The worried well are, by and large, Westerners overcome by health fears.

Many of these fears are driven by preventive health programmes — interventions — present not only in doctors’ offices but places of employment.

Denmark’s puzzling statistics

Some of these can actually harm one’s health. My reader from The Last Furlong has a report from Denmark which says that their public health programmes have actually increased the number of hospitalisations, oddly, after the country’s smoking ban in 2007. Soon afterward:

the number of hospital admissions exploded.

By 2012, there were

a staggering 1.33 million annual hospital admissions – it was 150,000 more compared to 2006, or 13% more. This is double the rate of increase compared to the corresponding period before the smoking law.

Is this a mere coincidence? Or are Danes fretting more about their health?

Another curious increase is in the number of Danish patients admitted for heart disease, which increased between 2006 and 2012. Surely, with healthier lifestyles being mandated, this should have continued to decline.

Then there is the public health intervention encouraging people to exercise more. The result is that more Danes, especially women, have been admitted to hospital for joint and bone fractures caused by the perceived need for rigorous physical workouts in the name of better health.

The Danish report concluded:

The plan to reduce medical expenses by means of patronage has not worked as intended. The “healthy” Denmark, on the contrary, has been a regular disease factory.

The figures make a total failure of the idea that the state should interfere in people’s lifestyle to prevent disease.

Preventive [medicine] makes healthy people sick – and pharmaceutical companies happy.

Preventive interventions dubious

Huffington Post has an interesting article on preventive medicine by Allen Frances, Professor Emeritus at Duke University. Dr Frances begins with a quote from Aldous Huxley:

Medical science is making such remarkable progress that soon none of us will be well.

Isn’t that the truth!

Frances says (emphases mine):

The evidence is compelling that we in the developed countries (especially the US) are overtesting for disease, overdiagnosing it, and overtreating. Wasteful medical care of milder or nonexistent problems does more harm than good to the individual patient, diverts scarce medical resources away from those who really need them, and is an unsustainable drain on the economy.

Westerners, especially Americans, might have noticed that screening advice and frequency has changed over the years. One example is prostate cancer screening:

It used to be recommended that men of a certain age be tested yearly. It is now recommended that the test not be done at all unless a man has a family history or other special risk factors.

Why the big change? Definitive long term studies prove that the test doesn’t save lives and instead ruins them by triggering invasive interventions with painful complications. Screening is usually too late to stop fast spreading tumours and too good at identifying slow growing ones that don’t count and are better left alone. If they live long enough, the majority of men will develop an incidental and benign prostate cancer before they die from something else. Picking up these tumours early causes great grief for no return.

But, surely, early screening encourages disease prevention? Frances disputes that line of thinking:

The reality is that getting there too early misidentifies too many people who are not really at risk and then subjects them to needless and harmful tests and treatments.

Along with that is the psychological stress not only for the patient but for his nearest and dearest.

As for the radiation from certain tests, he tells us:

If we do enough CT scans we can find structural abnormalities in just about everyone. But most findings are incidental and don’t have any real clinical meaning. Paradoxically, lots of otherwise healthy people will get dangerous cancers from the CT radiation that served no useful purpose.

Other questionable procedures

Dr Kenny Lin is a family physician and public health professional who practises medicine in the Washington, DC, area. He teaches at Georgetown University School of Medicine, Uniformed Services University of the Health Sciences, and the Johns Hopkins University Bloomberg School of Public Health. His website is called Common Sense Family Doctor.

He advocates a cautious, informed approach to batteries of medical tests.

With regard to routine blood tests:

In 2007, I co-authored an editorial in the journal American Family Physician about this topic. We wrote:

“‘Big-ticket’ tests [such as CT (Computed tomography) scans and MRIs] are easy targets for those seeking to reduce waste in health care. But what about the seemingly innocuous practice of performing routine tests such as a complete blood count (CBC) or urinalysis? … These tests would be useful only if they provided additional diagnostic information that would not otherwise be obtained during a history and physical examination. In fact, large prospective studies performed in the early 1990s concluded that these tests rarely identify clinically significant problems when performed routinely in general outpatient populations. Although the majority of abnormal screening test results are false positives, their presence usually mandates confirmatory testing that causes additional inconvenience, and occasionally physical harm, to patients.”

Don’t misunderstand me. There are certain situations in which targeted screening tests can provide valuable information for the early detection of diseases. To learn more about which tests are recommended for your or your family members, I recommend that you visit the excellent website Healthfinder.gov. But the next time you go to a doctor’s office and he or she proposes to check some “routine blood work,” be sure to ask what these tests are for and what would happen if any of them turn out to be positive, so that you can make an informed choice about what’s right for you.

As for mammography:

the only reliable measure of a screening test’s superiority is whether or not it leads to fewer deaths. For 3D mammography, there’s absolutely no proof that it does.

