A few months ago, Americans went to sleep thinking it was just an ordinary night. But the next morning, 30 million people woke up to a new a diagnosis of hypertension. We had a blood pressure epidemic on our hands. The newspapers were full of front-page stories alerting Americans to this new threat. The most erudite and well-respected physicians implored us all to get checked and treated immediately lest we suffer heart attacks, strokes — even death.
Welcome to the world of numerical epidemics. Once we base our definition of disease on numerical abnormalities, we can change the numbers in a way that expands those who have the disease. This has been occurring in dramatic fashion the past 20 years, especially since Medicare (by congressional decree) relinquished the task of defining normal numbers to specialty medical societies. Hence the American College of Cardiology can change the definition of an abnormal cholesterol reading or abnormal blood pressure reading such that more people will be labeled with a diagnosed disease related to these numbers. Likewise, the American Society of Nephrology can broaden the definition of what constitutes abnormal kidney function and expand the scope of those now diagnosed with kidney disease. The list goes on and on, from diabetes to dementia to skin cancer; the criteria for being declared sick is rapidly being broadened, instigating epidemics of diseases across the medical horizon.
These fabricated crises affect well more than half the population and drive a measure-diagnose-treat crusade to eradicate sickness by prescribing medicines, ordering tests, seeing specialists, and undergoing procedures, all in an effort to normalize errant numbers. We are squandering trillions of dollars, often to the detriment of our patients, merely to push a number across some arbitrary line of what we call “normal.”
Without a doubt, treating high blood pressure and high sugars in a measured and patient-centric way has saved hundreds of thousands of lives. Helping high-risk people with osteoporosis can similarly improve the lives of people we treat intelligently.
But when our zeal to fix all numbers transcends the science, when all patients are viewed similarly regardless of their individual risks, when numbers eclipse the meaningful health of those we are treating, and when what constitutes a “normal” value is constantly altered to make more people appear sick, we have all the makings of a Flexnerian epidemic, named for Abraham Flexner, whose 1911 Flexner Report set the standard for American medicine.
When Flexner and his colleagues insisted on reconstructing health care upon a bedrock of science, they assumed that if you can test someone and determine what is physiologically aberrant in his or her body, you can address that abnormality and perhaps fix it. Science, to the architects of the Flexner Report, is not fickle or subjective; it is measurable and absolute.
But they ignored the malleability of scientific “facts.” Studies can be designed to reach foregone conclusions. Cognitive biases can distort our views of what is medically relevant. Benefits of certain interventions to fix abnormalities can be exaggerated and risks minimized. And the very term “abnormal” is hardly objective since it has to be defined by someone.
Certain organizations — whether the American College of Cardiology or the Centers for Disease Control and Prevention — can influence our definition of normal, especially when assessments are based on medical studies that these groups handpick to use as the barometer of normal. These are only as reliable as those who design them, but their influence carries great weight.
Mr. S reads the Washington Post regularly, and in 2018 he came to see one of us, Andy, about the front-page headline regarding new blood pressure standards. A systolic reading of 140 used to be a normal pressure, but now it was deemed to be 120. This bold declaration, which created 30 million new hypertensives overnight, emanated from the SPRINT study, which concluded that aggressive treatment of blood pressure in older people results in a 25 percent decrease in stroke and heart attack, and a 40 percent cut in death. When SPRINT defined what a normal blood pressure was, a hypertension crisis gripped the nation.
Mr. S graphed his and his mom’s blood pressures over time. At ages 68 and 92, both fit in the category of old as defined by SPRINT, but the study did not look at people as old as his mom. He showed Andy the graphs. “Most of the time, we’re way above 120,” he said. “Mom especially. Her blood pressures seem to be all over the map. We need more medicines, doc. I’m going to see my heart doctor in a couple of weeks, but I’m afraid that if we don’t get the numbers down now we could get a stroke any time.”
As an engineer, Mr. S placed great value in the significance of numbers. That’s why he created spreadsheets and graphs whereby he could demonstrate the fluctuations and averages of his and his mom’s numbers. It was crucial information, he said.
The danger of basing a new normal on a single study — and then proclaiming from that study that we have a numerical epidemic that requires aggressive and immediate treatment, as so many doctors and media outlets did — is rife with flaws. The primacy of numerical measurements in diagnosis glosses over salient differences between people, some of whom might require different normal numerical values than others. It also fails to recognize the harms of treatment and the way that “fixing” one number can affect the body more broadly.
