Image: Pills from Toni Blay's Flickr Photostream

While Public Health zealots trumpet their claim to the moral high ground, it’s still worth asking: “are they right?”

Here’s a strange piece of news. This week, two of Britain’s top doctors (Knights of the Realm, no less) recommended in the strongest terms that tens of thousands of their hitherto well patients deliberately make themselves ill. They don’t know precisely who these victims of unnecessary sickness will be. But they know from their statistics that, if the millions of people targeted with prescriptions for statins decide to comply, the treatment will cause a certain percentage of them to develop muscle disease and possibly diabetes.

On the face of it, the exhortations of Sir Rory Collins and Sir Magdi Yacoub don’t seem very chivalrous at all. But, they and their supporters insist, this slightly bizarre enthusiasm for iatrogenic illness is grounded in reason not malice. They think that the ace in their hand is the fact that the overall amount of good that will come from mass medication outweighs the overall amount of harm. Their principle calculation is that, among the millions of statin poppers in Britain, you will find a small number of people who would have had a heart attack or stroke – and now they won’t (as well as the aforementioned unfortunates with the muscle pathology etc.). Some of the lucky ‘coffin dodgers’ (that’s not a technical public health term, you understand) could theoretically be the same people who are now suffering from aching and atrophying muscles. But probably not – because the vast majority of people taking the pills won’t either be saved from circulatory disease or suffer the other stuff. Essentially, they will only be taking the pills to make up the numbers – but they will never know that.

The main arguments this week have centred on the numbers and the balance between them. What is the true number (and percentage) of people who are ‘saved’? And what are the same stats about those that get so-called “side effects”? (a term which cleverly belittles these often painful and sometimes life-changing symptoms). It’s this technical argument about the magnitudes of harm and benefit that has led to some slightly unseemly statistical shroud-waving from Collins, who was widely reported as opining that the confusion caused by a recent BMJ article was killing people.

But I don’t think the exact figures are really the main argument here. The more time and effort that is expended on the technical argument, the more the attention of the general public is diverted from the medical, ethical and social issues. In spite of the self-righteous and vaguely totalitarian braying of the public health zealots, I for one would like to retain a space for debate and disagreement about the whole “lets treat the whole population” idea. So, in the quest for some slightly less toxic information than that found in the smoking ruins of the BMJ, I went to the respected “Numbers Needed to Treat” website which is known as NNT. There I found a sober reflection on some of the data, refreshingly free from the clamour and hyperbole so beloved by those medical knights. The figures relating to statins taken by people with no prior heart disease make fascinating reading. Here they are:-

Benefits (first expressed as % and then as “numbers needed to treat”)

  • 98% saw no benefit
  • 1.6% were helped by preventing a heart attack
  • 0.4% were helped by preventing a stroke
  • 1 in 60 were helped (preventing heart attack)
  • 1 in 268 were helped (preventing stroke)

Harms (first expressed as % and then as “numbers needed to treat”)

  • 2% were harmed by developing diabetes
  • 10% were harmed by muscle damage
  •  1 in 50 were harmed (develop diabetes)
  • 1 in 10 were harmed (muscle damage)

Playing ‘Public Health Top Trumps’ – Image ‘Fear Factor 100’, William Warby, Flickr

I think this is beginning to look like a ghastly playground game of Public Health Top Trumps. Sir Magdi and Sir Rory say that their 2% cardio-vascular benefit beat my 12% muscle and endocrine pathology. I say “no it doesn’t – my muscle and endocrine beat your cardio-vascular”. They say that causing harm is acceptable as long as some good comes from it. I say “no it isn’t”. Causing muscle pain and diabetes in otherwise healthy people is disgraceful. And all the more so when no one knows who is going to win and who is going to lose. Under those circumstances it just becomes a macabre game of chance and a frankly bizarre way to organise the wellbeing of the population.

I also think that, if each individual patient had these numbers truthfully and clearly put in front of them many of them would say “no thanks”.  Because they would see that the most likely outcome is the pointless taking of medicines, every day, for years (there will be no benefit, and no harm). They would also see that the second most likely outcome is pain and illness. And finally they would see that the least likely outcome is their personal avoidance of a heart attack or stroke – a fate they weren’t THAT likely to experience in the first place, to be honest.

“To be honest”. That simple phrase gets us to the nub of the issue really, doesn’t it?

Because when a real patient is in front of a real doctor they are usually told about risk reduction, not NNT. So they have it implied (not definitely stated of course, because that would be untruthful) that the pills are likely to benefit them personally. This is a kind of communication that I once called “worthy dishonesty” – a murky ethical area which later became the subject of an interesting article in the Journal of Medical Ethics.