Sir William Osler, the “father of modern medicine”, said that what distinguished humans from animals was the desire to take medicine. Osler died in 1919, but, like most of his brilliant aphorisms, it is still true, with the added development that now many of us take pills even if there’s nothing wrong with us. He also thought one of the first duties of the physician was to educate people not to take medicine. That idea, that medicines are potentially dangerous and should be avoided if possible, has gone out of the window – and that is a pity.
We’re now seeing a radical extension of the doctrine that “prevention is better than cure”, with damaging consequences. So, where prevention once meant living well, exercising, not smoking, having routine vaccinations etc, now it entails chucking strong medication at whole populations. This is population medicine as opposed to individualised medicine. Instead of the doctor looking at each patient who comes into the consulting room, taking a history and providing treatment tailored to that person, you medicate a population, or “epidemiological cohort”, in the jargon.
Lowering the population risk is thought to be worth doing, even though the awkward fact is that most of the patients do not need the pills, will never benefit from them, and may be harmed by them. This is a departure from established notions of preventative medicine. But it allows drug companies, who try to influence public health policy, to present their products as serving a protective function. And that does wonders for their bottom line.
Another example cropped up this week. Nice, the National Institute for Health and Care Excellence, the government body that guides prescribing habits in the NHS, proposed that the threshold be halved for offering statins to people, so they’re given to even more patients.
These cholesterol-lowering compounds are already one of the most prescribed drugs in the GP’s formulary, and one of the most frequently given to people who are well. I myself am on a low dose of atorvastatin, though I’m not in the highest–risk group.
Clearly, they do benefit people who have had a heart attack or stroke; whether those who just score highly for risk factors will benefit, on the other hand, is less certain. A meta-analyis in the Archives of Internal Medicine found no evidence for the benefit of statin therapy in patients who hadn’t had serious heart disease. And for every 136 people who take statins, one will get a case of liver injury. Other side-effects (admittedly, often rare) include acute renal failure, muscle aches and cataracts.
Population medicine means that individuals are taking the risk of harming their health, on behalf of the other members of the population who might benefit. And there’s the cost of treating the side-effects to consider. These are unquantifiable: in her excellent book The Patient Paradox, the Glasgow GP Margaret McCartney tells the story of an elderly patient who suffered such painful muscle aches as a result of her statin treatment that she had given up going to the tea dances which were keeping her fit.
Not that statins are the only mass medication. Another is the “polypill”, a mixture of three or four drugs designed to reduce population risk of heart disease. Every couple of years an enthusiast proposes that polypills should be dished out to everyone above a certain age. But obviously the more drugs you combine, the greater the risk.
The classic instance of a whole-population approach is fluoride in water. As Professor KK Cheng and others have pointed out in the British Medical Journal, there is precious little evidence that it does any good, whereas fluoride applied as toothpaste has been shown to prevent tooth decay.....