Margaret J Tyson (23 April 2005)
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Preventive Medicine: misuse and misinterpretation
- Pedro O. Ordúñez-García, MD (23 April 2005)
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We are mere mortals
- Graeme M Mackenzie (26 April 2005)
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From passive to active
- Takeharu Koga (28 April 2005)
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Corrupt governments are the issue
- Jennifer Parker, Frances Groen (28 April 2005)
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Best form of preventive medicine : Impeach all fancy (Non) disease entities from medical literature !
- venkatesan sangareddi (29 April 2005)
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Prevention or Cure? "Primordial" is the key word!
- Mayank Vashishtha (29 April 2005)
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short termism
- benjamin dean (2 May 2005)
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Take prevention out of the health care system
- Alan D Penman (3 May 2005)
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Preventive Medicine or Early detection of future illness?
- Friederike M. Perl (18 May 2005)
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Alternative wisdom
- Adrienne J J Garner (31 May 2005)
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Vadakkuppattu D Ramanathan, Dy.Director & Head, Tuberculosis Research Centre
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Dr.Godlee’s Editor’s Choice is thought provoking. The question of preventive medicine basically has two components. One is that of finding out whether somebody is in need of preventive therapy and the other is actually embarking on medical or surgical intervention as a precautionary measure. I have always wondered whether the very act of investigating can provoke a particular situation. Classically, it is like the measurement problem that physicists talk about. We are in a ‘brown state’ till a test is done. In other words, there is neither health nor disease till an investigation is performed (to paraphrase an old adage that there is nothing good or bad but thinking makes it so). Schordinger might have called this as the ‘medical cat’! However, there is a larger issue here. Do people have sufficient knowledge of health available to them easily? What is the quality of pre investigation counseling before actually doing a test in an apparently healthy individual? As a pathologist while conducting postmortems, I have come across massive lesions - infections, malignancies involving multiple organs in persons who were healthy or at least did not complain about symptoms pertaining to the pathological lesions. Do we know what would have happened in such individuals had they continued to live? Preventive medicine necessarily does not mean taking medicines or undergoing surgical interventions alone. It should encompass other means such as changing one’s life style etc., also. Therefore, these means should be more actively explored rather than go with the approach of ‘every ill needs a pill’. Finally, taxing does not always work. Remember there are poor people even in rich countries and they will also be taxed. Even when people are taxed, the taxes do not necessarily reach those in need but very often go to the coffers of arms manufacturers. V.D.RAMANATHAN MB, PhD (London), Dy.Director & Head, Division of Clinical Pathology, Tuberculosis Research Centre, Chetpet, Chennai - 600031, INDIA. Competing interests: None declared |
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Vaidyanathan Gowri, Doctor Oman, Muscat code 123
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Sir/Madam
Yes the preventive medicine we are talking about certainly can do more harm than good. Essentially the preventive medicine we do is "lab medicine and machines and all hi tech investigations including expensive MRI, etc.,) There is certainly a lot of place for an individual to look after themselves and in my opinion THAT is preventive medicine for eg: prevention of overweight in any individual & who has strong history of diabetes even if you do not screen for diabetes; not to smoke; avoid soft drinks which dissolve your teeth and enamel totally, etc. Imagine a 45 year old lady running from one cilinic to another every 6 months- year pap smear, mammogram, bone mineral density, tread mill if necessary where is the time for herself or her family??? More needs to be done to prove that most of these screening tests are useful. Vaidyanathan Gowri Competing interests: None declared |
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genova) Italy.
