.
This guest column is by Seiji Yamada, MD, a family physician, Associate Professor of Complementary and Alternative Medicine at the University of Hawai’i John A. Burns School of Medicine, and one of my mentors. This essay is an expansion of the one that was published in the AAMC journal Academic Medicine, chosen as one of the five best responses to the question put forth by editor Steven Kanter “How can academic medicine respond to peace-building efforts worldwide?”. Dr. Yamada’s original essay, “Academic medicine should start at home”, is at http://journals.lww.com/academicmedicine/Fulltext/2009/11000/Academic_Medicine_Should_Start_at_Home.18.aspx
Health Workers and Our Wars
What is the responsibility of American health workers with regard to our nation’s wars in Iraq, Afghanistan, and Pakistan? As Americans, our primary responsibility should be to influence the actions of our own government. As health workers, our expertise is in the realm of morbidity and mortality, encompassing the direct effects of violence as well as the indirect effects arising from the collapse of health services, poor access to water and food, and damage to infrastructure, economies, and societies. Thus, we should monitor our government’s actions, apply the scientific methods at our disposal, apply the moral and ethical principles to which we subscribe, formulate and recommend policy, and disseminate our findings to the people. In a democracy, the citizenry would then determine the course of action.
During this decade, our nation has been responsible for invading and occupying two countries halfway around the globe—Afghanistan since 2001 and Iraq since 2003. In the case of Iraq, the invasion of 2003 was preceded by comprehensive economic sanctions, which hampered the rebuilding of its infrastructure after the Gulf War of 1991. The consequences included childhood deaths, mental illness, juvenile delinquency, begging and prostitution, as well as cultural and scientific impoverishment.[1]
In 2002-03, the American people were not convinced by the Bush administration that war on Iraq was justified. However, despite massive demonstrations against the war prior to its launch, the intellectual classes, the corporate media, and our elected representatives went along with the administration. Democracy failed us in this respect. Prior to the war, we health workers should have been recounting the health toll of the First Gulf War and the sanctions regime. With its onset, we should have been disseminating the images and recounting the narratives of casualties of the war.[2] As it progressed, we should have been acutely interested in the number of casualties caused by the war. The best estimates for deaths among Iraqis are those of the July 2006 epidemiological survey that reported 655,000 deaths as a consequence of war.[3] This study did not distinguish among civilians, military, and irregular combatants. While its authors have been criticized for breaches in the non-identification of participants, the study is nevertheless considered the most accurate estimate.[4]
Insofar as we have failed to pay attention to such findings, American health workers have failed its constituents.
At the mention of history or political economy, many health workers groan. We are not interested in politics, they say. But unreflective citizens repeat the blather that they are fed by the corporate media. We need advocate for the cause of health—in particular for the health of those whose voices are otherwise unheard, whose deaths are otherwise uncounted, unmourned, unopposed, and unorganized against. In order to do so, our analysis must be geographically broad and historically deep, as Paul Farmer urges us.
As the United States pulls its troops out of Iraq and sends them to Afghanistan, as our military wields drones called Predator and Reaper in Pakistan, we should concern ourselves with whether the cause of peace is thereby served by such acts. Our commander-in-chief is apparently now reflecting upon whether to double down (again) in Afghanistan and pursue counterinsurgency, as urged upon him by his general in the theater.[5]
Apparently, “counterinsurgency” no longer connotes Vietnam or Central America.[6] But the “clear and hold” strategy utilized late in the Vietnam War was characterized by indiscriminate shelling and bombing of villages[7] and ran concurrently with the Phoenix program of torture and assassination.[8] Extrajudicial killings in the Federally Administered Tribal Areas of Pakistan are now being carried out by the CIA by missile attacks by drones, with the deaths of many innocents.[9] Of 701 people killed in 60 attacks in FATA between January 2008 and April 2009, fourteen were suspected militants.[10]
The British and the Soviets failed in their attempts to militarily control Afghanistan, while inflicting untold casualties on the populace. The Soviet Union’s invasion of Afghanistan proved to be its Vietnam. One would think that our own country would not repeat its mistakes in Vietnam, but our wars in Iraq and Afghanistan’s go on. As American health workers, we must concern ourselves with the morbidity and mortality caused by our own government’s actions. Let us get to work.
References
[1] Save the Children UK. Iraq sanctions: humanitarian implications and options for the future. Available at: (http://www.globalpolicy.org/component/content/article/170/41947.html). Accessed July 21, 2009
[2] Yamada S, Fawzi MC, Maskarinec GG, Farmer PE. Casualties: narrative and images of the war on Iraq. Int J Health Serv. 2006; 36(2):401-15
[3] Burnham G, Lafta R, Doocey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet 2006; 368: 1421–28.
[4] Tapp C, Burkle FM, Wilson K, et al. Iraq War mortality estimates. Conflict & Health 2008;2:1-13.
[5] Filkins D. Stanley McChrystal’s long war. New York Times Magazine, Oct 18, 2009.
[6] Parry R. Bush’s death squads. In These Times, Jan 17, 2005. Available at (http://www.inthesetimes.com/site/main/article/1872/). Accessed Jan 23, 2005.
[7] Steinglass M. Vietnam and victory. Boston Globe, Dec 18, 2005. Available at (http://www.boston.com/news/globe/ideas/articles/2005/12/18/vietnam_and_victory/). Accessed Sep 27, 2009.
[8] Chomsky N, Herman ES. The Washington connection and third world fascism. Boston, MA: South End Press, 1979.
[9] Mayer J. The predator war. New Yorker, Oct 26, 2009. Available at (http://www.newyorker.com/reporting/2009/10/26/091026fa_fact_mayer). Accessed Nov 15, 2009.
[10] Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. Available at (http://mondediplo.com/2009/11/02pakistan). Accessed Nov 5, 2009.
Sunday, November 22, 2009
Tuesday, November 17, 2009
Primary Care’s Image: A Problem?
.
Pauline Chen, a transplant surgeon and respected author of “Final Exam: A surgeon’s reflections on mortality” (Vintage Books) also write a “Doctor and Patient” column for the New York Times. On November 12, 2009, the topic was “Primary Care’s Image Problem”, in which she talks about the decreasing interest in primary care among medical students, and the perception among many, increased by many faculty members, that primary care was a backup to more “prestigious subspecialties…like dermatology, orthopedics, plastic surgery or radiology.” In particular, she talks of Kerry, one of her classmates, who wanted to (and did) enter primary care “despite” being at the top of her class, and how this amazed her friends. Dr. Chen addresses the attractions of the “ROAD” (radiology, ophthalmology, anesthesiology, and dermatology) to financial success as well as greater prestige, and the challenges it presents for having an adequate supply of primary care physicians.
While scarcely optimistic (“But even with current legislative efforts to address educational debt, payment discrepancies and lifestyle differences, many medical educators worry that the results will not be enough….Why? It is due to an issue deeper than money and paperwork. While the frisson of continually advancing treatments and approaches to patient care seem to envelope most other specialties, the image of primary care remains one of a vaguely anachronistic practice — a group of doctors who do not stand on the forefront of creative change and who are continually left holding the biggest bag of administrative expectations and clinical care coordination and demands.”), she also notes that “That image, however, may be changing”.
Dr. Chen attended a meeting of the Association of Deans and Directors for Primary Care, held in conjunction with the annual meeting of the Association of American Medical Colleges (AAMC) in Boston on November 9, 2009, where the discussion focused largely on changes in the type of practice, particularly in the creation of a “medical home” and a team approach to care. She quotes organization chair Bruce Gould, MD, of the University of Connecticut: “In a patient-centered medical home, I would not be the sole proprietor. Sometimes I would be the leader because of my specific skill set. But if we were dealing with adherence to diabetes care, the team’s social worker might be the leader….With a team approach each of us is freed up to practice at the top of our scope of training. And that leads to better patient outcomes and more job satisfaction.”
