Overdoing Prevention

Beware of Regular Check-Ups, Healthism by Numbers and Genetic Profiling

Preventative-MedicineHumane medicine as usually practised by general practitioners is a threatened species. In the old days doctors observed their patients in the circumstances of their lives; at least they watched them walk from the waiting room into the consultation room and they listened more than 123.4 seconds before interrupting them.

Another historical period bore witness to a technological medicine centred on systems, organs and cells, practised by true engineers of the human body, these second- and third-line specialists better paid than a dedicated general practitioner with a good clinical judgment. Medical progress became synonymous with medical specialisations in hospital settings which required expensive machines, expensive drugs and expensive training programmes to learn their use. High-technology fragmented care saves lives but treats Homo Mechanicus.

In the wake of the craze for a healthy lifestyle (mostly associated with our social, economical, educational and environmental status), we’ve entered another period characterized by proactive laboratory-based preventive measures based on schedules to screen for anomalies in plasma molecules, in body images and soon in genetic material, in hot pursuit of markers and risk factors, the significance and utility of which will unquestionably be exaggerated by interested parties.

It is your dossier that is dealt with, and nobody asks you any more how you’re getting on in general; no interest is shown in your social or economic situation, your living environment or habits, whether you live alone; nobody inquires about the stability of your job or your relationship, nobody even touches you any more [1], and nobody wastes any time over non-verbal signals that might differentiate a real depression from a bout of hypochondria.

The ritual stethoscope is applied over the clothes, missing a melanoma brooding on the back; the pulse is felt half-heartedly, a hand is passed over the abdomen without conviction, the blood pressure taken rather too swiftly, the lymph nodes are not systematically palpated, the breasts are examined too coyly. Your life, your body, your worries are less important than your blood assays, your body images, your answers to simplistic questionnaires.

Following the widespread of medicalization of the human body (disease mongering), the giving of disease-names to all the natural symptoms that may well be turn up in the course of a life, wealthy societies are now facing prevention zealotry, based on test results and known as health by numbers.

It is an ideology that asserts any aberrant value in your specimens is a disease that ought to be treated. If your health check is within standard values, then you are in good health.

If not, you ought to follow official recommendations and make sure your results return to the acceptable range. This has opened the door to a general intimidation of the population and for considerable wealth for the sponsors of preventive medicine and medicines. A decade ago this approach was already being described as presumptuous, authoritarian and overbearing by a pioneer of evidence-based medicine, David Sackett.

According to this paradigm, prevention becomes serious when it takes the form of a regular check-up report printed on laboratory paper!

Your “good” cholesterol has taken off and been at cruising altitude for quite some time, while the “bad” cholesterol has learned to keep low in the light of ‘treat to target’ strategies and thus avoid being hit by a statin’s lightning-strike.

But you may not be so lucky at the next measurement. At the slightest rise above the limit of ‘normal’ stipulated by lipidology committees whose manifest or covert conflicts of interest don’t stop the distinguished members from sleeping in peace, you risk being statinised overnight for a lifetime.

Bone density has to stay within a few standard deviations of the level you had when you were twenty – that’s directly from the guideline-maker’s mouth.

The prostate-specific antigen (PSA) level keeps its distance from a critical threshold to avoid a urology consultation and a burst of biopsy fire on your smooth, round and innocent prostate.

Glycated hemoglobin (a surrogate for past average blood glucose levels) returns to the straight and narrow after going off the rails last year, so you can continue without guilt to be occasionally wined and dined.

Blood pressure should keep a low profile in order to stay below the radar cover of the ayatollahs of tight control, some of who would like your pressure to remain at the level of your twenties.

The screening mammography image remains pure and stainless, sparing you from the anxiety over a repeat mammogram or the threat of a needle.

The screening electrocardiographic tracing shows neither jolt nor start, no treadmill is in sight, your health insurance premiums will not rise next year.

Not a single red blood cell has dared to venture on the faecal smear, saving you from a discussion about a far from enjoyable screening colonoscopy.

