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Colin Kopes-Kerr, MD
5989 Vista Ridge
Santa Rosa CA 95409

E-mail: cpkerr@nni.com



Kopes-eticHealth.com:

A New Dawn for Health Care Information

 

Books of Special Interest

[with Commentary by Colin Kopes-Kerr, MD]

 

1. Michael Pollan, The Omnivore's Dilemma (2007)

FOOD FACTS FOR AMERICANS

MY LIFE AS A CORN CHIP: You, sir or madame, are nothing more than a walking corn chip! I am too, of course. Each of us is personally responsible for consuming a ton of corn and corn by-products every year. How did we get to this ridiculous nutrition situation?
    The answer is nicely (and very troublingly) explained in Michael Pollan's new book, "The Omnivore's Dilemma." Have you ever envied the koala, who doesn't have to worry about choosing from the 45,000 different items that we stock in our supermarkets; 'if it looks and smells like a eucalyptus leaf, it must be dinner', and he's a happy koala. We omnivore's have it much tougher. Particularly in America, where, we have no particular single, strong, stable culinary tradition to guide and protect us in our food choices, our very choices are our nightmare and most likely cause of death. As Mr. Pollan explains, "The lack of a steadying culture of food leaves us especially vulnerable to the blandishments of the food scientist and the marketer, for whom the omnivore's dilemma is not so much a dilemma as an opportunity. It is very much in the interest of the food industry to exacerbate our anxieties about what to eat, the better to then assuage them with new products."
    Ecology also teaches that all life on earth can be viewed as a competition among species for the solar energy captured by green plants and stored in the form of complex carbon molecules. The agro-industrial complex has harnessed the energy of fossil fuels (fertilizers) to endow us with what can only be described at a great (and markedly wasteful) overabundance of energy (calories). In fact, we are consuming huge quantities of fossil fuel energy just to create this surplus.
    The story starts innocently enough in 1621 with the Pilgrims who borrowed the gift of zea mays (maize; corn) from the Indians, without the fecundity of which they simply would not have survived. No other plant could produce quite as much food quite as fast on a given patch of land as this Indian corn. This one plant supplied settlers with a ready-to-eat vegetable and a storable grain, a source of fiber and animal feed, a heating fuel, and an intoxicant. It was this dual identity as food and commodity that makes corn the prototypical capitalist plant. The modern story, however, doesn't get going until 1909 when a German chemist named Fritz Habel devised a way to dramatically increase crop yields by providing chemical nitrogen for plants (fertilizer) without having to wait for the sun or for bacterial activity to 'fix' atmospheric nitrogen. Without synthetic fertilizer billions of people would never have been born. With the Haber-Bosch process for commercializing the supply of fertilizer, growing corn became a process of converting fossils fuels into food. Those who have any concern about the 'energy crisis' should be aware that 'when you add together the natural gas in the fertilizer to the fossil fuels it takes to make the pesticides, drive the tractors, and harvest, dry, and transport the corn, you find that every bushel of industrial corn requires the equivalent of between a quarter and a third of a gallon of oil to grow it--or around fifty gallons of oil per acre of corn...Put another way, it takes more than a calorie of fossil fuel energy to produce a calorie of food...From the standpoint of industrial efficiency, it's too bad we can't simply drink the petroleum directly." This new process has its problems, of course--immense waste of fertilizer, acid rain, global warming, E. coli O157:H7, and 'blue baby alerts.'
    The history of corn farming then took a dramatic turn during the Nixon years when the Secretary of Agriculture, Earl Butz, engineered a change in the subsidy to farmers that thereafter paid the subsidy directly to farmers for their grain so they would sell their corn on the market rather than keep it off the market to support prices. What this did, at great expense to the government (~$5 billion), was to induce farmers to sell ever more of their already excessive production on the open market. As any supply-demand economist knows this could only lower the price of corn (as far as the public can see). Irrationally cheap corn prices, with these peculiar incentives, lead to an incredible excess of calories on the open (super) market. Our very own government has engineered both the current obesity crisis and the energy crisis. One-fifth of America's total petroleum consumption goes to producing and transporting our food. It takes approximately 35 gallons of oil to produce the average cow for slaughter. Whenever you get tired of paying more than $3.00 at the pump for a gallon of gasoline, just shop less at the supermarket.
In a nation of meat-eaters you might be surprised to find out that you are corn to your very core--because all the animals you eat (beef, chickens, pigs, etc.) are corn-fed and all the tasty flavors of snack foods and sodas come from high-fructose corn syrup (HFCS). You can't escape (at least not in the supermarket). Cows, of course, don't really want to eat corn; their rumens are designed to eat grass. In order to fix this little problem, the engineers (there are no real farmers in this enterprise) pump thousands of gallons of liquefied fat and protein supplements, vats of liquid vitamins and synthetic estrogens, and 50-pound sacks of antibiotics--Rumensin and Tylosin--to keep the food trough full in the middle of its manure lagoon, which miraculously transforms what might be a precious source of fertility--cow manure--into toxic waste. As Mr. Pollan says, "Eating industrial meat takes an almost heroic act of not knowing or, now, forgetting." Cows convert 32 pounds of feed into 2 pounds of meat. Similarly for chickens. The ratio of feed to flesh in chicken is two pounds of corn to one of meat, which is why chicken costs less than beef.
The disease that comes from E coli 0157:H7 is one of the by-products of this process. This is a new strain of the common intestinal bacteria (never seen before 1980) that thrives in feedlot cattle, 40% of which carry it in their gut. Ingesting as few as 10 of these microbes can cause a fatal reaction. Feeding these cows an acid diet (acidified by all the antibiotics) led to the development of acid-resistant E. coli, which then get past our very own human gastric defense system and kill us.
    This aside, all is not happiness and joy for the agro-industrial complex. There is one big problem. No matter how much they reduce the costs of raw corn and how much corn products they can produce, they are still restrained by the special nature of the consumer, who can eat only so much food, no matter how cheap it gets. ["Food industry executives used to call this the problem of the 'fixed stomach'; economists speak of 'inelastic demand.'] "The growth of the American food industry will always bump up against this troublesome biological fact: Try as we might, each of us can eat only about 1500 pounds of food a year. Unlike many other products--CDs, say, or shoes--there's a natural limit to how much food we can each consume without exploding. What this means for the food industry is that its natural rate of growth is somewhere around 1 percent per year--1 percent being the annual growth rate of the American population." The industrial answer to this dilemma is to create new non-food foods--e.g., cereals as medicine ("heart healthy") or indigestible starches (whose mission is to pass through your digestive system untouched), etc. "When fake sugars and fake fats are joined by fake starches, the food industry will at long last have overcome the dilemma of the fixed stomach: whole meals you can eat as often or as much of as you like, since this food will leave no trace. Meet the ultimate--the utterly elastic!--industrial eater."
    Now one can understand "why processing foods is such a good strategy for getting people to eat more of them. The power of food science lies in its ability to break foods down into their nutrient parts and then reassemble them in specific ways that, in effect, push our evolutionary buttons, fooling the omnivore's inherited food selection system. Add fat or sugar to anything and it's going to taste better on the tongue of an animal that natural selection has wired to seek out energy-dense foods. Animal studies prove the point: Rats presented with solutions of pure sucrose or tubs of pure lard--goodies they seldom encounter in nature--will gorge themselves sick. Whatever nutritional wisdom the rats are born with breaks down when faced with sugars and fats in unnatural concentrations--nutrients ripped from their natural context, which is to say, from those things we call foods. Food systems can cheat by exaggerating their energy density, tricking a sensory apparatus that evolved to deal with markedly less dense whole foods. It is the amped-up energy density of processed foods that gets omnivores like us into trouble...
    "It turns out that the price of a calorie of sugar or fat has plummeted since the 1970s. One reason that obesity and diabetes become more prevalent the further down the socioeconomic scale you look is that the industrial food chain has made energy-dense foods the cheapest foods in the markets, when measured in terms of cost per calorie. A recent study in the American Journal of Clinical Nutrition compared the 'energy cost' of different foods in the supermarket. The researchers found that a dollar could buy 1,200 calories of potato chips and cookies; spent on a whole food like carrots, the same dollar buys only 250 calories. On the beverage aisle, you can buy 875 calories of soda for a dollar, or 170 calories of fruit juice form concentrate. It makes good economic sense that people with limited money to spend on food would spend it on the cheapest calories they can find, especially when the cheapest calories--fats and sugars--are precisely the ones offering the biggest neurobiological rewards."
    When we (physicians and the public) speak of the 'obesity epidemic,' we generally do so with a very judgmental tone as though those who 'chose' to become obese are in some way deficient, defective, or inferior. It is our system that compels this result. Where is our compassion and empathy for what those of us with money have done to those without, whom we have left to follow their own sociological imperatives. This is not an 'us' vs. 'them' dichotomy. The majority of us Americans are overweight, if not obese, all for the same reason--we succumb to the powerful allure of cheap calories, which our government is working hard to provide (a policy which has ample historical precedents in the "bread and circuses" theory of government).
    For health professionals, the categorical imperatives of action are to fight for: (1) cheaper quality calories, and (2) an environment that makes exercise, the joy of walking and exploring, accessible. This cannot be done inside our offices.