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Editor, I can’t agree with such a statement that "the excessive self confidence of preventive medicine" is making us ill and miserable (1). Certainly, preventive medicines can work, if we know and can recognize at the bedside, on a very large scale, e.g., individuals affected by dislipidaemic AND diabetic constitutions, conditio sine qua non of type 2 DM, among a lot of other constitutions, such as gouty, arteriosclerotic, hypertensive, osteoporotic and particularly ONCOLOGICAL or Oncological Terrain (2-6)(See www.semeioticabiofisica.it). We may utilize today efficacious clinical tool in primary prevention, if we will it, but mass media have to be more “up-dated” (!) than today’s ones. In a few words, in my view, based on 48 year-long clinical experience, doctors would be able to estimate at the bed-side, for instance, the real risk of coronary heart disease, even in a deaf-mute, lacking in records and without relatives around him, in day to day practice as well as in the emergency room. But, for such a purpose we need a new physical semeiotics more efficacious and reliable than the poor, traditional, academic one. Fortunately, the future has already begun: since now, doctors can evaluate clinically, e.g., myocardial oxygenation, coronary endoarterial blocking devices function, coronary microcirculatory functional reserve efficacy, myocardial preconditioning, a.s.o. (2-6) 1) Godlee F.Preventive medicine makes us miserable. BMJ 2005;330 (23 April), doi:10.1136/bmj.330.7497.0-f . 2) Stagnaro Sergio, Stagnaro-Neri Marina. Introduzione alla Semeiotica Biofisica. Il Terreno oncologico”. Travel Factory SRL., Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm 3) Stagnaro-Neri M, Stagnaro S. Co Q10 in the prevention and treatment of primary osteoporosis. Preliminary data. Clin Ter. 1995 Mar;146(3):215-9 [ MEDLINE] 4) Stagnaro S., Stagnaro-Neri M., Le Costituzioni Semeiotico- Biofisiche.Strumento clinico fondamentale per la prevenzione primaria e la definizione della Single Patient Based Medicine. Ediz. Travel Factory, Roma, 2004. http://www.travelfactory.it/semeiotica_biofisica.htm 5) Stagnaro S., Diet and Risk of Type 2 Diabetes. N Engl J Med. 2002 Jan 24;346(4):297-298. letter [PubMed –indexed for MEDLINE]. 6) Stagnaro S., Stagnaro-Neri M., Single Patient Based Medicine.La Medicina Basata sul Singolo Paziente: Nuove Indicazioni della Melatonina. Travel Factory SRL., Roma, 2005. http://www.travelfactory.it/semeiotica_biofisica.htm Competing interests: None declared |
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benjamin dean, dr oxford
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Fiona Godlee argued that preventative medicine makes us miserable, but it all depends on what you mean by preventative medicine in the first place. I believe she manipulated the reader with a cunning play on words to make a false conclusion. There is no doubt that people can become miserable when overwhelmed by medical interventions that make little difference. Also it is a good argument that more things are labelled as diseases, enabling increasing medical therpaies to be used routinely. However I do not believe that this is the main role of preventative medicine. This is medicine on the borderline between the therapeutic and the preventative; a real grey area of controversy. I see preventative medicine as encompassing education, government policy and public health. Our country lags behind relative to other developed countries as far as nutrition, physical activity and recreational facilities are concerned. The key in preventative medicine lies in using our modern medical knowledge to influence fields outside medicine; where most of the benefit can be reaped. We need the government to take a lead in preventative medicine to keep the nation healthy, but to do this doctors must lobby the government. This will make more difference than investing many extra millions in the NHS. I don't think the nation would be miserable if they could find healthy food more readily available at cheaper prices, if they could pop out for a game of tennis on the local council courts easily and if smoking was banned in public places. These are just a few examples but this is where preventative medicine should begin, and I believe the aspects of preventative medicine talked about by Fiona Godlee represent a grey area bordering on medical therapy, not prevention. Real preventative medicine would make everyone a lot less miserable, but it will take a strong government to take the lead which looks rather unlikely in the current political climate where the long term health of the nation comes a distant second to winning votes. Yours, Dr Ben Dean Competing interests: None declared |
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BM HEGDE, Retd. Vice Chancellor MANGALORE-575 004, INDIA
