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SanthoshSanthosh Padmanabhan, Runner, ‘monk’, teacher to the underprivileged at the Ananya & Thulir schools and the chief coach from the running club, Runners’ High of which I was once a part, wrote a mail to me asking me about the appropriateness of routine health checks for runners who were newly joining him. This was my reply.
Dear Santhosh,

In this mail let me address the issue of preventive health checks.

I am aware that there is a large debate in the realm of public health whether preventive health checks are effective/useful or not.

What do people who are opposed to health checks say?

The detractors of health checks seem to point out that
a. Preventive health checks do not truly prevent diseases or their complications
b. On the contrary, they actually increase the number of diagnostic tests, medicine use & even increased number of surgical procedures.

I’ll give two examples to support the above concern:
1. There is a condition known as sub-clinical hypothyroidism, where the thyroid is mildly dysfunctional but not enough to cause biological abnormalities. Some and not all patients of sub-clinical hypothyroidism progress to develop actual thyroid disease and its complications. Routine health checks targeting thyroid disease can detect sub-clinical hypothyroidism. This in turn triggers additional hormonal and antibody testing by the doctors reading the test results. Also a number of physicians prefer to prescribe medications on detection of this sub-clinical hypothyroidism.

Yet, there is no clinical evidence that any of these testing or prescription of hormonal replacement benefits the patient!

2. Mammography is a routine health check test as many of us know. It is said to detect breast cancers very early and thus prevent breast cancer related deaths. Typically, very early cancers detected by mammography necessitates a counseling session and in most instances such counseling leads to the patient opting for limited surgery i.e.,removal of the affected breast.

Recent evidence, however has shown that about 50% of very early cancers detected by mammography disappear over a period of time, indicating that body’s own immune mechanisms are able to weed out many of the cancerous cells.

Logical projections have allowed public health scientists to conclude that:

If we do not detect these very early cancers, i.e., not perform routine mammography, but employ clinical methods of breast cancer surveillance, like self examination or periodic physical examination of the breasts by experienced physicians, that itself would lead to detection of cancer early enough to offer limited surgery. Technically this means that avoiding mammography in routine health checks would avoid unnecessary breast removals in 50% women without putting the other 50% to any disadvantage.

In both these above instances, imagine the psychological trauma, additional testing/ treatment and above all the huge healthcare cost burden to the society.

Does this mean that all health check is bunk?

No.

Complete health check or full body health check is not a panacea to all ill health. However, in specific disease entities early detection has been shown to change the course of disease. I’ll again give two examples:

1. Hypertension: Early detection of severe hypertension and its treatment has been clearly shown to be a very important and cost effective public health initiative. Such detection and proper treatment reduces complications like kidney failure, heart failure and strokes. This has been proven beyond doubt.

2. Screening for cervical cancer in women by Pap smear detects such cancer pretty early. It has been adequately proven by public health research that such screening allows very early treatment, surgical and otherwise, of women with cervical cancer. And such early treatment not only saves lives, but also saves a lot of money which would have been otherwise spent in treating, in futility, advanced cervical cancer.

So what do these examples tell us?

That there is no generalization possible on usefulness or otherwise of preventive health checks. In high end private clinics esp in western countries, tests such as whole body CT or MRI scans and other high cost tests are included in such health checks and are obviously useless and may even be harmful.

On the other hand in a country like India, where basic health awareness is poor health checks (which include testing of blood pressure, examination of the heart for possible valve disease and holes, testing for blood sugar, blood cholesterol, screening for cervical cancer) are not just useful, they should be made compulsory. In fact, with years of experience, I have realized that a large number of patients who come to us for ‘preventive health checks’ mandated by their insurance company or their employers etc have never undergone even basic screening earlier. Indeed, but for this compulsion, many of these individual would not have got their blood pressure, cholesterol or sugar checked. In India, where nearly 14% have diabetes, 10% have hypertension and about 8% have some form of cholesterol abnormality, such neglect would be a massive public health blunder.

The topic of preventive health check is very complex. Indeed, there is almost nothing preventive about such health checks. Such checks actually, give an accurate view of the problems that the patient already has.

Let me clarify: preventive health check will not prevent diabetes or hypertension. On the other hand, it will diagnose a hitherto undiagnosed diabetes etc and help prevent the complications.

So in my opinion, we need preventive health checks as long as they are designed to detect health issues for which early prevention is beneficial. We certainly do not need fancy tests like whole body scanning.

Towards the end of this mail, I should still address the issue of your runners needing health check. I do not know, if RH knows this: there were 4 patients who had heart attacks and one who actually died during our last annual long run of the city. And this wasn’t even a half marathon. We (Fortis is a medical partner for a large number of running events) realized that, often our runners are fueled by zeal rather than meticulous training. A reasonable number of runners believe that running absolves them of all sins: many smoke, a lot have poor eating habits, some sleep badly and most have work stress.

Testing our fitness for the events at hand is imperative under three circumstances:

a. If you are embarking upon a new endurance activity like long distance running, especially after a certain age (I would peg it at 30 years in India, as against 40 in the Caucasians, due to our inherent genetic risks) you must ensure that you have no medical issues.

b. People with risk factors like high BP, sugar, cholesterol, smoking, family history etc should certainly test themselves before starting ANY exercise program

c. There are unsuspecting conditions such as valve diseases, hypertrophic cardiomyopathy etc which will not be detected even on a routine health check. Special tests like echocardiography are required to exclude these conditions, which are often fatal. A 1500 rupee test once in a life time to make sure you are not going to collapse on the race? Far cheaper than the travel insurance which you keep buying for 110 rupees every time you fly domestic!!

Lastly, as an organization, Santhosh, there will be a question of liability, if one of the runners should develop a problem during a training run. While it is easy to absolve yourself with a declaration from the runners that you are not liable for any issues they have or develop during training (like how how the running events take a declaration from the participants during mega events), I believe that people like you, who have been responsible for making running popular among public, are justified in taking precautions to ensure that running does not get adverse publicity by untoward events on the track.

So as a cardiologist practicing in a country which is now declared the capital of heart diseases in the world, I’m entirely with you if you (autocratically) mandate that your runners have health checks before long distance running. In fact, I believe, you are doing them a favor by insisting on such testing!
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One Comment

  1. well said dr… my sincere hearty apploudzz to such a valuable discriptive reply to an appropriate ? asked.! lu.tc.


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