COMMENT: In medical school they taught me nothing about nutrition except for the Krebs and related cycles. In residency they taught me even less. Only 6% of physicians talk to their patients routinely and consistently about diet and nutrition. For the majority of the rest of us the reasons for our inaction is a deep-seeded feeling of inadequacy in understanding the subject and the lack of a supporting payment system (or else we would all have learned long ago). The shame is that this subject is so simple. The simple medical aphorism "Five servings of fruits and vegetables a day!" says it all. Learning nutrition does not have to be all biochemistry and food analysis tables. It can even be fun! I would go as far to say that if you just read two books on the subject, you can master all that you need to know and have fun at the same time. The two books are:
(1) The Okinawa Program, by Bradley J Willcox, Craig Willcox, and Makoto Suzuki. Three Rivers Press, NY. 2001. (paperback)
(2) The Omnivore's Dilemma: A Natural History of Four Meals. Penguin Press, NY. 2006. (hardcover)



 

2. Michael Fine, The Nature of Health (2007)

NO HEALTH, NO CARE, JUST HEALTHCARE (SIGH!)

PROVOCATIVE THOUGHTS FROM MICHAEL FINE'S NEW BOOK--"THE NATURE OF HEALTH":(1) "...[B]eing healthy in the United States today is very difficult, because we have largely wiped out community, which...is a necessary condition of health...We lost sight of the meaning of health gradually and by accident. Life span--the expected period for which a person is expected to live--is easy to measure, while health is both hard to define and hard to measure, so we began to substitute longevity--a long life--as a stand-in for health, and pretty soon began to believe that longevity is health. In fact, measurement can and in this context does function as a trap. We measure a thing because it can be measured, and then we find our system trying to su pply what we measure, not because it is what we want, but because it is what we can measure, and thus disseminate. Because we can easily measure life span, and people desire a long life span, our system is almost totally devoted to supplying longevity...
    "But the health we want is not really longevity at all, but rather the equal opportunity to function in the relationships appropriate to our culture and our place in the life cycle, which is a much more robust sense of health than mere longevity. This book argues that health is the ability to be part of a family and community that is supportive and secure. Our society's disappointment with its medical services industry arises from numerous inefficiencies, true, but even more it seems from the fact that the health we are paying for is very different from what we actually want. We seek the ability to be with our families and our friends, and to see our children grow up. Instead, it often seems that healthcare gives us harangu es about risk reduction, aimed at providing us an unending life, the manipulation of body image, so we can all aspire to look like an image crafted on Madison Avenue, and the relief of any discomfort of deviation form an externally defined ideal. We are all playing--and losing--a high stakes game of Three Card Monte; we put our money down where the card was but, all of a sudden--no money and no card.
    "...Health, both in individuals and communities, describes our ability to function as people in relationships. Thus, health is not possible unless the context of those relationships--families, communities, even states and nations--is intact and functioning as well. Still, it is the village, the community, where people experience health. Urban or rural, rich or poor, the character of the community affects the subjective experience of well being. The objective conditions of the community may influence both longevity, and happiness, but that does not change the fundamental requisites, namely, that individuals cannot be healthy without functioning families and communities for individuals to be healthy in... Life is relationship. Health is the love of others.
    "...Our culture, which might best be called postmodern consumer capitalism, eats social infrastructure for breakfast. Postmodern consumer capitalism is successful to the extent it can atomize individuals, families, and communities into the smallest unit of analysis that can trigger the purchase of a product...
    "Over a hundred years of studies, by the most skilled analysts in medicine and social science, have failed to show that medicine as a profession has a significant positive impact on population health. From John Snow to Rudolf Virchow to Rene Dubos to Thomas McKeown to Daniel Callahan to Barbara Starfield, Lisa Berkman, Ichiro Kawachi, Bruce Kennedy, and Leilu Shi, the practitioners and theorists who have examined the social determinants of health are continually rediscovering the same phenomenon: social organization, not medical care, determines population health. There is ample reason to believe the converse--that medical care worsens population health, but the balance between some medical care being somewhat protective and too much medical care being dangerous to population heath has not been well worked out...The major predictors of population health or ill health in the United States are smoking and environmental exposures, income inequality, and the enduring effects of racism on racial minorities--all measures of our ability or inability to function as a just community. Only one measure of the impact of medicine as a profession, the number of primary-care physicians per 10,000 population, measured state by state in the United States, appears to correlate with the variables we use to measure population health, such as infant mortality and total mortality. That correlation is not as strong as the correlation with smoking, income inequality, and race as a marker for racism. A number of measures of the impact of medicine as a profession, number of specialty physicians per 10,000 people, and number of hospital beds per 10,000 people, appear to have a negative impact on population health. Not only is medicine (except, perhaps, primary care) not population health, medicine may be injurious to population health. COMMENT: "Houston, we have a problem."
 

 

