|Home | About | Journals | Submit | Contact Us | Français|
Coronary artery disease has been intensively investigated for fifty years and enjoyed a therapeutic revolution in the past twenty. Biomedical technology and the pharmaceutical industry are knocking it for six. Guidelines and protocols are all around—no need now for professional experience and judgment: follow the white stripe down the middle of the road and the managers who monitor your performance will be happy. But not, according to Ole Færgeman, patients or populations. In his view the stories of success are dangerously wrong. Færgeman, a professor of preventive cardiology who did contribute to the latest clinical guidelines,1 is based in Aarhus, fifteen minutes by bicycle from Viby, headquarters of a Danish-Swedish dairy monopoly and half an hour by car from Randers, home of the largest pork producer in Europe. One year of the output of pigs from Randers is four times the carcase weight of the human population of Denmark. We need look no further for his motivation in venturing beyond the clinic and writing Coronary Artery Disease: Genes, Drugs and the Agricultural Connection.2 However, even without such a strong local stimulus in Dundee, I myself might have attempted such a book had I not been preoccupied with my opus on the WHO MONICA Project.3
Diseases result from the way we live. Quick fixes by drugs will not alter that. Coronary artery disease will continue predominant as the world urbanizes and industrializes. Each death prevented by pills is equalled by new ones as the world is cajoled and bullied by trade organizations and multinationals into the unwise farming practices of agro-business and corporate farming. For every wise man choosing the healthy option in diet, the food industry will find a less wise one to eat what he has rejected—choice but no net benefit. Internationally the European Union exports its surplus butter to Russia. When the British public adopted semi-skimmed and skimmed milk, commercial caterers decanted the surplus cream as the default whitener in coffee.
Current agricultural policies are not only bad for health but also degrade our inherited farmland by demanding ever-increasing production of grain to feed subsidized farm animals in feed-lots or confined animal feeding operations. In the latter, grain goes in and carcases and manure come out, without daylight or green pasture. Færgeman reminds us of things we have half forgotten, explains things clearly that we previously only half understood, and lucidly introduces us to areas of recent scientific thought, discovery, and controversy. His clear prose is punctuated by witty punch-lines, although the reader is left guessing how many of these are well-known jokes in Danish or entirely original. In exemplary fashion his chapters review the history of coronary artery disease, its rise and fall, predictions for the future, the cholesterol controversy, food and food choice, food sources, milk and lactase persistence, the agricultural connection, public policies and corporate farming. He then writes on genetics and why the Human Genome Project is likely to deliver less than has been promised: most chronic diseases such as coronary disease and diabetes are multigenic, not depending on a single gene or even a few. He goes on to discuss the consequences of the increasing lovey-dovey relationship between universities, governments and big business, and the threat to academia from short-term financial pressures. He writes on the complexity of disease and the danger of working to algorithms that assume the diagnosis to be definite and homogeneous. This may be the wish of managers and bureaucracies, but doctors must work for patients with diseases in all their varied permutations—fractals rather than the Gaussian distribution.
The preface by Professor Philip Poole-Wilson, currently President of the World Heart Federation, is supportive but accentuates the residual dichotomy between basic researchers and epidemiologists. Like other cardiologists, Poole-Wilson has come a long way from the cynicism with which only a couple of decades ago clinicians used to greet epidemiological recommendations on prevention. He agrees that in the absence of the classic risk factors coronary disease would be rare, but he is still intent on identifying the necessary or essential cause—the Holy Grail of laboratory scientists that will lead to complete abolition. To an epidemiologist, anything that increases the frequency of a disease is causation and anything that reduces it is prevention. What Poole-Wilson calls causes are disease mechanisms, which may conceivably be successfully interrupted but depend on a single common path. Færgeman argues that many genes act in parallel. Prevention does not necessarily depend on the discovery of fundamental causes and mechanisms, but rather the weakest link. Smallpox was eradicated by the systematic application of a technique promoted by an eighteenth century country doctor a century and a half before viruses were identified under the electron microscope.
This is a superb bird's eye view of the coronary pandemic, but inevitably there are quibbles on detail. The main text was written on a sabbatical in 1999 and subsequently revised several times with the uneven addition of references up to 2002. Only the 1999 and not the very relevant 2000 MONICA Project main results publications on coronary disease trends are discussed, albeit in considerable detail. I wonder whether, today, Færgeman would be less agnostic about controlling blood sugar in type II diabetes. In the historical section, James Herrick is named as the man who popularized coronary heart disease among physicians, so that it stopped being an uncommon diagnosis. He misses the point that Herrick's particular contribution was in describing the clinical features, in life, of myocardial infarction consequent to coronary thrombosis, so that it became a specialist hospital diagnosis rather than a post-mortem one thought incompatible with life. I question his contention that familial hyperlipidaemia should have been promoted more in popularizing coronary disease prevention. Although it provided a simple disease model—a raised cholesterol causes coronary disease—in Britain it led to widespread belief that most coronary disease was familial and predetermined, and failure to appreciate the importance of diet and the multifactorial approach. Lipidologists were evasive when asked how a condition with a gene frequency of one person in 500 could explain a disease killing one in four—although I always suspected the figure of 1 in 500 to be a best guess and it still seems to be difficult to substantiate. Færgeman explains why this simple disease model has now become very complex. He discusses food choice and gives us the usual jokes about the unpleasantness of a ‘healthy’ diet (many of them from England) without emphasizing how fashions change, and just how awful the so-called traditional diet of the 1960s would now appear to those with more sophisticated cosmopolitan palates, accustomed to year-round availability and variety of fruit and vegetables to balance their intake of meat and fish. A final minor grumble is that the book, though written by a Dane and published in Amsterdam, is written in American English and gives US sources even for the likes of Charles Darwin, Alfred Russel Wallace and Florence Nightingale. David Barker is not given a reference in his own right. The author has an alibi in that he wrote the book in the USA, but has the publisher? The President of the European Society of Cardiology, a Dutchman, gave me his opinion that European English is Oxford English, and that is what they use in the European Heart Journal. Perhaps the time has come for an international convention on standard English spelling—but maybe the dictionary publishers would resist, with their vested interest in the differences.
On going through Færgeman's text, I began by marking the passages I would have liked to quote in my review, but they proved far too numerous. Instead I encourage readers of the JRSM get a copy for themselves. This work offers more hope for controlling coronary disease than can ever be had from popping pills.