Nick Wald's great brainstorm, which came to him a few years ago during his father-in-law's struggle with cardiovascular disease late in life, has the virtue of utter simplicity, and perhaps also its drawbacks. As Wald, a professor of preventive medicine at the Wolfson Institute in London, has observed, "the difference between something being ridiculous and being obvious could be paper thin." Watching as the old man downed the usual cocktail of heart medications, Wald realized that his trouble could have been averted, or at least minimized, if he'd begun his regimen years earlier. Of course, he didn't have symptoms then, but that's the point: half the population in Britain eventually develop serious cardio-vascular disease. Rather than try to identify which half, why not just give the medication to everyone older than 55?
Out of that hunch grew a research paper, audaciously titled "A Strategy to Reduce Cardiovascular Disease by More Than 80%," and a product name, which Wald and his collaborator, M. R. Law, have applied to trademark: the Polypill. The Polypill would consist of six relatively inexpensive, generic components: a statin (to lower cholesterol), three different drugs to lower blood pressure, aspirin (to interfere with blood-clot formation) and folic acid (to reduce levels of circulating homocysteine, a suspected risk factor for heart disease). These are all drugs commonly prescribed for patients at risk for heart disease, and folic acid is found in multivitamins, but the idea of giving them routinely to everyone over a certain age is, as Wald and Law admit, "radical." In publishing the paper last summer, the editor of the British Medical Journal suggested the issue in which it appeared might be "the most important for 50 years."
It certainly has proved to be one of the most controversial. Numerous correspondents rushed to attack Wald and Law's methodology, which did not involve testing the Polypill in actual patients, but a statistical analysis of existing studies on the individual ingredients. Other critics pointed out that even something as seemingly innocuous as aspirin has the potential to cause serious or even fatal side effects, such as gastric bleeding. And a number of British doctors seemed uneasy with the very concept of a pill you give to everyone; it struck them as an abdication of the physician's duty to treat his patients as individuals. "Let's take this to its logical conclusion," wrote one outraged medic, "and put every drug known to medical science in the water supply."
A more measured response comes from Dr. Robert O. Bonow, president of the American Heart Association. "It's not totally a bad idea," Bonow says. "Cardiovascular disease is the leading cause of death worldwide,and we're not going to be able to do enough angioplasties to treat entire populations." But he worries that packaging six drugs in a single, one-size-fits-all pill carries the twin dangers of unnecessary side effects for people at low risk, and, conversely, undertreating those who need more aggressive care. He also has a philosophical objection: that the availability of such a pill might deter people from the lifestyle changes (such as losing weight and stopping smoking) that can do the same thing at no cost, and have other benefits as well. "It gives people exactly what human nature wants," Bonow says. "My idea of a polypill is exercise and a good diet."
Undaunted, Wald says he hopes to begin large-scale clinical testing of the Polypill soon, and, if results warrant, to have it on the market within a few years. Although he believes everyone could potentially benefit from it, he doesn't imagine its being sold over the counter to all comers, at least initially. People with certain conditions (such as asthma or bleeding ulcers) shouldn't take one or more of the proposed ingredients, and you wouldn't want to give the pill to someone who was already taking some of the components in another form. There are plans in Britain to create a middle ground between prescription-only and totally unregulated sales; certain drugs could be sold over the counter to customers based on a questionnaire administered by the pharmacist. Wald thinks the Polypill would be a good candidate for this system. "There's much to gain and little to lose by the widespread use of these drugs," he writes. "No other preventive method would have so great an impact on public health in the Western world."