3. Ivan Illich, Medical Nemesis (1976)

REVISITING IVAN ILLICH

MEDICAL NEMESIS AND THE EXPROPRIATION OF HEALTH: IS IT RELEVANT NOW?
    I run into very few people who know of Ivan Illich's revolutionary transdisciplinary critiques and fewer still who are familiar with the above titled critique of American medicine. I first encountered this book when it was published in 1976. I was early in my second year of medical school. He starts with the simple premise that medicine is a moral enterprise, which 'gives content to good and evil,' and the physician is a 'moral entrepreneur.' The book is a feisty polemic on how the operation of our health care system actually removes people from the ability to take care of themselves [not a very desirable outcome]. If you can read it with an open mind, you will find that the book is well researched and, apart from a few polemical extremes, pretty convincing. It left me with the feeling--"This sounds true. If it is true, what am I doing here?" A question that has plagued me ever since. I invite you to peruse the following sampler of his thought to reach your own conclusions.(1)
    According to Mr. Illich, "Health, after all, is simply an everyday word that is used to designate the intensity with which individuals cope with their internal states and their environmental conditions...In part at least, the health of a population depends on the way in which political actions condition the milieu and create those circumstances that favor self-reliance, autonomy, and dignity for all, particularly the weaker. In consequence health levels will be at their optimum when the environment brings out autonomous personal, responsible coping ability. Health levels can only decline when survival comes to depend beyond a certain point on the heteronomous (other-directed) regulation of the organism's homeostasis. Beyond a critical level of intensity, institutional health care--no matter if it takes the form of cure, prevention, or environmental engineering--is equivalent to systematic health denial..." He calls this self-reinforcing loop of negative institutional feedback 'medical nemesis.' The medical and paramedical monopoly over hygienic methodology and technology is a glaring example of the political misuse of scientific achievement to strengthen industrial rather than personal growth..." Medical nemesis can be reversed "only through a recovery of the will to self-care among the laity, [Mr. Illich was formerly a Catholic priest], and through the legal, political, and institutional recognition of the right to care..."
    He cites evidence that, "[F]or more than a century, analysis of disease trends has shown that the environment is the primary determinant of the state of general health of any population. Medical geography [which, of course, we don't teach to doctors], medical anthropology [which we don't teach], and the social history of attitudes towards illness [which we don't teach] have shown that food, water, and air, in correlation with the level of sociopolitical equality and the cultural mechanisms that make it possible to keep the population stable, play the decisive role in determining how healthy grown-ups feel and at what age adults tend to die."
    "Most of man's ailments consist of illnesses that are acute and benign--either self-limiting or subject to control through a few dozen routine interventions. 'The social ordering of compassion, nurture, and celebration' is our important legacy from primitive medicine. [Living wills would never have been an issue if terminal care had not been moved into the hospital and medicalized.] 'For a wide range of conditions, those who are treated least probably make the best progress. 'For the sick,' Hippocrates said, 'the least is best.' More often than not, the best a learned and conscientious physician can do is convince his patient that he can live with his impairment, reassure him of an eventual recovery or of the availability of morphine at the time when he will need it, do for him what grandmother could have done, and otherwise defer to nature. The new tricks that have frequent application a re so simple that the last generation of grandmothers would have learned them long ago had they not been browbeaten into incompetency by medical mystification. Boy-scout training, good-Samaritan laws, and the duty to carry first-aid equipment in each car would prevent more highway deaths than any fleet of helicopter-ambulances. Those other interventions which are part of primary care and which, though they require the work of specialists, have been proved effective on a population basis can be employed more effectively if my neighbor or I feel responsible for recognizing when they are needed and applying first treatment. For acute sickness, treatment so complex that it requires a specialist is often ineffective and much more often inaccessible or simply too late..."
    This is where I agree with him the most. Given our progressive shortage of primary care physicians and medical homes, any assumption that patients have timely access to physicians to triage their complaints and get them to higher levels of care is malignantly unrealistic. Our precious few primary care physicians should be providing initial episodes of care for those who need it after patients have been triaged by a community health worker in their own neighborhood. In our current primary care system all of these people have to come to the office for long waits with half ultimately being told that you don't need to be here. To send all of these patients to a doctors office for triage [the traditional medical model] is absurdly wasteful and, as Illich asserts, ultimately a denial of care. 'Hamster medicine' is a denial of care.
    "Medical procedures turn into black magic when, instead of mobilizing his self-healing powers, they transform the sick man into a limp and mystified voyeur of his own treatment." [Sound familiar?] "Medical procedures turn into sick religion when they are performed as rituals that focus the entire expectation of the sick on science and its functionaries [think colonoscopy] instead of encouraging them to seek a poetic interpretation of their predicament or find an admirable example in some person--long dead or next door--who learned to suffer... Medical procedures multiply disease by moral degradation when they isolate the sick in a professional environment rather than providing society with the motives and disciplines that increase social tolerance for the troubled." [Think of our own mental health crisis in Sonoma County.]
    "Medicine claims the patient even when the etiology is uncertain, the prognosis unfavorable, and the therapy of an experimental nature...Whenever medicine's diagnostic power multiplies the sick in excessive numbers, medical professionals turn over the surplus to the management of nonmedical trades and occupations. By dumping, the medical lords divest themselves of the nuisance of low-prestige care and invest policemen, teachers, or personnel officers with a derivative medical fiefdom." [Again, think of the mental health crisis. It was all over the Sunday Press Democrat.]
    "In a morbid society the belief prevails that defined and diagnosed ill-health is infinitely preferable to any other form or negative label or to no label at all. It is better than criminal or political deviance, better than laziness, better than self-chosen absence from work." [and, if you have Medicaid, you can get a lifetime prescription for Vicodin to boot] ... Professionally organized medicine has come to function as a domineering moral enterprise that advertises industrial expansion as a war against all suffering. It has thereby undermined the ability of individuals to face their reality, to express their own values, and to accept inevitable and often irremediable pain and impairment, decline, and death." [Have you ever experienced continuous dose escalation of pain killers in those without a specific diagnosis with absolutely no impact on the character or severity of the pain?]
    "Each culture gives shape to a unique Gestalt of health and to a unique conformation of attitudes towards pain, disease, impairment, and death, each of which designates a class of that human performance that has traditionally been called the art of suffering. [Physicians suffer too but have much better denial mechanisms.] ... All traditional cultures derive their hygienic function from this ability to equip the individual with the means for making pain tolerable, sickness or impairment understandable, and the shadow of death meaningful. In such cultures health care is always a program for eating, drinking, working, breathing, loving, politicking, exercising, singing, dreaming, warring, and suffering. Most healing is a traditional way of consoling, caring, and comforting people while they heal, and most sick-care a form of tolerance extended to the afflicted...Medicalization constitutes a prolific bureaucratic program based on the denial of each man's need to deal with pain, sickness, and death. The modern medical enterprise represents an endeavor to do for people what their genetic and cultural heritage formerly equipped them to do for themselves. Medical civilization is planned and organized to kill pain, to eliminate sickness, and to abolish the need for an art of suffering and dying. This progressive flattening out of personal, virtuous performance constitutes a new goal which has never before been a guideline for social life. [Those who treat the underserved admire constantly the grace and heroism in the way they manage their health and hopes; this phenomenon is rarely observed among those who have health insurance.]
    "...[O]nly pain perceived as curable is intolerable...Now an increasing portion of all pain is man-made, a side-effect of strategies for industrial expansion. Pain has ceased to be conceived as a 'natural' or 'metaphysical' evil. It is a social curse, and to stop the 'masses' from cursing society when they are pain-stricken, the industrial system delivers them medical pain-killers. Pain thus turns into a demand for more drugs, hospitals, medical services, and other outputs of corporate, impersonal care and into political support for further corporate growth no matter what its human, social, or economic cost..." [Chronic pain is the perfect raw material for corporate medicine. With traditionally trained physicians virtually any pain can be transformed into chronic, eternal pain--a never-sated market for ever more potent pain-killers and pain-modifying devices. Never mind that no one ever gets better. Corporate earnings are up quarter after quarter. What more could you ask for?] "In every traditional culture the psychotherapy, belief systems, and drugs needed to withstand most pain are built into everyday behavior and reflect the conviction that reality is harsh and death inevitable...The medicalization of pain...has fostered a hypertrophy of just one of these modes--management by technique--and reinforced the decay of the others...[I]t has rendered either incomprehensible or shocking the idea that skill in the art of suffering might be the most effective and universally acceptable way of dealing with pain."
    "...It now seems rational to flee pain rather than to face it, even at the cost of giving up intense aliveness. It seems reasonable to eliminate pain, even at the cost of losing independence. It seems enlightened to deny legitimacy to all nontechnical issues that pain raises, even if this means turning patients into pets. With rising levels of induced insensitivity to pain, the capacity to experience the simple joys and pleasures of life has equally declined...Increasingly, pain-killing turns people into unfeeling spectators of their own decaying selves."
    "Before sickness came to be perceived primarily as an organic or behavioral abnormality, he who got sick could still find in the eyes of the doctor a reflection of his own anguish and some recognition of the uniqueness of his suffering. Now, what he meets is the gaze of a biological accountant engaged in input/output calculations. His sickness is taken from him and turned into the raw material for an institutional enterprise. His condition is interpreted according to a set of abstract rules in a language he cannot understand. He is taught about alien entities that the doctor combats, but only just as much as the doctor considers necessary to gain the patient's cooperation. Language is taken over by the doctors: the sick person is deprived of meaningful words for his anguish, which is thus further increased by linguistic mystification. Before scientific slang had come to dominate language about the body, the repertory of ordinary speech in this field was exceptionally rich." [Think Chaucer. Think Shakespeare.]
    "As soon as medical effectiveness is assessed in ordinary language, it immediately appears that most effective diagnosis and treatment do not go beyond the understanding that any layman can develop. In fact, the overwhelming majority of diagnostic and therapeutic interventions that demonstrably do more good than harm have two characteristics: the material resources for them are extremely cheap, and they can be packaged and designed for self-use or application by family members." [Think oral rehydration solution; do not think Pedialyte.]...The skills needed for the application of the most generally used diagnostic and therapeutic aids are so elementary that the careful following of instructions by people who are personally concerned would probably guarantee more effective and responsible use than medical practice ever could. Most of what remains could probably be handled better by 'barefoot' nonprofessional amateurs with deep personal commitment [read Community Health Workers] than by professional physicians, psychiatrists, dentists, midwives, physiotherapists, or oculists...[A 1975 WHO publication actually advocated the deprofessionalization of primary care as the most important single step in raising national health levels.]
    "When the evidence about the simplicity of effective modern medicine is discussed, medicalized people usually object by saying that sick people are anxious and emotionally incompetent for rational self-medication, and that even doctors call in a colleague to treat their own sick child..." [To me, not to treat your own family shows a striking lack of confidence in the ability that we are selling (i.e., the ability to recognize a sick child or adult) and an ultimately dangerous dereliction of responsibility to those you love most. But that's just me.]
    "...Better health care will depend, not on some new therapeutic standard, but on the level of willingness and competence to engage in self-care...Iatrogenesis is clinical when pain, sickness, and death result from medical care; it is social when health policies reinforce an industrial organization that generates ill-health; it is cultural and symbolic when medically sponsored behavior and delusions restrict the vital autonomy of people by undermining their competence in growing up, caring for each others, and aging, or when medical intervention cripples personal responses to pain, disability, impairment, anguish, and death..."
"Health designates a process of adaptation. It is not the result of instinct, but of an autonomous yet culturally shaped reaction to socially created reality. It designates the ability to adapt to changing environments, to growing up and to aging, to healing when damaged, to suffering, and to the peaceful expectation of death. Health embraces the future as well, and therefore includes anguish and the inner resources to live with it...Health is a task...Success in this personal task is in large part the result of the self-awareness, self-discipline, and inner resources by which each person regulates his own daily rhythm and actions, his diet, and his sexual activity. Knowledge encompassing desirable activities, competent performance, the commitment to enhance health in others--these are all learned from the example of peers or elders...
    "A world of optimal and widespread health is obviously a world of minimal and only occasional medical intervention. [Think whole villages having a healthy lifestyle and eating a Mediterranean or Okinawan diet with the resulting 50% reduction in all-cause mortality--far healthier than the world's most extravagant health care vendor, the US.] Healthy people are those who live in healthy homes on a healthy diet in an environment equally fit for birth, growth, work, healing, and dying; they are sustained by a culture that enhances the conscious acceptance of limits to population, of aging, of incomplete recovery and ever-imminent death. Healthy people need minimal bureaucratic interference to mate, give birth, share the human condition, and die.
    "Man's consciously lived fragility, individuality, and relatedness make the experience of pain, of sickness, and of death an integral part of his life. The ability to cope with this trio autonomously is fundamental to his health."
COMMENT: If this seems at all radical to you, then stick to catechisms like the AMA's Code of Ethics. I am afraid I can't get past taking it as the most compelling common sense I have ever read in medicine. [Think Thomas Paine.]

