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PREVENTING HEART ATTACK: HOW STRONG IS THE EVIDENCE?
There are two extreme views on prevention of coronary disease. The positive, active view is that present evidence is overwhelming: in the light of it, all or most of us should change our way of life. We should change our diet, quit smoking, take regular vigorous exercise. The negative, passive view is that we need much more research before taking any steps at all: prevention is something for the remote future. Between these extremes, we as individuals have to make up our own minds.
On the one hand we have to face the problem of a disease of epidemic proportions, a threat to all of us and a major burden on society. On the other hand, a quarter century of research has yet to give us absolute proof that we can lessen the risk of coronary disease by changes in our way of life.
But is there such a thing as absolute proof? And if so, how much of a doctor’s work is based upon it? In fact, the scientific method does not offer ‘proof; its goal is, rather, to bring us closer and closer to the truth. As ideas are put to the test, most are found wanting; alternative ones then arise which are more accurate. Hence there is no ‘absolute proof in medical science, nor in other sciences. Still, we gradually become confident enough in our knowledge to feel justified in taking action. Doctors always base their decisions on a mixture of scientific evidence and judgment. Sometimes it is just not ethical to carry out a trial of a particular treatment, and sometimes the cost of a properly designed trial is prohibitively high. There are striking examples of treatments becoming accepted without evidence from controlled trials. Effective drugs for treating severe high blood pressure became available about 1952. Although they had troublesome side effects they became widely used, with good reason, for patients with severe high blood pressure. Yet it was not until the late 1960s that a controlled trial was completed which provided formal evidence that treatment was of value. Other instances are the use of insulin for diabetes and of digitalis for heart failure. In preventive medicine, too, there are abundant examples of empirical success.
Preventive medicine was on the scene long before most of the features of curative medicine had developed – surprisingly, in view of the popular image of a doctor today. Scurvy, which used to decimate sailors because of their restricted diet, was eliminated by the naval surgeon James Lind. In 1747 he discovered how to prevent the disease by a daily drink of lime or orange juice. The Admiralty acted on this discovery and by 1748 the citrus drink -adapted to seafaring palates by being mixed with rum – was established naval practice, to become enshrined in the nickname for British sailors of ‘Limey’. Lind’s evidence, we might add, was rather incomplete by today’s standards, and almost two centuries elapsed before vitamin ? was discovered and doctors realized that scurvy was due to deficiency of this substance.
In the same way, Dr Jenner introduced vaccination in 1796 as a specific measure to prevent smallpox. One of the triumphs of twentieth-century medicine, through the World Health Organization, has been to apply this long-standing method on a wide-enough scale virtually to abolish the disease.
Today much of an obstetrician’s work is aimed at prevention, and this is largely true in dentistry too. A visit to the hygienist is more congenial than a session in the dentist’s chair.
Of course, the ideal method is to base all treatment and prevention on rigorous scientific testing. But, in the view of most doctors who have personally worked on heart-disease prevention, the problem of common diseases such as heart attack requires a twofold approach. The first approach is that of continued active research; the second is of the application of existing knowledge to deal with those factors that increase the risk of this widespread and serious disease. The occasional scientist who demands ‘absolute proof before action is dreaming of something virtually inaccessible to medical science.
In the U.S.A. and increasingly in other countries many people have changed their life styles along the lines discussed in these pages. The average American diet has certainly changed – and national enthusiasm for jogging is evident on every street. The average blood-cholesterol level of American men has decreased in the past fifteen years; twice as many men now have relatively safe cholesterol levels as was the case twenty years ago. Many men, especially among the better-educated sections of the population, have given up smoking. It is not surprising that heart attack and stroke have become less common in the U.S.A.
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