All changed, changed possibly.
The sceptics emailing these rapid response pages may be right: the
benefits of the six ingredients in the PolyPill may not be additive; their
wanted-effects may antagonise each other in combination or their ill-
effects may prove synergistic. Wald and Law(1) may have got their
statistics or meta-analyses wrong and overestimated the benefits. Or they
may actually have been joking. or just trying to provoke a debate. On the
other hand, Richard Smith may be the one who was right in his Editor's
Choice - the 28th June issue of the BMJ may be the most collectable I
have every binned – ‘the most important BMJ for 50 years’. (2)
One thing is certain - seriously contemplating the possibility of a
pill which protects against 89% of coronaries and 80% of strokes, costing
only £60 a year, using established drugs in low doses so that preliminary
work-up and subsequent medical supervision is unnecessary, which thus
bypasses not only the pharmaceutical industry and the medical profession
but perhaps even the government itself (if they stand back and let us
choose whether or not to take the thing) is a thought-experiment of the
most fascinating and far-reaching kind.
After a predictable gut reaction of despair and outrage, I am now
seeing this thing in a more and more positive light. To start with, to get
the benefits of the polypill you don't need to be a patient. Any more than
you need to be a patient to take a walk, a vitamin pill, or a generous
slug of health-giving Merlot. What's more you don't need a doctor, you
don't need any checks and you don't need any records. You don't need to
know whether you are specially at risk (God wisely left this out of our
equipage at birth and so should we) and you don't need to be given any
neurosis-inducing labels. And neither does your insurance company, or your
employer. And the government has nothing to do with the matter at all.
The idea neatly side-steps the phenomenon of ‘coercive healthism’
which Petr Skrabanek attacked so definitively in The Death of Humane
Medicine (3). You don't need to be dragged into surgery for dubious tests
to let your doctor earn a living wage. You don't need to be labelled,
admonished, praised, patronised, worried... Or led into orgies of life-
threatening celebration... Legions of nurses can be returned to their
ancestral calling and be paid to nurse. Your nice, friendly GP can return
to the life-enhancing role of being a nice, friendly GP to people who are
ill and dying. (This will still happen, note, even if a decade or so later
All if this of course makes huge assumptions - that the low dose
PolyPill really will reduce cardiovascular events by a large amount; that
it really will prove so safe that routine surveillance is unnecessary.
But let's imagine that both are true.
In that case everything will indeed be changed. And it will be a
chance our society to show what we are really trying to do. Because the
polypill isn't going to get tested and approved by a pharmaceutical
industry which has nothing to gain and much to lose by its success. This
is the sort of project in the genuine public interest that this country,
through the NHS and the Medical Research Council, used to be good at. You
will wait a long time to see this kind of work done in North America.
This idea highlights some of the most fundamental issues facing
medicine. It is not at all clear whether our government wants people in
general to live a decade longer, and it is not at all clear whether people
in general want to live too much longer either. It will be interesting to
see whether our rulers, eager in the past to appear good doctors, decide
to explore making such potentially enormous benefits available to the
people who vote for them. Or whether they are going to quietly let the
idea (and us) die the death.
(1) Wald and Law A strategy to reduce cardiovascular disease by more
than 80% BMJ 2003;326:1419–23
(2) BMJ 2003;326 (28 June) Editor's choice The most important BMJ for 50
(3) The Death of Humane Medicine, Petr Skrabanek, The Social Affairs Unit,
Sixty next month and watching with interest...
This piece slightly adapted from an article in the August British Journal of General Practice (with permission, and encouragement)
Competing interests: No competing interests