 

 

4. Shannon Brownlee, Overtreated (2007)

THE CATALOG

WHAT'S WRONG WITH MEDICINE (IN THE U.S.)? While the resulting chronic dysphoria is familiar to everyone, many do not have an adequate factual base to make an actionable overall assessment. [How do I know? Because no action has been taken yet. Whereas if a reasonable and prudent person in the profession had the facts, s/he would feel compelled to act.] Most of us are just encountering the American health care system experience of Orwell's elephant; each of us knows what's wrong in our small context, but little else. I have been tracking these kinds of stories for over 20 years in this newsletter, but I still find it difficult to wrap my mind around this problem. Most of the news comes to us as scattered stories in everything from Time magazine, the Wall Street Journal, to the New England Journal of Medicine, and t hen they're pretty sanitized.
    This problem, however, has been remedied by the recent publication of Shannon Brownlee's "Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer." She strings together all the relevant data points into a compelling and fast-reading narrative, which will edify you (if you can keep from throwing up when you're done). "Most of us feel sorry for the uninsured, but we want no part of a plan that involves rationing. Instead, we've decided to put up with an unfair, dysfunctional, and spectacularly expensive system. In 2006, we spent an estimated $2.1 trillion on health care. That's almost as much as the worldwide market for petroleum, and more than the United States spends on food. We spend more per capita on health care that the Chinese spend, per capita, on everything."
    Here is her catalog of what's wrong with our profession of medicine.

1. Waste: We devote nearly a third of our health care spending to administrative tasks. Canada spends only 16%, which implies that we're wasting about $160 billion. Then there's the $30 billion in after-tax profits earned by health insurance companies. As one economist puts it, "I look at the U.S. health care system and see an administrative monstrosity, a truly bizarre melange of thousands of different payers with payment systems that differ for no socially beneficial reason."

2. Costs: While the number of doctors per capita in the US is lower than in other countries in the developed world, they earn far more--4.2 to 6.6 times the income of the average patient (vs. 3.2 to 4 elsewhere). "U.S. doctors make so much more than physicians in the rest of the world not so much because they charge more, but because of the volume of services they deliver, the large number of colonoscopies, for example, hip replacements, and office visits." In the hospital, price is the problem. The average cost per day in a US hospital is $1,666, four times the average in the rest of the developed world.

3. Unnecessary Care: Then there is the unnecessary care. "We spend between one fifth and one third of our health care dollars..., between $500 and $700 billion dollars, on care that does nothing to improve our health...One estimate puts the number of deaths due to unnecessary care at 30,000 Americans a years. That's the equivalent of a 747 airliner crashing and killing everyone aboard at least once a week." If the airlines did that, they would be out of business.

4. The Jack Wennberg story: In 1963, halfway through his residency, Dr. Wennburg had a patient who died of unexplained acute renal failure a few days after an otherwise successful cholecystectomy. The only clue to this event turned out to be a drug that the patient had taken to visualize her gallstones on x-ray--Orabilex. Other drugs in this class had clear adverse renal effects. Dr. Wennburg determined to confirm his suspicions by performing experiments on cats with escalating doses of the drug. All of the cats died of renal failure. He went to his hospital administrators (Johns Hopkins) and asked them to remove the drug from the formulary, which they did, but they refused to intervene with the FDA to have the drug removed from the market. This turned out to be a kind of 'epiphany' for him--the administrators' refusal to protect patients beyond the walls of Johns Hopkins. "He realized that there was more to being a doctor than simply treating one patient at a time; that doing the right thing, asking what he could do for his country, meant working to improve the health of communities."
    In 1965, despite the opposition of physicians, Medicare legislation was passed. It turned out to be the biggest bonanza ever to hit the medical profession. It transformed American medicine "from a cottage industry of solo practitioners at the beginning of one century into the medical-industrial complex by the turn of the next." In the first year of implementation, average physician income rose by 11 percent and continued to rise sharply for years afterwards.
    In 1967 Dr. Wennberg took a job with a regional planning program for Medicare. One of his early studies was to compare the rates of different surgical procedures in different regions in Vermont, a state then with only 444,000 people and 16 hospitals. He found that the rates of surgery varied dramatically by location even though the underlying demographics did not. It turned out that the variation was driven entirely by the doctors, who had no sense of what was a normal or appropriate rate of surgery per population. What the doctors were doing was based purely on their own intuition about what the patient 'needed' and the 'customary, preferred, or expected among peers at a particular hospital'. There was essentially no science. Even more disturbing, when Wennberg attempted to publish his findings, no medical journal would accept them.
In 1979 Wennberg went to work for Dartmouth Medical School. With colleague Elliott Fisher he extended his Vermont studies of utilization rates for medical procedures to the entire country. He found the same results. "They found that patients with back pain were 300 percent more likely to get surgery in Boise, Idaho, than in Manhattan. Doctors in hospitals affiliated with Harvard Medical School admitted patients to the intensive care unit four times more often than their colleagues at Yale University School of Medicine. Arthroscopic knee surgery--which would later be shown to be entirely ineffective at treating knee pain due to arthritis-was performed five times more often on arthritic patients in Miami than in Iowa city." Medicare spending for these procedures varied dramatically from region to region. The differences in cost were not due to variations in how much doctors an d hospitals charge, nor to differences in how sick patients were. The differences were due to physician discretion and the widespread performance of unnecessary procedures. "Doctors find ways to maintain their incomes," says Wennberg. "Look a medical license is like a hunting license. They go out and find enough patients to bag their limit, and their limit is set by some income target."
    Fisher estimates that at least 30,000 elderly Americans were being killed each year by too much medicine. That's 4 times the death rate from skin cancer; twice the number of deaths from brain cancer; two times the number of murders committed annually. Wennberg and Fisher estimated that as much as 30% of the medical care that is paid for by Medicare (about $700 billion in 2006) as well as private insurers is useless.

5. The Kerr White story: "In the 1960s, Kerr White (the man who would later send Wennberg to Vermont), an expert in public health at Johns Hopkins, argued that what the country needed was not more specialists but doctors who were specifically trained to keep people healthy. White...knew from his epidemiological work that while specialists were necessary, the overall health of the nation depended upon doctors with a broad understanding of many conditions as well as the importance of personal attention in diagnosis and treating most illnesses. White showed in paper after paper that intimate and long-term relationships between doctors and patients often mattered more than specialized training or new technology...The comforting presence of a familiar doctor, and the laying on of hands or the writing of a prescription, could (and still does) do wonders for many patients. But Kerr also discovered that patients were more likely to modify their behavior, to quit smoking, take their medicine properly, and begin exercising, on the advice of a trusted and caring doctor."

6. The Killing Fields--Hospitals: Useless care, however, is not an example of "no harm, no foul." The Fisher and Wennberg data show clearly that the hospitals with the highest utilization rates of these surgical procedures were associated with 2-6% higher patient mortality. In 1999 the Institute of Medicine published "To Err Is Human." The report estimated that medical errors kill between 40,000 and 98,000 Americans each year. It turns out that preventable hospital error is the 8th leading cause of death annually (ahead of motor vehicle accidents, ahead of breast cancer, and ahead of AIDS).
In 2003 a Rand researcher, Elizabeth McGlynn, published a study on 439 indicators of quality care. She reported that, on average, patients were given recommended care a little less than 55% of the time. A major factor in this appears to be the role of specialists who are aggressive in their area of specialization but who have no clue as to how to coordinate care. Fisher's data show that patients who were hospitalized with a heart attack, hip fracture, or colon cancer got more care, but not better care, in hospitals where there were more specialists. "And the extra care they got consisted of all sorts of discretionary tests and procedures that didn't improve their outcome; they increased patients' risk of dying."
    "What is known is that regions that have fewer specialists in relation to the population--and more primary care physicians--have better overall health." In hospital regions where there are more primary care physicians and fewer specialists there is both less undertreatment and lower mortality rates. "While Americans worship the specialist for his knowledge and technical expertise, the most important doctor for ensuring good health may be the underappreciated primary physician."
    Today, of course, we have rediscovered this, but we have not changed the system.

7. The effect of DRGs: In the 1980s President Reagan introduced the DRG system of payments in an effort to control the runaway costs of Medicare. DRGs did slow the rate of increase. But DRGs also helped drive the delivery of unneeded care since the DRGs for certain, generally procedural, services remained disproportionately lucrative. For example, in the treatment of heart patients in the hospital, the now clearly more appropriate aggressive medical therapy actually produces a loss (around 11%) for the average hospital whereas hospitals will make a 40% profit if an angioplasty is performed. "What this means is that any hospital administrator with an ounce of good business sense is going to want to maximize the number of patients in profitable service lines, which they have taken to calling 'Centers of Excellence,' whether or not they are, in fact, excellent." When Duke University tried to do the right thing in 1995 for heart failure patients by instituting a home outreach program with nurse case managers, the number of hospital admissions for congestive heart failure declined, saving insurers the 37% reduction in costs. But Duke University Hospital lost money; its revenue declined sharply.
    "This pattern of medical 'demand' expanding to consume the supply of resources is so pervasive in medicine that it even has a name: Roemer's law. In the 1960s, Milton Roemer, a health services researcher from the University of California, Los Angeles, coined the phrase 'A built hospital bed is a filled hospital bed.' Similarly for ICU beds--the more ICU beds that exists the more patients that are admitted regardless of the severity of illness. Same for specialists--the greater the supply of specialists, the greater the demand for the procedures that they do.

