Mass medicalisation is an iatrogenic catastrophe
BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2794 (Published 28 June 2018) Cite this as: BMJ 2018;361:k2794
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It is not surprising to see a Views and Reviews piece by James Le Fanu entitled “Mass medicalisation is an iatrogenic catastrophe” published in the BMJ(1) , as it fits with the “Too much medicine” line the journal promotes. However, allowing the obvious and fundamental misrepresentation of a scientist who has died, and thus no longer able to defend himself, shows a serious lapse in editorial judgment.
Geoffrey Rose’s 1985 paper “Sick individuals and sick populations”(2) is portrayed by Le Fanu as the source of all that is wrong in modern medicine. He describes it as “arguably the most harmful medical paper of the 20th century”. Rose’s subsequent elaboration of the central ideas to do with the determinants of population vs individual risk in his 1993 book “The Strategy of Preventive Medicine”(3) is slandered by Le Fanu as a “masterclass in intellectual sophistry”. Le Fanu clearly enjoys seeking attention by his use of florid language, but this goes beyond an intellectual dispute. The dictionary definition of sophistry is “the use of clever but false arguments, especially with the intention of deceiving”. This explicitly suggests deliberate dishonesty by Rose. This is not the Geoffrey Rose we knew.
Le Fanu goes on to say that Rose’s ideas supported what became mass medicalization with cholesterol lowering and other drugs, with the clear implication that somehow Rose was in league with the pharmaceutical industry in promoting this. Anyone who has even basic familiarity with what Rose actually wrote, practised and taught would know this is completely at odds with his views. Two quotes from the “Strategy of Preventive Medicine” discussing cholesterol lowering drugs make crystal clear how cautious Rose was about over-treatment and his central concern with adverse effects:
First, from pages 80-81
“ .. the long term use of drugs in prevention is justified only within a high-risk group. We have no means of excluding a level of risk which, however small for the individual, might exceed overall hope for benefit – except where that benefit is known to be substantial. This effectively rules out any mass use of long-term drugs, especially since trials rarely continue for longer than about 5 years, leaving us quite in the dark concerning lifetime effects. It is only in individuals known to be at exceptional risk that such uncertainty may be acceptable”.
And on page 146 – “To take a contrasting example, the situation with regard to the potent new cholesterol-lowering drugs is quite different. Experience with their predecessors warns us that unforeseen adverse effects may occur, and that these can only be identified and measured by large long-term controlled trials. It will be many years before even medium-sized trials have been completed, and no current trial has adequate power to identify important but delayed adverse effects. These drugs represent a major pharmaceutical advance, but their widespread promotion and use, outside high-risk groups, is quite wrong. The over-use of drugs is a constant danger in preventive medicine and a near-inevitable consequence of mass screening”.
The whole of the book is pervaded with this reasoning. Rose wrote with great clarity, and there can be no doubt about his position. So how could Le Fanu make such an unjustified claim about Rose? There are only two options: (1) he has not read Rose, but believes he has; 2) he is the person guilty of sophistry, intending to deceive.
It is thus regrettable that the BMJ is happy to publish things which are not a matter of interpretation, but are straightforward falsehoods. Have they commissioned this piece simply because they knew in advance it would support editorial prejudice?
Our “conflict of interest” statement (Le Fanu reports no competing interests, although he is currently promoting a book expanding on his piece, in which again Rose features as Public Enemy # 1) is that we all worked for and studied under Geoffrey Rose at one time, talked to him and heard him speak and lecture about these issues on many occasions. He was resolutely opposed to mass medicalisation as the solution to public health problems. One of us (GDS) published a paper (ironically in the BMJ) in 1992 entitled “Should there be a moratorium on the use of cholesterol lowering drugs?”(4), the conclusion of which was similar to the quotes from Rose above; this attracted considerable opprobrium at the time, but Geoffrey Rose was entirely supportive. He deserves more than to have his reputation posthumously traduced by someone so clearly ignorant of what he actually professed.
George Davey Smith, Professor of Clinical Epidemiology, Bristol Medical School, Bristol.
David A Leon, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine.
Paul Elliott, Professor of Epidemiology and Public Health, School of Public Health, Imperial College London.
