Dear Sir,



“Of the terrible doubt of appearances,

Of the uncertainty after all-that we may be deluded.”

Walt Whitman.



Who is a well man? The present day answer would be “the one who has not come in contact with the modern medical establishment.” With the sales hype of the total body scanner in full swing, every human being, who comes in contact with the medical establishment, would be declared abnormal, anyway. To complete the process the present total medicalisation effort of the above 50s would be the last nail on the coffin of human health. Healthy society would be a curse on medi-business. Before we force the whole population above 50 to take the composite pill daily, we better look at the darker side of the coin.

There is no controlled study available to date of multiple drugs used together for any ailment.1 There are no controlled studies of any one of those drugs (inside the pill) having had studies done on them on long term basis, beyond a maximum of five years. Not a single ingredient of the pill has been cleared of the risk of higher incidence of total deaths in the study group compared to the controls in the long run.2 The explanation given each time is that death was not the end point of the study and will not be significant in a five-year study period. Truthfully, therefore, we can not cross our hearts and say that these drugs, even singly, have acquitted themselves well in the long run. On the contrary, each of them has been shown to be dangerous in the long run term audits.3 One in four prescription drugs, of which there were 3.4 billion last year in the US alone, has had serious side effects. All that glitters is not gold in the long run with reference to most drugs.4



Reductionist science of controlled studies itself is flawed. Time evolution in a dynamic system like the human body depends on the total initial state of the organism and might not be altered just because someone has changed one or two body parameters of the initial state. There is the “butterfly effect” every time.5 This explains all our problems in drugs therapy and interventions thus far. We need better methods for controlled studies. Doctors have been predicting the unpredictable in the past.6 Even a simple drug like aspirin, which has been with us for hundreds of years, is not one hundred percent safe in the long run. While it certainly reduces the non-fatal myocardial infarctions, (or makes it painless) it increases total deaths marginally even in a very small dose.7 It is ironic that we still do not know what dose of aspirin is good for what condition. In an interesting editorial, years ago, entitled What Dose Aspirin? Late Prof. Mitchell questioned our logic.



Be that as it may, let us look at the dosage of drugs in hypertension treatment. In the early 70s, I was amazed that the raised pressures of poor patients, in the large government hospital that I used to work in Mangalore, South India, used to be well controlled even when they did not get the prescribed drugs in the hospital pharmacy for want of budgetary allocation. I used to ask them to take smaller doses, as small as 10 mg. Propranolol in place of 40-80 mg. The response was equally good. Then I mounted a cross over controlled study (patient being his own control-ideal holistic controlled study) of small doses thrice weekly vis-à-vis similar dose daily, with identical results. Who cares for such studies from the third world?8 Lots of water has flown under the Hoogly Bridge since then.



I had written in our book Hypertension-Assorted Topics, in 1993 9 (the book has the foreword by Barry Hoffbrand, the then editor of Postgraduate Medical Journal) that the only safe and effective drug is thiazide diuretic. This was confirmed by the ALLHAT study.10 Most of the other newer drugs were shown in bad light in the HOT study, despite the excellent response of box blood pressure.11 To cap it the very concept that blood pressure as the product of cardiac output and peripheral resistance is fallacious. Step-down treatment of blood pressure should be the ideal way to try and stop treatment when the pressure stabilises over a period of time. In well over half the hypertensive population the pressures do not go up again.



Let us try to promote wellness and try not to make everyone feel ill with drugs as a part of living. Even the water-soluble vitamins in the long run have shown their capacity to create trouble. Apparently healthy people being given so many drugs, even in small doses, for no good reason, only with the statistical prediction of 80% benefit, just can not be true if one understands the non-linear physiology of the human body.12 Let us leave healthy people alone except helping them to change their mode of living-the most important advice given in the first English textbook of Medicine by Charles Scharsmidt in 1773.9 We have come a full circle. Doctors’ main role is to preserve, and, if possible, promote the health of the public.13 Predicting future risks and trying to correct them does not fit in with the new science of Chaos and non-linear mathematics the way we have been doing it. Let us try to keep patient trust in doctors. If trust is lost everything is lost.14

Yours ever,

Bmhegde.

BIBLIOGRAPHY



1. Steven Milloy. Science without Sense, 1997. Cato Institute, Washington.



2. McCormach J, Greenhalgh T. Seeing what you want to see in randomised controlled trails: versions and perversions of UKPDS data. United Kingdom prospective diabetes study. BMJ 2000 June 24; 320 (7251): 1720 –3.



3. Anderson OK, Almgren T, Persson B, et.al. Survival in treated hypertensives: BMJ

1998; 317 : 167 - 71



4. Velazquer EJ and Califf RM, All that glitters is not gold; Lancet 2000; 353: 1568 – 69



5. Gleick J. Chaos – The amazing science of the unpredictable. 1998. Vintage Books,

London.



6. Firth WJ. Chaos – Predicting the Unpredictable. BMJ 1991; 303: 1565 – 8



7. Cleland JGF. Preventing atherosclerotic events with aspirin BMJ 2002; 324: 103 - 105



8. Hegde BM, Chandy PK and Bhat EK: A new method of treating mild to moderate hypertension. Karnataka Medical Jr. 1984 :51: 7-9





9. Hegde BM: Shetty MA, Shetty MR : Hypertension -1993, Bharatiya Vidya Bhavan

Bombay, India.



10. ALLHAT Collaborative Research Group: JAMA 2002; 288: 2981 – 97



11. Principal results of the Hypertension optimal treatment (HOT) Hot Study group:

Lancet. 1998;351(9118):1755-1762.



12. Hegde BM: Chaos a new concept in science. Jr. Assoc. Physi. India 1996: 44 : 167 –

168.



13. Hegde BM: Wellness a new concept – editorial JIMA 1996: 94 : 286 – 288



14. O'Neill O. Reith Lectures 2002. www.bbc.co.uk (bbc.com)