Money spent on screening obviously has to come from somewhere and often it is diverted from curative services. This is all very well for those whose diseases are picked up early and successfully treated but what about those who are not treated for diseases only identified later? This raises all kinds of moral dilemmas for the medical profession and for society as a whole.
Next, it is worth considering the emotional, social and occupational harm done to people who think they are healthy but who are subsequently labelled ‘ill’ as a result of a screening procedure. Labelling someone with a disease has profound effects on his or her life. This would not be so bad if doctors could be sure of their labels but they often cannot because such labels are difficult to apply. Doctors disagree profoundly, for example, over significant levels of raised blood pressure, cholesterol and many other apparently straightforward parameters of body function. This means that one doctor will expend time and his or her patient’s emotions investigating further a laboratory result which another would consider ‘normal’. And none of this takes into account the false positives and false negatives that occur in any screening programme and which cause worry and complacency respectively. So it can be clearly seen from all this that simply detecting disease early is not necessarily enough. A World Health Organisation Report, recognizing this as a real problem, says the following about screening programmes:
1. They must lead to an improvement in end results in those in whom a diagnosis is made (or in those around them in the community).
2. The therapy for the condition must have a favourable effect on its normal course-not simply bringing forward the date of the diagnosis but improving survival or function (or both).
3. There must be sufficient health services to ensure that diagnosis raised at screening can be properly confirmed and to provide meaningful medical care for the person.
4. People who have been diagnosed as having an abnormality must be prepared to go along with medical advice about what to do about it, or the whole procedure is a waste of time.
5. The long-term beneficial results must outweigh the long-term disadvantages.
6. The procedure must be cost-effective.
7. The problems produced by the disease that is being screened for must be large enough to make it worth while doing all the above. Clearly an extremely effective and cheap screening method for a trivial condition, however common, would be difficult to justify.
Having now injected a note of caution into the subject of health screening, we can ask what is worth doing in a preventive health context. Opinions vary, as you would expect, but there is little doubt that it is worth screening for the following seventeen conditions:
1. Abnormalities of growth and development in children.
2. Hearing loss.
3. Visual problems (acuity, squint, glaucoma).
4. Scoliosis (curvature of the spine).
5. Cardiovascular risk factors: hypertension, hyperlipidemia (high blood fats), diabetes, sedentary lifestyles, smoking and obesity.
6. Cancer (cervical, breast, large bowel, testicular).
7. Anaemia.
8. Kidney disease.
9. Sexually transmitted diseases (syphilis and gonorrhea).
10. Menopause problems.
11. Alcohol and drug abuse.
12. Various diseases of the chest other than lung cancer.
13. Various conduction and rate abnormalities of the heart.
14. Sickle cell trait in the black population.
15. Rubella immunity in females.
16. Phenylketonuria in newborn babies.
17. Hypothyroidism in newborn babies.
*30/72/5*
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