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Dear Editor, “Men are disturbed not by things which happen, but by the opinions about the things." Epictetus; First Century Greek Philosopher. "No I am no philosopher but, every one should preach this creed because it is rational." wrote Anton Chekhov in his wonderful book "WARD 6 AND OTHER STORIES" (1892-95) It is the sheer wantonness of the greedy medi -business that has brought the noble profession of medicine to this pass in the present Century. Reading Fiona Godlee's editorial brought back all those memories to my mind as I had been struggling to bring those facts to the notice of the medical world in the last four decades without much success. I was swimming against the powerful currents. Now that the most respected BMJ editor has written about the subjectI thought I could bring the salient features of all that I have written in many books and in many of my articles in this response. Modern medicine has become prohibitively expensive. It is going to be still more so with newer technology invading medical diagnosis and management more and more. Most of these technologies have not been audited and some of those that were inadvertently audited did not come up to the expectations of their promoters and, in some instances, have even caused more harm than good.(1) It is estimated that around 80% of the world population has not been availing the modern medical facilities! Around half of the rest who have even free access to modern medicine would prefer to have an alternative system, if available, even in the industrialized west. The reasons for the disillusionment are protean (2), but the lack of medical humanism is one of the foremost. Oregon state in the USA realized, to their dismay, that one bone marrow transplant in a terminally ill cancer child would cost as much to the taxpayer as looking after the health needs of one thousand pregnant women through pregnancy and delivery, as also the health needs of the babies for the first year of life. Recently, they enacted the Oregon Law that bans bone marrow transplants for terminally ill cancer children at the taxpayer’s cost. This did create trouble in the beginning but, eventually, many other states have followed suit. This could give one an idea of the magnitude of the financial load of covering every citizen with all the hi-tech stuff even in the rich nations. Most of these techniques only make life appear longer making the patient a slightly better cripple. Let us not bother to look at the scenario in the poorer countries for the purposes of this paper. Suffice it to quote the recent WHO document (WHO 2002) that shows that if the people of the poorer nations were to get clean drinking water, it would bring down two million deaths per year and prevent half a billion serious illnesses. Obviously our priorities are skewed very badly. The western pharmaceutical industry, however, is trying to push the costly, many times unproven, drugs and technology (3) into the third world, where even today the common man does not have access to clean drinking water, three meals a day with food uncontaminated by human and/or animal excreta, and a toilet to avoid the deadly hookworm infestation of children! Need for a new paradigm in medical care: Robust circumstantial evidence goes to show that the 80% of the world population that does not have access to modern medicine lives using their intuition in times of need and get benefit from many other time-tested alternative systems of medicine, many of them being much more ancient compared to the modern medical wisdom. One of them, the Indian system of Ayurveda, is much more ancient, having survived the discouragement in the recent past even in India. We now have unequivocal data to show that Ayurveda is the mother of most other systems, notably the modern medical system.(4) Present day modern medicine originated in the Nile Valley five thousand years ago as sorcery, witchcraft, magic and mumbo-jumbo. Present day “much of the news and advertisements of health education with which we are bombarded are designed to heighten our worries, not soothe them; many drug companies play upon our tendencies toward hypochondriasis.” Wrote Herbert Benson in his celebrated book Timeless Healing.(5) In its onward journey through Arabia and then Greece, modern medicine came under the spell of Ayurveda taken to Greece by the army of Alexander, the Great. There are two authentic works to support this hypothesis. INDIA IN GREECE is an excellent treatise written by a great Greek scholar, E. Pococke, who lived in India for years. He wrote this book in 1832 AD. Another authoritative book is the one on Ancient Indian Medicine written in 1936 by Late Prof. P. Kutumbiah, MD, FRCP., who served as the Professor of Medicine both, in Vellore and, later, at the Madras Medical College. This apart, the popular belief about the eradication of the only scourge of mankind, smallpox, needs a major change to get at the truth. Dr. T.Z.Holwell, FRS, was a Fellow of the London Royal College of Physicians. He spent twenty years in “The Bengall Province” of the Raj to study the Indian system of vaccination and its power in preventing small pox. After twenty years of prospective controlled studies, he concluded, in his report to the Royal College, submitted in the year 1767 AD, that the Indian system of vaccination, which existed for “times out of mind,” with a type of attenuated small pox virus, was ninety per cent effective in preventing small pox deaths and had very little side effects. This report, in its original shape, is still available in the archives of the College library. It can not be Photostatted but is in the Internet as a Revised Version. Surprisingly, it survived the great fire in the library some years later. Holwell favored permitting the anecdotal experience of Edward Jenner to be used freely in view of the Indian experience of antiquity! He pleaded with the President and Fellows of the Royal College to recommend to the King the free use of Jenner’s unproven method in view of his solid proof from Indian vaccination system. Rest is history known to all. (6) Suggested New Classification of Diseases: To understand the new paradigm one needs to classify human diseases based on the treatment needs thus.