Pills or public health?
BMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1791 (Published 18 April 2019) Cite this as: BMJ 2019;365:l1791All rapid responses
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Educational campaigns about medical diseases prevention are insufficient until now, since they did not involve a change in attitude and people's behavior
People know very well that tobacco is nefarious and still smoke, they are aware that obesity involves serious cardiovascular risks and continues to eat. It is clear that the messages provided by the information campaigns do not have the desired effect.
How to translate information into action? it is necessary to develop a strategic approach of communication with the population
Doctors constantly provide advices to patients but continue to prescribe drugs for hypertension, diabetes and other conditions. Giving a prescription takes a few seconds when the effect of the drugs is scientifically proven while the discussion with the patient about lifestyle modification takes about ten or fifteen minutes and it requires a repetition at each visit especially as the impact of advice provided to people is not safe.
Poorly conducted campaigns have four risks: they do not lead to any action or change, they can reach an unintended audience, can have a negative impact, and may involve a backlash (the effect of vaccination campaigns for HPV is a good example)
People who refuse or seek to avoid drugs may be more likely to introduce changes in their lifestyle. We know that changing people's habits requires a desire, an effort and a reorganization of their lives
It is not enough to know the harmful effects of the habits you have taken, but you must have a positive attitude towards change and act accordingly.
Replacing bad habits with other healthier ones is a rather difficult and not certain task and we continue to see obese, smoking people ... but especially an increase in cardiovascular mortality which constitutes the first cause of death at present.
It is true that the cost of drugs is expensive, but it must be compared to that of awareness campaigns.
Treating dyslipidemia in the elderly and demanding more stringent blood pressure leads to an increase in medical prescriptions but also a strict control of the lifestyle of people at an age when they will be unable to make efforts and focus on the details everyday.
The task of the doctor becomes more and more difficult in the face of the new recommendations, an individualization of the care is the best solution.
Grace Abi Rizk MD MS EPID
Associate professor
Competing interests: No competing interests
Much depends on the state of development of a region. In MIC and LMIC , where the nutritional epidemiologic transition has resulted in a steep upward rise of non .communicable diseases- diabetes , coronary artery disease and where detection , diagnosis and treatment could be delayed , public heaith measures of control , disincentives are imminently necessary. In contrast , in developed countries the measures can considered as restrictive and even coercive dictating on dietary matters personal and private. Drugs will eventually be necessary when lifestyle changes fail. Yet the admission is necessary that in modern medcine , we may be treating with mutiple drugs and that too longer ( statins beyond 75 ) as a case in point. The crucial task is striking a balance between public health (preventive and promotive) and individual therapeutics. Dr Murar Yeolekar. , Mumbai.
Competing interests: No competing interests
Given the arbitrary benefits of pillls over public health the fact that pill is still widely accepted needed to evaluate further...
Why do the public health interventions fail or looked down upon by general public? Simple answer is that we fail to identify what to whom at what time... simple epidemiology of time, place and person triad. Inability to establish proper situation analysis lead to improper and non sustainable interventions making public health a laughing stock. Therefore its non other than inefficiency of our own that pulls people towards pills. Therefore its time to take things onto more technical aspects to push people away from pills towards healthy lifestyle.
Competing interests: No competing interests
We know that hypertension,diabetes, hypercholesterolemia and smoking are risk factors for cardiovascular disease. Control of these risk factors does reduce the risk of stokes and heart attacks.
Giving pills only gives people a false sense of security and as a consequence some of them will ignore doing exercise and some will eat more sugary food and more fat as well as salt despite being diabetic,obese and hypertensive, simply because they wrongly feel they are secure by the pills.
Making life style changes (eating less sugar and less salt ,reducing weight and doing more exercise) as the primary intervention for managing such illness while preserving pills as back up for those who could not achive adequate control of their risk factors may improve the moral of people by not designating them as sick people, make them feel in charge of improving their health and with time they feel healthier as they get rid of such illnesses without taking pills. If they fail to achieve good control then pills will be given with instructions that keeping on healthy life style ,with time , the need for pills may become less.
