“ Surgeons must be very careful

When they take the knife!

Underneath their fine incisions

Stirs the culprit-Life!”

American Poetess Emily Dickinson (1830-1886)**



The British Medical Journal dated 2nd August 2002 has a very interesting editorial by the editor, Dr. Richard Smith himself. MY letter to the editor in the same issue runs like this:



I have been saying this for a long time!


4 August 2002

Dear Sir,

Congratulations! You have hit the nail on its head in your editorial. Jonathan Swift was dead right. "Knowledge" wrote Karl Popper "advances not by repeating known facts, but by refuting false dogmas". One of the greatest dogmas in modern medicine is that drugs and surgical procedures only cure illnesses. It is the immune system that really heals. The latter needs to be assisted.

I teach my students that if any one wants to preserve his/her health intact he/she should avoid hospitals and doctors to the extent possible, but when one is ill, one needs to see a doctor without delay and be a partner in the management. Most of what we do today in modern medicine reminds me of what our ancestors did by branding for every major illness and blood letting to cure, swearing by their efficacy. We are able to comfort most of the time, which our forefathers in medicine could not achieve. That is the progress we have achieved in the last century, though. Hippocrates could well be right when he said: "cure rarely, comfort mostly, but console always."

Modern medical claptrap, assisted by the drug industry and instrument manufacturers, has made doctors forget their greatest role in consoling every patient.

The false sense of faith in our scanners, scopes, and the powerful chemicals and the heroic surgical techniques (poor patient playing the hero's role, though), has made us forget our primary role of consoling the suffering patients who still have confidence in us. Most drugs harm the system in the long run; there are hardly any exceptions, although they do help when given for symptom relief for a short period of time. There are exceptions to every rule and it is the exceptions that prove the rule. While there is no pill for every ill, every pill has some ill following its use.

Time really is ripe for more openness in our work. We need very bold editors, indeed!

Yours,
bmhegde (copied from the eBMJ)



I know most of you won’t believe this, but this is exactly what I have been writing for nearly four decades. Some of my colleagues and many in the industry have been very angry with me. Truth is always bitter but has to be exposed sometime or the other for the good of humanity at large. Doctors are being brainwashed from day one at the medical school.1 The public, especially the so-called “educated class,” is being systematically influenced through doctored articles in magazines and advertisements in print and electronic media. Medical profession would do well to remember the prophetic words of Jonathan Swift, one of the most admired Irish authors:



“Satire, is like a glass through which the observer could see everyone else’s face but his own.”





It is time that the medical world had a better look at its own face to mend things. I was amazed to read an article extolling the virtues of coronary angioplasty in the Sunday magazine section of one of the leading Indian newspapers, while the truth is that almost all the large prospective studies from 1978 to 2000 did not show this procedure in good light; the latter fact was left out in the narrative, knowingly or unknowingly, by the learned author!2



In an unprecedented move The Times, London published an article on the 3rd August 2002, exposing the hazards of the “white coat hypertension”-an entity where the hapless healthy person is labeled as hypertensive by the cursory check by the doctor on routine screening. If the individual is healthy his blood pressure should go up marginally (in some studies even as much as 20-30 mm of Hg systolic) due to the sheer anxiety of seeing the doctor. This entity adds millions of healthy individuals to the label of hypertension. Almost all of them receive life long expensive medications to lower that pressure. Future predictions of epidemics are based on this kind of data!



Doctors are made to believe that they are practising this kind of medicine in the long-term interest of their patients lest the latter should get life threatening complications decades later! Lay press calls hypertension the “silent killer” and creates more anxiety. This pushes up the BP of all hypochondriacs. The fact, however, is that after the first five years on drugs, the projected death rate in drug controlled hypertensives gradually goes up three times compared to their normotensive cousins.3 I have even written a book on this enigma called “white-coat hypertension,” but who cares? Patients are made to believe that they are protecting themselves against future dangers. Both are untrue, scientifically.4





“We shall not cease from explorations
And the end of exploring

Will be to arrive where we started

And know the place for the first time.