(7) • * Emergency Medicine…………………………..10% of the sick population. * Minor illness syndromes………………………35% • * Doctor-Thinks-You-Have-a-Disease……….15% • * Patient-Thinks-He-has-a-Disease………….10% • * Neoplasias………………………………………..10% • * Chronic Degenerative Diseases…………….10% • * Iatrogenic Diseases…………………………..10% Classified like this most of the diseases, where modern hi-tech medicine, with all the glittering array of diagnostic tools, the expensive interventions and drugs are of utmost need, fall into the first category of emergency diseases. The new specialty of emergency medicine in the west is the most welcome timely step in the right direction. Rather, it heralds the need for the paradigm shift, referred to earlier. It is here that the advances of modern medicine could make a dent in improving the lot of the suffering humanity and, possibly, also in preventing avoidable deaths. In the emergency set up even the unproven technology could be justifiably used in extreme situations. Time has come for a proper audit of the present use of hi-tech medicine under all the illness situations classified above. I strongly feel that in the non-emergency situations we need not (possibly, should not) resort to hi-tech modern medical help. We could easily put together an inexpensive method of managing most of those 90% illnesses using a judicious mix of the best in many useful alternative systems of medical care.(8) Rarely in some of those situations, like the neoplasias, modern medicine could be used in conjunction with scientifically tested alternatives, to reduce the cost and the intolerable side effects of chemotherapy and radiation. The two mentioned above have not shown themselves in very good light so far. Many of the newer, yet to be tested but, much hyped, chemo- therapeutics are prohibitively expensive for the poor. These methods of cancer management have not made a significant dent in total cancer deaths. Cancer deaths have still to level off before showing a tendency to come down. This could be contested using statistical methods known to modern researchers, though. There are excellent remedies for the control and/or prevention of the major class of minor illness syndromes, that cause the largest sick absenteeism in productive fields everyday, in Ayurveda as well as other alternative systems. Some of them have been tested by the modern medical methods already. The powerful anti-viral properties of Indian spices, mainly garlic, ginger, and pepper have been studied in the leading western laboratories. More than all that is the thrust in Ayurveda of methods to keep the healthy well. These health-promotive strategies, not disease preventive strategies, are the backbone of Ayurveda. “Swasthasya swastha rakshitham.” [Keep the well healthy] This is the most important slogan in that system and there are many methods of health promotion based on life style changes, food habits, exercise, yoga, meditation (making the mind tranquil), and also certain herbal remedies to slow the ageing process. Time does not permit me to dwell into the useful methods in many other systems of health care delivery people have been using down the ages. Unfortunately, quacks and unqualified people have brought disrepute to most of those systems.(9) It is because those methods have not been scientifically evaluated before being let loose on the gullible public. This must stop forthwith! The reader could be surprised to know that the ancient school of medicine of Shushruta needed a much longer period of training to be a doctor than most modern medical schools today. The students studied human anatomy in much greater detail for much longer time to achieve perfection! All these need to be looked into before we jump at the new bandwagon of other systems. What I am advocating is not too many systems to be used concurrently. The best brains in the various systems will have to put their heads together to evolve a new system, the complementary system of medical care, that has a scientifically judicious mix of the best in all those systems along with the emergency hi-tech care for a wholistic medical care delivery system that could economically do most good to most people most of the time. There was an audit of the effect of modern medicine in the USA about two decades ago. Whereas 59% of the improvement in human health and fall in disease incidence there could be attributed to improvement in sanitation, improved nutrition, better education, decent housing, economic empowerment of the masses, and healthier life style avoiding tobacco and alcohol, only 3.4% of the change could be due to modern medical claptrap! One needs to repeat this in many other countries to get a better picture that might motivate even the skeptics to agree to the paradigm shift. Surprisingly, even in the emergency set up, although I feel that the latter definitely needs hi-tech, a comparative study of the per capita deaths of the wounded soldiers in the Vietnam and Falklands wars did show that it was marginally better in Falklands compared to Vietnam. While the American soldiers in Vietnam had the best base hospital in the nearby Saigon, the British did not have such luxury in the South American war theatre. Many a time the wounded soldiers in Falklands were left to be tended by the forces of Nature, before being attended to and, that too, not in a sophisticated hi-tech modern base hospital. One of the explanations for this disparity could be that we have been interfering with Nature’s methods of dealing with human injury with the help of the sympathetic system evolved to protect the hunter-gatherer forefathers of man, from the most important