I admit that I found it somewhat frustrating, having been in the room, that the 3 physicians Dr. Chen quotes are all general internists, despite the fact that at least half the participants in the meeting and 2 of the 5 speakers were family doctors. I agree with the general theme expressed by many that it is important for primary care doctors to work together and not fight, but there are important differences in these specialties. In addition to the fact that family doctors care for adults and children and often pregnant women, the breadth of their practice makes them more suitable for rural practice, where there may be only a few doctors. While most family doctors do not practice in rural areas, about 20% do, which is comparable to the percent of the overall population; indeed, family medicine is the only specialty that “distributes” according to where people live.
More important for this discussion is that virtually all family physicians practice primary care, thus it is the primary care “bellwether”, going up more when student interest in primary care is up, and down more when it is down. Internal medicine, on the other hand, offers those who complete its 3-year residency the option of entering primary care / general internal medicine practice (or hospitalist practice, which is not primary care) or continuing into a subspecialty fellowship (cardiology, gastroenterology, pulmonary medicine, etc.); it is thus less sensitive to these ups and downs. As I have discussed previously (most recently in “Rankings of medical schools: do they tell us anything?” on September 25, 2009), the trend for general internal medicine is definitely down. General pediatrics, the third primary care specialty, has not seen a decrease, although the distribution and career trajectories are an issue, as I have discussed in “Primary care, pediatrics, and physician distribution” on May 21, 2009. Indeed, facing a shortage of pediatric subspecialists, many pediatrics groups are trying to encourage subspecialization.
Dr. Chen’s article ended with some guarded optimism, and an invitation to join the discussion on Tara Parker-Pope’s “Well blog”, “Giving primary care more respect”. With 180 responses (by November 16), it is clear that there are a lot of opinions out there, from physicians, medical students, other health professionals, and the general public. I admit to adding my comments, and “plugging” my October 8, 2009 blog piece “`Uncomplicated’ Primary Care?”, where I argue that primary care is anything but uncomplicated.
I thought that some comments on this from medical students on this issue might be welcome. The following comments are from students who spent 6 weeks with rural family physicians in Kansas between their first and second years of medical school, from quotes they gave to a reporter from the Kansas Family Physician, publication of the Kansas Academy of Family Physicians:
“This summer, I learned that people don’t choose family medicine because they want an easy profession. They choose it because they want to be life-long learners and truly want to help the community. Their knowledge base and diagnostic ability is no less than any specialist. The only difference they think ‘big picture’, and don’t focus on any one organ system.”
“A young man in his mid-30s came into the clinic. He was a partial quadriplegic of 15 years from a car accident. He was not there complaining of any acute symptoms or any problems; he was just there because he wanted to find a new doctor…Out of curiosity, I asked him what he was looking for in a physician. His only reply was: ‘I want someone who cares about me, not for me.’”
“I could not help but be impressed with the enormity of information family physicians are expected to ideally know. We are talking about working with every organ system of the body and also understanding the procedures and diagnostic tests that go along with these systems.”
“I learned family medicine is not simply caring for patients with chronic health issues or diagnosing and treating the common cold. While family physicians do both of those things almost every day, they also provide a variety of other care. They can deliver babies, provide women’s health, perform EGDs and colonoscopies, manage chronic pain, and diagnose extraordinarily well in the acute setting, just to list a small amount of what they do weekly.”
“Nothing compared to the feeling I got watching a family physician take care of the mother during delivery, perform an emergency C-section, and then treat the infant all within the same day. The ability of a family doctor to care for both mother and child simultaneously made me truly appreciate the rich complexity of family medicine.”
“A family physician should be held in the highest regard among physicians, for he or she must have the patience of a geriatrician, the gentleness of a pediatrician, the courage of an ER physician, the steady hand of a surgeon, and a knowledge base of every medical specialty.”
There are more, and many of them – which maybe I’ll post later – specifically talk to the role of the rural family doctor. Remember, these are not a random sample of students; they elected to do this experience. Many of them are from rural backgrounds and many are also planning careers in family medicine. All of them, having just finished their first year of medical school, have a long way to go before deciding on their specialty, and undoubtedly some will take some variant of the “ROAD”. We know from recent research that empathy takes a nose dive in the third year of medical school (“Are we training physicians to be empathic? Apparently not”, Sept 12, 2009).
However, it is great to hear these attitudes and know that at least among some students family medicine and primary care do not have an “image problem.” We can only hope that it persists in them, and in their peers. Hope, and do everything we can to foster it.
.
Pauline Chen, a transplant surgeon and respected author of “Final Exam: A surgeon’s reflections on mortality” (Vintage Books) also write a “Doctor and Patient” column for the New York Times. On November 12, 2009, the topic was “Primary Care’s Image Problem”, in which she talks about the decreasing interest in primary care among medical students, and the perception among many, increased by many faculty members, that primary care was a backup to more “prestigious subspecialties…like dermatology, orthopedics, plastic surgery or radiology.” In particular, she talks of Kerry, one of her classmates, who wanted to (and did) enter primary care “despite” being at the top of her class, and how this amazed her friends. Dr. Chen addresses the attractions of the “ROAD” (radiology, ophthalmology, anesthesiology, and dermatology) to financial success as well as greater prestige, and the challenges it presents for having an adequate supply of primary care physicians.
While scarcely optimistic (“But even with current legislative efforts to address educational debt, payment discrepancies and lifestyle differences, many medical educators worry that the results will not be enough….Why? It is due to an issue deeper than money and paperwork. While the frisson of continually advancing treatments and approaches to patient care seem to envelope most other specialties, the image of primary care remains one of a vaguely anachronistic practice — a group of doctors who do not stand on the forefront of creative change and who are continually left holding the biggest bag of administrative expectations and clinical care coordination and demands.”), she also notes that “That image, however, may be changing”.
Dr. Chen attended a meeting of the Association of Deans and Directors for Primary Care, held in conjunction with the annual meeting of the Association of American Medical Colleges (AAMC) in Boston on November 9, 2009, where the discussion focused largely on changes in the type of practice, particularly in the creation of a “medical home” and a team approach to care. She quotes organization chair Bruce Gould, MD, of the University of Connecticut: “In a patient-centered medical home, I would not be the sole proprietor. Sometimes I would be the leader because of my specific skill set. But if we were dealing with adherence to diabetes care, the team’s social worker might be the leader….With a team approach each of us is freed up to practice at the top of our scope of training. And that leads to better patient outcomes and more job satisfaction.”
I admit that I found it somewhat frustrating, having been in the room, that the 3 physicians Dr. Chen quotes are all general internists, despite the fact that at least half the participants in the meeting and 2 of the 5 speakers were family doctors. I agree with the general theme expressed by many that it is important for primary care doctors to work together and not fight, but there are important differences in these specialties. In addition to the fact that family doctors care for adults and children and often pregnant women, the breadth of their practice makes them more suitable for rural practice, where there may be only a few doctors. While most family doctors do not practice in rural areas, about 20% do, which is comparable to the percent of the overall population; indeed, family medicine is the only specialty that “distributes” according to where people live.