T.S.Eliot.



Identical logic, syllogism of Aristotle, is invading the field of human blood sugar measurements in healthy people. Drug companies are getting doctored data to show that high risk people (what does that mean?) would do well to take quite expensive medicine, glitazide, even when their sugar levels are within normal limits, to prevent the future onset of diabetes. The scientific data, however, shows that even diabetics who have established disease without symptoms, do not do well on those drugs in the long run.5 More than all that the “leaders” in their specialties are taken around the country to give “educative” lectures in five star luxury hotels extolling the virtues of the system that they are yet to understand fully. This would soon create an epidemic of diabetes and hypertension helping the drug company business.6 and Do epidemiologists cause epidemics?7 The paradox is that the medical profession does not take enough care of the really sick severe hypertensives and diabetics, making life miserable for them. Audits have clearly shown inadequate management of severe hypertensives and diabetics- the class that could benefit most from drug therapy, by the profession in their enthusiasm to care for the healthy people. Resistant hypertension and resistant diabetes both have a large share of doctor responsibility, since drug compliance is very poor in both those classes of patients. A good doctor has a vital role in improving patient compliance, but that takes time and patience-the two traits not stressed in the present day medical education.



Future predictions in the dynamic human body never could prove correct. Doctors have been predicting the unpredictable for decades. The story repeats in the area of cancer and AIDS. While cancer has not been defeated even with all our publicity, a recent world congress of AIDS showed that all the expensive new drugs did not change either the mortality or morbidity scenario. On the contrary these drugs encouraged youngsters to venture into dangerous life styles! This strategy gets helps the drug and instrument manufacturers. Most apparently healthy people, even before the age of sixty and certainly after that, take, on an average, 4-6 pills per day. Their doctors believe that they are being very scientific and cover their skin against any future legal claims and the poor patient is made to believe that he/she is protecting himself against all future complications and death. Both the assumptions are far removed from the truth. Every single pill has ills following its use in the long run. Even an innocuous pill like paracetamol did kill 136 people in one year in small country, the UK, due to liver damage. While drugs are needed to control symptoms on a short-term basis, long term use of any drug is fraught with danger. Emergency care is the only area where modern medicine and technology have really helped the sick and they are indispensable there.



This scenario has produced a new category of disease, not described in the past in any system of medicine, which I would like to call as doctor-thinks-you-have-a-disease syndrome. This new non-disease produces so much of social distress in that the hapless victim suffers constant anxiety of incubating a disease. His family suffers psychologically and financially. The whole purpose of living-for life, liberty, and pursuit of happiness- as envisioned in the preamble to the American Constitution, written by Thomas Jefferson in 1772, is lost forever. It would be difficult to get an American who is not taking some drug or the other all his/her life; if not anything else at least a multivitamin. Even the latter has side effects. At times they could even be fatal! Naturally we in India will have to follow that, as America is our intellectual master these days. This is the largest catchment area for drug companies and instrument manufacturers, who make trillions of dollars profit with this trick. It is more profitable to target the whole healthy population of this world to make money rather than aiming at the sick as the latter number is very small compared to the healthy ones. Luckily, nearly 80% of the world population today has no touch with modern medicine! Screening healthy people could seriously damage their health. There are two exceptions. Heavy alcoholics and heavy smokers blunt their body messages of initial illnesses that they realize there is something amiss only when it is too late. They could profit by regular screening. The latter two categories of people are not healthy individuals, anyway! Even mammography, with all its advertisements, has not been shown to be beneficial!8



For a few people who could not get into this arena of regular check ups because of poverty, another new disease awaits to rob them of their happiness. Happiness is man’s only birthright! They are always anxious that they have not been properly evaluated to be kept constantly healthy. They live under the shadow of doubt. The constant anxiety could give rise to most chronic dangerous diseases. I class this group under another new disease category-patient-thinks-he-has-a-disease syndrome. The reasons why these people do not get into the first net thrown by the drug and industry group could be economical. Poverty being the mother of all illnesses they succumb to real disease sooner than later. Poor pay for their poverty with their lives, anyway.



