When the Cure for Prevention Becomes the Disease

Prevention is better than cure.

In the seventh grade at Craddock High School in Wardha—renamed Mahatma Gandhi Vidyalaya in 1968—we were made to memorize essays for the English theory paper. “Rome was not built in a day,” “A stitch in time saves nine,” “All that glitters is not gold”: these were etched into our young minds by rote, not reason. I once wrote an entire essay word-for-word in an examination and scored eight out of ten. The exam over, we moved to the next class and forgot both the essay and its meaning.

Years later, at Government Medical College, Nagpur, in 1973, Preventive and Social Medicine entered our Final MBBS curriculum. Professor Ketkar taught us screening tests, and once again we memorized—sensitivity, specificity, positive predictive value—to clear our exams. The exams over, MBBS in hand, we forgot the nuances of screening as we entered the wards: interns, then residents, then, eventually, MDs in Medicine.

In the summer of 1982 I arrived in Sevagram as a senior resident and slowly climbed the rungs of an academic career. It took a decade of practicing evidence-based medicine to understand what screening tests actually do: their genuine benefits, their hidden harms, who should be offered them, and—more important—which tests should never be run on people who have no symptoms at all. It took another decade to see why some of our most popular screening panels—routine PSA for prostate cancer, mammograms in low-risk young women, thyroid ultrasounds, population-wide vitamin D testing—generate more noise than signal.

Just as I thought the profession was learning caution, a new wave arrived: Cardiac CT Angiography, or CCTA. It found an aggressive champion in a well-known Bengaluru cardiac surgeon, who argued that every Indian past thirty should undergo the scan—symptoms or none—to “catch coronary artery disease early.” His delivery was persuasive, his logic sounded self-evident, and soon worried citizens and their doctors were lining up for routine cardiac CTs.

Who, after all, would refuse a crisp, three-dimensional picture of their own coronary arteries, if it meant averting a sudden cardiac event?

The logic is seductive, but medically it hides a serious flaw. CCTA uses X-rays and intravenous contrast dye to visualize coronary plaque and narrowing. In an emergency room, for a patient with acute, unexplained chest pain, it is a superb diagnostic tool. But cast as a wide net over healthy, symptom-free people, it triggers a chain of harms nobody asked for.

Consider a smoke alarm so sensitive it goes off every time you toast bread. The alarm itself does no damage. But you panic and call the fire brigade; the firefighters break down your door and hose down your living room. The damage to your house was never caused by fire—it was caused by the system’s response to a false alarm. Clinicians have a name for this: the cascade of care.

In an asymptomatic person, a Cardiac CT Angiogram often turns up minor, inconsequential variations or soft plaques—findings that would never have caused a heart attack or shortened anyone’s life. But once a finding is on a radiology report, it cannot be unseen. First comes the psychological injury: a healthy person is suddenly relabeled a “heart patient,” anxious about a heart that was never in danger. Then, to be safe, comes an invasive coronary angiography. Minor narrowings get stented, patients go on lifelong antiplatelet drugs, and along the way come the real risks—arterial puncture, bleeding, contrast-induced kidney injury, radiation exposure—all for a survival benefit that has never been shown to exist.

Large clinical trials have repeatedly found that screening low-risk, asymptomatic people with advanced cardiac imaging does not reduce heart attacks or lower overall mortality compared with standard, non-invasive risk assessment. You cannot fix a problem that was never going to hurt the patient. You can, however, cause real harm hunting for it.

Fifty years after Professor Ketkar’s lectures at GMC Nagpur, I have learned that the truest prevention is unglamorous. It does not live inside a multi-slice CT scanner, and it is not sold in a corporate “executive health package.” It lies in the unsexy basics: controlling blood pressure, keeping blood sugar and lipids in check, eating whole foods, staying active, and staying off tobacco.

When we trade proven lifestyle measures for aggressive screening of healthy bodies, we are not practicing sound medicine. We are simply calling the fire brigade to a slice of burnt toast.

More medicine is not always better medicine. Sometimes the best clinical judgment lies in knowing when not to test.