More important for this discussion is that virtually all family physicians practice primary care, thus it is the primary care “bellwether”, going up more when student interest in primary care is up, and down more when it is down. Internal medicine, on the other hand, offers those who complete its 3-year residency the option of entering primary care / general internal medicine practice (or hospitalist practice, which is not primary care) or continuing into a subspecialty fellowship (cardiology, gastroenterology, pulmonary medicine, etc.); it is thus less sensitive to these ups and downs. As I have discussed previously (most recently in “Rankings of medical schools: do they tell us anything?” on September 25, 2009), the trend for general internal medicine is definitely down. General pediatrics, the third primary care specialty, has not seen a decrease, although the distribution and career trajectories are an issue, as I have discussed in “Primary care, pediatrics, and physician distribution” on May 21, 2009. Indeed, facing a shortage of pediatric subspecialists, many pediatrics groups are trying to encourage subspecialization.
Dr. Chen’s article ended with some guarded optimism, and an invitation to join the discussion on Tara Parker-Pope’s “Well blog”, “Giving primary care more respect”. With 180 responses (by November 16), it is clear that there are a lot of opinions out there, from physicians, medical students, other health professionals, and the general public. I admit to adding my comments, and “plugging” my October 8, 2009 blog piece “`Uncomplicated’ Primary Care?”, where I argue that primary care is anything but uncomplicated.
I thought that some comments on this from medical students on this issue might be welcome. The following comments are from students who spent 6 weeks with rural family physicians in Kansas between their first and second years of medical school, from quotes they gave to a reporter from the Kansas Family Physician, publication of the Kansas Academy of Family Physicians:
“This summer, I learned that people don’t choose family medicine because they want an easy profession. They choose it because they want to be life-long learners and truly want to help the community. Their knowledge base and diagnostic ability is no less than any specialist. The only difference they think ‘big picture’, and don’t focus on any one organ system.”
“A young man in his mid-30s came into the clinic. He was a partial quadriplegic of 15 years from a car accident. He was not there complaining of any acute symptoms or any problems; he was just there because he wanted to find a new doctor…Out of curiosity, I asked him what he was looking for in a physician. His only reply was: ‘I want someone who cares about me, not for me.’”
“I could not help but be impressed with the enormity of information family physicians are expected to ideally know. We are talking about working with every organ system of the body and also understanding the procedures and diagnostic tests that go along with these systems.”
“I learned family medicine is not simply caring for patients with chronic health issues or diagnosing and treating the common cold. While family physicians do both of those things almost every day, they also provide a variety of other care. They can deliver babies, provide women’s health, perform EGDs and colonoscopies, manage chronic pain, and diagnose extraordinarily well in the acute setting, just to list a small amount of what they do weekly.”
“Nothing compared to the feeling I got watching a family physician take care of the mother during delivery, perform an emergency C-section, and then treat the infant all within the same day. The ability of a family doctor to care for both mother and child simultaneously made me truly appreciate the rich complexity of family medicine.”
“A family physician should be held in the highest regard among physicians, for he or she must have the patience of a geriatrician, the gentleness of a pediatrician, the courage of an ER physician, the steady hand of a surgeon, and a knowledge base of every medical specialty.”
There are more, and many of them – which maybe I’ll post later – specifically talk to the role of the rural family doctor. Remember, these are not a random sample of students; they elected to do this experience. Many of them are from rural backgrounds and many are also planning careers in family medicine. All of them, having just finished their first year of medical school, have a long way to go before deciding on their specialty, and undoubtedly some will take some variant of the “ROAD”. We know from recent research that empathy takes a nose dive in the third year of medical school (“Are we training physicians to be empathic? Apparently not”, Sept 12, 2009).
However, it is great to hear these attitudes and know that at least among some students family medicine and primary care do not have an “image problem.” We can only hope that it persists in them, and in their peers. Hope, and do everything we can to foster it.
.
Thursday, November 12, 2009
HR 3962 is still a bad bill, and Stupak-Pitts is a scandal
.
After the House of Representatives passed HR 3962 recently, I celebrated the defeat of the opponents of health reform. I tried to make it clear, and I will emphasize here below, that the bill is not only far from perfect, it is bad. I just think it would have been worse, a victory for those who wish to keep the status quo (for example, virtually all the Republicans). To my knowledge, Ohio congressman Dennis Kucinich is the only representative who voted against it from a progressive perspective, and I applaud him for that.
I was at a conference recently at which former Senator Tom Daschle spoke. He invited us to envision a huge stadium with the 300,000,000 Americans in it, and the President at the center asking “what should we do about health reform?”, and the huge multiplicity of opinions that would come. He then suggested that the Congress, with its 535 representatives and senators, was a microcosm of those people, expressing all their multiple beliefs. Well, maybe the multiple beliefs, but not in the same proportion. I feel quite certain that, while there would have been a lot of opponents, the 300,000,000 Americans would have been a lot more supportive of health reform, much more meaningful health reform, than the 535 representatives. This is because they don’t get huge contributions from lobbyists from the insurance industry, pharmaceutical industry, hospital industry, and other big corporations, as well as doctors and lawyers and other rich people. Congress does, and it definitely affects their way of seeing things.
HR 3962 is a bad bill that will finance insurance companies, not save money, and not cover all people. I think, I know, we can do better than that. A single-payer plan, for example, such as that proposed in the Medicare for All bill sponsored by Rep. John Conyers (D, MI), and almost voted on by the house in an amendment by Rep. Anthony Weiner (D, NY) to include single payer. This is actually quite a victory, that it came so close, given the efforts of both the Administration and the Congressional leadership to keep it “off the table” from the beginning of this debate. We can hope that, at least, the amendment sponsored by Rep. Kucinich permitting states to pilot single-payer plans, that passed out of committee with bipartisan support, will be considered. It would be a scandal to not allow those states that wished to to try to model a single-payer program.
Speaking of scandals, HR 3642 is further poisoned by the inclusion of the “Stupak-Pitts Amendment”, named after its sponsor, Michigan Democrat Bart Stupak, which not only continues the Hyde Amendment’s ban on the use of federal funds for abortions, it expands on it, by forbidding any plan that may have anyone getting a federal subsidy from offering coverage for abortion care. No “public option” can offer abortion coverage. This will mean that virtually no insurance policy will offer coverage for abortions, including the ones that do at the current time. Companies could offer two separate policies, so that portion of the population not getting subsidies (above 400% of poverty) could buy the other policy, but there is no evidence that they will do so. Under current state laws, five states offer the possibility of insurance companies offering “abortion riders”, allowed under Stupak-Pitts, but there is no evidence that any of them do. Women do not anticipate that they will need an abortion; like other medical care that may come unanticipated (such as the need for emergency surgery, or a diagnosis of cancer) it needs to be covered in the “regular” policy. See the excellent analysis by Jodi Jacobson, “The ‘Real Life’ Effects of Stupak-Pitts: An Analysis by Legal Experts at Planned Parenthood”, or at the Planned Parenthood site, http://plannedparenthoodaction.org/healthreform/668.htm.
The only exceptions allowed under Stupak-Pitts are for abortions resulting from rape, incest, or danger to the life of the mother. Note that this would not only include danger to the mental health of the mother, but would exclude terminations for fetal anomalies, even those incompatible with life. Thus, as is already the case in states such as Mississippi and Louisiana, which have such laws, women can get prenatal testing with ultrasound and amniocentesis, but have no legal access within their states for terminations if something is demonstrated to be wrong. They cannot even be referred. Luckily, at this time, they can go to other states. The Stupak amendment would make the current situation worse.