In this whole game of the drug and technology mania, the key element in human health and disease is forgotten. It is the human mind. The seed of every single disease is first sown here. The seed then grows in the soil, i.e. the human body and its environment, getting help from tobacco smoke and alcohol, eventually to result in disease. Final penetrance of the type of disease depends, of course, on the genetic predisposition. To cite an example, heavy alcoholics could either die of liver damage early on or live to get a heart attack or sudden death due to heart muscle disease, depending on their genetic pattern. Similar is the story of tobacco smoke resulting in either a heart attack, lung cancer, or emphysema based on the genetic background of the person. This, in essence, is the long and short of human illness. Any anxiety that upsets the happy human mind is the beginning of a disease. The medical profession’s present preoccupation in creating more anxiety will result in higher morbidity and mortality. The earlier we understand this the better for mankind.



** I could rewrite the poem by Emily Dickinson, incorporating the physicians as well, thus:



Physicians must be very careful

When they give a pill for every ill!

Deep inside their victim

Stirs the Culprit-Life!



That said, I must provide some solid evidence to throw light on the darker side of the moon described above to make the narrative more authentic for a discerning reader! Here are some of the important landmark studies.



There are three important research papers giving us details as to how the drug industry runs the medical education in America and how they start brainwashing students from day one. All of them are in the most respected medical journals. 9,10,11 The futility of screening healthy individuals about which I have written above has been brought out very well in the editorial in BMJ: 12



Long term follow up of patients either advised bypass surgery by doctors or those who have had bypass surgery showed that in asymptomatic patients the operation did not do any good. Worse still, only 16% of patients who underwent this operation did get some benefit and that was by way of pain relief. Angioplasty audit did not show any extra benefit in those patients who underwent the procedure compared to medical management.13 In addition, this procedure almost always led to bypass surgery and the latter was more hazardous following angioplasty. There is now evidence to show that these results are even tampered with and doctored to show benefit!14 There is a very significant study from Harvard that showed that the biggest culprit to “catch” patients and frighten them is the routine use of angiogram in every one with chest pain.15 Early bypass after a heart attack has been shown to be the biggest risk factor for strokes in the immediate future.16 There is a plea for going slow on both these areas. Incidentally, doctors' mistakes and unnecessary interventions have resulted in 1,00,000 deaths in the USA in one year of study!17 Compared to Canada, where fee-for-service does not obtain, the bypass rate in the USA was ten times more. However, at the end of one year, surprisingly, equal number of patients in the two groups were alive despite ten times more intervention in the USA!



Another area where India is trying to catch up with America is in the field of corporate hospitals, which are called for-profit-hospitals in the USA. In the recent issue of the Canadian Medical Association Journal there has been a study on the role played by such hospitals and the conclusions are better summed up in the words of the guest editor David Naylor. Patients treated in these hospitals had 2% increased risk of death. In Canada it means 2200 extra deaths per year equal to total traffic deaths in that country or deaths due to colon cancer! “Does anyone still want to contract out patients to those hospitals?” asks Dr. Naylor.18



Paradoxically, many newer studies have shown that most, if not all, of the major killer diseases are not caused by anyone of the risk factors that the medical profession is trying to sell and correct with drugs and interventions.19 Major risk factors are hatred, jealousy, pride, ego, anger, and destructive hostility. We do not seem to have woken up yet to manage these negative traits in society. We need to move in that direction. That is real patient care, i.e. caring for the patient and people at large. Simple life style changes and sensible diet with exercise would save millions of lives than all these interventions put together. Even intercessory prayer, in well-controlled study, has reduced death and disability in heart attack patients.20



A strike by all the doctors in Israel recently where they attended to all emergencies but avoided routine work and elective interventions for three months, death rate and disability fell down remarkably, only to go up to the usual level after doctors came back to work. This speaks volumes in favor of what is written above. Let us hope that sanity will prevail.







