Are Our Attempts to Reduce Risks Of Disease Helping or Harming?

As a physician in the 1990s, Robert A. Aronowitz was taught to put women who were about to go through menopause on hormone replacement therapy. They were being sold as risk-reducing medicines—they were supposed to reduce bone fractures, osteoporosis, and heart disease.

However, Aronowitz disagreed with this practice. He believed there weren’t good clinical trials to prove the efficacy of the therapy. When clinical trials were eventually conducted in 1991, researchers found that the drugs were causing the problems they were meant to prevent and the hormone replacement therapy recommendation was retracted.

That incident has remained in Aronowitz’s mind. Now a professor of the history of medicine at the University of Pennsylvania, he has spent the last six years thinking about the efficacy of supposed “risk-reducing” medications and tracking their prevalence in our country. As Aronowitz says, “Medicine has shifted in large part from treating specific diseases to providing peace of mind for risks.” In his controversial new book, Risky Medicine: Our Quest to Cure Fear and Uncertainty, he unpacks the ways in which our culture has conflated risk of disease with actual disease and where everyone is increasingly being taught that they are at risk for everything. Aronowitz argues that this increase in risk-centered medicine may lead to overtreatment for some populations and may actually be more harmful than helpful.

But what are some of these procedures and medications and how might the increase in risk-centered medicine be dangerous to general population? Hippo’s new science editor, Jenny Chen, sat down with Aronowitz to find out.

JC: What is risk-centered medicine?

RA: It’s medicine that’s focused on uncovering risk as opposed to the treatment of illnesses that may or may not happen in the future. A lot of what medicine and healthcare today is that. There’s always been an element of anticipatory treatment, but recently, the balance has tipped. It’s gotten so that many people feel healthy and are defined as healthy by their risk for disease. For example, I might see a friend and ask them how they’re doing and they’ll say, “My health is good—I’m avoiding gluten, my cholesterol levels are normal, my tests came back normal,” etc. etc.

All those things that are not health necessarily—those are things you’re doing to prevent disease. It is somewhat psychological at that level—peace of mind, reducing uncertainty. Those things in and of themselves are not bad, but if the cost of medicine is towards that instead of towards effectively reducing morbidity, then we might have to start asking some questions.

JC: How did you get interested in studying risk-centered medicine?

RA: I’m a physician and a historian of science and medicine. I’ve been concerned with the over-diagnosis and over-treatment of people in my practice and with friends and family. It’s clinically been apparent to me that there’s an over-treatment issue. 

When I was writing my book on breast cancer (Unnatural History: Breast Cancer and American Society), I became interested in the age-adjusted mortality of breast cancer—the amount of people dying from breast cancer hadn’t really changed from 1930-1990, but the people diagnosed had exponentially increased. This gap between death rate and number of people diagnosed became really interesting to me.

JC: So why are we becoming increasingly interested in treating risk rather than disease?

RA: The pharmaceutical companies have a problem. They’re selling effective medicines for a disease. If the medicine is effective, it should cure the disease. But then you’ve exhausted your demand. What’s the solution to the problem? If you have drugs that treat risk, you potentially have a product that could be taken by a population for their entire lives. Even if you have a tenth of the population, just for half their lives.

One pharmaceutical executive came to a class of mine and said “the Street” (Wall Street) demands a 10% increase in revenue every year from companies. Where is that going to happen? The answer lies in treating symptoms and risk. That’s where the economic rewards are pushing us. 

JC: In the book, you cite many instances where “risk-based medicine” was actually ineffective in preventing disease. Can you share one of those examples?

RA: When I was a physician in the 1990s, it was being drummed down our throats that women who were going through menopause should be on hormone replacement therapy. Hormone therapies were being sold as risk-reducing medicines—bone fractures, osteoporosis, and heart disease. There was a lot of money behind it. Companies were subsidizing books like Feminine Forever.

There often weren’t good clinical trials. When they eventually did a clinical trial of the hormone replacement therapy, they had to cut the trials short because the drugs were causing the problems they were meant to prevent! At this mass indication the recommendation to take hormone replacement therapies was taken back.

JC: So what’s the alternative to a risk-centered medicine? What would you like to see?

RA: I often say, “Don’t throw the baby out with the bathwater.” Risk prevention is definitely important. But we need to have more clinical trials in as many cases as possible for these risk prevention procedures.

If something is experimental, let’s treat it as if it were experimental. Once something gets out in the mass population like PSA testing for prostate cancer, it’s hard to tell people to stop. So we need to test thoroughly before PSA testing or anything similar gets into the mass population. 

Obviously, there are many risk-centered approaches that make sense: people with heart attacks are told to take beta-blocker, and I think that’s a good idea, but there are good clinical trials, and it’s a limited population that it’s being prescribed for. On the other hand, as I discuss at the end of the book, I had a friend who developed leukemia, and it turns out that one of the medicines he had taken earlier on his life to reduce the risk of another disease put him at risk for leukemia. I don’t second guess the use of that drug for the individual. It may have been needed at the time. What bugs me is that the same drug is advertised on TV and the potential risk is smashed at the bottom of the screen. The idea is to give it to as many people as possible. We have to pull back from that brink of mass marketing.

JC: Final words?

We need to return to the caution and skepticism that I was taught in medical school. It should be retaught, but also for doctors—when fear has been oversold and efficacy has been oversold.

My major anxiety and worry is about the future development and marketing of risk ideas and risk practices. There’s so much appeal to reducing fear and anxiety not to wait. But it may be in society’s best interest to wait. 

Further Reading:

Greene, Jeremy. Prescribing By The Numbers: Drugs and the Definition of Disease. Johns Hopkins University Press.

Dumit, Joseph. Drugs for Life: How Pharmaceutical Companies Define Our Health.  Duke University Press.
Barsky, Arthur. Worried Sick: Our Troubled Quest for Wellness. Little Brown and Co.

Image Credit: Casey Fleser via flickr