A group of at least 40 women in Congress, led by Diana DeGette of Colorado, have signed on to a letter demanding that Stupak-Pitts be removed from any final health reform bill. They deserve all the support that they can get, from other members of Congress, from their constituents, and from those who are residents in districts with representatives who voted for Stupak-Pitts. Note that this effort is led by women in Congress. This, obviously, is not a coincidence. Women are the people who get pregnant, including when it is not planned, including when the fetus has anomalies incompatible with life. There are many women, as well as men, who oppose abortion in the sense that they would not have one, that they might counsel friends and relatives not to have one, but also believe that the ultimate decision about what happens to a woman is hers, not theirs. There are also many women, as well as men, in Congress and in the public, who support the concept of Stupak-Pitts and Hyde and other restrictions on abortion, who believe it is their right to make decisions for other women. But none of the men will ever get pregnant themselves. There are many women who were strongly opposed to abortion who have had abortions because their circumstances were special. No men have had to. The role of men, including, obviously, the Catholic Bishops – who, amazingly, are all men! – in fighting for restrictions on abortion, is grossly immoral and offensive.
President Obama has indicated that he will seek some revision of Stupak-Pitts, as described in the New York Times article “Obama seeks revision of plan’s abortion limits”, but even his position would continue the Hyde Amendment restrictions. This has to stop. Women’s lives and health need to stop being the pawns of politicians.
After the House of Representatives passed HR 3962 recently, I celebrated the defeat of the opponents of health reform. I tried to make it clear, and I will emphasize here below, that the bill is not only far from perfect, it is bad. I just think it would have been worse, a victory for those who wish to keep the status quo (for example, virtually all the Republicans). To my knowledge, Ohio congressman Dennis Kucinich is the only representative who voted against it from a progressive perspective, and I applaud him for that.
I was at a conference recently at which former Senator Tom Daschle spoke. He invited us to envision a huge stadium with the 300,000,000 Americans in it, and the President at the center asking “what should we do about health reform?”, and the huge multiplicity of opinions that would come. He then suggested that the Congress, with its 535 representatives and senators, was a microcosm of those people, expressing all their multiple beliefs. Well, maybe the multiple beliefs, but not in the same proportion. I feel quite certain that, while there would have been a lot of opponents, the 300,000,000 Americans would have been a lot more supportive of health reform, much more meaningful health reform, than the 535 representatives. This is because they don’t get huge contributions from lobbyists from the insurance industry, pharmaceutical industry, hospital industry, and other big corporations, as well as doctors and lawyers and other rich people. Congress does, and it definitely affects their way of seeing things.
HR 3962 is a bad bill that will finance insurance companies, not save money, and not cover all people. I think, I know, we can do better than that. A single-payer plan, for example, such as that proposed in the Medicare for All bill sponsored by Rep. John Conyers (D, MI), and almost voted on by the house in an amendment by Rep. Anthony Weiner (D, NY) to include single payer. This is actually quite a victory, that it came so close, given the efforts of both the Administration and the Congressional leadership to keep it “off the table” from the beginning of this debate. We can hope that, at least, the amendment sponsored by Rep. Kucinich permitting states to pilot single-payer plans, that passed out of committee with bipartisan support, will be considered. It would be a scandal to not allow those states that wished to to try to model a single-payer program.
Speaking of scandals, HR 3642 is further poisoned by the inclusion of the “Stupak-Pitts Amendment”, named after its sponsor, Michigan Democrat Bart Stupak, which not only continues the Hyde Amendment’s ban on the use of federal funds for abortions, it expands on it, by forbidding any plan that may have anyone getting a federal subsidy from offering coverage for abortion care. No “public option” can offer abortion coverage. This will mean that virtually no insurance policy will offer coverage for abortions, including the ones that do at the current time. Companies could offer two separate policies, so that portion of the population not getting subsidies (above 400% of poverty) could buy the other policy, but there is no evidence that they will do so. Under current state laws, five states offer the possibility of insurance companies offering “abortion riders”, allowed under Stupak-Pitts, but there is no evidence that any of them do. Women do not anticipate that they will need an abortion; like other medical care that may come unanticipated (such as the need for emergency surgery, or a diagnosis of cancer) it needs to be covered in the “regular” policy. See the excellent analysis by Jodi Jacobson, “The ‘Real Life’ Effects of Stupak-Pitts: An Analysis by Legal Experts at Planned Parenthood”, or at the Planned Parenthood site, http://plannedparenthoodaction.org/healthreform/668.htm.
The only exceptions allowed under Stupak-Pitts are for abortions resulting from rape, incest, or danger to the life of the mother. Note that this would not only include danger to the mental health of the mother, but would exclude terminations for fetal anomalies, even those incompatible with life. Thus, as is already the case in states such as Mississippi and Louisiana, which have such laws, women can get prenatal testing with ultrasound and amniocentesis, but have no legal access within their states for terminations if something is demonstrated to be wrong. They cannot even be referred. Luckily, at this time, they can go to other states. The Stupak amendment would make the current situation worse.
A group of at least 40 women in Congress, led by Diana DeGette of Colorado, have signed on to a letter demanding that Stupak-Pitts be removed from any final health reform bill. They deserve all the support that they can get, from other members of Congress, from their constituents, and from those who are residents in districts with representatives who voted for Stupak-Pitts. Note that this effort is led by women in Congress. This, obviously, is not a coincidence. Women are the people who get pregnant, including when it is not planned, including when the fetus has anomalies incompatible with life. There are many women, as well as men, who oppose abortion in the sense that they would not have one, that they might counsel friends and relatives not to have one, but also believe that the ultimate decision about what happens to a woman is hers, not theirs. There are also many women, as well as men, in Congress and in the public, who support the concept of Stupak-Pitts and Hyde and other restrictions on abortion, who believe it is their right to make decisions for other women. But none of the men will ever get pregnant themselves. There are many women who were strongly opposed to abortion who have had abortions because their circumstances were special. No men have had to. The role of men, including, obviously, the Catholic Bishops – who, amazingly, are all men! – in fighting for restrictions on abortion, is grossly immoral and offensive.
President Obama has indicated that he will seek some revision of Stupak-Pitts, as described in the New York Times article “Obama seeks revision of plan’s abortion limits”, but even his position would continue the Hyde Amendment restrictions. This has to stop. Women’s lives and health need to stop being the pawns of politicians.
Sunday, November 8, 2009
Celebrating the Defeat of the Opponents of Health Reform
.
Last night, late on November 7, 2009, HR 3962, the health reform bill jointly worked out by 3 House committees, passed the House by the narrow margin of 220-215. All Republicans but one (Anh "Joseph" Cao of Louisiana) plus 39 Democrats voted against it. This is reason enough to be glad that it passed, despite the limitations of the bill itself. It did not come so close because of progressives concerned about those limitations voting against it; it came so close because there are so many in Congress who are opposed to any improvement in the access to health care for the American people. It is important that they were defeated, even if by a slim margin, because they are voices for an untenable and unjust status quo.
The bill that passed the House is not a good health reform plan on the face of it. It will leave millions of Americans uninsured. It will not provide a significant limit on the ability of insurance companies to profit from the health problems of our people. A wise and clear analysis of the limitations of the bill is provided by John Geyman, MD, Professor and Chair Emeritus of Family Medicine at the University of Washington and author of the official blog of Physicians for a National Health Program (PNHP). In his piece Health Care Reform 2009: No Bill is Better than a Bad Bill, he makes the case that it should not pass. PNHP’s official position before the vote was: “We have been asked how to tell members to vote on the House bill. Our response is that the bill is ‘like aspirin for breast cancer’.” I agree with their analysis of the bill, and still hope (but am not optimistic) that a better bill will eventually emerge from conference, but have to disagree that it would have been better for it to have been defeated, because that would not have been seen as a victory for progressives, but rather have been a victory for the forces of darkness.
