Aceso Under Glass Valentine’s Day Special

My original plan was to finish Selling Sickness and write an overall book review, but I have reached that stage where I can’t continue reading it until I get some of my current thoughts out of my head, so we’ll be doing this in stages.

There exist many, many criticisms of the pharmacutical industry, all of which I dislike for framing it as the fault of the pharmaceutical companies and not the FDA.  If you want to learn more about this, Bad Pharma is a good source.  Selling Sickness‘s is more specifically about claim is that pharmaceutical companies deliberately manipulate both the public’s and the medical field’s view of illnesses, and “defines health people as sick” for their financial benefit.

I really, really wish Selling Sickness had defined its terms better.  Let’s use heart attacks as an example, because it is Valentine’s day.  No one questions that heart attacks are extremely bad, that they are associated with high blood pressure and high cholesterol, and that giving medications that lower blood and cholesterol to people who have already had a heart attack lowers the chance of a second one and increase life expectancy.  From this some people concluded that high blood pressure and cholesterol cause heart attacks, and we should lower them with drugs even in people who have never had a heart attack.  Selling Sickness describes that as turning healthy people into sick people.

Let me say out several different possibilities that would account for all available information:

  1. High blood pressure and/or high cholesterol damage your coronary system, causing heart attacks.
  2. Sufficiently high blood pressure and/or high cholesterol damage your coronary system, causing heart attacks, but we have drawn the cut off in the wrong place.
  3. High blood pressure and/or high cholesterol damage your coronary system, causing heart attacks, if and only if you have already had a heart attack.
  4. High blood pressure and/or high cholesterol and heart attacks share a root cause, the common treatments treat that cause, and the indicator numbers go down as a result.
  5. High blood pressure and/or high cholesterol and heart attacks share a root cause, the common treatments treat only the symptoms and leave the chance of a first heart attack unchanged, but coincidentally help after a heart attack.
  6. There are multiple causes of high blood pressure and high cholesterol have multiple causes, one of which also causes heart attacks.  Drugs happen to attack root cause if you have it, lower blood pressure and cholesterol to no effect if you do not.
  7. High blood pressure and/or high cholesterol damage your coronary system only in conjunction with an unidentified third factor, and so drugs reduce lifetime mortality if and only if you have that factor.  People who have a heart attack have that factor by definition and thus benefit from blood pressure/cholesterol medications.  They would benefit from them before their heart attack as well, but we have no way to identify them ahead of time.

Under which of these scenarios would you call someone with high blood pressure sick?  It’s a trick question because sick and healthy aren’t actually medical terms. The term for something given to an asymptomatic person that keeps them from developing symptoms in the future isn’t “making them sick”, it’s  “preventative medicine”, and it’s generally considered a good thing.

If high blood pressure and cholesterol don’t immediately cause symptoms but do damage your coronary system, taking drugs to combat them is a good call (dependent on side effects).   You could call them sick or not, it doesn’t matter.  If there was a pill that kept you at your physical and mental peak for 100 years you’d take it, even if your only health condition is being mortal.  Or maybe high blood pressure/cholesterol does indicate illness, but for one of the reasons outlined above, medication helps the numbers without improving symptoms or outcomes.  Then you’re sick but shouldn’t take medicine.  How useful medicine is has nothing to do with the English words “sick” and “healthy'”.

To be fair, researchers make the same mistake.  What we ultimately care about is if medication improves an individuals quality and quantity of life (with exact weightings dependent on the individual).  That takes a long time to do because people take forever to die.  You only get 20 years total from when you first register the molecule.  For a drug intended to prolong life given to people in their 50s, the drug could go off patent (destroying any ability to recoup the cost of the trials) before it got out of trials.   Even waiting for heart attacks takes a very long time and a very large sample size,because heart attacks aren’t actually that common.  So researchers use proxy measures like high blood pressure and cholesterol, on the assumption that anything that lowers those must prevent heart attacks.  Even researchers who aren’t trying to recoup financial costs do this, because they would like to produce results some time before they retire.  The problem is that even if high blood pressure and cholesterol are tightly coupled with heart attacks, this method will inevitably over-include things that somehow affect the proxy measures without affecting heart attacks, and miss things that decrease heart attacks or lifespan without affecting the proxy numbers.  And of course it’s entirely possible the FDA let pharma companies nudge the cut offs for treatment much lower than they should be, because that’s easy.

So yes, there are a lot or problems with aggressively treating proxy numbers, but “applying the sick label to healthy people” isn’t one of them.

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