The medical fiasco
Fierce debates are raging around the world today in many medical specialty areas, from psychiatry to kidney medicine, from chronic to acute diseases, over whether the boundaries defining illness have been pushed too wide and whether too many people are being turned into patients unnecessarily and to what extent medical errors and irrational medicine use causes unnecessary harm. But no such debate seems anywhere on the horizon in Pakistan.
A blog published recently on the subject in a leading online paper by this scribe was responded to with fierce opposition by the medical profession. However, the fact remains that modern medicine’s ability to help the sick is fast eroding; and increasingly doubted for its propensity to being service provider centered and causing harm to the sick and even the healthy.
Table: Examples Overdiagnosis Overtreatment
• Asthma: Data coming from Canada suggests 30 per cent of people are wrongly diagnosed with asthma, and 66 per cent of those may not require medications, but are given asthma treatments.
• Attention deficit hyperactivity disorder: Widened and vague definitions of this psychological diagnosis have led to concerns about overdiagnosis and overtreatment.
• Breast cancer: Systematic literature review suggests up to a third of screening detected cancers may be overdiagnosed.
• Chronic kidney disease: Controversial definition of this problem results in wrongly classifying 1 in 10 overdiagnosed as having disease.• Gestational diabetes: Expanded definition classifies almost 1 in 5 pregnant women overdiagnosed as having disease.
• Highblood pressure: Systematic literature review suggests possibility of substantial overdiagnosis.
• High cholesterol: Up to 8 per cent of people with near normal cholesterol treated for life may be overdiagnosed.
• Lung cancer: 25 per cent or more of screening detected lung cancers may be overdiagnosed.
• Osteoporosis: Expanded definitions may mean many treated low risk women experience net harm.
• Prostate cancer: Risk that a cancer detected by prostate specific antigen testing is overdiagnosed may be over 60 per cent.
• Thyroid cancer: Much of the observed increase in incidence may be overdiagnosis.Definitions:Overdiagnosis occurs when people without symptoms are diagnosed with a disease that ultimately will not cause them to experience symptoms or early death. Such overdiagnosis results in overtreatment.
To contextualise this article, and to extend the scope of the debate, let me reiterate that half of all deaths in Pakistan are of children less than five years of age who are dying of diarrhea, respiratory infections, and infectious diseases (e.g., diptheria, measles, and whooping cough). These ailments can be effectively controlled by inexpensive public health measures and essential medicines. Our health budgets, however, continue to be spent instead on purchase of expensive drugs and diagnostic technology, often of dubious utility, and in treating problems which never were problems to begin with nor needed any treatment.
The incidence of over-diagnosing and over-treating people from asthma to breast cancer, from high blood pressure to low bone density is on a dramatic rise. Many factors – including the best of intentions – are driving these trends. Advent of new technologies with the ability to detect ever smaller “abnormalities”, commercial and professional vested interests, health system incentives favouring more tests and treatments, cultural beliefs that more is better, etc are all providing the energy on which such growing trends thrive.
The cumulative burden from such over-diagnosis poses a significant threat to human health. The consequence being, the harm of unneeded tests and therapies, and the opportunity cost of wasted resources that could be better used to treat or prevent genuine illness. There are medical, social and cultural reasons behind over-diagnosis. The challenge is to articulate the nature and extent of the problem more widely, identify the patterns and drivers, and develop a suite of responses from the clinical to the cultural.
As we move forward in the modern health care paradigm, it is important to acknowledge that there is a good deal of evidence to suggest that methods and achievements of medicine are frequently overrated and under researched causing a significant barrier in the societal attempt to achieve health.
Ayyaz Kiani is a public health specialist. He heads Devnet – a network of development consultants. Based in Islamabad, he has travelled around the world and continues to do so to meet fellow travelers. He can be contacted at firstname.lastname@example.org
The views expressed by this blogger and in the following reader comments do not necessarily reflect the views and policies of the Dawn Media Group.