Preventive Medicine in the Pillory

Recently, public trust in preventive medicine plummeted with the publication of the Women’s Health Initiative’s trial on HRT. Preventive medicine found itself in the pillory being pelted from all sides.

Newspapers published a plethora of letters from anxious women angered that, contrary to expectations, the risk for cardiovascular disease actually increased with HRT! So too did the risk for breast cancer!

The Australian Consumers Association pointedly asked “Why weren’t these products tested more thoroughly before they were prescribed so broadly and why weren’t we told of the possible risks earlier?”. Breast cancer support groups were dismayed and distressed by how the trial’s outcomes were disseminated. But the most blunt assault came from the demigod of evidence-based medicine — David Sackett.

In The Arrogance of Preventive Medicine — his commentary on the trial — Sackett asserted that preventive medicine is aggressively assertive in “pursuing symptomless individuals and telling them what they must do to remain healthy”; presumptuous in its confidence “that the interventions it espouses will on average do more good than harm”; and overbearing in “attacking those who question the value of its recommendations”.

What are we to make of all this?

In its heyday preventive medicine was concerned with threats to the well-being of societies. Among its major achievements was eradication of deadly infectious epidemics. More recently, it has focused on the continuity of individual well-being and aggressively promotes personal preventive interventions. But Sackett argues that this advocacy needs to be underpinned by “the highest level of randomised evidence that our preventive manoeuvres do more good than harm”.

For preventive medicine is this not a sine qua non along with primum non nocere?