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Why the stats about statins don't tell the whole story

For those without the relevant risk factors, statins aren't the wonder-pill they've been sold as by the media.

Maggie came hot-foot from a “health check” where she’d had her cholesterol measured. “Six point two!” she told me. “The nurse said that’s high.” She sounded rather spooked. “I’d like you to give me a statin.”

I’ve known Maggie for years. She’s a sensible academic in her early fifties. She’d done enough googling to learn that a “high” cholesterol means you are “at risk” of cardiovascular disease (CVD) – heart attacks and strokes – and that statins lower cholesterol and reduce CVD risk by 25 per cent. Her request for treatment made perfect sense to her . . . except she had fallen for the same myth that leads to several million people in the UK swallowing a statin every day for no good reason at all.

Focus for a moment on that 25 per cent risk reduction. If you’re at high risk of something nasty, then lopping off a quarter of that risk makes sense. The people at greatest risk of heart attacks and strokes are those who have previously suffered one. Giving statins to these patients (secondary prevention) does convey modest benefits. If you take 100 heart attack survivors and get them to take a statin for five years, you’ll save one life, prevent two or three non-fatal heart attacks, and avert one stroke. That is worthwhile, even if the statins will fail to prevent at least 15 other heart attacks/strokes, and will cause two patients to develop diabetes, and provoke muscle weakness in ten others. Notice, though: 95 per cent of these highest-risk patients will derive absolutely no benefit from their five years of statin consumption.

Come back to Maggie. Using a statin on someone without existing CVD is termed primary prevention. Maggie has no other risk factors (high blood pressure, smoking, diabetes, and so on) and so her chance of developing heart disease is very low. In Maggie’s case, because her risk is so small to start with, a 25 per cent reduction is minuscule and meaningless. You’d have to treat hundreds of Maggies for years on end to hope to make a jot of positive difference to one of them, and the side effects from statins (we’re still discovering what these are) will far outweigh any putative benefit.

There are large numbers of people just like Maggie who are taking statins and who should come off the tablets. But what about individuals at greater risk – people with high blood pressure or obesity, or smokers? Is there a level of risk at which primary prevention is worthwhile? For some time the UK’s National Institute for Health and Clinical Excellence (NICE) has suggested a threshold of 20 per cent risk over ten years.

At first glance, the trial data does suggest a marginal impact at this sort of level: roughly two heart attacks/strokes are averted among 100 people treated for five years. But, crucially, death rates are not altered; no lives are saved by using statins. This probably reflects the harm also caused by statins, and how any small reduction in CVD is negated by disability and death from other causes.

Taking up regular exercise, or adopting a Mediterranean diet, reduces CVD risk by degrees comparable with statins – in the case of diet, substantially more so. If someone smokes, quitting is similarly helpful. What’s more, once one has adopted these lifestyle changes, statins become virtually redundant. Lifestyle modification is also cheap; there are very few harms besides. And, unlike with statins, these measures protect against other causes of death and disability, such as cancer and the frailties of advancing age. Oh, and they’re good for mental health, too.

This February, NICE initiated a consultation on halving its primary prevention threshold to 10 per cent risk. If achieved, this would add hugely to the six million people in the UK who take statins on prescription. Rather than exacerbate our statin fetish, NICE could design simple decision aids that would help doctors understand the more effective improvements that lifestyle changes can bring to health and well-being – and which would illustrate these benefits to patients.

Once we’d talked things through, Maggie resolved to start attending the university gym a few times a week. She decided to forget the statin prescription, too. As a nation, we’d do well to try the same. 

This article first appeared in the 26 February 2014 issue of the New Statesman, Scotland: a special issue

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New Times: David Runciman on networks and the digital revolution

The digital revolution has had two profound effects on how power is distributed – both of which squeeze the state's power.

Left-wing political parties exist to use the power of the state to rectify unjust distributions of power in society. What has gone wrong with this project? First, the political parties bit. Established parties everywhere are struggling to seem relevant to most people’s everyday concerns: they look increasingly like the tired relics of a more hierarchical age. The exception, of course, is the current Labour Party, which has opened itself up to become the biggest mass-membership party in Europe. But the trade-off has been to move away from seeing the acquisition of power as its primary purpose. These days parties can only really draw people in by offering to be vehicles for the expression of political resentment and disenchantment. But that is no way to rectify the causes of their resentment; neglecting the challenge of power usually ends up making things worse.

