The good news and the bad news

Despite the ongoing crisis surrounding cardiovascular disease, it seems that we as a society has made improvements. Dr Simon Cowap explores what we have achieved - and what we have left to do.

 Bad news stories make good news.

 The occasional dramatic hospital stuff-up or GP misdiagnosis always gets front page treatment, while the countless numbers experiencing good care in our hospitals and surgeries pass pretty much without comment. Shining a light on today’s “crisis” of cardiovascular disease, it’s time to redress the balance and focus on something that’s gone well.

 In 1985, when I was nearing the end of my medical degree, the death rate for men from cardiovascular disease was 612 per 100,000. By 2014, it was 179 per 100,000. For women death rates dropped from 410 to 132 per 100,000. Overall, there was almost a 70% reduction in the death rate. A lot of Australians – 45,053 – still died of CVD in 2014, but if death rates had remained where they were while I was a student that figure would have been 150,176. That’s over 105,000 people who didn’t die from CVD in that year alone. And the even better news is that the rate has dropped every one of those years and is likely to go on dropping, though the curve is flattening out a bit.

 This drop hasn’t happened by accident. It’s hard to be certain, but most pundits attribute half the decline to preventative measures such as lifestyle advice and management of cardiovascular risk, and half to better management of end organ disease such as AMI and stroke. So if that’s the case, we in primary care can take the credit for 62,500 of those saved lives. Given that there are nearly 25,000 GPs in Australia that’s almost exactly 2 1/2 each. So whenever you’re next feeling crappy about something, remind yourself of that statistic and give yourself a pat on the back.

 Risk reduction and preventive care has become the absolute bread and butter of general practice. Overall we have been very successful, but within this mostly rosy picture there are significant anomalies. On the good side, daily smoking rates amongst adults have halved from over 30% in 1985 to 14.7 % in 2015. On the bad side, obesity rates in adults have tripled from 10% to about 30% over the same period, and diabetes rates have gone from about 1.3% to 6%.

Overall we have been very successful, but within this mostly rosy picture there are significant anomalies.

 I don’t know about you, but I spend as much time if not more counselling people about weight loss as I do about smoking, generally with less success. Why have I, and the rest of my colleagues, had so much less impact on people’s weight than their smoking?

 That’s a pretty big question and I’m sure has many different answers. Eating is a much more complex behaviour than smoking, and if my experience with alcohol is anything to go by it’s easier to quit something than to keep doing it but change how you do it. Maybe that’s the reason for the success of the 5+2 diet – instead of controlled eating you just quit for a day every now & then.

 For all their differences, there’s one thing you can’t ignore that contributed to the success of quit smoking campaigns and is absent from anti-obesity efforts. The campaign against smoking was backed up by serious regulatory, financial and legal efforts. Cigarettes are taxed heavily, there advertising is banned, they are sold in plain packages and smoking is forbidden in an increasing number of places. In my opinion, it’s high time we started taking the same approach to sugary drinks and fast food, and I strongly agree with the AMA and the Committee of Presidents of Medical Colleges in their recent call for a sugar tax.

 Naturally enough, Barnaby Joyce, the cane growers and the soft drink industry disagree - and you can hardly blame people for acting in their own self-interest. Others dislike it from a libertarian perspective, as another example of the interventionist nanny state. According to them, we’re rugged individualists who should have the freedom to choose to put whatever crap we want into our bodies (and put up with the consequences).

 My response to that is twofold. Firstly those same people ‘choosing’ to become obese will turn up at hospitals when they have a heart attack and expect the nanny state to take care of them. Secondly, it is based on a fundamental mistake about the nature of human beings - that we are creatures of unfettered free will constantly engaged in making rational choices about our conduct. Of course personal responsibility is hugely important, but we are primarily social creatures, and change across a population always requires attention to social as well as individual determinants of behaviour. The reduction in smoking rates and the road toll are prime examples of this.

 The medical profession as a whole and general practice in particular has done a great job in reducing CVD risk. But we can’t go much further unless government listens to us and we get serious about the residual risk factors.

Simon CowapDr Simon Cowap MBBS (Hons), FRACGP
Simon is something of an accidental GP who likes to pretend he’s an artist trapped in a professional’s body. He dropped out of his first degree (arts) and went to London to play bass guitar in a band too musically challenged even for punks. Dropping back in to university, he subsequently also failed to complete a science degree and a Masters of philosophy. His remarkable lack of artistic success has been continued by the non-publication of his several novels. Somewhere along the line he did finish a medical degree. He still harbours dreams of literary success but his family have forbidden him to give up the day job.