BIBLIOGRAPHY.





1. Editorial. Drug-company influence on medical education in USA. Lancet 2000 Sep 2; 356(9232):781-83.



2. Bucher HC, Hengstler P, Schindler C, and Guyatt GH. Per-cutaneous transluminal coronary angioplasty versus medical treatment for non- acute coronary heart disease: meta-analysis of randomised controlled trials. BMJ 2000 Jul 8; 321(7253):73-7.



3. Andersson OK, Almgren T, Persson B, et.al L. Survival in treated hypertension: follow up study after two decades. BMJ 1998 Jul 18; 317(7152):167-71.



4. Strandberg TE, Salomaa VV, Naukkarinen VA, et.al Long-term mortality after 5-year multi-factorial primary prevention of cardiovascular diseases in middle-aged men JAMA 1991 Sep 4; 266(9):1225-9.



5. Goddijn PP, Bilo HJ, Feskens EJ, et.al B. Longitudinal study on glycaemic control and quality of life in patients with Type 2 diabetes mellitus referred for intensified control. Diabet-Med 1999 Jan; 16(1):23-30.



6. McCormack J and Greenhalgh T. Seeing what you want to see in randomised controlled trials: versions and perversions of UKPDS data. United Kingdom prospective diabetes study. BMJ 2000 Jun 24; 320(7251):1720-3.



7. Editorial. Do epidemiologists cause epidemics? Lancet 1993 Apr 17; 341(8851):993-4.



8. Charatan F. US panel finds insufficient evidence to support mammography. BMJ 2002 Feb 2; 324:255.



9. Angell M. Is academic medicine for sale? N-Engl-J-Med 2000 May 18; 342(20):1516-8.



10. Campbell EG, Louis KS, and BlumenthalD. Looking the gift horse in the mouth: corporate gifts supporting life sciences research. JAMA 1998 Apr 1; 279(13):995-9.



11. London SJ and Romieu I. Health costs due to outdoor air pollution by traffic. Lancet 2000 Sep 2; 356(9232):782-3.



12. Stewart-Brown S and Farmer A. Screening could seriously damage your health. BMJ 1997 Feb 22; 314(7080):533-4.



13. Krumholz HM. Cardiac procedures, outcomes, and accountability. N-Engl-J-Med 1997; May 22; 336(21):1522-3.



14. Hux JE and Naylor CD. In the eye of the beholder. Arch-Intern-Med 1995 Nov 27; 155(21):2277-80.



15. Graboys TB, Biegelsen B, Lampert S, et.al Results of a second-opinion trial among patients recommended for coronary angiography [see comments]. JAMA 1992 Nov 11; 268(18):2537-40.



16. Cronin L, Mehta SR, Zhao F, et al. Stroke in Relation to Cardiac Procedures in Patients with Non-ST-Elevation Acute Coronary Syndrome- A study involving >18000 Patients. Circulation 2001;104:269-274.



17. Charatan, F. Medical errors kill almost 100000 Americans a year. BMJ 1999 Dec 11; 319(7224):1519.



18. Devereaux PJ, Choi PT, Lacchetti C, et al. A Systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals. CMAJ 2002 May 28; 166(11):1399-406.



19. LindenW, Stossel C, and Maurice J. Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch-Intern-Med 1996 Apr 8; 156(7):745-52.



20. Harris WS, Gowda M, Kolb JW, et. al. A randomized controlled trial of the effects of remote, intercessory prayer on outcomes in-patients admitted to the coronary care unit. Arch-Intern-Med 1999 Oct 25; 159(19): 2273-8.