(1) Le Fanu J. Mass medicalisation is an iatrogenic catastrophe. BMJ 2018;361:k2794.
(2) Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14:32-38.
(3) Rose G. Rose’s Strategy of Preventive Medicine. Oxford university Press 1993.
(4) Davey Smith G, Pekkanen J. Should there be a moratorium on the use of cholesterol lowering drugs? BMJ 1992;304:431-4.
Competing interests: Our “conflict of interest” statement (Le Fanu reports no competing interests, although he is currently promoting a book expanding on his piece, in which again Rose features as Public Enemy # 1) is that we all worked for and studied under Geoffrey Rose at one time, talked to him and heard him speak and lecture about these issues on many occasions. He was resolutely opposed to mass medicalisation as the solution to public health problems. One of us (GDS) published a paper (ironically in the BMJ) in 1992 entitled “Should there be a moratorium on the use of cholesterol lowering drugs?” , the conclusion of which was similar to the quotes from Rose above; this attracted considerable opprobrium at the time, but Geoffrey Rose was entirely supportive. He deserves more than to have his reputation posthumously traduced by someone so clearly ignorant of what he actually professed.
I have been provoked to respond to this article, which was after all headed 'Provocations', so on that level it has been successful. I would have been as depressed as the author, were it not for the fact that his argument that so many more people are at risk of being put on medication due to changed in blood pressure thresholds rests on the idea that lifestyle change would not be effective. He makes no mention of wider lifestyle change, but concentrates purely on dietary change, which he alleges have little or no effect on physiological variables. He puts aside the idea that dietary salt/sodium intake has any influence on blood pressure based on the 'classic' Glyncorrwg study.
I found this venerable study of 18 patients in the 1983 archive of this journal, with some difficulty. I would draw his attention to another classic study: the DASH-salt study, which did find a beneficial effect of dietary sodium restriction in and it also confirmed a rather more dramatic benefit for those who took the DASH diet (roughly-speaking a mediterranean diet), but this time in over 400 people (1). Accepting this finding would mean that far from asking a whole lot of people to take antihypertensives, we would, at least in the first instance, be asking a lot of people to amend their diet and lifestyle. So no need to reach for the antidepressants just yet Dr Le Fanu. True, for diet and lifestyle measures to work on a population level, social mores will need to change, but that is not beyond the wit of man.
1. Effects on Blood Pressure of Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension (DASH) Diet. Sacks FM, e al. N Engl J Med 2001; 344:3-10
Competing interests: No competing interests
Dr Le Fanu, as always, is an excellent read, racy, entertaining and as here, with a good nubbin of truth. Many years ago as a GP trainee in rural Wales in my first solo session Mrs Jones (not her real name) a spritely elderly woman informed me that she had come for her tonic. I was keen, after all, it was my first day, I asked her what might be the matter – nothing I just need my tonic. Of course I unsuccessfully tried to elicit a symptom or two and broached the idea of perhaps taking her blood pressure all to no avail. My tonic please you know the one that Dr Jones always gives me. I explained carefully (and smugly) that we had moved on from tonics and that now we had real medicines carefully designed and proven to alleviate symptoms and cure disease. She walked out and promptly received her tonic from the only real doctor on the premises. Now of course 40 years later I realize that Dr Jones knew a thing or two.
We are very unlikely to detach pharma or for that matter many colleagues from this folly – it is just far too profitable for both (only bettered by the medical publishing industry, I gather) but we could alleviate it a little by returning to Dr Jones’ tonic. We would need to give it a fancy name, or many fancy names (probably no need for trials though) make it quite expensive (no trouble there either) and extol its virtues widely (you know, international conferences, leading opinion leaders fly in, lots of freebies) and of course we would need to work on making it as harmless as possible, that might be the hard part. The problems with many modern medicines is that they actually work and as Dr Le Fanu quite rightly points out that often brings with it nasty side-effects because pharma concentrates on the few cells, receptors or chemistry that their molecule is designed to interrupt not on Mrs Jones.
