A draft article by Spyros Makridakis about blood pressure and iatrogenics takes issue with the statement that “The treatment of hypertension has been one of medicine’s major successes of the past half-century.” Over the last half-century, the article says, the death rate for people with high blood pressure decreased by almost exactly the same amount as the death rate for people without high blood pressure. Apparently “one of medicine’s major successes” is a case where the health benefit no more than equaled the health cost — leaving aside what the treatment cost in time and money.
Because very high blood pressure (systolic > 180 mm Hg) is quite dangerous and blood pressure drugs really work, this is a surprising outcome. Makridakis points out that doctors start treating high blood pressure when it rises above systolic = 140 mm Hg, a point when there is little or no increase in death rate. This article tells doctors to immediately prescribe drugs when systolic blood pressure is above 160. Yet death rate clearly increases only when systolic blood pressure is above 180. Makridakis concludes (as do I) that blood pressure drugs have significant health costs as well as benefits. The drugs are so often prescribed when they do no good and the costs are so high that the overall health costs of blood pressure treatment have managed to be as high as the overall benefits. Even when handed a relatively easy-to-measure problem (high blood pressure) and a relatively simple solution (blood pressure drugs), our health care system managed to achieve no clear gain. If this is “one of medicine’s major successes”, medicine is in bad shape.
The last paragraph of Makridakis’s article makes a surprising statement: “We strongly believe that medicine is extremely useful.” It does not explain this belief, which is contradicted by the rest of the article. I was puzzled. I wrote to the author:
I recently read your paper on “High blood pressure and iatrogenics”. The main part makes good sense. Then it ends with something quite puzzling: “We strongly believe that medicine is extremely useful.” No doubt a few areas of medicine are extremely useful. For large chunks of medicine, it is hard to tell whether they do more good than harm, because so many drugs and other treatments have undisclosed or unnoticed bad effects.
For example, tonsillectomies — for a long time the most common operation — is associated with a 50% increase in mortality in one study. The notion that cutting off part of the immune system is a good idea makes as much sense as the idea that cutting out part of the brain is a good idea. Another example is sleeping pills. They are associated with a three-fold increase in death rate soon after they begin to be taken. I am not saying that medicine overall does more harm than good. I am saying that a strong belief about the outcome of such an assessment (does medicine overall do more good than harm?) doesn’t make sense.
Thank you for your email. The paper you mention is a draft posted for comments. I agree with you that my statement is wrong. It should have read: : “We strongly believe that medicine can be extremely useful”. For instance, this could be the case in treating heart attacks, strokes, traumas from car accidents or bullet shots. But in most other cases the harm from treatment can be greater than the benefits. In addition, the harm from preventive medicine can exceed its value. Thank you for pointing out this mistake to me.