I recognize that for women or loved ones of women who believe their lives to have been saved by mammography, no amount of scientific evidence that I or anyone else can marshal will change their minds …

So how can we counter the prevailing narrative of the Task Force [recommending fewer mammographies] as a group of cold-hearted scientists who are more concerned about population-level data than the individual lives of the women we love? We can tell the human story of the guideline developers – half of whom are women over the age of 40 who have personally faced the mammography decision at some point themselves – but we can do much more than that. We can tell a representative story of the hundreds of thousands (or millions, perhaps) of women who experienced serious emotional or physical harm as a result of screening mammography

He goes on to recount a case that Dr Louise Aronson wrote about for the Journal of the American Medical Association. Mammogram results for this patient, Elizabeth, revealed ‘gross’ abnormalities. Not surprisingly, she was called back for more mammograms over the next few weeks. She was beside herself with worry as was her family. She could barely concentrate at work and that year the family Thanksgiving gathering was sombre, to say the least. Aronson wrote:

Meanwhile, her physicians were at war: based on the x-ray films, the radiologists argued she had metastatic cancer with a less than 50% chance of 5-year survival, while her surgeons, based on the biopsy pathology, contended she had a rare, mostly benign condition. Fortunately, the surgeons were right. Still, sorting that out took weeks, and because the condition was associated with increased cancer risk, they insisted on bilateral surgery to remove all of the suspicious areas. So Elizabeth’s mammogram didn’t find cancer, but it did lead to the permanent mutilation of her breasts, huge medical bill copays, significant lost time from work, months of extreme stress, and ongoing anxiety about her disfigurement and risk of cancer.

Was it worth it?

Then there are the CT scans for lung cancer. These are just as contentious as mammograms. Many of Dr Lin’s readers fiercely defend them, however, his post warns that the risks may outweigh the benefits in some cases:

1. The risk of developing cancer from the CT scan itself isn’t trivial. A recent analysis published in the Archives of Internal Medicine found that a single chest CT scan exposed patients to the radiation equivalent of more than 100 chest X-rays, and that at age 60, an estimated 1 in 1000 women or 1 in 2000 men would eventually develop cancer from that single scan. (Participants in the lung cancer screening study actually underwent three consecutive annual CT scans.)

2. False alarms are extremely common. In the NCI’s lung cancer screening study, researchers found that 1 in 3 patients had at least one false-positive result after undergoing two CT scans. Of those patients, 1 in 14 needed an invasive lung biopsy to be sure they were cancer-free.

3. Even if screening catches lung cancer early, there’s no guarantee your prognosis will be better. This is due to “overdiagnosis,” or the unnecessary diagnosis of a condition (typically cancer) that will never cause symptoms in a patient’s lifetime, either because it’s so slow-growing or the patient dies from some other cause … because there’s no way of knowing at the time of diagnosis if a lung cancer will be fatal, inevitably many patients will be needlessly subjected to the side effects of treatment.

4. Finally, it’s highly likely that a CT scan for lung cancer will find some other abnormality that will require further investigation. You might think this is a good thing, but studies show that most of these abnormalities turn out to be false alarms, too

Finally, there are the private screening companies that send you a nice letter about the package of tests they can perform on you. The target market is the 50+ age group, and, even here in the UK, we receive such solicitations.

Dr Lin warns:

1. “Blocked arteries” / stroke screening is most likely a carotid ultrasound scan, which doesn’t help because most patients with asymptomatic carotid artery blockages will not suffer strokes. Although the screening test is “non-invasive and painless,” the confirmatory test, angiography, is not (it actually causes a stroke in a small number of patients) and unnecessary carotid endarterectomy can lead to death.

3. “Hardening of the arteries in the legs,” or screening for peripheral vascular disease with an arterial-brachial index, hasn’t been proven to prevent heart attacks but will certainly lead to many false positive results.

He discusses three other tests of dubious value and concludes:

In a nutshell, that’s why companies like Life Line have no business portraying these services as “preventive health screenings,” in my church or any other community setting. (I’ve sent an e-mail to my pastor recommending that they be dis-invited for the reasons I’ve outlined above.) It’s one thing to draw blood for a cholesterol test and take someone’s blood pressure (which will cost a whole lot less than $149), and quite another to offer these other procedures which are, at the very least, a waste of money and quite possibly harmful.

Solutions to excessive testing

Dr Frances makes the following recommendations, excerpted below:

  • Tame and shame Big Pharma. Stop the direct to consumer advertising that is allowed only in the US and New Zealand. Prohibit all Pharma contributions to professional associations and consumer groups. Regulate and make transparent all the marketing ploys used to mislead doctors. Force the publication of all clinical research trial data.
  • Recognize that all existing medical guidelines that define disease thresholds and make treatment recommendations are suspect. They have been developed by experts in each field who always have an intellectual conflict of interest (and often enough also have a financial conflict of interest) that biases them toward overdiagnosis and overtreatment in their pet area of research interest …
  • Employers, insurance companies, and government payors should be smarter consumers of health services and should stop paying for tests and treatments that do more harm than good and are not cost effective.
  •  Consumers should be smarter consumers and not buy into the idea that more is always better.
  •  Medical journals need to be more skeptical of the medical research enterprise and should look toward the harms, not just the potentials, of each new purported advance.

He concludes by reminding us that there are many really ill people who cannot get the healthcare they need and deserve.

Big Pharma, he says, is every bit as big a monster as Big Tobacco. On that point, I would disagree. Big Pharma is much more dangerous than ‘Big Tobacco’ — I use the term advisedly — will ever be.

Big Pharma probably kills more people around the world than tobacco. If statistics were honest, we could find out the truth. Unfortunately, we’ll have to wait a few more decades. By then, tobacco will no doubt be back in style!

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