Herb Freeman, a long-time social activist and observer (and a close relative), writes:
“Because of the tenor of the health bill discussion in the House today [November 7] on C-span, and after receiving an e-mail showing what cost of living and earnings were in the US 100 years ago, I started to Google how and when other changes were made. In looking up information on other federally-mandated social modifications (or improvements), such as abolition of child labor (1938), compulsory public education (early 1900s), fair labor standards (especially the 40-hour week, 1938) and food standards and examination, I came across some surprising things:
Wikipedia mostly quotes libertarian approaches to public education as destructive to the "educable" and wasteful to the "others."
The impact of the 40-hour week is largely negated by 12-hour work days, elimination of overtime after an 8-hour day, partially because of the lack of a national health plan, which makes insurance too expensive for employers and partially from lost vacations to compensate from static wages.
I reviewed the arguments made, both at the time of passage and to this day, against 68 or more laws that protect people from gross exploitation as workers, and they are exactly what I heard today on C-Span for several hours on the health bill from these dinosaurs from Texas, Mississippi, Wisconsin and Utah, etc.”
The cruel and vicious racist and classist arguments that were made against child labor laws and a 40-hour week and fair wages, that were based in ideas that some people were “educable” and others were not, that exploitation was ok, are the same ones we heard in the health care debate. They were evil and wrong back then, and they are evil and wrong now. The laws that Mr. Freeman refers to, which offer some protection for workers, have indeed been eroded, but to the extent that they exist, and that there is a strong belief on the part of most people that they are good things, help to protect against the worst of exploitation. Many of them also passed, in their day, by narrow margins. I think that the importance of passing HR 3962 was that, by a narrow majority in the House (representing, of course, a much larger majority in the country, that of the people who are not rich or corporations to give money to congresspeople), is that it rejected the narrow-minded selfishness and toadying-to-their-wealthy-benefactors of its opponents
I am not optimistic that the Senate bill will be better (Professor Leonard Rodberg, PhD, Chair of Urban Studies at Queens College/CUNY, describes in Don McCanne’s Quote of the Day how the current plan is bad (he calls it a DOG, but I like my dogs!) or that there will be much improvement in the bill that comes out of conference. It is very unfortunate that there is not a single-payer plan, and that Rep. Anthony Weiner’s single-payer plan was not brought to a vote. I still hope that the proposal by Rep. Dennis Kucinich to allow states to pilot single-payer programs (which passed the committee with support from even some Republicans) may yet happen. Single payer got much further along in the debate than the administration and leadership, which tried to kill it at the beginning of the debate, hoped.
But the most important point is that, whatever, the content of the bill, on this one night, by a narrow margin, a bill passed that says the American people should have access to health care, whatever its limitations in actually providing for it, passed, and it passed over the opposition of those who only support legislation that benefits the privileged minority, and opposed, as they have always opposed, programs that benefit all of our people. I celebrate their defeat.
Last night, late on November 7, 2009, HR 3962, the health reform bill jointly worked out by 3 House committees, passed the House by the narrow margin of 220-215. All Republicans but one (Anh "Joseph" Cao of Louisiana) plus 39 Democrats voted against it. This is reason enough to be glad that it passed, despite the limitations of the bill itself. It did not come so close because of progressives concerned about those limitations voting against it; it came so close because there are so many in Congress who are opposed to any improvement in the access to health care for the American people. It is important that they were defeated, even if by a slim margin, because they are voices for an untenable and unjust status quo.
The bill that passed the House is not a good health reform plan on the face of it. It will leave millions of Americans uninsured. It will not provide a significant limit on the ability of insurance companies to profit from the health problems of our people. A wise and clear analysis of the limitations of the bill is provided by John Geyman, MD, Professor and Chair Emeritus of Family Medicine at the University of Washington and author of the official blog of Physicians for a National Health Program (PNHP). In his piece Health Care Reform 2009: No Bill is Better than a Bad Bill, he makes the case that it should not pass. PNHP’s official position before the vote was: “We have been asked how to tell members to vote on the House bill. Our response is that the bill is ‘like aspirin for breast cancer’.” I agree with their analysis of the bill, and still hope (but am not optimistic) that a better bill will eventually emerge from conference, but have to disagree that it would have been better for it to have been defeated, because that would not have been seen as a victory for progressives, but rather have been a victory for the forces of darkness.
Herb Freeman, a long-time social activist and observer (and a close relative), writes:
“Because of the tenor of the health bill discussion in the House today [November 7] on C-span, and after receiving an e-mail showing what cost of living and earnings were in the US 100 years ago, I started to Google how and when other changes were made. In looking up information on other federally-mandated social modifications (or improvements), such as abolition of child labor (1938), compulsory public education (early 1900s), fair labor standards (especially the 40-hour week, 1938) and food standards and examination, I came across some surprising things:
Wikipedia mostly quotes libertarian approaches to public education as destructive to the "educable" and wasteful to the "others."
The impact of the 40-hour week is largely negated by 12-hour work days, elimination of overtime after an 8-hour day, partially because of the lack of a national health plan, which makes insurance too expensive for employers and partially from lost vacations to compensate from static wages.
I reviewed the arguments made, both at the time of passage and to this day, against 68 or more laws that protect people from gross exploitation as workers, and they are exactly what I heard today on C-Span for several hours on the health bill from these dinosaurs from Texas, Mississippi, Wisconsin and Utah, etc.”
The cruel and vicious racist and classist arguments that were made against child labor laws and a 40-hour week and fair wages, that were based in ideas that some people were “educable” and others were not, that exploitation was ok, are the same ones we heard in the health care debate. They were evil and wrong back then, and they are evil and wrong now. The laws that Mr. Freeman refers to, which offer some protection for workers, have indeed been eroded, but to the extent that they exist, and that there is a strong belief on the part of most people that they are good things, help to protect against the worst of exploitation. Many of them also passed, in their day, by narrow margins. I think that the importance of passing HR 3962 was that, by a narrow majority in the House (representing, of course, a much larger majority in the country, that of the people who are not rich or corporations to give money to congresspeople), is that it rejected the narrow-minded selfishness and toadying-to-their-wealthy-benefactors of its opponents
I am not optimistic that the Senate bill will be better (Professor Leonard Rodberg, PhD, Chair of Urban Studies at Queens College/CUNY, describes in Don McCanne’s Quote of the Day how the current plan is bad (he calls it a DOG, but I like my dogs!) or that there will be much improvement in the bill that comes out of conference. It is very unfortunate that there is not a single-payer plan, and that Rep. Anthony Weiner’s single-payer plan was not brought to a vote. I still hope that the proposal by Rep. Dennis Kucinich to allow states to pilot single-payer programs (which passed the committee with support from even some Republicans) may yet happen. Single payer got much further along in the debate than the administration and leadership, which tried to kill it at the beginning of the debate, hoped.
But the most important point is that, whatever, the content of the bill, on this one night, by a narrow margin, a bill passed that says the American people should have access to health care, whatever its limitations in actually providing for it, passed, and it passed over the opposition of those who only support legislation that benefits the privileged minority, and opposed, as they have always opposed, programs that benefit all of our people. I celebrate their defeat.
Wednesday, November 4, 2009
Poverty and Uninsurance Diverge: So let’s solve the problem!