danger those days of predation! Complementary Medical Care Delivery System: The idea of mooting this strategy is to stimulate people to think about this possibility to make medical care available to all the people of the world, rich and poor, that is not only equally effective but cost effective as well. We must take care to see that the new system is put in place after due care to see that untested, unproven, and potentially dangerous methods do not get included. The scientific methods and agencies overseeing this stupendous task must not only be highly competent, but should be equally authentic. We hear of the fraud in medical research in modern medicine almost daily, to be brushed aside lightly. With that background, the people at the helm of affairs must have proven track record. There would be great opposition from the all-powerful drug and technology lobbies that literally run medical education in the west these days.(10) They start brainwashing the future doctors from day one at the medical school, only to stop at their graves! It is heartening to know, though, that there are very good people even in those areas, but they are like an occasional oasis in the vast desert sand and are an endangered species, indeed. We should be able to get their help in this humanitarian venture. With the present worldwide communication facilities the task of bringing the best people together need not be difficult. Well meaning people in the modern medical field should take the lead to bring respectability to this effort. We need to do a lot of education of the common man and the media to accept this line of thinking in the midst of the powerful and rich medical claptrap.(11) I am happpy to say that I have been a part of such an effort recently organised by the Penn State University in Washington DC on WHOLE PERSON HEALING. More about it at a later date. The Pharma industry has a vested interest in keeping the system as it is. The present hi-tech medical care delivery system is a big business. This is the very reason why medicine has lost its heart today. The time-honoured doctor patient relationship is replaced by the doctor being viewed as the seller and the patient the buyer of medical technology, bringing in its wake the consumer movement into medicine.(12) The crux of the medical scenario is the trust that the patient has in his/her doctor that provokes the immune system to heal the sick. Healing is a much larger concept than the concept of “curing” used commonly by doctors.(13) Doctor only dresses the wound; the immune system heals it.(14) Let us bring back the patient confidence in his/her doctor back into the medical arena for the common good, before it is lost for ever. “No man, no author, not even the greatest, ever provide the last word on anything. Men are vain authorities who can resolve nothing.” (II, 13) Michel de Montaigne. BIBLIOGRAPHY 1. Robin ED. Death by Pulmonary Artery Flow Directed catheter. Time for a moratorium. Chest 1987; 92: 727-729 2. Steven Milloy. Science without Sense, 1997. Cato Institute, Washington 3. New Scientist, 17th september 1994, page 23 4. Ancient Indian Medicine, Kutumbiah P. Oxford University Press 5. Benson H. Timeless Healing. 1996 Simon and Shuster, Sydney 6. Hegde BM. Vaccination in India, JAPI 1998; 46 : 472-473 7. Hegde BM. Are We Barking up the wrong tree? The Cardiologist 2000:Vol. 3 No.4 :1-3 8. Coleman V The betrayal of Trust, European Med. J. 1994; :4 9. Editorial. Flight from Science. BMJ 1980; :1-2 10. Editorial. Drug company influence on medical education in the USA Lancet 2000; 356: 781 11. Austin JA. Why patients use alternative medicines? JAMA 1998; 279: 1548-53 12. Weil A. The significance of integrative medicine for the future of medical education. Am.J.Med 2000; 108: 441-443 13. Smith GD, and Ebrahim S. Data Dredging, bias, or confounding. BMJ 2002; 325: 1437-1438 14. Bernardi L, Bandinelli G, Cencetti S, et. al. Effect of Rosary Prayer and Yoga mantras on Autonomic cardiovascular rhythms: Comparative study. BMJ; 2001; 323: 1446-1449 Competing interests: Worried about the ravages of the present medical care system. |
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Margaret J Tyson, Independent researcher PhDs, The Orchard, Woodseats Lane, Charlesworth, Glossop SK13 5DP
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Preventive medicine and preventive healthcare: are they the same? When I think of preventive medicine/healthcare I’m thinking of changes to lifestyle not taking herbal/preventive medicines from health shops. This means not going to the GP! It means not taking more medication but less! It means not looking at your medical health records (electronic or not)! It certainly does not mean visiting a health shop! It means a society where living a healthy and enjoyable lifestyle is integral through public health population measures and education. It means not even thinking about your health until you catch a disease or have some genetic problem to solve. Once this happens we can all live a happy life and go back to the days when you only saw a GP every year or so. Preventive medicine/healthcare does not have to make us miserable! Margaret Tyson (Dr) Competing interests: None declared |
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Pedro O. Ordúñez-García, MD, General Director Hospital Gustavo ALdereguía, Cienfuegos 55 100. Cuba
