The most important BMJ for 50 years?

I suggest, gentle (or even angry) reader, that you keep this issue of the BMJ. It may well become a collector's item. It's perhaps more than 50 years since we published something as important as the cluster of papers from Nick Wald, Malcolm Law, and others (p 1419, p 1423, and p 1427).

They argue convincingly that a pill with six ingredients could prevent 80% of heart attacks (or other events caused by ischaemic heart disease) and strokes. Anybody with cardiovascular disease would take the pill, and so would everybody from 55—without any investigation. As heart attack, stroke, and other cardiovascular events kill or disable half the population of Britain—and a similar proportion in other developed countries—widespread use of the pill would, write the authors modestly, “have a greater impact on the prevention of disease in the Western world than any other single intervention.”

There are many remarkable things about these papers, and one is that you could almost have thought of it as well. I remember Nick Wald telling me about the idea over a year ago and challenging me to guess the ingredients. I guessed aspirin, a statin, a diuretic, and an angiotensin converting enzyme inhibitor but not the others. It was, I judge, genius to think of the idea and hard work to identify the exact ingredients. The authors have also taken an original step by showing that most of the benefits (and many fewer of the side effects) can be had from taking antihypertensives at lower dose and in combination.

The authors have filed a patent application, but what might be patentable? The idea? The combination of drugs? It's not clear, and the economics and politics of the project are fascinating. The six ingredients are all off (or about to be off) patent, so the pill might be made very cheaply. This is good news for the developing world, as Anthony Rodgers notes in an editorial (p 1407), but large pharmaceutical companies are not keen. Not only will the profit margin be low but also many of their expensive drugs may be made redundant. A large generic company—perhaps one from India—might be best suited to manufacture the pill.

And what will happen to cardiologists and cardiac surgeons? Will they have to retrain as psychiatrists, hoping that nobody invents a “happy pill” to oblige further retraining?

Then there is the question of medicalisation. The BMJ last year published a theme issue questioning the medicalisation of birth, death, unhappiness, and risk. Now we are publishing studies that argue that everybody should take pills from 55. But do doctors need to be involved? We could do away with the screening—evaluated so carefully by a group from London on p 1436. Maybe too we could buy the pills in supermarkets and pubs—perhaps even washing them down with a glass of red wine and preventing still more deaths.

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