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Wyandotte and Johnson counties form the Kansas side of the Kansas City metropolitan area. Wyandotte, mainly Kansas City, KS, where I live, is an old “rust-belt” inner city, packing-house industrial city, and is the poorest county in Kansas. Johnson, to its south, consists of older inner suburbs and newer, were-recently-farmland suburbs, and is the richest and most populous Kansas county, with more than 3 times the population of Wyandotte. In Johnson County, only 14% of the population is below 200% of the poverty level, compared to Wyandotte County’s 44%, but it actually a slightly larger absolute number (73,200 to 67,400) because of Johnson County’s larger population. More interesting is the uninsured rate; while it has fewer than 10% more people under 200% of poverty, Johnson County has 2.5 times as many uninsured people as does Wyandotte County.
Wyandotte and Johnson counties form the Kansas side of the Kansas City metropolitan area. Wyandotte, mainly Kansas City, KS, where I live, is an old “rust-belt” inner city, packing-house industrial city, and is the poorest county in Kansas. Johnson, to its south, consists of older inner suburbs and newer, were-recently-farmland suburbs, and is the richest and most populous Kansas county, with more than 3 times the population of Wyandotte. In Johnson County, only 14% of the population is below 200% of the poverty level, compared to Wyandotte County’s 44%, but it actually a slightly larger absolute number (73,200 to 67,400) because of Johnson County’s larger population. More interesting is the uninsured rate; while it has fewer than 10% more people under 200% of poverty, Johnson County has 2.5 times as many uninsured people as does Wyandotte County.
This means, obviously, that there are many non-poor uninsured people, and this is a national phenomenon. For most of this century, poverty and uninsurance rates tracked together. But in the late 1990s, with poverty rates decreasing, uninsurance rates continued to rise. With the recent recession, both have climbed, but uninsurance is rising at a higher rate. (See graph).
This dissociation between poverty and uninsurance is a very troubling phenomenon; while it is bad enough for poor people to not have financial access to health care, more and more of the uninsured are not poor.
Thus the case for health reform: let’s do something about this. Let’s dissociate the “privilege” of having health insurance from being employed by an entity large enough to afford to provide it, and make sure everyone has financial access to high quality care. Unfortunately, the current plans in the Congress will not do so. The recent assurance by Senate Majority Leader Reid that the Senate bill will contain a “public option”, as will the House bill, obscures the fact that the public option it contains will be weak; in an ostensible effort to not give the public option an “unfair advantage” over private insurance plans, it has been given an unfair disadvantage – it will not be able to use its public status to set rates for provider compensation, as does Medicare, or for drug prices, as Medicare (under the bad restrictions of Part D) also does not.
This is, of course, bizarre: why should anyone, other than the insurance companies themselves, care that they can continue to make money hand over fist while providing inadequate coverage, and not be held accountable by having to compete with a public option that provides comprehensive coverage and does not have to make a profit? Oh yes, the senators and congressmen who get contributions from those insurance companies, yes, but the rest of us? Why should we care? And why should we not insist that our representatives represent our interests, and not those of the insurance companies?
Much of the opposition – not only to single payer, but to a “public option” has been based on, not to put too fine a point on it, lies spread by opponents who are mostly on the payroll of insurance companies. These lies have led people to think that they will lose the excellent medical care, and extensive freedom of choice that they have under the current system (oh, whoops, forgot, they don’t!) if we have a government program. Writing in the Oct 28, 2009 issue of JAMA, Joseph S. Ross and Allan S. Detsky look at “Health care choices and decisions in the United States and Canada”[1], choosing Canada specifically “…because the Canadian health system, with much greater government involvement, is often publicly portrayed in the United States as limiting choice.” They review the restraints on choice of insurance plans, hospitals and doctors, and diagnostic testing and treatments, and conclude, modestly that “…there is clear evidence that for Canada’s health care system, less choice in insurance coverage (although guaranteed) has not resulted in less choice of hospitals, physicians, and diagnostic testing and treatments compared with the United States. In fact, there is arguably more choice.” More than “arguably”, I’d say, based on the evidence provided in their piece.
The fewer obstacles that are placed in the way of services to people, the more efficient they are, the more they are appreciated, and the less they affront the dignity of the people receiving them. When comprehensive services are provided to everyone, there is no need to put people through rigorous screening to see if they are poor enough, or don’t have other insurance, or are deserving enough to receive them.
Ironically, or maybe not, the same legislators who decry government bureaucracy are those who demand that bureaucracy through establishing restrictions on programs that help people. This includes, of course, income and citizenship verification for those seeking help with health care; after all we wouldn’t want people to “cheat” and avail themselves of public services when they didn’t “need” them, when their incomes exceeded the 200% of poverty, or 100% of poverty, or 38% of poverty* that we require. If there were one program for everyone, a single-payer or Medicare-for-all program, then all this bureaucracy could be eliminated. We wouldn’t have to screen people, because everyone would be eligible. It would be everyone’s program.
I have written before about the enormous administrative cost involved in both insurance companies (payers) and providers having huge teams of people to try to deny payment or get paid; in one more way, a single-payer plan would eliminate administrative waste and bureaucracy. Funny that those anti-government-bureaucracy folks can’t – or won’t – see it this way.
*38% of poverty was what one's income used to have to be to get financial assistance in Kansas if you were a childless adult -- and it was $100/month. Now it is not available at all.
[1] Ross JS, Detsky AS, “Health care choices and decisions in the United States and Canada”, JAMA, Oct 28, 2009;302(16):1803-4.
.
This is, of course, bizarre: why should anyone, other than the insurance companies themselves, care that they can continue to make money hand over fist while providing inadequate coverage, and not be held accountable by having to compete with a public option that provides comprehensive coverage and does not have to make a profit? Oh yes, the senators and congressmen who get contributions from those insurance companies, yes, but the rest of us? Why should we care? And why should we not insist that our representatives represent our interests, and not those of the insurance companies?
Much of the opposition – not only to single payer, but to a “public option” has been based on, not to put too fine a point on it, lies spread by opponents who are mostly on the payroll of insurance companies. These lies have led people to think that they will lose the excellent medical care, and extensive freedom of choice that they have under the current system (oh, whoops, forgot, they don’t!) if we have a government program. Writing in the Oct 28, 2009 issue of JAMA, Joseph S. Ross and Allan S. Detsky look at “Health care choices and decisions in the United States and Canada”[1], choosing Canada specifically “…because the Canadian health system, with much greater government involvement, is often publicly portrayed in the United States as limiting choice.” They review the restraints on choice of insurance plans, hospitals and doctors, and diagnostic testing and treatments, and conclude, modestly that “…there is clear evidence that for Canada’s health care system, less choice in insurance coverage (although guaranteed) has not resulted in less choice of hospitals, physicians, and diagnostic testing and treatments compared with the United States. In fact, there is arguably more choice.” More than “arguably”, I’d say, based on the evidence provided in their piece.
The fewer obstacles that are placed in the way of services to people, the more efficient they are, the more they are appreciated, and the less they affront the dignity of the people receiving them. When comprehensive services are provided to everyone, there is no need to put people through rigorous screening to see if they are poor enough, or don’t have other insurance, or are deserving enough to receive them.
Ironically, or maybe not, the same legislators who decry government bureaucracy are those who demand that bureaucracy through establishing restrictions on programs that help people. This includes, of course, income and citizenship verification for those seeking help with health care; after all we wouldn’t want people to “cheat” and avail themselves of public services when they didn’t “need” them, when their incomes exceeded the 200% of poverty, or 100% of poverty, or 38% of poverty* that we require. If there were one program for everyone, a single-payer or Medicare-for-all program, then all this bureaucracy could be eliminated. We wouldn’t have to screen people, because everyone would be eligible. It would be everyone’s program.
