| Over the past two decades the scope of self-medication has grown
far beyond the traditional realm of minor, largely self-limiting conditions.
Now recurrences of many doctor-diagnosed illnesses are self-treatable
and this summer people with typical migraine suitable for self-administered
triptans will be identified in pharmacies.
In arguably the most controversial move of recent times, a medicine to
reduce the risk of future serious illness has been available on UK pharmacy
shelves for almost two years. The availability of simvastatin 10mg (to
reduce the risk of heart attack in people at moderate risk) was seen
by many as heralding a possible new era in self care: when individuals
would take responsibility for their future health and in doing so help
address major public health problems. Is this realistic and how might
self-medication develop in the future?
It is self-evident that health care systems focus more on the ill than
the well. Yet enormous expenditure goes on treating illnesses that are
largely preventable. Cardiovascular disease causes more premature deaths
in UK males than all cancers combined and 10 times more premature deaths
in females than breast cancer. The parallel epidemics of obesity and
type II diabetes that are predicted to lay siege to the health economies
of western nations are, likewise, largely preventable conditions.
A health care system can deliver prevention when there is an intervention
(such as vaccination for communicable diseases) that it can administer
to whole populations. If there were a vaccine for heart disease, do you
suppose for a moment that there would be a debate about whether we should
make it available for all? But in obesity and heart disease the principal
means of prevention do not lie in the hands of doctors but in those of
ordinary people. Much of future health care has to begin with self care.
Of course the positive maintenance of health should start as early in
life as possible. There is no question that a healthy diet, exercise
and the avoidance of harmful habits (eg, smoking) are critical in preventing
disease. However, many people will still struggle to live a “healthy
lifestyle”, even if they are educated young as to what this means.
Exhorting adults to avoid things that are bad for them but which they
have, nonetheless, learnt to enjoy, will influence some but certainly
not all. People are often only motivated to take action when they reach
an age or develop a condition where “lifestyle” changes alone
may be too little and too late.
In the future it will simply not be a sustainable health care strategy
to wait for people to develop diseases before sending in the medical
cavalry. So, to borrow a Blairism: could there perhaps be a Third Way?
Some years ago Wald and colleagues1 intrigued many — and appalled
some — by suggesting that the toll of heart disease could be massively
reduced if the whole population above a certain critical age were given
a “poly-pill” combining the medicines known to reduce the
major risk factors. On epidemiological grounds it was difficult to fault
the logic: the human and health care burden of heart disease would be
slashed at the cost of a few adverse effects for some. However difficult
this may have been to deliver in practice, it was at least refreshing
new thinking.
This unashamedly “population-based” approach to preventable
illnesses perhaps gives a clue as to how self care might develop in the
future. What if, at a given age (depending on the disease in question),
everyone at risk was given the opportunity to buy an evidence-based medicine
that could reduce the risk of developing a disease in the future? Is
that so far removed from taking a vitamin preparation to “preserve
health”, as so many do already? Of course this is also not too
far from the statin model of self-medication already available and it
depends heavily on educating the consumer to recognise risk for it to
succeed. In some conditions, heart disease being one, the ignorance of
our population is such that this is not a short-term proposition.
Of course not all “at risk” populations are the same. If
you are obese and strongly at risk of developing type II diabetes (with
all the problems that come with it) you may be highly motivated to act
and a self-medication option as a supplement to lifestyle changes may
be extremely attractive. In my view there are many other examples of
predictable conditions that could be prevented by individuals taking
action before obvious disease develops.
The fact is health care systems are unlikely to fund population-based
prevention based on pharmacological interventions. But where such options
exist, what is wrong with offering them to people who will benefit, provided
it is reasonably safe to do so?
The recent history of self care and self-medication, in particular, is
fascinating. Do you remember when it was almost unthinkable that H2-receptor
antagonists could be bought from
a pharmacy? Now you can buy a pack from a supermarket or garage forecourt,
along with a host of other effective medicines. What was unthinkable
becomes commonplace when the dire predictions of the nay-sayers (a traditional
accompaniment to every switch) are shown to be groundless. Experience
shows that people self-medicate sensibly on the whole and with the added
safeguard of pharmacist intervention for new switches there are many
drugs for long-term use that could qualify as “P”.
I believe the switch of the first statin signalled a potential turning
point in how we regard self care. For the first time, it was recognised
that the benefit of a drug to prevent serious disease should be made
available to a larger at-risk population than could be afforded within
the doctor-led health service. The success of ground-breaking changes
such as this may not come overnight, since that depends in part on a
change in the public’s perception of responsibility for health.
A population-based approach to health requires individuals to understand
and accept personal responsibility for their future well-being. We may
need more examples of self care interventions in disease prevention before
this becomes mainstream thinking.
So will self care have a prime role in preventing disease in the future?
I do not think it is affordable not to have self care as a crucial part
of the future mix for health care provision. However, much will depend
on the willingness of the pharmaceutical industry and, in turn, pharmacists
to seize the opportunity to shape the future of self care.
Reference
1. Wald NJ, Law MR. A strategy to reduce cardiovascular
disease by more than 80%. BMJ 2003;326:1419–21. |
The
Pharmaceutical Journal