You’ve managed to get through the questions about memory retention. But you may not be so lucky if you become a job-seeker after 50: a brain scan may be required to check for amyloid deposits, the latest pet-surrogate (unproven) biomarker of blockbuster-happy drug developers.

You’ve also done the questionnaire about the latest mood disorder added to the mental disease catalogue, the infamous Diagnostic and Statistical Manual of Mental Disorders (alias DSM). And you passed the one on feelings of depression, escaping a consultation inevitably followed by a trip to the pharmacy to have a prescription filled for you-know-what.

Your dossier is in good health. But your health check transforms you into a patient – a patient under surveillance.

“They” will take care of you, and your children, and your aging parents. The health industry has its eye on you with the complicity of governments, researchers, educators, editors, health professionals, the media, all of whom have become financially dependent on Big Pharma to different degrees, creating a “pharma-co-dependence” where the co stands for complicity, collusion, compromise, connivance and other terms beginning with co. [3]

Big Pharma will gradually gain access to check-up data, computerised databanks of health records being sold to them behind the doors for “research purposes”. Information technologies applied to medicine warm the hearts of chief executive officers of private health industries.

After all, prescription profiles are already being discreetly sold by pharmacists to the likes of Intercontinental Marketing Services (IMS) who pass them on to Big Pharma for fine-tuning their marketing strategies.

You’ll be seen again in six months: that’s the guideline from the last consensus conference where ‘truth’ is arrived at too often by votes rather than by evidence, the latest in a list of clinical guideline issued by a foundation receiving generous corporate grants supposedly with ‘no strings attached.’

When a prescriber confides to a journalist that “today we have far more tools for investigating and treating … dyslipidemia, osteopenia, pre-diabetes and cognitive decline!” you’d be entitled to wonder which drug rep fed him this scoop.

Genetic profiling is in the offing.

Insurance agencies, employers, head-hunters, guidance counsellors, matrimonial agencies, sperm donor clinics as well as Big Pharma (benefiting from fiscal advantages of orphan drugs for orphan diseases), are wholeheartedly in favour of it, not to mention the manufacturers of costly genetic screening tests who give a new meaning to the expression “personalised medicine” in their promotional material.

Incidentally, it’s strange that so many patient associations are interested in genetic profiling since diagnostic progress in the field of rare genetic diseases has so far not been followed by therapeutic progress or anything that might resemble a cure.

Inherited title or wealth will be replaced by biological inheritance, just as we currently breed herds of cattle and sow our wheat fields. Genetic strata will become hundred of times more numerous than there are current castes in India. Some will lead to gene therapy, the most dangerous approach ever dreamed up in modern medicine. Especially if society leaves genomic research in the hands of private interests.

What is denounced here — overdiagnoses leading to overtreatments with preventive medicines in healthy people — costs more money than it saves. Its sponsors and prescribers aren’t my heroes. But I tip my hat off to practitioners who act as carers when people are ill, no matter where or when, for as long as it takes, who resolutely continue to provide quality, timely and continuous first-line care, especially in open-access health care systems. They treat Homo Vivens.

About the Contributor

Pierre Biron is a retired pharmacologist and Honorary Professor, Faculty of Medicine, Université de Montréal, Montreal, Canada.

Translated from French by Iain Bamforth.

One response to “Overdoing Prevention

  1. Merci Dr. Biron! You have beautifully captured so many of the key issues facing the medical profession, and specifically those facing patients. When you wrote: “It is your dossier that is dealt with, and nobody asks you any more how you’re getting on in general”, you perfectly captured a very common patient experience, including my own while hospitalized after a heart attack.

    But it’s not only in the diagnostic tests and doctor visits that we all see these care changes. Few patients, for example, would likely be surprised by a 2010 report from the Center for Advancing Health called “Snapshot of People’s Engagement in Their Health Care“ which revealed that 91 percent of chronically ill patients did NOT receive a written plan of care when they were discharged from the hospital. By that stage, we are simply the MI or the kidney failure or the CVA in Bed 8, a traffic obstacle that needs to be booted out the door. More on this at: http://myheartsisters.org/2012/11/11/study-91-discharged-without-written-care-plan/

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