If you look closely at the ways diseases are defined and at the panels of experts who draw the line between sickness and health, you find an extraordinary phenomenon.
Many of these panels are heavily conflicted: they are populated by people who have extensive financial relationships with drug companies. This is the case in many different specialties and is a cause of great concern, as I’ve outlined in today’s British Medical Journal.
How have these panels changed the boundaries between sickness and health?
In recent decades, the thresholds that define hypertension (high blood pressure), for example, have been slowly lowered, which then expands the number of people who are defined as having a condition.
This occurred after a group of US experts decided to create a new diagnostic category called pre-hypertension. The result? A majority of older Americans are categorised as having the condition.
If you look at the panel that made that decision, 11 of the 12 members worked with drug companies, and many had extensive ties to more than ten companies.
Do patients with pre-hypertension need medication?
There wasn’t an explicit recommendation that people with pre-hypertension should to be treated by drugs.
What it did was broaden the boundaries that are defining this medical condition called hypertension. So you are enlarging, enhancing and expanding the potential patient pool.
How are these reclassifications justified?
The justification often appears very legitimate and is often driven by goodwill and the desire to do the best for people.
The justification is that “if we catch it early we’ll nip it in the bud”: If we get these people who have slightly raised blood pressure and we get them to make lifestyle changes we’ll get them to reduce these risks and have less disease.
It’s a compelling argument but if you look closely you see similar arguments used in many different parts of the medical landscape.
The aggregate result is that more and more healthy people are reclassified as potential patients, and more and more of these people are prescribed medications with potentially harmful side-effects. Its critically important to weigh up the risks and benefits of accepting a medical label, and a medication.
For example, if I’m at very high risk of a heart attack, the side effects of a drug that might reduce my risk won’t be too much of a concern to me. But if am a relatively healthy person at a very low risk of a heart attack, the side effects of the medications become much more significant.
For what conditions are preventive medicines most commonly prescribed?
Examples include high cholesterol, high blood pressure, type 2 diabetes, osteoporosis. If you look at all of these conditions, you will see that over recent decades there has been a change in the thresholds, the cut-offs, the diagnostic processes, that have resulted in vast numbers of healthy people being classified as sick. This then opens the door to long-term drug therapy.
That’s why lipid-lowering drugs have been among the most successful of all time, and it’s why these areas are huge cost centres for governments providing drugs for these conditions.
It’s important to say that for many people those drugs may well have benefits. But for many of the people on these long-term preventive medicines, they’re really not receiving any benefit at all; they’re simply running the risk of the side effects.
What about psychiatric conditions?
We have broadened the definitions of treatable depression to include mild depression, so many more people have been classified as mentally ill and prescribed anti-depressants, namely SSRIs.
The SSRI medications carry a range of very significant side-effects and yet, arguably, they have been promoted to people who are going through the processes of ordinary life. Distress, grief or the loss of a loved one have been re-imagined in the broader culture as if they were the signs of some mental illness.
With SSRIs there is a long list of significant side-effects, notably effects on sexuality: very, very severe effects on people’s sexuality from drugs that are arguably being promoted to what are healthy people.
There are other examples, like the massive controversy about medication being promoted and prescribed to large numbers of healthy children categorised as having ADHD. There are concerns about long-term impacts of this widespread amphetamine use on young bodies and young brains.
I’m not saying that ADHD doesn’t exist – it’s a very complex argument about where you draw the line – but ADHD is another example where the boundaries have been widened far too aggressively and the market for those amphetamines has grown enormously as a result.
With such a small group of highly specialised clinicians and researchers, isn’t it inevitable that these conflicts of interest will occur?
This argument has been used for a long time and it’s starting to wear very thin. Academics, researchers and doctors are increasingly choosing to run their professional lives more independently of financial relationships with drug and device manufacturers.
There is a pool of high-quality, independent people within any given specialty. So this is an intellectually lazy argument that doesn’t hold any water. It’s a self-interested argument run by senior doctors, many of whom have spent their life on the drug company drip.
It’s a fallacious and dangerous argument that is not valid. My BMJ piece shows that if you look for high-quality, independent authories, you will find them. The problem has been that we haven’t really looked hard enough for those and there has been an acceptance within the medical profession that it is okay for the senior members of a specialty to be utterly financially entangled with the drug industry.
Increasingly, the medical establishment is saying that this is not okay and it is, in fact, harmful to the credibility of the medical profession. It’s harmful to public trust in the medical establishment, and for at least a decade or more there has been a growing sense that there needs to be a disentanglement between the profession and the industry in order to restore public trust.
How do we redefine health and ill-health and who should make these decisions?
We really are just at the stage where we are asking that question. A number of voices are saying it’s time to throw out the old panels and bring in fresh, new ones which are independent of financial relationships and are much more broadly representative of different interests.
Who would we have on the panels? This is a conversation that is happening within the medical establishment globally. This is a cutting edge conversation: how can we rationally start to redraw the lines between health and illness outside the shadow of drug companies?
My sense is that a lot of people take the definitions of illness as if they were written in stone; as if they were handed down by God. But the trouble is, if you start to look at god’s work, you find that it was done by a group of individual men and women sitting in a room at a particular time and date, and that some of those processes have been highly problematic. Those processes require major renovation.
One of the things that’s changed in healthcare in the past 10 to 15 years is we’ve become much more aware of the evidence that suggests that social and environmental factors determine people’s health.
My sense is that in this process of renovating these panels, it’s possible we may start to reconceptualise some of these so-called conditions.
In terms of these risk-factor-based conditions, like high blood pressure, high cholesterol, high blood sugar, low bone mineral density – we have mistakenly seen these risk factors as diseases.
We are pouring billions and billions of dollars globally into clinical strategies to fight these conditions. Maybe we’d get much better bang for the buck if we reconceived the nature of certain medical conditions and how to treat and prevent them.
Join the conversation by answering these questions in the comments field below:
Do the lines between health and illness need to be redrawn?
How can this be done?