Julia Pakpoor and Shivan Sivakumar: Is high hanging fruit high value?

In the face of chronic non-communicable diseases, the mantra goes, prevention is better than cure. If we know what causes disease, and if we can prevent its risk factors, we would soon not need most of its treatments.

As two academics working in an area where causative factors of complex diseases are often not well established, forgive us for our sense of idealism that people would avoid risk factors, if only we could tell them what they were.

Cardiovascular diseases are the leading cause of death across the world. In 2012 approximately 17.5 million people died from cardiovascular diseases, representing a striking 31% of deaths globally [1]. Epidemiological study has well characterised the risk factors of cardiovascular diseases, which are primarily modifiable behavioural factors. Obesity and smoking are the two most notable examples, and it is now easier to think of diseases for which they are risk factors than ones for which they are not [2, 3].

Public health initiatives that promote smoking cessation and curtailment of rising obesity would therefore constitute two of the most important national and global health initiatives of our lifetimes. It is difficult to think of any other health measures for which the public benefit could be as large.

Although our understanding of disease pathogenesis for many complex diseases is incomplete, and there are undoubtedly many more contributory genetic or environmental factors to be elucidated, the groundbreaking discoveries have been made and the biggest yields have been reaped. We do not need to identify a genetic variant that increases the risk of cardiovascular disease by an odds ratio of 1.1. We do not need to know the precise mechanisms through which some obscure factor acts to influence disease progression.

Put simply, there are still bigger fish to fry. While fighting a losing battle against the most ravenous killers, and failing in tackling their preventable causes, worldwide we are spending vast fortunes on the development of new treatments for preventable diseases, and continuously seeking more causative risk factors for those that are not.

Should a collaborative public health investment among academic medical health professionals of both our funding and our time be made towards the prevention efforts of the most common causes of ill health in this country (and internationally), for which the causes are not only already known, but modifiable? Is there a duty to spend public funding on endeavours that would confer huge health benefits on a global and population level? Are we right to indulge our personal academic medical curiosities?

It is time to reflect on what influences medical research to choose its directions, and whether our pursuits as academic health professionals are as altruistic as we may think they are. Disease prevention strategies require extended periods of time, the support of successive governments, and substantial collaborative efforts across all sectors of society. These are not a worthwhile investment for industry guided objectives.

Medical research has an overflowing bottleneck, and until we are able to better align research output with public health interventions, we will continue to seek out knowledge that will remain confined to the academic community, and which will be of no practical benefit to our patients. I am not sure that we will be able to stand our ground in defending ourselves to the future generations who will suffer as a result of our inadequate action. This pandemic of non-communicable diseases is devastating to the individual, to social mobility, and comes at an incomprehensible cost to our health service, which may not be able to survive it.

Julia Pakpoor is an academic foundation doctor at the University of Oxford. She is a previous BMJ Clegg Scholar.

Shivan Sivakumar is an academic clinical lecturer, Department of Oncology, University of Oxford, Oxford, UK.

Disclosures: We have read and understood BMJ policy on declaration of interests and declare that we have no competing interests.


  1. http://www.who.int/cardiovascular_diseases/en/ Accessed 31 August 2016.
  2. Hubert HB, Feinleib M, McNamara PM, Castelli WP. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study. Circulation 1983;67(5): 968-977.
  3. Ambrose JA, Rajat BS. The pathophysiology of cigarette smoking and cardiovascular disease: an update. Journal of the American College of Cardiology 2004;43(10): 1731-1737.