Hardly a day passes without some big doctor in Delhi, Calcutta, or Bombay proclaiming to the world that there is an enormous increase in the incidence of heart disease in India. It is galloping. And they also stress the need for more and more interventional units which can make all these unfortunate victims of heart attacks normal again. Very curious indeed! This reminds me of a statement which Vincent Churchill made in the House of Commons. “In any statement there are three questions. 1) who makes the statement? 2) how he makes the statement? and, 3) what does he say? Of the three, the last is the least important”. How true! When a big man says something it is immediately believed by the majority of people and is copied by them.



This has been the case from the time of cave-man to the present day world. Take for example the statement made by President Clinton, the most powerful man in the world at his peak glory. He said that oral sex is not a sexual act. Within six months the Journal of the American Medical Association, JAMA, published a study, which said that oral sex is not a sexual act. Of course, the editor. A very good one at that. Dr. Lundburg was dismissed by the American Medical Association for publishing this article. That makes two very important points. Statements, however ridiculous, far removed from the truth, if made by important people makes headlines. The next important thing is that if one makes up his mind, and if he is reasonably intelligent, in the present day science of linear mathematics, one could get “scientific” study showing the results to agree with one’s concept.



An extensive and in-depth retrospective study of heart attacks and heart diseases, including other vascular diseases, was done by William Stehabens, a professor of Pathology in New Zealand, who studied the problem both in the USA and in Europe for a period of five years. His conclusions very clearly showed that there has never been any absolute increase in the incidence of heart or vessel diseases in the western advanced industrial countries in the last one hundred years. The relative increase, reported in smaller studies from time to time, was based on labeling and wrong diagnostic criteria. If that were so in the western countries, where there are good records in at least two countries, Switzerland and United Kingdom since 1841, the state of affairs in India could only be guessed. Although we have had similar patchy, but not as rigorous studies as were reported from the West, we in India have never had any documentation of coronary heart disease or vascular diseases in the distant past at all. From this very sketchy, unscientific data from small studies done from here and there, to say that there is enormous increase in these diseases in the last few years is not only unscientific, but it is very, very far from the truth.



There have been small studies of incidence of heart diseases in communities where the study design and even the definition of the population, and the basic difference between incidence of the disease and its prevalence, have not been taken into consideration. To sum up, almost all the studies that have been reported in India do not qualify to proclaim that there has been an increase in these diseases in the recent past. Having said that, we must look at the way we report diseases. Even in the West labeling of particular disease increases the fear psychosis in the population which brings more apparently healthy people into the net of the medical fraternity and artificially blows up the statistics. Applying disease statistics to healthy people results in large scale false positives.



A very good example is the enormous increase in coronary deaths in Moscow City Hospital, where it was reported in the seventies, that, on an average,20-30 people died daily of heart attacks in the intensive care unit in the city alone. A more thorough investigation into this, by two leading American pathologists, showed the fallacy of this report. Majority of the people died suddenly in the Moscow of a totally unconnected disease, alcoholic cardio-myopathy, and not coronary heart disease. This, of course, led to Gorbochev banning Vodka; marking the beginning of the end of his regime there! Another area is that of high blood pressure, where recent audit showed the fallacy of checking blood pressure in all those recent studies. Similar reports have cropped up in India in large numbers in the recent years.



Whereas the British Hypertension Society propagates a level of 160 mm mercury systolic and 100 mm Hg. diastolic as the cut-off points for the treatment of high blood pressure, the Americans have brought it down to 140 and 90 mm correspondingly, and more recently to 120/80. Naturally, the incidence would go up in America vis-à-vis England. But if one looks very carefully at these reports the truth comes out. Between the blood pressure readings of 140/90 and 160/100 there are estimated to be about 50-60 million Americans. To get these extra sixty million Americans into the label of hypertension, the level must have been brought down arbitrarily. If the 60 million were to be treated with the help of the modern drugs, the drug companies would easily net 8-10 billion dollars per year. It is the similar scenario in the field of heart disease in our country today. The more number of centers established to look after this kind of patients, investing large amounts of money, the larger will be the labelling of heart disease in society. Doctors would only be too eager to intervene, if possible. This brings to mind an interesting study of impotence in treated high blood pressure patients.



While thirteen percent of patients who were given diuretics for lowering blood pressure reported impotence as a side effect, the same population when questioned by a psychologist, about their sexual functions in great detail, reported an incidence of 87% erectile dysfunction. This speaks volumes about the way we go about conducting “scientific studies”. It was Mark Twin who once said: “For a man with a hammer in hand, and wanting to use it badly, everything in this world looks like a nail needing hammering”. We have built a system wherein we are now frightening the gullible public about newer, dangerous, fatal diseases galloping towards them to kill them.



