Intended for healthcare professionals

Rapid response to:


A cure for cardiovascular disease?

BMJ 2003; 326 doi: (Published 26 June 2003) Cite this as: BMJ 2003;326:1407

Rapid Response:

Social implications of different preventive approaches need to be carefully considered

In a couple of recent meetings on diets rich in fruits and vegetables
I half-seriously argued that whatever the uncertainties surrounding their
beneficial effects on ischaemic heart disease and stroke they may soon be
made irrelevant by eating a "banasta" a day, namely a genetically
engineered banana containing a dose of statin.

Wald and Law present an otherwise realistic preventive
scenario[1].Taking the estimated beneficial effect of the composite pill
at face value Richard Smith raises [2] , among other issues, the question
of medicalization of health interventions. Strictly speaking an
intervention, in the present case a pill, can be legitimately regarded as
inducing less rather than more medicalization if actually shown capable of
eliminating the need for screening for cardiovascular risk factors and of
reducing the need for therapeutic and rehabilitation services, intensive
in technology and personnel.

But equally important is the question of whether the intervention
enhances or reduces people's autonomy in the etymological meaning of self-
given rule of behaviour. Can a lifetime (after age 55) use of a pill
result in weakening of personal, and then collective, efforts to abandon
tobacco smoking, avoid overweight, exercise regularly ( which all affect
the risk of diseases like cancers at different sites) ? How far this may
in turn help in perpetuating, in a vicious circle, the influence of agents
like the tobacco industry ? How much will it reinforce the tendency to
depend on pills rather than on feasible but will-based behavioural changes
? Empirical evidence in different populations (eg by gender, country,
social class) is needed on these issues.

One of the less often quoted sections in the classic book [3] on
preventive strategies by Geoffrey Rose stresses (chapter 8, p.113 and
ff.) prevention as largely relying on responsible free choices rather than
on the passive adoption of ready made solutions or, in the health
education area, on conviction forced through propaganda. Primary and
primordial prevention on "healthy" people contribute not only to disease
avoidance but also, through the specific means it becomes implemented on a
vast scale, to the habit formation of citizens, hence to their general
attitude towards solving societal problems of direct personal
relevance.This aspect should not be underrated whenever a new preventive
approach is proposed.

[1] Wald NJ and Law MR. A strategy to reduce cardiovascular disease
by more than 80%. BMJ 2003; 326 : 1419-23.

[2] Smith R. The most important BMJ for 50 years ? BMJ 2003; 326 :

[3] Rose G. The strategy of preventive medicine.Oxford University
Press, Oxford, 1992.

Competing interests:  
None declared

Competing interests: No competing interests

30 June 2003
Rodolfo Saracci
MD . Director of research in epidemiology, IFC-National Research Council
via Trieste 41, 56100 PISA (Italy)