I have written before about the enormous administrative cost involved in both insurance companies (payers) and providers having huge teams of people to try to deny payment or get paid; in one more way, a single-payer plan would eliminate administrative waste and bureaucracy. Funny that those anti-government-bureaucracy folks can’t – or won’t – see it this way.
*38% of poverty was what one's income used to have to be to get financial assistance in Kansas if you were a childless adult -- and it was $100/month. Now it is not available at all.
[1] Ross JS, Detsky AS, “Health care choices and decisions in the United States and Canada”, JAMA, Oct 28, 2009;302(16):1803-4.
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Saturday, October 31, 2009
Dietary Supplements can be Dangerous for your Health
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Lots of people take non-prescription “food supplements”, nutritional additives, “vitamins”, “energy tonics”, etc. These are particularly attractive if they are labeled “natural” or “organic”. For some folks, the goal is “general health” – the vitamins, minerals, herbs and other preparations, the herbs that. Many of the users of these substances, whether bought from retail outlets or over the internet are precisely those who disdain prescription medications, who don’t like to “take drugs” but take these “natural” substances. Others are taking them for a specific purpose – weight loss, muscle building, pain relief, energy – often when their doctors have refused to prescribe them, because they are dangerous, or illegal, or both.
Thus, we might conceive of two groups of the 114 million of us who take these medications. “Group 1” are those who believe in “natural” and are trying to “naturally” get healthier. “Group 2” wants magic drugs to help them achieve a goal, would be happy to take them if they could find a doctor to prescribe them, but can’t. Unfortunately, this is much a more hypothetical than real distinction, as there is considerable overlap. Many people in the first group can find their way into the other when they develop symptoms. Especially if the treatments are ostensibly “natural”.
A “Perspective” article in the New England Journal of Medicine, October 15, 2009, by Pieter A. Cohen, MD, titled “American Roulette – Contaminated Dietary Supplements”, discusses these issues. Cohen starts by discussing a police sergeant who lost his job after random drug tests found him positive for amphetamines – an unlabeled ingredient present in the weight-loss supplement he had been taking. It goes on to discuss contaminants found in many such over the counter supplements, both imported and made in USA, sold in retail stores and over the Internet. He notes that the 140 contaminated supplements that the FDA has identified are only a small percentage of those on the market; recently 75 weight-loss drugs were found to be contaminated. And “contamination” is not always the correct word. It implies inadvertent (although perhaps through inadequate quality control) substances present that are not on the label – such as rodent hairs or lead or other heavy metals (beryllium, cadmium, arsenic, etc., which are all poisons that accumulate in the body), bacteria, and plant molds. However, frequently the “off-label” ingredients are there on purpose – they are the drugs that are actually having the desired effect – amphetamines for weight loss or energy, anabolic steroids for muscle building, corticosteroids for arthritis relief, opiates for pain. And these are drugs that are illegal to sell without a prescription (and often heavily restricted even with a prescription!) so they are left off the label. And, in part because the FDA has had its budget gutted and has too few inspectors, are undetected.
There are other reasons that the FDA does not detect such accidental or purposeful adulteration. One is the Dietary Supplement Health and Education Act (DSHEA) of 1994, that limited the ability of the FDA to regulate them. The DSHEA was pushed by the supplement manufacturers, with support of many ordinary people who feared that increased FDA regulation would lead to loss of free access to these substances. Before 1994, Cohen writes, “These supplements, which include botanical products, vitamins and minerals, amino acids, and tissue extracts…were considered food additives, and their manufacturers were required to show proof of safety before marketing them. Since the passage of the DSHEA, dietary supplements are presumed to be safe and can be marketed with very little oversight.” And American consumers, looking for magic potions, pay the price in their health.
There are a few things to remember when considering purchasing and taking dietary supplements, even ones you have long taken. They include:
--“Natural” does not mean “good” or even “safe”. There are plenty of natural poisons, and most substances, taken in excessive amounts can have adverse effects. Similarly, “made in a pharmaceutical laboratory” does not mean “bad”; usually, if it is a reputable and inspected lab (including the pharmaceutical manufacturers I often criticize) it means that there is much more quality control.
--If a substance actually has “good” effects, it can also have “side effects”. Substances only have effects. They don’t know what you want and don’t want. If a substance is actually having biological effects on your body (as opposed to psychological placebo effects), it doesn’t matter if it is “natural” or manufactured, from a plant or a chemical. If, for example, the estrogens in plants “work” just as well as those from animals (mare urine) or chemically produced, they will have the same sort of risks.
--Unregulated or under-regulated substances are often “contaminated”, and this is particularly true for those made in other countries and often bought over the Internet. In this case I mean truly “contaminated”, with the lead, bacteria, molds, and toxins I mention above.
--Plants vary in potency. Thus “1 leaf” or “1 ounce” of a plant may have very different amounts of active ingredient depending upon where and what season it was grown in, and just in terms of random variation. If you buy the actual plants – and if you are a skilled enough botanist to be sure of what you are buying – the variable potency needs to be considered. If, however, you are buying capsules said to contain a specific plant, you are, as described above, shooting craps with your health, because these are subject to much less regulation than “standard” pharmaceuticals.
--If it seems too good to be true, it almost certainly is. If a substance you buy, over the Internet or from a retailer, works amazingly well, it is likely that it contains, probably unlabeled, a very potent drug such as steroids, amphetamines, or opiates. Maybe you knew that and wanted it because your mean doctor would not prescribe them. Maybe that makes you unwise. However, if you bought them under the impression that they were “natural” and “safe”, you may be in for a big surprise. And this is likely to be in terms of the serious adverse effects that led them to be highly regulated in the first place.
Finally, the people manufacturing and selling these “supplements” are profit-making companies. Calling themselves “organic” or “natural” does not make them automatically nice, safe, good guys. As in any other industry, as we have seen so often over the last year, there are opportunists who will lie, cheat, steal, and poison you to make a buck. Strong regulation, well-funded regulation, is the only thing we have on our side to protect us. Limiting regulations of substances that can affect our health is almost always wrong. The DSHEA was a mistake, and well-meaning people who supported it made a mistake in doing so. They now need to demand that their legislators protect them at least as much from over-the-counter dietary supplements as they do from prescription drugs!
.
Lots of people take non-prescription “food supplements”, nutritional additives, “vitamins”, “energy tonics”, etc. These are particularly attractive if they are labeled “natural” or “organic”. For some folks, the goal is “general health” – the vitamins, minerals, herbs and other preparations, the herbs that. Many of the users of these substances, whether bought from retail outlets or over the internet are precisely those who disdain prescription medications, who don’t like to “take drugs” but take these “natural” substances. Others are taking them for a specific purpose – weight loss, muscle building, pain relief, energy – often when their doctors have refused to prescribe them, because they are dangerous, or illegal, or both.
Thus, we might conceive of two groups of the 114 million of us who take these medications. “Group 1” are those who believe in “natural” and are trying to “naturally” get healthier. “Group 2” wants magic drugs to help them achieve a goal, would be happy to take them if they could find a doctor to prescribe them, but can’t. Unfortunately, this is much a more hypothetical than real distinction, as there is considerable overlap. Many people in the first group can find their way into the other when they develop symptoms. Especially if the treatments are ostensibly “natural”.
