Public health and individual health
Posted by Henry Bauer on 2011/01/02
In the previous post [Medicine isn’t science — nor should it be, 2010/12/26; see also “Doctors aren’t scientists, and medicine isn’t science”, 25 November 2008], I pointed out that medical practice ought to be concerned with the individual, making it fundamentally different from science which is concerned with universal laws. “Public health”, too, is different from what physicians practice because its focus is on populations and not on individuals.
Public health practice relies on epidemiology and statistics. It deals in averages and medians and ignores outliers. By contrast, patients who are statistical outliers from a population standpoint are nevertheless individuals whose health is the direct, sole concern of their doctors. The Hippocratic Oath has to do with caring for individuals, not populations.
There may be something of an analogy to political matters. Politicians and policy makers are concerned with collections of people, with majorities and averages. No matter how often it may be pointed out that modern ideals for democracies include safeguards for equal rights for minorities, and that it is the freedom of individuals that matters and not the preferences of the majority, in practice the ideal of personal liberty has to be fought for continually. Perhaps especially in times of crisis, slogans and sound-bites and generalities tend to take over, and people become of a mind to “destroy villages in order to save them”, to recall an infamous remark from the Vietnam-war era.
Public health practices may not overreach quite to that extent, but there is an inherent contradiction between the Hippocratic Oath and regulating for population-wide health. Vaccination, for example, is unquestionably a public-health good, and thereby good for untold numbers of individuals. Yet there are some individuals who are damaged by it, and officialdom seems just to shrug that off as unavoidable collateral damage, as well as reacting without empathy or sympathy to individuals who would prefer to accept the risk from non-vaccination to the risk from vaccination.
How cavalier can be those who focus on public health and not individuals is illustrated by the advocates of “interventions” that comprise administering medications to entire populations in order to improve statistically measured health. An iconic example is the proposal that every adult over 55 should, without prescription or prior medical examination, take life-long a “Polypill” that would purportedly reduce strokes by 80% and coronary events by 88%, according to calculations based on meta-analyses of hundreds of studies on hundreds of thousands of human beings; the Polypill (for which a patent application had been lodged) would comprise a statin, aspirin, folic acid, and three blood-pressure-lowering drugs (a diuretic, a beta-blocker, and an inhibitor of angiotensin-converting enzyme). An editorial in the British Medical Journal suggested that this was the most important medical news in half a century (“Editor’s choice: The most important BMJ for 50 years?”, BMJ 326, 28 June 2003).
Perhaps “cavalier” is not the right description for what common sense can identify as blatant insanity. It was proposed by professors at the Wolfson Institute of Preventive Medicine and the School of Medicine and Dentistry of the University of London, and endorsed enthusiastically by the editor of the British Medical Journal and a director of a Clinical Trials Research Unit [Anthony Rodgers, “A cure for cardiovascular disease? Combination treatment has enormous potential, especially in developing countries”, BMJ 326 (2003) 1407-8]. Do these medical professionals not know that every medication has “side” effects? That liver damage is almost inevitable when drugs — physiologically active substances foreign to the body — are administered long-term? That “side” effects of statins had already been known to be potentially fatal, Baycol having been withdrawn from the market a couple of years before the Polypill was proposed? It is far from reassuring that most of the on-line Rapid Responses to this British Medical Journal article took the proposal as quite a serious one, finding fault only with various technical details; only about 1 in 6 of the Responses found the concept laughable, e.g., “I am just wondering if the ‘compelling’ observational evidence that lowering serum homocysteine reduces heart disease is as ‘compelling’ as the observational evidence that estrogen did the same thing”.
Another clash between statistical and individual medicine is the controversy over whether or not there is such a thing as chronic Lyme disease (Medicine isn’t science — nor should it be). Mainstream practitioners admit that some patients treated for acute Lyme diseases with the officially proclaimed sufficient short-term antibiotic regimen may suffer “post-Lyme inflammatory” conditions and that in “rare” cases the infection might not be defeated by that regimen. Yet the treatment of these unfortunate outliers is left to maverick doctors who run the risk of losing their licenses because their professional associations and officialdom and insurance companies do not regard these outlier individuals as the proper concern of their individual doctors. In some ways this is the more remarkable because doctors have so much leeway in other respects, for example, they may prescribe any approved drug for any condition, and are not liable to disbarment for having recourse to off-label uses of drugs; why not off-label length of antibiotic treatment for chronic Lyme?
HIV/AIDS, too, illustrates how stark can be the difference between population-wide policy-making and caring for individuals. The eradication of “HIV” is the main thrust of officialdom and the groupies of HIV/AIDS theory, and draconian means are pushed toward that end, for example, the circumcising of as many African males as possible and the testing of everybody followed by antiretroviral treatment of all “HIV-positive” individuals, whether or not they are ill. That’s in the face of the unquestioned facts that the “HIV” tests have not been approved to diagnose “HIV infection” and that, even if they had been, universal testing of low-prevalence populations would turn up more false positives than true positives, so that toxic antiretroviral drugs would be administered unnecessarily and damagingly to a large number of people, a few tenths of a percent of the population (Weiss SH & Cowan EP, “Laboratory detection of human retroviral infection, Chapter 8 in Wormser GP (ed.), AIDS and Other Manifestations of HIV Infection, 4th ed., 2004). From the individual’s point of view, the question whether a positive test is a false positive is all that matters. Even the official mainstream acknowledges the existence of long-term non-progressors, or elite controllers, who remain perfectly healthy despite testing “HIV-positive”. Population data indicate that elite controllers may constitute about half of all those who would test “HIV-positive” under universal testing.
Such instances as the proposed Polypill and the medical profession’s response to chronic Lyme disease incline me increasingly to the view that the HIV/AIDS catastrophe is not a unique aberration but rather quite a natural culmination of developments in medicine and science over the last half century or so, illustrating a final triumph of authoritative expertise over evidence-based common sense; or to put it in another way, of eminence-based rather than evidence-based medical practice, a neat locution I found in C. Andrew Aligne, “Flu skepticism”, American Scholar, 79 (#2, Spring 2010) 6].