Competing interests: No competing interests
Dr Le Fanu writes an entertaining polemic conflating Geoffrey Rose’s Population Strategy and the marketing shenanigans of Pharma. His vigorous prose betrays some edgy antipathy to Rose’s effort and he attempts his own ‘masterclass in intellectual sophistry’ with the special pleading of the ‘classic’ Glyncorrwg study (of eighteen patients in 1983).
Unfortunately, a focus on statistical distributions has not been influential in important areas of modern medical culture. The Guideline/Pathway recommendations of specialist societies and expert authorities have paid scant regard to the obvious fact that the outcomes of medical intervention can be presented overall only as distributions. They have been obliged to deal with this to some extent by shifting from ‘target values’ and intervention thresholds towards the assertion of desirable ranges for physiological variables. This has various consequences depending on the variables concerned. Typically, the focus on target values produces an inadvertent, systematic, underperformance for intervention, because of the asymmetry of necessary effort [1].
A scepticism about the relation of indicators to outcomes is well founded, but the optimism of intention survives any number of disappointments in neglected outcome distributions.
Using distributions to indicate trends is perfectly legitimate, as presented in UK Renal Registry Reports 1997-2007, but will be context dependent. Applying them to phenomena like treatable renal anaemia is more appropriate than to largely settled population characteristics.
In each case it is critical to measure and express harms as well as benefits, through distributions. Of course, the failure to present the former, as a pair, damns the exercise of large group intervention. It does not invalidate the insight of trying to move beyond the tail of a distribution to achieve maximum benefit.
1. Will EJ. Intention and outcome in guideline-based nephrological practice: a suitable space for ‘clinical technology’. Nephrol Dial Transplant 2007:22: 3110–3114 doi:10.1093/ndt/gfm516
Competing interests: No competing interests
Dr Le Fanu - journalist, yes, but a practising doctor now retired - makes a point which the present generation of doctors in this country migh care to take note of.
There is no such thing as universal truth, true for all times. We ought to keep our mind open - even to those who are “ heathens”.
I read about a Frenchman (Prof Henri Joyeux) from the Land of Liberty, Equality, Fraternity. Apparentlly he questioned whether some sacred text was “ disciplined”; he appealed successfully. Being ignorant of the French Language, I do not know the details. Perhaps the BMJ’s news section could explore?
But, mass medicalisation is a component of mass medication. Iatrogenic catastrophe. Can it be prevented? Not, if free thought is extinguished under the asbestos sheet smothering discussion and debate.
Competing interests: No competing interests
James Le Fanu makes a very important point, but medical practice does not exist in isolation from the society it treats. Yes, perhaps we have been persuaded by the pharmaceutical industry and well-meaning others to treat every digression from the mean as illness. In mitigation though, within a free society this is only possible when its individual members wish to seek betterment through treatment. This wish, combined with a belief that happiness, health and longevity are rights that should be available to all, means that some agency is going to arise to provide 'solutions'. Like democracy, medicine might be the worst form of treatment but it is still better than all the rest. Better because its allegiance with science means that it is built on hypotheses that are subject to question, testing and adaptation, just as Le Fanu demonstrates.
Competing interests: No competing interests
Dear Editor,
Dr Le Fanu should be congratulated for his take on the important yet fairly silent epidemic of soaring prescribing practices. [1]
May I please draw your attention to the following sentence: “The simple expedient of redefining diabetes, hypertension, and hypocholesteraemia in this way increased their prevalence in the US by, respectively, 14%, 35%, and 86%...”. Surely this should read “hyper”cholesteroleaemia and not “hypo”cholesterolaemia.
Typographical errors aside - big pharma playing a role in revising disease definitions to effectively increase the prevalence of low serum cholesterol is such an absurd idea I doubt you would even entertain the concept for the Christmas issue of the BMJ.
References
1. Le Fanu J. Mass medicalisation is an iatrogenic catastrophe. BMJ 2018;361:k2794.
Competing interests: No competing interests
Dr James Le Fanu’s article entitled “Mass medicalisation is an iatrogenic catastrophe” does not mention the widespread prescribing of antidepressants, however his discussion applies equally well to that particular class of drugs. Indeed it could be said that we live in an era of mass medicalisation of emotional distress. I have lived through the era of the benzodiazepine medical disaster, the “wonder drugs” of the 1960s, drugs which caused so much harm to so many patients including myself. Patients first raised the alarm about the horrendous difficulties of withdrawing from these drugs, TV documentaries were made, a class action was brought in the 1990s and the patient campaign for justice continues to this day. After 40 years of consuming Nitrazepam for myoclonic epilepsy, withdrawal on medical advice has devastated my health, leaving me mostly bed bound for the past 4.5 years, requiring a walking frame and wheelchair and cognitively impaired. My current GP tells me that “benzos are poison, I never prescribe them”.