8. A Case Example of the Specialist Trap #1--Shasta Regional Medical Center and the California Heart Institute in Redding, CA: Dr. Chae Hyun Moon was a cardiologist who had graduated from the Korean medical system in 1972. He was willing to work hard. He pushed aggressively to get the hospital to expand their range of cardiac procedures to catheterization, angioplasty, and open-heart surgery instead of referring them away to larger centers. He had succeeded by 1987 and was shortly thereafter joined by Dr. Fidel Realyvasquez Jr., a Stanford-trained cardiothoracic surgeon, and together they ran the California Heart Institute. Dr. Moon was able to rake in the Medicare dollars averaging over 2 procedures every single day at his peak and billing Medicare for over 4 million dollars that year. The doctors did very well. The town loved them since they brought both commerce--health care is an industry--and private philanthropy as they dispersed token amounts of their incomes.
    However, people were dying--'heart patients' who didn't even know they were sick until Dr. Moon's oculostenotic reflex catapulted them to a cath and a stent or CABG. After one family physician, Dr. Patrick Campbell, witnessed a death in a patient who did not appear to have heart disease, he took action. Over the next couple of years he collected evidence of the unnecessary and inappropriate procedures from his patients. When he and other local physicians formally complained to Redding Medical Center administrators, no action was taken by the investor-owned hospital.
    Ultimately, Dr. Campbell was able to convince the FBI to undertake an investigation. The investigation showed that in 27 years at Redding, Dr. Moon had catheterized some 35,000 patients in this lightly populated, largely rural area. In the opinion of outside consulting specialists, between one quarter and one half of the patients who underwent catheterization or surgery at Redding Medical Center had been operated on inappropriately. At least 167 patients had died during or shortly after cardiac surgery.
    Not until 2006 did the California State Medical Board move to revoke the doctors' licenses. Tenet Healthcare Corporation, the investor-owned corporation who owned the hospital, agreed to pay $59.5 million to the federal government to settle charges of Medicare fraud.
It did not end well for Dr. Campbell either. He was resented and ostracized by the town that lost its two most famous doctors and had to close his practice.
    Was the Moon-Realyvasquez-Redding Medical Center-Tenet Healthcare Corporation criminal behavior an isolated bad apple in a profession that was otherwise coping well with change? Not likely. According to Ms. Brownlee, "The story of a small hospital in northern California symbolizes a flaw in American medicine that goes far deeper--and is shared by nearly every single medical institution in the country." I agree.

9. A Case Example of the Specialist Trap #2--Surgery for Low Back Pain: In 1985 Congress created the Agency for Health Care Policy and Research (AHCPR), intended to evaluate medical interventions for effectiveness and to create sound evidence-based guidelines for practitioners. In 1993 the agency had the ill luck to choose to perform an evaluation of the management of acute lower back pain--a very common problem. On the panel happened to be an expert on back pain from the University of Washington, who had recently published an analysis of existing research on spinal fusion surgery for low back pain. "When the AHCPR's expert panel recommended nonsurgical remedies for most lower-back pain, back surgeons went wild. Sensing a threat to their livelihoods [which for many of them exceeded $1 M annually ], because the AHCPR's guidelines could alter Medicare and Medicaid reimbursement decisions, the surgeons bombarded Congress with letters contending that the agency's panel was biased.
    "One surgeon, Neil Hahanovitz, founded the Center for Patient Advocacy, a nonprofit group that orchestrated a sustained lobbying campaign not just against the AHCPR's back-pain guidelines but against the entire agency. Kahanovitz found sympathetic ears in the new, antigovernment Republican congress, led by Newt Gingrich. The agency's name appeared on a House Budget Committee's 'hit list' of 140 federal programs targeted for elimination. The surgeons were joined in their efforts to kill the AHCPR by Sofamor Danek, a manufacturer of pedicle screws, devices consisting of plates or rods that are used during spinal fusion surgery--typically adding thousands of dollars to the cost. Sofamor Danek unsuccessfully sought a court injunction to prevent the agency from publishing its guidelines on back pain. Despite support for the AHCPR from the American College of Physicians, the Am erican Medical Association, and the American Hospital Association, the House of Representatives zeroed out its budget. The agency survived thanks to the Senate, but only just barely, with a 25% budget cut. The AHCPR was given a new name, the Agency for Healthcare Research (AHRQ), and stripped of its authority to recommend payment decisions to Medicare and Medicaid."

10. A Case Example of the Specialist Trap #3--High-dose Chemotherapy for Breast Cancer: In 1981, a rising superstar in the oncology field, Dr. William Peters, who was then working in the Dana-Farber Cancer Institute, got to test his theory that, if a little cancer poison is a good thing, a lot of it must be great. Of course, high-dose chemotherapy completely wipes out the bone marrow requiring an accompanying bone marrow transplant. In theory it sounded reasonable. Unless you were a patient. But desperate women (men, too) do desperate things. He tried it out on a few select cases with some apparently good results (rapid, early remission) and some bad results (virtually 100% recurrence and death).
Peters published a study in 1993 in which he claimed that his cases demonstrated that high-dose chemo was far superior to the standard regimen. He compared the outcomes of his transplant cases to the outcomes of breast cancer patients receiving standard treatment. Approximately 70% of his transplant patients were cancer free 48 months after transplant; only 35% of women were alive 48 months after standard therapy. Selection bias (choosing healthier patients for the transplant group) could have accounted for much of this. After only a relatively few cases and no RCTs this treatment, promoted by desperate patients, aggressive oncologists, and an attorney with a special interest in these cases (e.g., the Nellie Fox case in which HealthNet got penalized for denying insurance coverage) succeeded in convincing the courts that this option should be considered 'standard of care.' It was, of course, a huge moneymaker for any facility that offered it. (It led to a whole new industry represented by Response Oncology, basically a franchise operation to teach eager hospitals how to get in on this hot new thing.) By 1994 the number of transplants increased from fewer than a hundred a year in the 1980s to 9000 transplants annually.
    The appropriate 5-year RCT was not published for 10 years. In 1999 at the annual meeting of the American Society for Clinical Oncology results from 5 different clinical trials of high-dose chemotherapy were presented. Four of the 5 trials found no benefit from high-dose chemotherapy and bone marrow transplantation. The single favorable trial in 154 patients by a South African oncologist named Werner Bezwoda was completely fabricated. Ultimately 42,000 women were subjected to this useless therapy before the medical profession finally turned its back on it. "The story of high-dose chemotherapy has come to symbolize everything that's wrong with the way many new, unproved medical treatments are swiftly embraced by physicians and patients..."
    It is easy to find many similar examples--radical mastectomy, carotid endarterectomy, arthroscopic knee surgery for DJD, drug-eluted stents. It goes on and on and on.

11. Diagnostic imaging--the curse of the 21st century: As Malcolm Gladwell (author of Blink and The Tipping Point) puts it: "The human task of interpretation is often a bigger obstacle than the technical task of picture taking." One radiologist explains the phenomenon with: "An image gives the illusion of a greater sense of certainty. But it's still an illusion; it's an article of faith that overpowers rational argument." In fact, physicians simply will not follow well-validated rules that could dramatically reduce the utilization of these tests. There are lots of 'reasons' for the escalating number of these procedures--Emergency Room needs for bed control and malpractice insurance, physicians emotional needs to feel 'confident' of their diagnosis, ignorance of the harm that the tests do (cause cancer and generate false positive results requiring further evaluation). After two decades of using CT scans to support a diagnosis of appendicitis there has still been no improvement in the rate of negative appendectomies. Nor has there been any clear improvement in the outcomes of stroke patients. Nor in persons at risk for cancer. And certainly not in people who undergo whole-body CT scans; these people are clearly harmed by the medical entrepreneurs who offer these tests. (A 60 year old who undergoes an annual whole-body CT scan over the next 15 years has a 1 in 220 risk of dying from cancer due to radiation exposure.)
    Same story for MRIs. National Imaging Associates, a company that helps insurers decide how to pay for imaging services, estimates that at least two thirds of MRIs contribute nothing to physicians' ability to diagnose their patients accurately. "In 2002, Blue Cross Blue Shield of Missouri calculated that 20 to 30 percent of their claims for PET, CT, and MRI scans were for unnecessary tests."
    Dr. Stephen Baker, a Chairman of his prestigious hospital's radiology department, and an expert in utilization of imaging techniques feels the rent in his soul. "'The work I do to reduce utilization is at cross-purposes with the hospital.' On the one hand, he wants the young doctors in his department to learn how to use radiological images judiciously, so that an image adds to their ability to make sound judgments, to improve care for their patient, rather than detracting. He knows that if imaging machines were not so readily available, doctors would be less likely to use them so indiscriminately. On the other hand, as chief of radiology he must continually purchase new imaging machines to bolster the hospital's bottom line, knowing all the while that availability of newer, faster devices only encourages physicians to perform even more unnecessary t ests. 'There is a certain amount of cognitive and moral dissonance here,' he says. 'My success as a chair of the department of radiology depends on how many toys I can get for the department. So I have to win turf battles, and get more and more. That's what I do every day. Then I go home and think, 'What the hell am I doing?'" Sadly, "Testing has replaced thinking on the doctor's part and feeling cared for on the patient's. What's lost in the process, says Stephen Baker, is the personal relationship, the trusting interaction that once formed the basis for healing."
    If it is not bad enough that radiologist are performing all these tests, doctors in private practice have figured out the economics too. Non-radiologists (through private investment in imaging centers) are now accounting for about a quarter of all imaging procedures billed to Medicare. Of course, doctors who reap a financial benefit from imaging tend to order more images--about 8 times more than radiologists.