SPRINT looked at a few thousand highly screened people, all of whom had severe heart disease, which was not the case with Mr. or Mrs. S. It found that by adding an extra medicine to those with blood pressures over 140 systolic, and getting that pressure below 120, there was substantial improvement in outcome. But what does a 25% relative reduction in heart attack and a 40% relative reduction in death actually mean? How many people actually benefited from aggressive blood pressure lowering in this very select group?
It turns out, not many: One out of 1,000 people treated aggressively avoided a heart attack or stroke, and two out of 1,000 lived longer by pushing pressures below 120 systolic. But we don’t know how much longer they lived. Not only does the study fail to reveal that fact, it also doesn’t tell us if people live longer because of lower pressure or from some other benefit the add-on medicines might confer in regard to their underlying severe heart disease.
Also, though SPRINT claimed to measure adverse outcomes of aggressive treatment, it did not adequately assess the more subjective effects of low blood pressure that we see every day in our offices: dizziness, fatigue, falls, increased confusion, among others.
Mrs. S was a perfect example. Her blood pressure fluctuated widely, as is true of many her age, and whenever her heart doctor pushed her pressure too low — usually at the behest of her son — she stayed in bed all day and was very confused. The numbers looked great, but Mrs. S didn’t. Also, lowering the blood pressure aggressively triggers other problematic side effects, some of which were seen in SPRINT but largely ignored by those who touted the study’s miraculous findings. There was no mention of the five out of 1,000 people in the treatment group who developed severe kidney disease over the brief trial period, and the 10 out of 1,000 were hospitalized for dangerously low blood pressure.
Mrs. S’s kidney function declined with the addition of her new blood pressure medicine. Already she had been given a diagnosis of chronic kidney disease, stage 3, something with which 90% of our elderly patients had been labeled ever since the definition of kidney disease changed. None of these people ever get sick or need dialysis; the diagnosis is merely an inconsequential numerical blip that was now defined as an illness. But now Mrs. S believed that she had a disease. Mr. S brought her to a kidney doctor, who performed pages of labs regularly and an occasional X-ray. Until now, her kidney function had stabilized, but suddenly with the new pressure medicine it bumped up. “We should stop the medicine,” one of us (Andy) told her son. “Her pressure is too low, and her labs look worse. She feels terrible.”
“Mom’s kidney doctor begs to differ,” he said. “She wants mom’s pressures as low as possible, and she is closely monitoring many of mom’s kidney tests to be sure we’re on the right track.”
Performing tests is one thing. Interpreting the outcome is another. In the late 19th and early 20th centuries, William Osler, a Canadian physician, emphasized patient care over numerical testing and research. Through an Oslerian lens we simply cannot declare that there is a “normal” blood pressure below which everyone should fall. Everyone is unique, everyone has their own “normal” number, and it is up to a discerning doctor who understands their patient well to interpret the blood pressure reading in a way that makes sense for that particular patient. But Mrs. S’s doctor had one goal in mind: normalize the number.
Unfortunately for Mrs. S, soon after her kidney doctor insisted she be put on another pressure pill, she promptly fell down and broke her wrist. “Purely a coincidence,” her son later said. “She tripped.”
Many studies have demonstrated the danger of aggressively lowering blood pressure, some of which, such as a large Veterans Administration study, showed worsening renal function and a higher death rate in people aggressively treated who had underlying kidney disease, a fact that escaped the notice of those who declared the immediacy of our new hypertension epidemic. In fact, a study published after SPRINT showed an increase of death in people treated aggressively when they did not have severe heart disease, which was the case with Mrs. S and son. This study did not receive much attention.
Osler frequently taught that a doctor cannot simply treat a number; he must treat the patient. Mrs. S feels better with higher blood pressure. Maybe her body is pushing her pressure up to get blood through her many narrow arteries, and by lowering the pressure too much she is putting herself and her organs in danger. Also, her blood pressure is not the same from minute to minute, so how can we possibly gauge what her pressure really is and what it should be? Her son, and her specialty doctors, didn’t care about all of that nuance. They read the guidelines, and they vowed to fix her. After all, this was an epidemic.
Excerpted with permission from “A Return to Healing” by Andy Lazris and Alan Roth. Copyright @ 2025 by University of Toronto Press.
Andy Lazris, M.D., is a physician practicing primary care and geriatric medicine in Maryland. Alan Roth, D.O., is a physician practicing family medicine and palliative care in New York. He is chairman of the MediSys Health Network Department of Family Medicine and Ambulatory Care.