I also consumed antidepressants for 35 years, including Effexor for approximately ten years. I am now drug free but have lost my physical health and independence in the process. The online patient community for drug dependence, withdrawal and iatrogenic harm is growing ever larger, most members are considerably younger than me. Patients in the UK are desperately seeking help to safely taper off antidepressants and to a lesser extent benzodiazepines, antipsychotics and other drugs of dependence. Most cannot find a doctor with appropriate knowledge or understanding of the withdrawal process and denial of drug damage is very common indeed. Patients are instead diagnosed with CFS, MUPS, fibromyalgia, neurological functional symptoms, somatisation, even personality disorder when they complain too much. The horrendous symptoms can be relentless and so patients are thought to be "obsessed" or even making themselves worse by seeking support online. Psychological therapies are increasingly the recommended “treatment” for those iatrogenically harmed, so that patients can change the way they think about their symptoms, while nothing is actually done to alleviate them. The concerns of our community are clearly outlined in a petition to the Scottish Parliament. (1) The many patient submissions which describe iatrogenic harm make for harrowing reading indeed.
The BMA has responded to our concerns and called for a UK-wide 24-hour helpline (2). This is supported by the All Party Parliamentary Group on Prescribed Drug Dependence. (3) Public Health England is undertaking a review of prescribed drug dependence and the devolved nations have now been given observer status.(4) The Scottish Government plans a parallel review. A programme of research is underway at Southampton University.(5) How much are these collective efforts costing the taxpayer? SSRI antidepressants were marketed by the drug companies as non-addictive. In fact the withdrawal symptoms from SSRIs are almost identical to those from benzodiazepines (6) and the addictive properties of benzodiazepines are common knowledge. Individual patient accounts of antidepressant withdrawal are every bit as harrowing (7) as those of benzodiazepine withdrawal and the resulting damage equally life-changing and even irreversible given current medical knowledge. The Royal College of Psychiatrists has responded by making a public statement that antidepressant withdrawal lasts two weeks for the vast majority of patients but the College has been unable to support this statement with scientific evidence. A subsequent complaint to the College remains unresolved. (8) A podcast by the Royal Society of Medicine also gave the impression that antidepressant withdrawal is not something to be concerned about. (9) Yet both RCPsych and RCGP are keen to point out the harmful effects of benzodiazepines.
In February, newspaper headlines which accompanied coverage of the recent Lancet meta-analysis of antidepressants (10) declared that the debate about antidepressants was now over, antidepressants do in fact work and one million more patients should be prescribed them. There are already at least 9 million patients in the UK consuming these drugs. Critics of the Lancet meta-analysis have a different view. (11)(12) It seems to me that the drive to increase awareness of mental health issues has simply created yet another benzodiazepine medical disaster. Dr Allen Frances, US psychiatrist and former chair of the Task Force for DSM IV has described the widespread prescribing of antidepressants as a "public health experiment", He also acknowledged the immense difficulties associating with antidepressant withdrawal and the associated lack of research (13). In a single TV interview he has vindicated the ongoing campaign mounted by the online patient community in the UK, a campaign that representatives of medical bodies have sought to discredit. As an active campaigner, my own attempts to communicate with the President of RCPsych have failed. I have been partially blocked on Twitter by RCGP and completely blocked by RCGP Scotland. Public Health England does not wish to hear directly from harmed patients. These are interpreted as messages of dismissal by the patient community and replicates the experiences of individual patients in the consulting room.
For me, Dr Des Spence, Glasgow GP, sums up the situation well.
“What is happening is wrong and wholly preventable. There is a need for a public inquiry and an urgent need to stem the relentless rise of dependence-forming medications in the UK.”