12. Drugs--the bad ones--the Prescription Drugs: Manufacturing pharmaceuticals is a business, not a profession. The drug company's obligations are to its shareholders for greater return on investment. Prevailing drug information is all Madison Avenue and no science. The pharmaceutical industries have killed the science by manipulating study design and sample size and by refusing to publish complete results. By paying physicians as consultants they are able to manipulate standard-setting bodies. The largely drug-company sponsored National Cholesterol Education Panel in 2001 redefined the criteria for who needs to be on a statin more than doubling the number of Americans deemed to 'need' a statin.
    Modern drug advertising directly to consumers, currently a major determinant of excessive and useless prescribing, started with two young Madison Avenue hotshots named Joe Davis and William Castagnoli in 1985. They had been hired by Merrell Dow to advertise its new antihistamine, a drug called Seldane. They very cleverly got around an FDA proscription of drug advertising without full disclosure of all relevant side effects. They simply didn't mention any drug name in their ads. The ads just called attention to the fact that a 'new drug for allergies is out.' The ad campaign was launched in 1988. The results were phenomenal. Any prior squeamishness about the propriety of going direct to consumers quickly vanished from the industry. TV network executives applauded the drug industry as a vast, untapped source of public information and ad revenue. In 1997, after years of litigation with the drug companies, the FDA finally caved in and allowed the companies to name their drugs with just the brief, annoying list of lethal effects that we've all come to accept during commercial interruptions.
    Of course, it doesn't stop there. The drug companies aggressively create diseases in order to deliver 'lifestyle' drugs to cure them--like erectile dysfunction, insomnia, social anxiety disorder, restless legs syndrome, etc. The ads are slick and sexy. As one physician puts it, "Calling what drug companies do 'advertising' is like calling D-day a bunch of guys wading in the surf." You could not possibly sell so many expensive insomnia drugs if you did have the drug-company supported National Sleep Foundation telling everyone that their restless nights were a serious disease. But we do, and it works.
    Drug companies aggressively market all their wonders that can prolong life so as to extend the mean duration of medication taking regardless of health status. To live long is to take more medicines. One geriatrician, Dr. James Goodwin, laments the tendency for physicians and patients to see the inevitable breakdown of the body as a series of treatable diseases.
"So little of what is done for old people seems aimed in any direct way at making the patient feel better. With medicalization, the role of physicians has become so expanded and technologized that we fail at our most important task-providing relief from suffering. Medical care of the elderly is particularly distorted by this new focus. Medicalization externalizes experience whereas the major tasks of aging are internal. Every clinician has witnessed the medicalized 80-year old obsessed with arthritis, Alzheimer's disease, and serum cholesterol levels. Contrast this patient with someone else in the same physical condition, who admits that her knees are bad and that she has trouble remembering things. Which patient is better off? Attention to some proto-illnesses arguably could benefit 80- and 90-year-olds: certainly osteoporosis, probably also high blood pressure. But 80-year-olds can ill afford the ceding of responsibility and loss of control inherent in medicalization. The challenges of very old age are spiritual, not medical. The appropriate role of the physician is as counselor or helper, not as scientific expert.
What's a doctor to do? When one doctor, Dr. John Abramson, a family practitioner in a small town forty-five minutes north of Boston, discovered that the data reported on Vioxx and Celebrex in the New England Journal of Medicine, thought to be one of the most trustworthy sources of medical information, authored by physicians with drug company sponsorship, was deliberately misleading with potentially fatal consequences for patients, he actually did something. His response to an inability to trust the leading medical journals was to close his practice and to research and write the book Overdo$ed America.
    Why does it go on? Because "individual physicians cannot imagine that their prescribing habits are being influenced by something as insignificant as a free meal. The academic can't see anything wrong with taking a speaking fee from a pharmaceutical company, as long as he already agrees with everything his corporate sponsor wants him to say." The mood is changing as more of the real information comes to light and the drug companies get caught in one scandal after another.

13. The HMO debacle: In 1970 there were only 33 HMOs in the entire country. "A little more than a decade later, with stagflation in full bloom and employers clamoring for relief from mounting health care costs, private insurers felt emboldened to exert some measure of control over physicians and hospitals. The old fee-for service way, they said, rewarded greedy doctors, who padded their incomes by giving patients unneeded tests and procedures and putting them in the hospital unnecessarily. Their version of HMOs, dubbed managed care, would impose discipline on medical providers...They would be paid to 'manage' their patients." In a system already overburdened with paperwork, it would increase and the costs would come out of physician incomes. What happened, as one doctor put it, "[We] were overwhelmed by a cartel of large insurance companies, all determined to find the level at which doctors and hospitals refused to work, and then to pay just over that." By 1990 HMO enrollment had leaped from 3 million in 1970 to over 36 million.
    "By keeping a tight lid on physicians' fees, managed care paradoxically drove costs up, largely because its executives failed to predict the obvious: The minute doctors sensed their incomes going down, they began to behave less like professionals and more like pieceworkers in a shirt factory" and completely alienated from the ownership of the healing mission. We now refer to this piecework professional culture as 'hamster medicine'; it has become a permanent feature of the professional landscape.

 

5. Kidder, T. Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World.  2003


    Tracy Kidder met Paul Farmer when Paul was 35. Farmer had graduated Harvard Medical School, also with a PhD in anthropology from Harvard. Worked in Boston 4 months of the year, living in a church rectory in a poor neighborhood, worked the rest of the year without pay in Haiti. Saw himself as a poor people’s doctor and an action kind of guy. About medicine, “I don=t know why everybody isn’t excited by it.”
    He claimed as his mentor, Rudolf Virchow, the principle architect of the foundations of scientific medicine--the first to propose that the basic units of biological life were self-reproducing cells, and that the study of disease should focus on changes in the cell. Virchow made important contributions in oncology and parasitology, coined at least fifty medical terms still in use today, defined the pathophysiology of trichinosis, led a successful campaign for compulsory meat inspection in Germany, designed a sewage system for Berlin that transformed it from a fetid sty into one of Europe’s healthiest cities, found a nursing school and hospitals, was a practicing archaeologist who played a role with Schliemann in discovering Troy, helped to define the field of medical anthropology, was a teacher, physician, and politician (so effective that Bismarck once challenged him to a duel). Most important to Farmer was Virchow’s emphasis on a fundamental law of epidemiology: “If disease is an expression of individual life under unfavorable conditions, then epidemics must be indicative of mass disturbances of mass life.” For this his prescription was “full and unlimited democracy.” Among other apt conclusions, Virchow had stated: “Medicine is a social science, and politics is nothing but medicine on a large scale…It is the curse of humanity that it learns to tolerate even the most horrible situations by habituation…Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community...Physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.”
    Tracy Kidder started out with the attitude, “The world is full of miserable places. One way of living comfortably is not to think about them or, when you do, to send money.”
    Haiti has the distinction of being Latin America’s first independent nation and the world’s first black republic. Haiti is the poorest country in the Western Hemisphere. Per capita incomes are about one America dollar a day. It has the worst health statistics in the Western world. 25% of Haitians die before they reach 40.
    Paul did his main work in Cange in central Haiti, which he first encountered in 1983, in a hospital that he built known as Zanmi Lasante (“Partners in Health”). Patients were supposed to pay user fees, about 80 cents per visit. As the policy was enforced, every patient had to pay the eighty cents, except for women and children, the destitute, and anyone who was seriously ill. And no one, Farmer ruled, could be turned away. A million peasant farmers relied on Zanmi Lasante. A hundred thousand lived in its catchment area, which was served by 70 community health workers. Seven doctors worked there. Zanmi Lasante had built schools and houses and communal sanitation and water systems throughout its catchment area. It had vaccinated all the children, and had greatly reduced both local malnutrition and infant mortality. It had launched programs for women’s literacy and for the prevention of AIDS; in its catchment area it had reduced the rate of HIV transmission from mothers to babies to 4%, about half the current rate in the US. In Haiti, tuberculosis still killed more adults than any other disease, but no one in Zanmi Lasante’s catchment area had died from it since 1988. The money came from a small public charity set up by Farmer called “Partners in Health” with headquarters in Boston. It cost about $150 to $200 to cure an uncomplicated case of TB (vs. about $15,000 to $20,000 in the US).
    Mr. Kidder noted that his local hospital in Massachusetts was treating about 175,000 patients a year and had an annual operating budget of $60 million. In 1999 Zanmi Lasante treated roughly the same number of people for about $1.5 million.
Farmer’s lifestyle involved about 4 hours of sleep a night, no investment portfolio (his paycheck went straight to PIH), no family around, no electricity, no hot water, and lots of unsavory food, what he called “the fifth food group.” Of his work he says, “I feel ambivalent abut selling my services in a world where some can’t buy them. You can feel ambivalent about that, because you should feel ambivalent. Comma.” [“Comma” is a Farmerism that is short for “asshole.”]

