“If only I’d known … ” I’ve heard it a lot, that phrase, when people talk to me about their various medical misadventures. ” If only” someone had realized the potential consequences of that surgery or those drugs or that ostensibly innocuous test – before they’d done it. Maybe they’d have asked for a second opinion or talked to a few people who had done the same thing. Waited. Not assumed that it was safe and easy, like the brochures promise. Except of course most of us don’t know – so we go ahead. It’s only later that we realize that everything carries a risk; all drugs have side effects; all medical interventions are ambiguous.
The popular narrative is self-assured, authoritative and leads us to believe that medicine Knows. Knows why we get sick, how we get sick. The problem is, most of the time it does not. Particularly when it comes to prevention.
Acute illness – well, as a rule it does OK but the model is different. Let’s face it, if you’ve just fallen off a ladder and heard an ugly “crunch”; you have a temperature of 42C and a stiff neck and are delirious; if you are doubled over in agony with abdominal pain – the risk of what could happen without medical intervention is probably far worse than the alternative. So you rightfully race to the ER and get help – do whatever it takes. Hey, I’m with you; when I’m deathly ill I’m not stopping to look at statistics or evidence or googling “abdominal pain”, I want Dr. House.
The problem is when we extend this model to prevention. That’s when we’re walking along, singing a merry song – having a good day thank you very much – when our glance idly falls on some seemingly innocuous headline or pamphlet or poster warning that You Are At Risk. A ticking bomb, in fact, unless you do something immediately. You need that blood pressure checked, those glucose levels looked (diabetes on the rise you know), your cholesterol measured. You need to head over to that mammography clinic post haste. Or if you’re a guy, you need to have that PSA looked at. Or a bone density test. In other words, you need to engage in “pro-active” health care. Most people naively believe that this is good advice – and that’s when they can get into trouble (and many realize medicine is nowhere near as blindingly accurate in this as most of us think).
On television, on web sites, on the radio – whatever it is, whether it’s drama or news, it’s all presented with authority. Implication: we know what causes heart disease, we know how breast tumours evolve into cancer, we know how normal physiology morphs into pathology.
The trouble is we don’t.
And unlike those doctors on House or Mercy or whatever the medical show du jour happens to be, the outcome in real life is rarely neat and often not pretty. Contrary to what the news items tell us, it’s not all overwhelmingly positive and very little is “miraculous” or a true “breakthrough”.
Here’s where the risk/benefit thing kicks in. If you’re in pain, sick and feeling like hell, you don’t care what the risks are. It has to be better than whatever’s going on right now. Plus, that high temperature and stiff neck could be meningitis – which could kill you in less than 48 hours if you don’t get antibiotics. That crunch in your spine could mean paralysis. That abdominal pain could be appendicitis. Whatever the down side of the surgery, the side effects of the drugs, well, they probably aren’t worse than death.
But when we merrily head over to the clinic to have our blood checked for lipids, we are assuming that those panels of experts who’ve decided that anything above or below X is bad and wrong and abnormal know what they’re talking about. We assume that “they” know what ideal blood pressure is for a person of our age and weight and size; a person who eats the way we do and has the family we have; is, in other words, us. When we docilely head over to have mammograms and PSA testing as we’re bid, well, that’s where it gets tricky.
Take cholesterol. True, in a fairly smallish subset of people, hyperlipidemia or the tendency to create more cholesterol than the body needs, will create problems. Often, these are the folks who have had one or more close relatives drop dead of a massive coronary at a young age, say 50. Interestingly, often there is a geographical connection – people from northern countries such as Scotland seem to have this tendency.
What evidence there is (and virtually all of it comes from drug companies) does tell us that after a person has had a heart attack, lowering cholesterol with medication does seem to reduce their risk of a second one. But in people who’ve never had a heart attack, what is called primary prevention? Not so much.
Not that you’d know it from the television ads for statins and other cholesterol lowering meds on TV that here in Canada we get from across the border. (Direct-to-consumer ads are only allowed in the U.S. and New Zealand – all other countries ban them.) They make it sound as though it’s a moral imperative to take drugs if your numbers aren’t right. In fact, cholesterol is needed for normal physiologic functioning. It protects against infection and not having enough, as Finnish researcher Ravnov has shown, can be dangerous.
(For more see his site: http://www.ravnskov.nu/cholesterol.htm and also the Cholesterol Skeptics site: http://www.thincs.org/ which includes hundreds of names of physicians, researchers and other bit ‘names’. Also see “Should we lower cholesterol as much as possible?” in the BMJ (3 June 2006; Vol 332, pp 1330-32)
What they don’t tell you is how many of those expert panels the makers of these drugs have funded. Or that the whole idea behind cholesterol as a risk factor came from the Framingham study, a longitudinal study begun in the late 1940’s in Framingham (Massechusetts), in a report where a researcher hesitantly noted that it seemed as though cholesterol might be a factor in heart disease. (That was what the Framingham study initially was looking at, cardiac disease and why its incidence seemed to be on the rise at that time. And, they wanted to test out some cool new technologies that were being developed like the electrocardiogram.)
Science deals in probabilities, in maybe’s; it is a dynamic process. Individuals are not statistics and what works for one may very well not work another. Plus, medicine is just as prone to fads and fashions as anything else. Unfortunately, too often in the culture we have it descends into dogma.
And that isn’t healthy.