Intended for healthcare professionals

Editor's Choice

Are we at risk of being at risk?

BMJ 2010; 341 doi: (Published 02 September 2010) Cite this as: BMJ 2010;341:c4766

Moynihan is Closer to the Best Available Model


Moynihan has benefitted us more than you allow in your Editorial, (4
Sep 10). His model of the chronic state is a 3-model, is Normal/Pre-
hypertensive/Hypertensive. Yor conventional 2-model is

I suggest that the better model of what is happening (in the chronic
state), is the "Lansley Continuum Model." In the context of hypertension,
- and in many other contexts, - "Normal" is taken to mean "the unaffected
human state," or "the human state undamaged by any disease process." In
other words, there is conceived to be a dis-continuity between the outcome
for the unaffected, and the outcome for the diseased. I suggest that this
is true, but incomplete.

It takes only a moment's reflection to show that "Normal" and
"Optimum" are not identical concepts. It is easy to believe, - and the
evidence is consistent with the idea, - that a reduction in "Streetman's"
diastolic blood pressure by 5mm, evidences both a marginal reduction (dP)
in his peripheral resistance, and an equivalent marginal enhancement (dE)
in his distal blood flow. However "normal" Streetman's blood pressure was
before, it is now closer to the optimum blood pressure for (1) lowered
artterial/arteriolar wear-and-tear, and for (2) the enhanced physical
delivery of all immune-cell types to the peripheries, which must be
associated with enhanced peripheral blood flow. This latter may account
for the observed connection between a good tissue blood-supply, and that
tissue's long-term resistance to cancer

My idea is that a continuum model, goes with the concept of the
"Polypill," (aspirin + statin + antihypertensive). There has historically
been much resistance to the idea that whatever your cholesterol level is,
a lower cholesterol level will benefit your circulation long-term; most of
this antagonism, it seems to me, centres on a dogmatic adherence to a
"Normal/Abnormal" model of what is going on. Your current observations on
Moynihan adhere to this model too, - when the real likelihood is that a
5mm reduction in your diastolic blood-pressure will be closer to the
optimum, for your long-term cardiovascular- (and possibly your cancer-)
survival. I am praising Moynihan's 3-stage model for being closer to my
Continuum model, than is your 2-stage model.

I cannot forbear to say that the historical Normal/Abnormal model has
political attractiveness, because it implies that the "Normal" should not
be medicated. Indeed, - it may be profoundly cynical of me, - but I think
!some of the observed political lack-of-enthusiasm for the "Polypill," may
evidence a political resistance to our population's longevity increasing.
It is fine, of course, for natives of India! but not for us in the UK.

It would all be fine if the "unaffected, undiseased" state of the
human body, lay at its very point of optimum survival-chance, but it
doesn't. Let's "get real" about this, I'm suggesting.

Yours faithfully,

Dr Peter Lansley

BMA membership no. 6499719

Competing interests: No competing interests

07 September 2010
Peter H. Lansley
Retired UK Military Doctor