    Dr. Farmer speaks of “WLs”—White liberals. “I love WLs, love ‘em to death. They’re on our side. But WLs think all the world’s problems can be fixed without any cost to themselves. We don’t believe that. There’s a lot to be said for sacrifice, remorse, even pity. It’s what separates us from roaches.”
    When he first came to Cange he started his work with a simple needs assessment. He enlisted five Haitians and went from hut to hut through Cange and two neighboring villages tallying up the numbers of families, recent births and deaths, and the apparent causes of morbidity and mortality. He then planned the first line of defense--vaccination programs, protected water supplies and sanitation--and at the heart of the defenses, a cadre of people from the villages trained to administer medicines and give classes on health, to treat minor ailments and recognize the symptoms of grave ones like TB, malaria, typhoid. Then he planned a project for women’s gynecological services, health education, and family planning to reduce local maternal mortality, which led to so many subsequent health and economic disasters in families. The second line of defense was the hospital.
As he undertook the treatment of TB and noted his initially poor results, he designed a study. During the study, each group of TB patients got free treatment, but one group got other services as well, including regular visits from community health workers and small monthly cash stipends for food and child care and transportation to Cange. Of the patients who received only free medicine, a mere 48% were cured. By contrast, everyone in the group that received the cash stipends ($5 per month) and other services made a full recovery. Whether a patient believed that TB came from germs or voodoo made no difference. This study became for him a command to worry more about his patients’ material circumstances than about their beliefs. No patient has died of TB at Zanmi Lasante in 12 years.
    As a footnote, Kidder notes that one of the major causes of the poverty in Cange and Zanmi Lasante was the Peligre Dam in the Lac de Peligre. This project was planned by the US Army Corps of Engineers and built by corporations in the mid-1950s during the reign of one of Haiti’s American-supported dictators with money from the US Export-Import Bank. It was advertised as “a development project.” Under the rubric of improved irrigation and power generation land was taken from peasants (now under water) without compensation while agribusinesses downstream, mostly American-owned back then, benefited. The wealthy in Port-au-Prince received electricity. The peasants received neither irrigation nor electricity.
When asked, “How can you expect others to replicate what you’re doing here?”, he responds, “Fuck you.” Then adds, “The objective is to inculcate in the doctors and nurses the spirit to dedicate themselves to the patients, and especially to having an outcome-oriented view of TB...In other words, ‘Fuck you.’...Do you know what ‘appropriate technology’ means? It means good things for rich people and shit for the poor.”
Farmer got a break o make his vision come into being. He found a like-minded, retired Bostonian, who had run a construction company and done well, and who now wanted to see his money used for work like this.
AIDS came to Cange about two years after Farmer arrived in 1985. One of the things that Farmer is incensed about was the action of the CDC in formally classifying Haitian origin as a risk factor for AIDS. When Farmer did his own research, which he later published, he found that, in fact, AIDS came to Haiti from the US via tourists who mingled with prostitutes in Port Au Prince.

    At the end of the 20th century TB was still killing about 2 million people a yea--more adults than any other infectious disease except for AIDS; TB shared a ‘noxious synergy’ with AIDS. In poor countries, TB was the most common proximate cause of death among people who died with AIDS. About 2 billion people on earth, one-third of all humanity, have TB bacilli in their bodies. It turns into clinical illness in about 10% of those infected. Each year about 2 million people die from TB. The new standard of treatment for TB in the developing world was with standard first-line drugs in a program of directly observed treatment (DOTS). The new problem in TB control and in Haiti was multi-drug resistant TB (MDR). About 750,000 people around the world now have this disease.
    Unfortunately, the official WHO DOTS manual contained the following statement: “In settings of resource constraint, it is necessary for rational resource allocation to prioritize TB treatment categories according to the cost-effectiveness of treatment of each category...In developing countries, people with multi-drug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries.” This was unacceptable to Farmer. He noted with some annoyance that when there was an outbreak of multi-drug resistant TB in New York City in the late 1980s, centered in prisons, homeless shelters, and public hospitals, no one took this attitude. About a billion dollars were spent and effectively ended the outbreak. In 1993, at the best US center for this disease, National Jewish in Denver, only about 60% of cases could be cured and at a cost of up to $250,000 per case. There seemed no solution to the cost problem. Farmer recruited some allies and went on the international lecture circuit giving speeches citing and rebutting WHO policy. WHO stated that “MDR-TB is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease.” To which he responded, “But is treating MDR-TB really too expensive? Even if TB control is to be governed by considerations of cost-effectiveness, it s should be easy to show that failure to diagnose and treat MDR-TB is what is really costly. Consider the case of the family in Texas in which one member had exposed nine others to MDR. Care for these ten persons alone exceeded one million dollars.”
    “Myth number two: Some people think DOTS alone will stop outbreaks of MDR. This is nonsense. What will happen if programs treat drug-susceptible TB successfully and let MDR flourish? Transmission of MDR will continue, and even where MDR cases are now a tiny percentage of all TB cases, their relative importance will grow. Moreover, DOTS will amplify already existing drug resistance. In short, failure looms for programs now deemed success stories.” His audience often responded to his talk as “provocative,” to which he responds: “What’s provocative. I just said we should treat sick people, if we have the technology...I remember signing an oath to assist the patient and do him no harm. I don’t really remember signing that I would do it in a cost-effective way. The only time that I hear talk of shrinking resources among people like us, among academics, is when we talk about things that have to do with poor people...Strictly speaking, all resources everywhere are limited, but they’re less limited now than ever before in human history. Making a distinction between prevention and treatment is artificial--merely an excuse for inaction.”
As Margaret Mead has stated, “Never underestimate the ability of a small group of committed individuals to change the world. Indeed, they are the only ones who ever have.” Farmer and friends found a way out of the cost dilemma. They analyzed the structural pieces of the problem. The price of a drug has little to do with either its usefulness or the costs of manufacturing it. Often, the price is high simply because only one company makes it. In the case of second-line drugs used in the treatment of MDR-TB, huge amounts of drugs are required because treatment lasts so long. Most candidates for treatment, however, have no money. Thus there is no incentive for drug companies to manufacture quantities of the drugs at “reasonable” prices. Capreomycin is one of these second-line drugs; it is manufactured exclusively by Eli Lilly. Eli Lilly was selling it for $21 a vial in Peru; the same vial in Boston, where Farmer got his supply, cost $29.90. Farmer found out that the drug cost only $8.80 in Paris, and he tried to buy some there. He was told he couldn’t. “There’s a global shortage of capreo due to an emergency in Peru.” Then Farmer encountered someone named Guido Bakker, a Dutchman in his twenties, who worked for a nonprofit company, the International Dispensary Association, IDA. It specialized in driving down the prices of essential drugs, the kinds of drugs that poor countries need most urgently. IDA tended to deal only with generic drug manufacturers. IDA got the MDR-TB drug scarcity problem some relief by teaming with Doctors Without Borders to sponsor generic production. The solution to the problem got a further boost when, after intense political lobbying, they got the WHO to add second-line TB drugs to its list of ‘essential medicines’. This acted as a major inducement to generic manufacturers to get involved. Oddly, various eminent TB experts wrote to the WHO saying that they ‘couldn’t countenance’ the elevation of second-line antibiotics to the essential drugs list. Increased generic supply gradually reduced the cost of these drugs. By the year 2000, projects working with MDR TB paid 95% less for four of the second-line drugs than they would have in 1996, and 84% less for two others. The drugs to treat a 4-drug resistant case of MDR now cost Partners in Health/ Zanmi Lasante about $1500 instead of $15,000.