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Editor—Thanks Fiona Godlee (1) for your confession but I can’t accept it. The preventive medicine is a big sachet where everybody wants to put inside almost anything and consequently it is often misused and misinterpreted. Repeatedly the preventive medicine is polluted by magic, cosmetic or for profit medicine could be makes us miserable but mammography (medical therapy, not prevention) is not a good flag to defend the Fiona Godlee position. However, when we talk about clean water, immunization, healthy diet or tobacco free policy as preventive medicine is highly probable that a lot a people can be feeling safe and fortunate. The term preventive is context depended and it can be manipulate. For example, recently the word preventive (term building by social sciences) was used jointly to the word war (term building by political science) to produce the combination: “preventive war”, the most newly and miserable verification of misuse and misinterpretation of prevention. Since we need strong supporting evidence to adjust the crossing of preventive medicine, also we need to be preparing to prevent to be manipulated. References: 1.Godlee F. Preventive medicine makes us miserable. BMJ 2005; 330 Competing interests: None declared |
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Graeme M Mackenzie, GP Whitehaven CA28 7RG
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We can all cope with simple preventive medicine: don't smoke, take more exercise, watch your weight etc. However preventative medicine has become too complex for most people. The stress of suppressing all the information on the many interventions that are available to prevent disease, is what makes us ill. We are mere mortals and will get ill and die. By colluding in the availability of more and more information on the many ways we will get ill and die, are we colluding in a process that is completeing again the basic idea of being alive and what that means? Competing interests: None declared |
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Takeharu Koga, Assistant professor of Medicine Kurume University School of Medicine, Department of Internal Medicine, Kurume, 830-0011 Japan
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I appreciate Dr Heath's point of view on current preventive medicine (1) and
an editorial comment on it (2). Prevention is more important than treatment,
in the sense that a subclinical illness is much easier to manage than an overt
illness and accompanying complications. However, preventive medicine
currently prevailing in developed countries overstresses diagnosis and drugs,
that ironically seem to impose "unhealthy" impact on patients, economically
and emotionally. These medical interventions are "passive" in a sense that they wait for diseases to develop. The most efficient disease prevention is the removal of chances for diseases to develop. There are numerous solid epidemiological evidences that major diseases in developed countries are intimately associated with daily life-style. Therefore, the most efficient disease prevention is the behavioral modification of daily life, where patients do not just sit back and wait for diseases to develop but play an "active" role to reduce the risks. Fortunately, growing bodies of evidence are consistently indicating that a healthy life-style, including avoiding smoking, careful diet (3) and appropriate physical activities (4), is actually promising to prevent major diseases and promote health. These behavioral modifications spend little medical resources and are achievable by the majority, but they require appreciation of the benefit and a great deal of motivation and patience to be taken up and maintained by people. 1). Heath I. Who needs health care--the well or the sick? Bmj 2005; 330(7497):954-6. 2). Godlee F. Preventive medicine makes us miserable. BMJ 2005;330(7497): 0-f-. 3). Trichopoulou A, Orfanos P, Norat T, Bueno-de-Mesquita B, Ocke MC, Peeters PH, et al. Modified Mediterranean diet and survival: EPIC-elderly prospective cohort study. Bmj 2005. 4). Andersen LB, Schnohr P, Schroll M, Hein HO. All-cause mortality associated with physical activity during leisure time, work, sports, and cycling to work. Arch Intern Med 2000;160(11):1621-8. Competing interests: None declared |
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Jennifer Parker, Health services manager Oakland, CA 94602, Frances Groen
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What ails the developing world is poor infracture to prevent disease. Funds generated by any scheme will be stolen by corrupt government officials. By the way...these are the very same thieves who stole funds dedicated to human and physical infrastructure improvements such as education, water & sanitation systems, food/agriculture programs, etc. Nothing less than a pay-for-performance/outcome approach and much closer scrutiny of foreign aid expenditures by a watchdog auditing agency, as foreign governments develop credible fund managment practices, will turn the tide. Competing interests: None declared |
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venkatesan sangareddi, Assistant professor of cardiology Madras medical college chennai 600003
