Richard Smith: Reclaiming blood pressure from doctors

Richard SmithWe all know about obesity. We can see fatness. Obesity belongs to all of us, and it’s a global problem. Politicians care about obesity. But who cares about blood pressure? Raised blood pressure may be a bigger risk factor for premature death and suffering than obesity, but people don’t see it. Blood pressure belongs to doctors. Well, it’s time for a revolution. The people must claim blood pressure.

Blood pressure has to be measured with a machine. Until recently those machines were found only in hospitals and clinics. They were strange machines filled with mercury, a dangerous substance. Sometimes the doctor would take (note the word, synonyms are capture, steal) your blood pressure, putting a cuff on your arm and inflating it. It was uncomfortable. You’d feel the pressure and your heart beating. The doctor with a stethoscope in his (no sexism intended) ears would stare at the column with numbers on a scale. Eventually he’d let the air out of the cuff. You could hear and feel the deflation.

“Is it normal, doctor?”
“Pretty well.”
“What is it?”
“About 120 over 90.”
“Is that good?”
“It’s good enough.”
Usually that would be the end of the conversation, but sometimes the patient might ask. “What does it mean, 120 over 90? What’s 120? What’s 90? What should it be?”

The doctor would attempt an explanation, possibly using the words systolic and diastolic, certainly referring to the pumping of the heart.

And if you’re really sick, perhaps in hospital after a major operation, the nurses come and measure your blood pressure every 20 minutes. They write the results on a chart. The chart goes up and down. Should it go up or down? What’s best?

People, even very smart people—perhaps even Carol Vorderman—are ignorant about blood pressure. Even people with high blood pressure, who may be taking pills for it, are ignorant. “I don’t think I can have high blood pressure. I’m a relaxed guy. I don’t get headaches or flushes. I don’t feel my heart beat. I don’t think I really need these pills. And why exactly am I taking them anyway?”

Worse, people are scared of blood pressure. It’s mysterious. Both words—blood and pressure—sound bad. When I was “doing the hippy trail” in 1973 my friend passed out when an Indian doctor took my blood pressure.

But doctors are ignorant about blood pressure as well, calling hypertension a disease when blood pressure is a risk factor for cardiovascular disease. My suspicion is that most doctors in the world are still treating hypertension rather than overall risk of cardiovascular disease. They treat the young, thin, non-smoking woman with raised blood pressure and not the overweight, middle aged man who smokes with slightly raised blood pressure, failing to recognise that the man is at much higher risk of a heart attack or stroke.

Although hypertension may not be a disease it does not stop the formation on national, regional, and world hypertension societies with presidents, conferences, journals, and substantial incomes, usually from drug companies. Blood pressure is big business.

Well, it’s time for blood pressure to come out of the medical ghetto. Anybody can now buy a machine to measure blood pressure, and very soon you’ll be able to measure your blood pressure with a smart phone. The results can be sent to an app so that you can plot your blood pressure by the day, week, or month. You can see how it varies. You can learn that if you exercise more, drink less alcohol, eat more fruit and vegetables, lose weight, and eat less salt your blood pressure will drop. You can see that it drifts up as you get older, and you might stop that happening by changing how you live.

In short blood pressure can become like weight, everybody’s business and responsibility, not something that belongs to doctors.

I’ve been thinking about this because I’ve been advising the Popup Clinic, a programme to help people measure their blood pressure, understand what it means, and take any action if necessary, mostly action that doesn’t depend on doctors and drugs.

When I was a medical student I heard Ivan Illich lecture on doctors “expropriating health” as teachers had tried, less successfully, to capture learning. Now I see many examples—not just with blood pressure but also with end of life care, childbirth, mental illness, and much else—of a swing back. I believe it will be good for people, doctors, and health.

Competing interest: RS is an unpaid adviser to Popup Clinic.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.