    Then there is the Cuban example. Cuba has life expectancies about the same as in the US. It has achieved control over diseases still raging in Haiti only 90 miles away. By American standards Cuban doctors lack equipment, and even by Cuban standards they are poorly paid. They are, however, well-trained, and Cuba has more of them per capita than any other country in the world--more than twice as many as the US. Everyone has access to service and even to procedures like open heart surgery. According to a study by WHO, Cuba has the world’s most equitably distributed medicine. Cuba was now in the position of exporting doctors to other needy countries. Cuba also has the lowest per capita incidence of HIV in the Western Hemisphere, and it has the most accurate HIV statistics in the world. (Testing is mandatory.) On an island of 11 million, only 2,669 tested positive as of 2000; the virus progressed to AIDS in 1,003 of these, and 653 died. Only 5 children caught HIV from their mothers, and all of those children were still alive. Because Cuba had acted quickly to clean up its blood supply, only 10 people had contracted HIV from transfusions. Yet Cuba is not a particularly rich country.
    The book concludes with a dramatic story of a boy named John. John’s official age was unrecorded, but he appeared to be about eleven or twelve. He had swellings in his neck, but they were harder than the usually fluctuant swellings of scrofula. Dr. Farmer was concerned about cancer. A PIH physician found an oncologist in Mass General who was willing to make the diagnosis for free, if they could get the tissue there. This required a biopsy that Farmer did not feel comfortable doing. A competent Haitian surgeon was willing to do the biopsy for a thousand dollars. Time for the specimen to travel to MGH resulted in a diagnosis of cancer four days later. It was nasopharyngeal carcinoma, which, if caught early, could be cured in 60-70%. It was decided that it was only practical to stage the disease and administer chemotherapy in Boston. It took a month to negotiate with MGH to do the treatment for free. John was much worse by this time. Now his legs and arms were emaciated; you could see all the bones. He had been given a tracheotomy, required regular suctioning, and was in constant pain from the masses in his neck. It was very difficult to look right at him. In fact, he was too sick to be transported by commercial airline. It was determined that a private flight would cost about $20,000. The question was, Could/should PIH/ Zanmi Lasante use their resources in this way for this patient? When this decision had to be made Farmer was on an international trip and could only be reached by e-mail. Two of his young PIH doctors had to decide what to do and whether to act without his direct involvement. The first e-mail that was sent was:
    “John’s condition is growing more tenuous. He is curious, sweet as can be, interactive with us and they would not have let him on the plane. And yet weak, weak, weak, and I fear would not survive the trip to the airport and they would not have let him on the plane. Polo [Farmer], I know this sounds crazy but he still has his fighting chance. This could still be a localized tumor with abscess tipping him over and increased mass size. I will take responsibility to pay for this flight. We are proceeding with plan while we wait to hear from you.”
    The initial response was, “Serena, honey, please consider other possibilities.”
    This was interpreted as a ‘no.’ Usually Dr. Farmer would say something like, “I trust you. Go ahead.”
Other staffers were injecting comments like, “What are we going to do if another kid like this comes to us?”
    “I'm looking at only one child, The fact that he has free care at the other end makes it excruciating,” Serena said.
    A staffer got on the computer and wrote Dr. Farmer, “You have to say yes or no.”
    The reply came, “Well, it could be worse. I’ll be there within twenty-four hours, but would not try to second-guess all of you there. Getting him on a plane is the only way to save his life, so I’m for it. In any case, his hope is in leaving Haiti, by one way or another, like many other Haitians, alas.”
John made it to MGH, but only to have the initial scans show invasion of bone and metastases through out his body. He is made comfortable, spends some hospice time with his mother in the home of a PIH staffer in Boston, and died in a few weeks.
    In reaction to observing all this, Mr. Kidder feels a need to ask Farmer, only after a decent interval, what were his thoughts on this whole case. Finally, on another 11 hour hike for a house-call, he does. “What about the case of John? What about the twenty thousand dollars that PIH spent on the medevac flight to get him out of Haiti? Not long after John died, a PIH staffer, a relatively new one, said to me that she couldn’t help thinking of all the things they could have done with that twenty thousand dollars. What is your response to that?”
Dr. Farmer responds:
    “Let me say a couple of things about this particular case, if you like. One is, remember of course that John was referred to Boston as dying of a treatable tumor, a very rare tumor. He wasn’t referred to Mass General before we knew what he had. So when he was referred, it was for free care because ha had such a rare thing and it was treatable, and the predicted cure rate was sixty to seventy percent. All right. Good enough. That was what the decision was made on. And there as no way for us to find out that John didn’t have locally invasive disease without metastases, because it required a diagnostic test that we can=t do here. So the other thing is, the bottom line is, why do we intervene as aggressively as we can with that kid and not with another? Because his mother brought him to us and that’s where he was, in out clinic...

    “I have to tell you, though, I’m a little troubled by these comments from the new PIH-er. Because I have to work with these people. The last thing I want to do is expend my energy trying to convince my own co-workers. Now I have to, of course. But I don=t like it.”
Kidder tries to apologize for the staffer, “Your PIH-er wasn’t saying you shouldn’t have brought John to Boston. Only that it was a shame you had to spend so much, given what else you could do with twenty grand.”
    “Yeah, but there are so many ways of saying that,” Farmer replies. “For example, why didn’t the airplane company that makes money, the mercenaries, why didn’t they pay for his flight? That’s a way of saying it. Or how about this way? How about if I say, I have fought for my whole life a long defeat. How about that? How about if I said, That’s all it adds up to is defeat? A long defeat.
“I have fought the long defeat and brought other people on to fight the long defeat, and I’m not going to stop because we keep losing. Now I actually think sometimes we may win. I don’t dislike victory.
    “You know, people form our background--like you, like most PIH-ers, like me. We’re used to being on a victory team, and actually what we’re really trying to do in PIH is to make common cause with the losers. Those are two very different things. We want to be on the winning team, but at the risk of turning our backs on the losers, no, it’s not worth it. So you fight the long defeat.
    “And most of the time when people ask about triage, most of the time they’re asking not with open hostility but deep distrust of our answer. They already have the answer. And that of course is the energy-draining process, because you understand that a substantial proportion of the questions are asked in a, you know, in a very, what’s the word?”
    “With an animus?” Kidder suggests.
    “Yeah.” Farmer is silent for a moment.
    “The salary of a first-world doctor. How about that? Talk about all the money that could have been spent on other things, what about a doctor’s salary?
    “Well, of course. See, the truly humble think of that before they say the other. I’m not truly humble. I’m trying to be humble. So let me ask you another question. What is it that makes people not think that? Why doesn’t a young American doctor say, ‘Gee, my salary is five times what John’s airplane ride cost. And I’m twenty-nine or thirty-some years old.’ If you say that stuff out loud, you sound like an asshole. Whereas if you say the other stuff, you just sound thoughtful. Now what’s wrong with that? What’s wrong with this picture? If you say, ‘Well, I just think how much could have been done with twenty thousand dollars, you sound thoughtful, sensible, you know, reasonable, rational, someone you really want on your side. However, if you were to point out, But a young attending physician makes one hundred thousand dollars, not twenty, and that’s five times what it cost to try to save a boy’s life.’ “That just makes you sound like an asshole. Same world, same numbers, same figures, same currency. It’s just, you know, I never have been able to figure it out. I mean, I’ve figured it out, but I realize now it takes so much time to get to that point, to explain it, without offending someone. I have to limit the amount of time I put into explaining all that or it just sucks your soul dry. “
    This conversation then leads to the last rumination of the book as they complete the seven hour house-call trek. Kidder ponders that some would say that this is what is wrong with the Farmer approach. “Here’s an influential anthropologist, medical diplomat, public health administration, epidemiologist, who has helped to bring new resolve and hope to some of the world’s most dreadful problems, and he’s just spent seven hours making house calls. How many desperate families live in Haiti? He’s made this trip to visit two. All the serious, sympathetic critiques of Farmer’s work comes down to these two arguments: Hiking into the hills to see just one patient or two is a dumb way for Farmer to spend his time, and even if it weren’t, not many other people will follow his example, not enough to make much difference in the world.” To this he imagines Farmer’s response as something like this: “If you say that seven hours is too long to walk for two families of patients, you’re saying that their lives matter less than some others, and the idea that some lives matter less is the root of all that=s wrong with the world.”
    Farmer’s creed has been expressed as, “Patients come first, prisoners second, and students third; that doesn’t leave out much of humanity. He doctors first of all because he believes it is the right thing to do. If you do the right thing well, you avoid futility. Doctoring is the ultimate source of his power. Every sick person is a potential patient, and every healthy person is a potential student. He is fighting poverty all the time, in a long defeat. For him the reward is inward clarity, and the price perpetual anger or, at best, discomfort with the world. Paul Farmer was not put on earth to make anyone feel comfortable, except for those lucky enough to be his patients. He does not want his hospital to be some laboratory for the world. It should be enough just to serve the poor.”
As Kidder leaves Haiti on the long, muddy, unpaved road from Cange to the airport, they get, at one point, stuck behind a slow-moving cart with a sticker on it that in Creole says, “Lord, a word on all this.”
    In an afterword, Kidder notes that Cange / Zanmi Lasante saw its first open-heart surgeries, performed by teams from the Brigham and South Carolina. He feels tempted then to ask Farmer if this was ‘appropriate technology’? He wants, not to hear the answer, but just to hear Farmer say it.
 


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