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Sir , This is with reference Dr. Fiona Godlee’s article “preventive medicine makes us miserable” I agree with most of the points with the author. Modern medicine has had a tremendous impact on the health status of our population . There has been at least 5 -10 years of prolongation of average life expectancy in last 2 centuries. This is mainly attributable to the fall in infant mortality and better sanitation and hence less infectious diseases. This is the classical era of preventive medicine of last century. Now the preventive medicine as A science has gained momentum even in less developed countries. The aim of this concept is not really to prevent diseases. It labels many healthy people sick or potentially sick and enabling the profit hungry industry to exploit these general healthy population. As practicing cardiologist I can say with conviction about the universal abuse of an clinical entity which is largely a non disease.- Mitral valve prolapse. While cardiologist all over the world working overtime to provide better health care , Its found a section of population have poor quality of life because of the same doctors. Barlow would not have thought in his wild imagination an ultrasonic device in the name of echocardiography will make this entity the most common cardiac disease (?non disease ) diagnosed in our planet. Panic attacks and psychiatric disease are well recognized to occur in association with MVPS . In our observation it occurs in 90% following the diagnosis, almost never preceding the diagnosis. Hence we believe the whole clinical syndrome and subsequent suffering is entirely attributable to the physician behavior than the disease behavior. The management guidelines of MVPS say the treatment for this entity is reassurance. Labeling a patient with a fancy cardiac terminology and then asking them to forget is most deplorable. The clinical entity of MVPS has a great penetration in almost all rural and mofusil centers in India .Thanks to growing scan centers which offer so called preventive master health check up(which always include a set of ultrasonic images of different organs).The energy and money are wasted in totally superfluous entities Many unnecessary fancy diagnosis are made following a health screen. There is a definite and urgent need for scrutinize the ICD manual and possibly impeach many of the fancy non disease entities from the medical literature .To name a few one can consider the following .(Osteopenia, chronic fatigue syndrome, Non ulcer dyspepsia etc). Competing interests: None declared |
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Mayank Vashishtha, PRHO, General Surgery Ayr Hospital, Ayr KA6 6DX
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The good old adage- Prevention is better than cure- that we so often hear is as powerful today as it was at the time of its inception. I believe that the self confidence of Preventive medicine is genuine and has a sound foundation. What needs to be changed in the healthcare delivery systems across the globe is not the primary concept of prevention, but the way it is understood and implemented. I agree that the present system makes the population see doctors more often, leading to anxiety and several other problems as mentioned in the article. But that is just one aspect of prevention- Secondary prevention- i.e. early diagnosis and treatment or in other words, decreasing the prevalance of disease. But how can we forget the other more significant aspects of prevention-i.e. Primordial (eliminating exposure to risk facors) and Primary prevention(reduction of incidence of disease in susceptible population). The present day governments need to direct their healthcare infrastructure resources in Primordial prevention which targets the "General Population" and is more cost effective, and does not develop iatrogenic anxiety as it does not involve exposure of people to doctors! Instead it creates confidence in the community as they learn to develop a healthy day to day lifestyle and does not make them feel Ill or miserable as the author claims. It is cost effective because it does not involve sophisticated tests or treatments, and can be carried out by mass media or the primary community health worker. And the resources spent go into building a stronger foundation for a healthy nation. I agree with the author that for the new age, we need new adages. So I suggest- "Primordial" is the key word!!! Competing interests: None declared |
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benjamin dean, dr oxford
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The Labour government has revealed its latest health white paper (which can be found at the department of health website). Having skimmed through the endless case studies and promises, I am deeply unimpressed with the plans for dealing with our nations many health problems. This may have something to do with the misconception among many policy makers that to improve health one must change health policy. Along these lines the white paper pledges to improve our health with personal health guides and endless personal support services. I believe this approach is a massive waste of money and ideologically flawed. A recently published study has yet again demonstrated the very wide socio-economic divides present in Britain compared to other developed countries (1). Much of the evidence also points to the fact that those is the poorer socio-economic groups are the poorest in health. There are obviously many reasons for this relationship but some studies have indicated that the unhealthy option is often cheaper than the healthy one. It is sad that despite Britain's strong economy and massive wealth, it is desperately hard for the poor to get out of the cycle of poverty (1). The reasons for this are complex but our failing education system must be partly responsible. The poor's health will not benefit from the sticky plaster that is the white paper. To address the nation's health the government must address the massive socio-economic divide in our society and therefore give the poorest the means to help themselves. The poor will not benefit from being spoon-fed, which is what much of the white paper does. After all it is widely agreed by economists that the way to help the poor in Africa is to provide them with the means to help themselves out of poverty, not to spoon-feed them with aid handouts. Whatever the government's reasons behind its unwillingness to address the real issues behind our nation's failing health; I believe they will not sacrifice short term economic growth for anything, whether it be the health of the nation or the environment. The white paper is a pathetic sticky plaster: the government merely wants to be seen to be doing something when truthfully it will not make the sacrifices needed to deal with the problem. 