Population control and uncertainty—a doctor’s role

Exciting editorial, indeed! What would be the population next year?
In our linear thinking it is this year’s population multiplied by the
fertility rate! This never comes true! Uncertainty wins the race. If we
apply non linear mathematics, the uncertainty gets reduced considerably.
The same holds good for clinical therapeutic outcomes. Is there any
certainty at all in medicine? Why are we running away from the naked truth
that our present thinking based on the faulty statistical science of
modern medicine does not/can not have certainty as an outcome. My article
in the JAPI and the landmark paper by Professor WJ Firth in the BMJ in
1991 categorically explain the roots of uncertainty. (1) (2) (3)
Professor Firth is a professor of physics!

I do not see any citations of those papers; mine can be ignored:
ignoring Professor Firth’s warnings would become costly in the long run.
Therapeutic certainty is a malignant myth in modern medicine despite all
the statistical Olympics. MRC study of mild-moderate hypertension showed
that to save one probable stroke death in society in the next five years
we have to drug 850 apparently healthy people unnecessarily for five years
just because we do not know who amongst the 850 will get that stroke-one
for all and all for one! (3) The ADRs in those 850 people will only be
statistics. If we find out the absolute risk reduction and the number
needed to treat (NNT) in each of our RCTs and share them with our patients
they will make their own decisions in partnership with us. (4) (5) (6) (7)
(8) (9) (10) (11)

Population and environmental concerns in this issue make interesting
reading. I wonder if the Amazon forest is gradually getting denuded
because of the population growth? I was lecturing in a prestigious US
university last week and found, to my horror, the destruction of a
beautiful wooded hillock behind the University Inn where I used to go for
evening walks. I was told that the city authorities have filed a case
against the builders for violating the environmental laws. Do we have a
population problem in the US? Man, with his proclivity for comfort and his
greed, will eventually destroy all the natural resources sooner than
later. After poisoning the last river, cutting the last tree and
genetically modifying all the natural foods, and polluting the ground
water table with chemical germicidals man would realize that money can not
be eaten as food!

Let us take India as an example of population explosion. India can
not be classified as a poor country any more. We have more number of
billionaires than the US has. We also have the other India where the
infant mortality exceeds Sub Saharan Africa. We have a total load of 47
million malnourished children dying at the rate of 6000 per day due to
NIDS (nutritional immune deficiency Syndrome). The total AIDS load of
about 40 million in this world pales into insignificance if one knows that
there are 530 million hungry people out there in the world on a given day.
We vaccinate these malnourished/undernourished children with multiple
vaccines. God only should know as to where does the globulin come from to
produce anti-bodies in response to vaccination. As if that is not enough a
recent paper in the BMJ was advocating vaccinating poor children in the
third world with all the newer vaccines to eradicate those diseases
globally. (12)Some people even doubt if small pox, the only disease so far
eradicated, had much to do with vaccination alone as only a small fraction
of the world was vaccinated at that time. Do these diseases have their own
dynamic cycles? Story is the same with tuberculosis, diptheria, plague,
bacterial pneumonia etc. McKevon's book "Role of Medicine", out of print
now, goes into these in great detail.

I was shocked to read a Nobel Laureate, quoted in the BMJ paper,
opining that in the “broader effect as an "autocatalytic process"
connecting health and development, whereby improving health through direct
means such as vaccines unlocks the capabilities of populations to thrive
economically.” While I do not understand economics, I do understand
immunology where this statement does not make much sense to me. Reminds me
of that famous paper of George Orwell-“Politics and the English language”-
where Orwell quotes Professor Harold Laski using complicated language to
confuse politicians. More than Harold Laski we, in medicine, use Greek and
Latin sprinkled English to confuse the world. We seem to have lost the
woods of poverty while counting the trees of the germ theory to the total
exclusion of the warning by Louis Pasteur himself that the “germ is
nothing; it is the soil that is everything?” (10) There are wonderful
immune boosters in Ayurveda, the Indian system of medical wisdom. Who
cares? (13)

The greatest discovery of the 21st century is the certainty of man’s
ignorance about most of the wonders of this world. Science should aim at
trying to understand the working of the world rather than trying to change
the world order to suit our conveniences. If only we had incorporated
human consciousness in medical science to understand health as well as ill
health, like physics is doing to understand the quantum world where
uncertainty rules the roost, (14) we would have made much more progress
compared to our reductionistic scientific outlook in medicine.

Yours ever,
Bmhegde

References:

1) Hegde BM. Chaos- a new concept in science. J Asso. Physi. India
1996; 44: 167-168

2) Firth WJ. Chaos-doctors predicting the unpredictable. BMJ 1991; 303:
1565-68.

3) Hegde BM. Uncertainty is the only certainty in patient care.
http://bmj.com/cgi/eletters/331/7528/0-f#122966, 3 Dec 2005

4) MRC study group. MRC mild-moderate study-principal results. BMJ 1985;
291: 97-104.

5) Oliver MF. Risks of correcting risk factors of coronary artery disease
and strokes with drugs. NEJM 1982; 306: 297-298.

6) Andersson OK, Almgren T, Persson B et. Al. Survival in treated
hypertension: follow up after two decades. BMJ 1998; 317: 167-171.

7) Editorial. Who benefits from medical interventions? BMJ 1994 Jan 8th.
http://bmj.bmjjournals.com/egi/content/full/308/6921/72.

8) Dusen LV. The business called medicine. CMAJ 1997; 157: 1724.

9) Le Fanu J. The case of the missing data. BMJ; 2002; 325: 1490-93.

10) Shannon B. Why too much medicine is making us sicker and poorer? 2007.
Bloomsbury USA. Page 343.

11) Alderman MH. BP management: individualized treatment based on absolute
risk and then potential for benefit. Ann Intern Med 1993; 119: 329-35.

12) Chokshi DA & Kesselheim AS. Rethinking global access to
vaccination. BMJ 2008; 336: 750-753.

13) Hegde BM The best complementary system for early authentication
http://bmj.com/cgi/eletters/330/7484/166#93635, 21 Jan 2005.

14) Gribbin J. In search of Schrödinger’s cat. 1991. Transworld
Publications, London.

Competing interests:
None declared