Prescribing by Numbers: Drugs and the Definition of Disease

Conclusion. The Therapeutic Transition

c o n c l u s i o n The Therapeutic Transition Iconoclastic defenders of nontreatment must also be expected to defend their position, foreign as it is to the spirit of American medicine. —Committee on the Care of the Diabetic, 1980 In the spring of 2003, the medical public was advised to purchase several copies in advance of a particular issue of the British Medical Journal that was predicted to become a collector’s item.In surprisingly exhortative terms for the British publication, the editor proclaimed that the lead article might represent “the most important piece of medical news for the past 50 years.”1 This article, by two British epidemiologists, pronounced the deliverance of humanity from the nemesis of heart disease through the Polypill, a salvo of preventive medications compressed into a single tablet that all adults over a particular age would be encouraged to take, daily, with no need for screening or doctor’s visits . Ignoring the undertones of Orwell and Huxley that its name suggested, the authors hailed the Polypill as the final solution to the epidemic of cardiovascular disease that had ravaged the industrialized world for the better part of a century. The Polypill was not a joke.2 In the eyes of its creators—who had, indeed, already applied for a patent on the formula and for a trademark on the name Polypill—it was a logical and evidence-based strategy to eliminate cardiovascular disease.3 Using a meta-analysis of more than 750 published clinical trials that summed the experience of over four hundred thousand research subjects, the authors had set out to determine and model the combination and dosage of drugs that would yield “a single daily pill to achieve a large effect in preventing cardiovascular disease with minimal adverse effects.”4 The resulting tablet combined a statin, three blood-pressure-lowering agents (a thiazide diuretic , a beta-blocker, and an angiotensin-converting enzyme inhibitor), folic acid, and aspirin. The mixture of drugs applied to the general, healthy population , was projected to reduce coronary events by 88 percent and reduce stroke by 80 percent. One out of every three people over the age of fifty-five taking this pill would benefit, the authors claimed, gaining an average of eleven more years of life free from heart disease or stroke.5 For an entirely theoretical intervention, the Polypill attracted an impressive degree of international attention and controversy: its results were translated into several languages, posted on nearly three thousand Web sites worldwide, and drew more than one hundred letters to the editor from across the globe.6 Although the majority of respondents were critical of one or more aspects of the paper’s claims, citing methodological, epistemological, rhetorical, logistical ,and moral lapses on the part of the authors,most respondents thought that in one form or another,the Polypill represented an innovation of the most frustratingly obvious kind: “There are many remarkable things about these papers ,” the British Medical Journal’s editor summarized, “and one is that you could almost have thought of them yourself.” Indeed, as several respondents pointed out, since the average citizen over fifty-five in most developed nations was already effectively committed to multiple forms of pharmaco-prevention, putting them all together in one pill hardly seemed like a drastic intervention.7 Other respondents wondered in their letters whether the Polypill should be limited to the prevention of heart disease when so many other conditions were now preventable. As almost all middle-aged men were at risk for benign prostatic disease and almost all women at risk for osteoporosis, why not make a male Polypill that contained prostate-protecting Cardura (doxazosin) and Proscar (finasteride) and a female Polypill that added bone-protecting Fosamax (alendronate) and calcium in addition to the other six ingredients?8 And although many commentators suggested that the calculations of efficacy were predicated on impossible levels of compliance, a CNN poll conducted shortly after the announcement indicated that 95 percent of viewers over fifty-five would take the Polypill, if it became available on the market immediately.9 The Polypill represents the ultimate extension of the school of preventive 222 Prescribing by Numbers pharmacotherapy traced through the history of Diuril, Orinase, and Mevacor. And yet, by favoring the mass treatment of an entire population over screening for specific physiological markers of risk, the Polypill also suggests a...