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.