This naturally creates fear psychosis in the general public. Fortunately, those who are not exposed to our print media are, to a certain extent, saved from this onslaught. However, the electronic media today gets to every village and even the simple villager gets this wrong message in a big way in our country. While coronary heart disease is not synonymous with blocks in epicardial coronary vessels, most of the centers catering to this disease mainly go after delineating the coronary arteries. This again is a good business. It is now known that a person who inherits the athras gene, about 30% of Caucasians have it, some blocks in the vessels, as early as ten to fifteen years of age, is not unusual, but it is not a disease. Studies of Vietnam and Korean War victims among the American soldiers in the age group of 18-22 years had between 40-70% blocks in the coronary vessels, while they were battle fit otherwise! However, this does not mean coronary artery disease. Heart attacks come when a clot blocks the coronary vessel. Why does a man get a clot is a million dollar question.



Some light is thrown on this problem recently. The human mind seems to be at the root of the genesis of the clot. Severe depression, hostility, anger, jealousy, and many other bad human feelings have been shown to trigger the onset of a clot. The leading culprit in the bargain is an intense hostility. Having said that, I must remind our colleagues that creating a fear psychosis in society is possibly one way of increasing the incidence of coronary heart disease. Ignorance is bliss is a good dictum in this area. By labeling people who are asymptomatic, or who have blocks in the coronary vessels but without any lack of blood supply to the hearts, we harm a lot of people.



One study showed that this is the case. The shopping plaza-blood pressure-checkup in the USA, where anyone could get the blood pressure checked each time he/she went shopping. The labeling went so high with more and more anxious people walking into these machines to check their blood pressures, in the next five years a retrospective audit showed that sick absenteeism went up exponentially. The check-up has since been stopped.



The illness concept that we are trying to sell to the gullible public today, probably results in more illness in society because we create the fear of diseases in people. This works even in the field of communicable diseases. Whereas the health authority should get the warning about these diseases to keep themselves on their toes, common man should not be unnecessarily frightened. The latter could be counterproductive. On the contrary a wellness concept, telling people that health is their birth right and illness is an exception and an accident. To give a concrete example, while people are being frightened to say that heart diseases are coming to eat them up, even if we showed that the incidence is only 10-20% of the population, we would still be creating a scare in the minds of the healthy 80% of people would be living with the constant fear of death from heart attacks. On the contrary, if we were to tell them that in the same society with the same “so called” risk factors operating at the same level, 80% of the population does not suffer from heart disease.



This wellness concept would make people happy. Happiness would reduce the incidence of heart attack. Studies have shown that even when people with established coronary heart disease presenting with anginal pain, the episodes increase enormously when people get depressed only to disappear when once the mood gets elevated and depression lifts. The difference could be as much as twenty attacks of angina in a depressed individual and when once the depression lifts it could come down to one or two attacks in a month. This speaks volumes about even the so called unstable angina, where clot is the root cause of pain.



Audit in the West has revealed the secrets of this way of thinking. A study in Nottingham area showed that 49% of the angiograms done there were inappropriate. A study in Boston showed that of the two hundred people referred for aniogram and by-pass surgery to the Harvard medical school, a second opinion by a group of scientific cardiologists showed that only a six of them needed angiogram and by-pass surgery. It works out at 3%. The remaining people were followed up for a period of fifteen years and they fared better than the people who underwent interventional procedures. None of them suffered any bad consequences because their coronaries were not bypassed. More glaring study was the one reported recently in Philadelphia and Ontario, the two areas with the similar population density. While in Philadelphia ten times more interventional procedures were done for patients after a heart attack in the hospital, only one such patient received intervention in Ontario. Surprisingly, at the end of one year the number of people still alive and the number of people who died have been almost identical in the two places. This is a shocking revelation of the overuse of cardiac interventional procedures. Writing an editorial in the same issue of The New England Journal of Medicine, a professor of Cardiology, Dr. Krumholz, says that in America interventions are done more for making money. A thinking British professor of cardiac surgery, Tom Treasure, has made a fervent plea to government to reduce the number of cardiac surgical centres in that country.





In this background my reading of the recent newspapers of the big cardiologists talking about the epidemic of coronary disease in India makes a very sad reading. When are we going to realise the fallacy of the situation? Should we really be contributing to the increase in the disease in our population? I think it is time for all of us to cross our hearts and answer the above two questions.



I strongly feel that the world can change only when each one of us changes. I have had a transformation of my heart long ago. After having seen the ravages of our onslaught on the population in the last forty years of my experience as a practising cardiologist I have come to the conclusion that the population is better off without much intervention from our side. When a patient comes to us in pain having symptoms of heart disease it is our moral and legal obligation to do what we could to the patient. Even though the scientific data in the area of intervention may not be unequivocal. But to say that we would improve the health of the apparently healthy people in society by doing what is called screening for future possible damage to themselves and trying to say that we would correct it for their good in future is at the moment not scientific but more dangerous. The linear mathematics that we have been using in medicine of predicting the future has been proved totally wrong and doctors have now been known to predict the unpredictable.



I feel strongly that we must have a heart transplant for ourselves. It is not the same heart transplant fathered by Norman Shumway of giving another human being’s heart to a totally damaged irrevocable patient’s heart. I am talking of transplanting a kind heart which understands the problems in its entirety in place of a heart which only looks at things from one particular angle, that too, an angle which benefits us. This kind of transformation of the heart which in a manner of speaking I have named as heart transplant would probably do a lot of good to society. We must have few excellent centres, but not the sprouting up of cardiac centres like mushrooms all over the place looking for the gullible public to come for intervention. In fact, today there are lots of people who need this kind of intervention in cardiac surgery but we are not prepared to intervene because they are not the ones who would probably pay us.