1. Intergenerational Mobility in Europe and North America. A Report Supported by the Sutton Trust. Jo Blanden, Paul Gregg and Stephen Machin. April 2005. ( available at www.suttontrust.com). Competing interests: None declared |
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Alan D Penman, Associate Professor University of Mississippi Medical Center, Dept of Medicine (Geriatrics), Jackson, MS 39216
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Let’s start by separating the concept of prevention from the practice of preventive medicine (and the concept of health from the practice of health care). In the 21st century, most people want to live long, active, disease-free lives, and most – at least in the so-called developed countries - have a fairly good idea by now how to do this, the main constraints being lack of willpower and time. For the most part, achieving a healthy lifestyle (and preventing, or at least delaying the onset of, disease) does not, and should not, need the involvement of the health care system. In fact, as you rightly point out (1), it often makes us miserable. This has been recognized for a long time: in recent times, Illich was the most vocal critic of the health care system and its threat to health (2), but Herodotus hinted at the problem when he visited Egypt 2,400 years ago and observed the proliferation of specialists (3). The term “Preventive Medicine” may even be an oxymoron. Incorporating prevention into mainstream medical practice has medicalised it: Illich called it disease-hunting (2). The widespread adoption, many years ago, of the paradigm of three levels of prevention (primary, secondary, and tertiary) may have started it. The function of the physician in the health care system should be limited to diagnosis, treatment, and rehabilitation. By all means, have “prevention specialists”, but let’s make sure they are trained and licensed separately, outwith the traditional health care system. Let people regain control over their health - but we've made them so dependent on the health care system that we will have to show them how to do this. Health education needs to be made a core subject in the school curriculum, starting in primary school. Educated consumers will make healthy – or, at least, better - choices. And yes, government does have a role - public health agencies need to start fulfilling their mission, namely, to assure the (social and economic) conditions necessary for people to make those better choices and live healthy lives. References 1. Godlee F.Preventive medicine makes us miserable. BMJ 2005;330 (23 April), doi:10.1136/bmj.330.7497.0-f. 2. Illich I. Limits to medicine. Medical nemesis: the expropriation of health. Middlesex, England: Pelican Books, 1977. 3. Herodotus. The histories. London, England: Penguin Books, 1996. Competing interests: None declared |
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Friederike M. Perl, Breast Surgeon Interdisciplinary Breast Centre Diakonie Klinkum D-70176 Stuttgart Germany
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Dr. Godlee's Editor's Choice is a welcome note of balance after much screening hype in the past years. However, may I suggest that it is not so much "preventive medicine" that makes us miserable but rather early recognition of asymptomatic conditions whose natural course can and will not, in the majority of cases, be positively influenced by any action medical or otherwise. Even though it happens frequently, prevention and screening should not be confused. True prevention, like prolonged breast feeding, will not make anybody miserable. Furthermore, regarding harm produced by screening, may I add that cutting short healthy, i. e. "complaintfree" time before and adding poor quality time after diagnosis will, for most people, mean a very serious drawback of screening (once they start thinking about it). Even the most ardent mammography enthusiasts admit that some 70% of women destined to die from breast cancer will die at the same point in time regardless whether they had their tumours "early" detected or not (the critics say, not 70% but close to 100% will not have a mortality benefit). Isn't this a major ethical problem: to tell them ahead of time without offering any real benefit? Thank you, Dr. Godlee, for stimulating a much needed debate with your thoughtful approach to this uneasy issue. Competing interests: None declared |
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Adrienne J J Garner, Locum GP HP4 2PN
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Re: Preventative medicine makes us miserable. I have always tended to live by the old adage: If it ain't broke don't fix it! Or, alternatively, Don't go looking for trouble and it won't find you ! Dr Adrienne Garner Competing interests: None declared |
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