The medical profession is divided and patients are ultimately paying the price and will continue to do so for some considerable time to come. After all, the damage from benzodiazepines continues to this day.
(1) http://www.parliament.scot/GettingInvolved/Petitions/PE01651
(2) https://www.bma.org.uk/collective-voice/policy-and-research/public-and-p...
(4) https://www.gov.uk/government/news/prescribed-medicines-that-may-cause-d...
(5) https://www.southampton.ac.uk/news/2016/07/antidepressent-study-kendrick...
(6) https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1360-0443.2011.03686.x
(7) http://cepuk.org/2017/09/20/2017-prescribed-drug-withdrawal-survey-initi...
(8) https://www.madinamerica.com/2018/06/sami-timimi-john-read-latest-develo...
(9) https://holeousia.com/2018/05/01/rsm-health-matters-podcast-episode-1-an...
(10) https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32802-7/fulltext
(11) http://cepuk.org/2018/02/22/peter-gotzsche-cipriani-review-not-add-anyth...
(12) http://cepuk.org/2018/02/22/antidepressants-work-new-research-proves-not...
(13) https://edition.cnn.com/videos/tv/2018/05/17/amanpour-allen-frances-anti...
Competing interests: No competing interests
Dear editor
Having seen a reference cited in "The medical miracle delusion", I have found and am on my way to read Dr Le Fanu's The Rise and Fall of Modern Medicine. Forty years ago or so I was a very young medical student, proud of a very selective profession and have icidentally read "Medical Nemesis, first published in 1975, also known as Limits to Medicine, by Ivan Illich (died 2002). Illich was a passionate and very clever person; he subjected contemporary Western medicine of the seventies to detailed attack.
Dr Le Fanu's articles and books give the idea that the 21st century has not progressed so much in this field; maybe we are entering a new Middle Ages. Illich stated that the medicalization in recent decades of so many of life's vicissitudes—birth, aging and death, for example—frequently caused more harm than good and rendered many people in effect lifelong patients. He introduced to a wider public the notion of iatrogenic disease (it was a brutal contact for a medical student).
In the 1970s, Illich was popular and sold in pocket books in France. However, his influence paradoxically seemed to decline after the 1981 election of Mitterand, a socialist president.
I’d like to add something else about Illich, the notion of:
“Counterproductivity
The main notion of Ivan Illich is the concept of counterproductivity: when institutions of modern industrial society impede their purported aims. For example, Ivan Illich calculated that, in 1970s America, if you add the time spent to work to earn the money to buy a car, the time spent in the car (including traffic jams), the time spent in the health care industry because of a car crash, the time spent in the oil industry to fuel cars...., and you divide the number of kilometres traveled per year by that, you obtain the following calculation: 10,000 km per year per person divided by 1,600 hours per year per American equals 6 km per hour, the real speed of a car.”
Quote from Wikipedia
For prevention, real prevention, here is a suggestion. If you can ride a bike, it’s not too late for an 18-20 km per hour (11-15 miles) ride, even 25 if you own an electric one!
Competing interests: No competing interests
Re: Mass medicalisation is an iatrogenic catastrophe
Professor Davey Smith doth protest too much. It would, of course, be absurd and slanderous of Geoffrey Rose's reputation to assert that at any time he endorsed the current policy of mass medicalisation. Rather the central tenet of his 'Big Idea' as set out in his "Strategy of Preventive Medicine" is precisely the contrary - that small reductions in (for example) salt or saturated fat consumption at a population level would have a greater impact in preventing circulatory disorders than identifying and treating (with drugs) those at high risk.
The main and indeed insuperable problem with this strategy are the laws of homeostasis on which our survival depend ensuring the constancy of physiological variables such as blood pressure and cholesterol level despite the vagaries of dietary consumption. His advocacy of treating the many rather than the few is, however, readily achievable by pharmacological means and it is indisputable that the pharmaceutical industry has over the past three decades exploited the population approach to its own immensely profitable advantage.
Reassured, I hope, that my observations are not prejudicial in the way Professor Davey Smith has interpreted them, perhaps he might address my substantive argument and suggest how the current enthusiasm for mass medicalisation and its devastating consequences can be reversed.
Competing interests: No competing interests