We would need cardiac surgeons whose hearts bleed to look at the large volume of damaged heart valves seen in our poor people of the villages and he or she should look for ways and means of trying to do his/her bit to prevent the simple disease in childhood. Simple rheumatic fever in children might result in damaged valve when the child grows up. India has a large number of then who do not have the means or even the ability to reach the high-tech centres in our metropolitan cities. If only we do a concerted effort to eradicate rheumatic fever in India the future generation of Indians will not have valve disease as is seen in the advanced West. The same goes for congenital heart diseases, nay, for coronary artery diseases as well. If we look after pregnant women in the first trimester with adequate nutrition and no viral infections we will have a generation of healthy children born without a congenital defect in heart and also possibly without coronary heart disease in later life. There is a very important study in this direction which shows that those children born to mothers who did not have adequate nutrition in the first trimester of pregnancy were born with defective coronary vessels, defective pancreas, defective livers and defective various organs resulting in later life in a higher incidence of coronary heart disease, diabetes and high blood pressure.



There is a lot that the medical fraternity will have to do for the poor Indian masses. Let us wake up to this reality. However, society does not seem to respect people working in this area. They are not given the true prominence that they need. It is only the performers who really can sell their wares to the world who get the limelight and they are being looked up to by the gullible people as the massiahs of the new message. Unfortunately, studies in the West have shown that if there is any improvement in the incidence or mortality of coronary heart disease it is mainly due to the change of life style of the western world contributing to 59.4% of the improvement. Where as all the interventions that people talk about has been responsible for only3.9% of the improvement. Despite the fact that this is the truth the people in the news are the interventionists. Curiously one of the meanings of the word intervene in the New American Heritage Dictionary is to go in between with malice. Hope the divine interventionists would have a heart transplant to look at the real sorrow of the millions of people who are becoming their patients in the future by not being able to do simple things when they are children or before they are born. We would not know the long term consequences of putting the cart before the horse. In this case by putting stress on intervention rather than prevention I must remind us what happened in the motor car industry. In the thirties when Henry Ford first time thought of mass production of motor cars at the end of the economic depression Henry Ford was as a hero. When he found that the mass produced cars were not selling because the roads were not good he sought with the American Government funded borrowed money to construct motorways. Having done all that he probably got prosperity for the western world. Today we see the ravages of the motor car polluting the atmosphere. Poisoning the very air that we breathe and this has become a menace today. But how of us have ever heard of the name of the Alexandar Lassagonis. Lasagnas was appointed as a scientific adviser to the British motor corporation in late fifties 1959 to find out ways and means of reducing fuel consumption in automobiles because of the crisis putting pressure on the western world for precious oil from the gulf. Lassagonis came up with a brilliant idea. Instead of having the long engines lying from front to back he put the engine transversely and this smaller engine put transversely gave Lasagnas gave a lot of leg space inside the car and he invented the new mini which hit the British roads in the sixties and has stayed on even to date reducing pollution to a great extent from the large engines to the small cylinder engines, but as effectively and at the same time reducing petrol consumption. It is Lassagonis who should venerated in the field of motor industry. But unfortunately it is Henry Ford and Benzes who steal the limelight.



Once again this is a fervent appeal to our fraternity to not just understand any disease process but over stand it, if I may use that word. To overstand is to stand above the problem and have a panaromic view of the entirety of the problem and come with a solution which will probably be good for the whole population and not for that restricted number of population which could be useful to our way of thinking.



Another ploy employed to sell the ideas generated in this scientific fashion is the concept of the life span having been increased by the recent interventional procedures. I was listening to two senior professors holding forth on this subject in a recent meeting in Coimbatore, India. Both of them claimed that modern medicine with all its high-tech gadgetry has increased human life span. Nothing is farther from the truth. What has happened in the last fifty odd years is the death graph originally drawn up in the eighteenth century by a British Norman Crumpets has actually changed its shape instead of large number of people dying young now people die in old age. But there has not been any change in the human life span. Human life span has, in fact, if anything comes down in the last hundred odd years. Even today there are people living far beyond hundred years in the conventional societies still pursuing sustenance economies in some parts of Uzbeigstan and in the Polynasean islands where people live up to hundred – hundred and twenty years. With all the modern facilities it is estimated recently that maximum life expectancy of a western Caucasian would not go beyond eighty nine years. Now what is it that these two professors had misunderstood? It is the word life expectancy which is a statistical chart used to fool the gullible amongst the medical fraternity in addition to the gullible public. It simply means that today people born could expect to live longer than their predecessors did both in the West and even in a country like Indian. The life expectancy of Indians in 1947 was twenty seven years and today it is more than sixty seven years. Does this mean that the life span of an Indian has gone up from twenty seven to sixty seven? Far from it. Our lifespan is fixed on the day we are made in our mother’s womb,