However, this is just a symptom of the wider problem, which is the changing nature of power. Technology lies at the heart of it. The digital revolution has had two profound effects on how power is distributed. First, it has empowered individuals, by providing them with unprecedented access to information, tools of communication and the means of expression. This is power exercised as choice: we all now have multiple ways of registering our likes and dislikes that never existed before.

Second, the digital revolution has empowered networks, creating vast new webs that span the globe. Some of them, such as Facebook, are close to being monopolies. We end up joining the networks that other people have joined, because that’s where the action is. This gives a small number of networks an awful lot of power.

Both of these developments are deeply problematic for the power of the state. The proliferation of choice makes citizens much harder to satisfy. Many of us have got used to micromanaging our lives in ways that leaves government looking flat-footed and unresponsive, no matter how hard it tries. At the same time, states face global networks that they have no idea how to control. International finance is one of these: money is information and information now has too many different ways to flow. States are getting squeezed.

The paradox is that the same forces that are squeezing the state are also giving impetus to left-wing politics. There are huge imbalances of power being created in networked societies. The monopolists are hoovering up money and influence. Personal connections count for more than ever, now that networked connections have become ubiquitous. Education is turning into a way of pulling up the drawbridge rather than moving up the ladder. One temptation for the left is to assume that the evidence of injustice will sooner or later outweigh the disabling effects of these social forces on the state. That is part of the Corbyn gamble: hang around until people are sufficiently pissed off to start demanding social-democratic solutions to their problems.

I don’t think this is going to happen. There is nothing to suggest that popular dissatisfaction will find its way back to the state as its best outlet. It will be channelled through the networks that are making the life of the state increasingly difficult.

The other temptation is to think that the left can achieve its goals by bypassing conventional social democracy and channelling its own ambitions into network politics. This is the other side of the Corbyn gamble, or at least the view of some of the people who have attached themselves to him: a new politics is coming that uses digital technology to mobilise fleet-footed networks of activists who can generate change without going through the cumbersome and time-consuming process of winning general elections. That also looks pretty wishful to me. These networks are just another vehicle for expressing personal preferences. They don’t have any means of changing the preferences of people who think differently. You need to win power to do that.

The state’s power is being squeezed by networks of empowered individuals, but these networks don’t have the kind of power necessary to do the redistributive work of the state. What is the left to do? It needs to try to find value in the fact that the state is not just another network. The right does this instinctively, by talking up the state’s security functions and championing ideas of sovereignty and national identity. But that does nothing to address the deleterious effects of living in a modern networked society, where we are swamped by personal choice but impotent in the face of corporate and financial power.

Rather than trying to harness the power of networks, the left should stand up for people against the dehumanising power of Big Data. The state isn’t Google and should not try to pretend to be. We don’t need more choice. We don’t need more efficiency of the kind that digital technology is endlessly supplying. We need protection from the mindless bureaucratic demands of the new machine age: the relentless pursuit of information, regardless of the human cost. There are limits to what the state can do but it retains some real power. It still employs real human beings; it educates them and provides them with welfare. It should do what is in its power to make the work tolerable and the education meaningful, to provide welfare in ways that don’t leave people at the mercy of faceless systems. The left needs to humanise the state.

At the moment, too much energy is being spent trying to humanise the party. We are told that people are tired of robotic, careerist politicians; they want unspun versions of people like themselves. But robotic politicians aren’t the problem; the coming age of robots is. While the party tries to feel more comfortable with itself, the effects of a networked society are running rampant. Acquiring the power of the state is still the best way to fight back. It doesn’t matter if that has to be done in an ugly, mechanised, artificial way, by careerist politicians with whom we wouldn’t choose to spend our personal time. Better an ugly, artificial politics than an ugly, artificial world. 

David Runciman is a professor of politics and the head of the department of politics and international studies at Cambridge

This article is part of a New Times collection of the future of the left. Read the other pieces here.

 

This article first appeared in the 22 September 2016 issue of the New Statesman, The New Times