So people will feel they are healthy and able to sustain their well being without pills.
Competing interests: No competing interests
Re: Pills or public health?
We carefully read the very interesting Editor’s choice Pills or public health? [1] As the editorialist Fiona Goodlee called the attention, this contradiction is emerging more and more around the world, with different points of view and consequences for patients, medical doctors and health systems.
In 1984 Geoffrey Rose published his seminal paper Sick Individuals and Sick Populations. [2] Rose's article remains highly relevant to public health. He defined two main approaches to obtain good results against different health problems: a) the high risk or “screening” strategy (the “traditional” clinical method, where the target is the individual person) and b) the population strategy (health promotion, intersectorial, where the target is the groups, the community). Both have advantages and disadvantages, but they are complementary to obtain best results.
New tools as guidelines, protocols and algorithms, have emerged in daily clinical scenarios for individual care (first Rose’s strategy) during the last decades. Commonly, the great majority of them include health education recommendations for “healthy” lifestyles, plus large lists of drugs (“pills”). Those “pills” frequently are expensive, with adverse effects, and not all are always safety proved especially in long-term treatments. But, as another colleague previously wrote, “giving a prescription takes a few seconds… while the discussion with the patient about lifestyle modification takes about ten or fifteen minutes and it requires a repetition at each visit”, and many doctors are often in a hurry due to different causes. Furthermore, the growing process of medicalization of the societies facilitate this behavior because the public thoughtful that it is compulsory to get a defined diagnosis of their complaints and to obtain almost some prescription at the end of any medical consultation.
However, when these new of methodological tools for improving the quality of care and guarantee patients’ safety are full accessible to health professionals now, it is necessary -maybe more than ever-, don’t forget the clinical expertise in the complete evaluation of each patient. Some important conceptions as patient centered medicine, narrative medicine and personalized medicine don’t be eluded. Only a harmonic equilibrium among updated knowledge and adequate abilities and ethics in caring patients, will be the ideal combination for any medical act. [3]
Interesting answers to this new dilemma are the Preventing Overdiagnosis (and overtreatment) initiative [4] and the Deprescribing proposal, the planned and supervised process of intentionally stopping a medication or reducing its dose that might be causing harm, or no longer be of benefit. [5]
However, we cannot overlook that proved public health approach through population activities (the second Rose’s strategy) is always also needed to promote a healthy, educated and equilibrate environment in a community to prescribe only necessary pills by doctors and to accept it by patients.
Finally, our answer to the question Pills or public health? is: Both, pills (right indication and use) and public health (always).
Alfredo D. Espinosa-Brito, professor of medicine. Hospital Universitario Dr. Gustavo Aldereguía Lima. Cienfuegos, Cuba. Hospital Dr Gustavo Aldereguia Lima, Ave 5 de Septiembre and Calle 51A, Cienfuegos, 55 100, Cuba.
alfredo_espinosa@infomed.sld.cu
Alfredo A. Espinosa-Roca, professor of medicine. Medical Sciences University of Cienfuegos, Cuba. Ave 5 de Septiembre and Calle 51A, Cienfuegos, 55 100, Cuba.
Competing interests: Non declared.
References
1. Godlee F. Pills or public health? BMJ 2019;365:l1791.
2. Rose G. Sick individuals and sick populations. Int J Epidemiol 1985;14:32–38.
3. Espinosa-Brito A. Revalorando el papel de las guías de práctica clínica. Revista Finlay [Internet]. 2017 [cited 2019 Abr 27]; 7(2):[aprox. 12 p.]. Available in: http://revfinlay.sld.cu/index.php/finlay/article/view/473
4. Brodersen J, Kramer BS, Macdonald H, Schwartz LM, Woloshin S. Focusing on overdiagnosis as a driver of too much medicine. Editorial. BMJ 2018;362:k3494 doi: 10.1136/bmj.k3494
5. Thompson W, Farrell B. Deprescribing: What Is It and What Does the Evidence Tell Us? Can J Hosp Pharm. 2013;66(3):201–202.
Competing interests: No competing interests