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Rapid Responses: Rapid Responses published:
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How broad is the broad enough perspective?
- BM Hegde (3 October 2008)
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"Health Is Not Merely The Absence of Disease......"
- Andrew Mimnagh (6 October 2008)
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Haiku for WHO*
- Hugh Mann (8 October 2008)
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BM Hegde, Editor in Chief, Jr. Sciecne of Healing Outcomes Mangalore, India.
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Dear Fiona Godlee, I am a bit confused by your editorial and the connected articles in this issue. You and the authors of the cited articles are advocating a broad perspective to preventing cardiovascular disease, and rightly so. (1) At the same time you are forgetting the most important aspect of the risk factors for CVS diseases-the mind of the victim. Several studies, including the White Hall study have shown that hostility, depression- clinical or, even, occult-and various other work related stressors as the most important risk factors. (2, 3, 4) While all your contributors and the rapid responders seem to be totally engrossed in some of the questionable risks like cholesterol, raised sugar and arterial pressure, and that evanescent homocycteine (5) the whole gamut of the vital role of the human mind seems to have slipped away. All the components of the poly-pill, 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 ADRs. (6, 7, 8) Ebrahim Shah and GD Smith go one step further to show that the pooled effect of multiple risk factors interventions on mortality were insignificant and small. (9) Professor Michael Oliver had shown that drug use for risk reduction was almost useless. (10) Smith and Eggar ask a very pertinent question as to “who benefits from medical interventions” in this scenario? (11) These all add up to the case of the missing evidence of Sherlock Holmes. Did not Hippocrates warn us to study the patient better than the disease? Sun light is more powerful than the poly-pill to lower many of those risks mentioned, especially cholesterol. Sunlight might even lift one’s mood on a gloomy wintry morning-all for free. No body 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! Every one seems to swear by epidemiology. The latter’s capacity to forecast the future has been questioned by some of the leading epidemiologists like Ebrahim Shah and others. (12, 13) 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.” Karl Marx, in his wiser and older years, wrote: “From what I know of Marxism today, I know of one thing for sure. I was never a Marxist myself.” I am writing this to clear my conscience so that I shouldn’t feel tomorrow that I didn’t effort enough to stop the adding of these multiple chemicals (poly-pill) to the general water supply to prevent diseases. Our obsession with the “disease” concept is our undoing. (14) Human illness and wellness need a very, very broad perspective, indeed! Yours ever, bmhegde References: 1) Fiona Godlee A plea for broader perspectives on health BMJ 2008; 337: a1923 2) Blumenthal, J, M. Babyak, et al. "Usefulness of psychosocial treatment of mental stress-induced myocardial ischemia in men." Amer J Cardiol, 2002, 89: 164-168. Hippisley-Cox J, Feilding K, Pringle M. Depression as a risk for IHD. BMJ 1998; 316: 1714-9. 3) Whiteman MC, Fowkes FGR, Deary IJ. Hostility and the Heart. BMJ 1997; 315:379-81. 4) Toole JF, Malinov MR, Chambless LE, Spence JD, Petigrew LC, Howard VJ, Sides EG, Wang CH, Stampfer M. Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death. The vitamin intervention for stroke prevention (VISP) randomized controlled trial. JAMA 2004; 297:565-75 5) Ravnskov U. Cholesterol lowering trials in coronary heart disease: frequency of citation and outcome.BMJ 1992; 305:15-19. 6) McCormack J and Greenhalgh T. Seeing what you want to see in randomized controlled trials: versions and perversions of UKPDS data. BMJ 2000; 320: 1720-23. 7) Andersson OK, Almgren T, Persson B et. Al. Survival in treated hypertension: follow up after two decades. BMJ 1998; 317: 167-171. 8) McClellan M, McNeil BJ, Newhouse JP. Does more intensive treatment of acute myocardial infarction in the elderly reduce mortality? Analysis using instrumental variables. JAMA. 1994; 272: 859-866. 9) Smith GD & Eggar M. Who benefits from medical interventions? BMJ 1994; 308: 72-74. 10) Risks of correcting risk factors for stroke and CAD with drugs. N. Engl.J.Med.1982; 306: 297-298. 11) Shah E & Smith GD. The pooled effect of multiple risk factor interventions on mortality. BMJ 1997; 315: 1468.Editorial. . Do epidemiologists cause epidemics? Lancet 1993; 341: 993-994 12) Pickering WG. Does medical treatment mean patient benefit? Lancet 1996; 347: 379-80. 13) Editorial. Do epidemiologists cause epidemics? Lancet 1993; 341: 993- 994. 14) Tinnetti M & Fried T. The end of the disease era. Am. J. Med. 2004; 116: 179-185. Competing interests: Interested in the truth. |
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Andrew Mimnagh, General Practitioner Eastview Surgery L22 4QD
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Hopefully all recognise the opening of the World Health organisation definition of Health, or perhaps near definition. The complex interaction of what is Health and what is the range of "healthcare provision" will doubtless present many views from the metaphysical "you are healthy if you view yourself as healthy" to the "it really is the absence of a detectable pathology and W.H.O. are a bunch of wet tree hugging etc." Surprisingly the increasing trend in General Practice is for clients, <-it is "out" to call them patients-> to request more and detailed investigation to validate the existence of health. There has been a traditional "capitalist" model in medical care pre 1947. The patient desperately trying to stay well to avoid the Doctor and the ensuing bills, an enormous personal stake in their wellbeing. The profession ran on this simple financial exchange with enough bartering of non-financial value items, food stuff, services, but also more abstract such as "unbridled respect" from patients and from the profession sufficient "pro Bono" from practitioners happy with their own personal circumstances to ensure the profession did not feel too much like wealthy usurers. The difficulty we face post 1947 is no one has really determined how should regard health or ensure a direct personal engagement in its acquisition and maintenance. The profession has striven to become "more approachable and human", by and large until the recent spectre of "post code lottery of care" and its antidote "the co-payment" the public existed in a comfortable bubble of perception of "no-cost " health care.An unbridled co-dependency. By the market forces model why would an individual "invest effort" in their health if unlimited free bailout was available? (For the benefit of future readers it is 2008 and there is a world banking crisis, "the Credit Crunch" ,risk taking banking organisations receiving a probably unlimited bailout for their risks going wrong; economic commentators advising it was the perception the safety net had to be there that occasioned the behaviour). The NHS has created the untrammeled "Health Consumer" the ultimate paradox of all healthcare being the one commodity that cannot ever be sold is HEALTH. Competing interests: None declared |
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Hugh Mann, Physician Eagle Rock, MO 65641 USA
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Healthcare 101: Competing interests: None declared |
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