A “Perspective” article in the New England Journal of Medicine, October 15, 2009, by Pieter A. Cohen, MD, titled “American Roulette – Contaminated Dietary Supplements”, discusses these issues. Cohen starts by discussing a police sergeant who lost his job after random drug tests found him positive for amphetamines – an unlabeled ingredient present in the weight-loss supplement he had been taking. It goes on to discuss contaminants found in many such over the counter supplements, both imported and made in USA, sold in retail stores and over the Internet. He notes that the 140 contaminated supplements that the FDA has identified are only a small percentage of those on the market; recently 75 weight-loss drugs were found to be contaminated. And “contamination” is not always the correct word. It implies inadvertent (although perhaps through inadequate quality control) substances present that are not on the label – such as rodent hairs or lead or other heavy metals (beryllium, cadmium, arsenic, etc., which are all poisons that accumulate in the body), bacteria, and plant molds. However, frequently the “off-label” ingredients are there on purpose – they are the drugs that are actually having the desired effect – amphetamines for weight loss or energy, anabolic steroids for muscle building, corticosteroids for arthritis relief, opiates for pain. And these are drugs that are illegal to sell without a prescription (and often heavily restricted even with a prescription!) so they are left off the label. And, in part because the FDA has had its budget gutted and has too few inspectors, are undetected.
There are other reasons that the FDA does not detect such accidental or purposeful adulteration. One is the Dietary Supplement Health and Education Act (DSHEA) of 1994, that limited the ability of the FDA to regulate them. The DSHEA was pushed by the supplement manufacturers, with support of many ordinary people who feared that increased FDA regulation would lead to loss of free access to these substances. Before 1994, Cohen writes, “These supplements, which include botanical products, vitamins and minerals, amino acids, and tissue extracts…were considered food additives, and their manufacturers were required to show proof of safety before marketing them. Since the passage of the DSHEA, dietary supplements are presumed to be safe and can be marketed with very little oversight.” And American consumers, looking for magic potions, pay the price in their health.
There are a few things to remember when considering purchasing and taking dietary supplements, even ones you have long taken. They include:
--“Natural” does not mean “good” or even “safe”. There are plenty of natural poisons, and most substances, taken in excessive amounts can have adverse effects. Similarly, “made in a pharmaceutical laboratory” does not mean “bad”; usually, if it is a reputable and inspected lab (including the pharmaceutical manufacturers I often criticize) it means that there is much more quality control.
--If a substance actually has “good” effects, it can also have “side effects”. Substances only have effects. They don’t know what you want and don’t want. If a substance is actually having biological effects on your body (as opposed to psychological placebo effects), it doesn’t matter if it is “natural” or manufactured, from a plant or a chemical. If, for example, the estrogens in plants “work” just as well as those from animals (mare urine) or chemically produced, they will have the same sort of risks.
--Unregulated or under-regulated substances are often “contaminated”, and this is particularly true for those made in other countries and often bought over the Internet. In this case I mean truly “contaminated”, with the lead, bacteria, molds, and toxins I mention above.
--Plants vary in potency. Thus “1 leaf” or “1 ounce” of a plant may have very different amounts of active ingredient depending upon where and what season it was grown in, and just in terms of random variation. If you buy the actual plants – and if you are a skilled enough botanist to be sure of what you are buying – the variable potency needs to be considered. If, however, you are buying capsules said to contain a specific plant, you are, as described above, shooting craps with your health, because these are subject to much less regulation than “standard” pharmaceuticals.
--If it seems too good to be true, it almost certainly is. If a substance you buy, over the Internet or from a retailer, works amazingly well, it is likely that it contains, probably unlabeled, a very potent drug such as steroids, amphetamines, or opiates. Maybe you knew that and wanted it because your mean doctor would not prescribe them. Maybe that makes you unwise. However, if you bought them under the impression that they were “natural” and “safe”, you may be in for a big surprise. And this is likely to be in terms of the serious adverse effects that led them to be highly regulated in the first place.
Finally, the people manufacturing and selling these “supplements” are profit-making companies. Calling themselves “organic” or “natural” does not make them automatically nice, safe, good guys. As in any other industry, as we have seen so often over the last year, there are opportunists who will lie, cheat, steal, and poison you to make a buck. Strong regulation, well-funded regulation, is the only thing we have on our side to protect us. Limiting regulations of substances that can affect our health is almost always wrong. The DSHEA was a mistake, and well-meaning people who supported it made a mistake in doing so. They now need to demand that their legislators protect them at least as much from over-the-counter dietary supplements as they do from prescription drugs!
.
Tuesday, October 27, 2009
PSA Screening: “One of Medicine's Great Success Stories"?
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Guest blog by Robert Ferrer, MD MPH
I spent 2 days at home recently with the H1N1 flu and caught up on some of my newspaper reading. In the Oct 11, 2009 New York Times Magazine, (p.38) was an advertising supplement, "Health and Wellness Outlook Special Report: Cancer Treatment Options," paid for by some of our finest cancer centers. [1] In the prostate cancer section, I found this interesting assertion, in big capital letters: "The PSA test for prostate cancer detection and management is one of medicine's great success stories." It goes on to say that 90% of prostate ca is now diagnosed when curable and that the death rate has declined by 40% since the PSA test began to be widely used in the 1980's. The source is the chair of urology and senior vice president for translational research at Roswell Park Cancer Institute in Buffalo, where the the PSA test was developed.
I found the assertion curious because this past March the New England Journal of Medicine published 2 long-awaited studies[2],[3] on whether PSA testing was effective: one found a modest benefit and the other virtually none. Both noted that a very large number of men had to be screened and treated for every one who benefited. These articles received extensive press coverage. And just as I was going to my laptop today to assemble this and other maybe-not-such-a-great-success-story evidence for PSA screening, this week's JAMA showed up with a terrific paper by Esserman, Shieh, and Thompson.[4] They have this to say about PSA screening:
"After 2 1/2 decades of screening for [breast and] prostate cancer, conclusions are troubling: Overall cancer rates are higher, many more patients are being treated, and the absolute incidence of aggressive or later-stage disease has not been significantly decreased. Screening has some effect, but it comes at significant cost, including over-diagnosis, overtreatment, and complications of therapy."
So how do we get from "great success story" to "troubling"? How can diagnosing cancer early not be a good thing? The answer lies in the kind of cancers we can detect with screening. Slow growing cancers, the kind unlikely to kill you, grow... slowly and so are around for a long time to be detected by screening. On the other hand, fast growing cancers can go from undetectable to lethal even in the year between cancer screenings. So the cancers we detect through screening are more likely to be the non-lethal kind. Well, isn't that still a good thing? Can't cancer harm without killing?
Yes, but the issue here is what we call "cancer." Our screening tests can detect collections of cells that are, by pathologists' standards, "cancer" when viewed under the microscope, yet not every collection of such cells is destined act like cancer; that is, to grow or spread (metastasize) to other parts of the body. Some are destined to remain dormant until the person eventually dies of something else. And therein lies the problem with PSA screening. It detects many of the ones destined to be dormant or slow growing for every one destined to be lethal. The exact number is uncertain, but the large European study in the NEJM this March estimated 1410 men needed to be screened and 48 cases of prostate cancer treated to prevent 1 death. [2] The American study released in parallel found the benefits to be even smaller. [3]
What this means, is that the consequence of PSA testing for many men is adding 6-12 years of life diagnosed -- and often treated -- as a cancer patient, without actually living any longer.
Just how much over-diagnosis can we attribute to PSA? In the August 2009 issue of the Journal of the National Cancer Institute, H. Gilbert Welch and Peter Alberson calculate than in the first 19 years of the PSA era, 1987 to 2005, about 1.3 million additional cases were diagnosed and 1 million more men treated.[5] They estimate that about half of these extra cases represent over-diagnosis, meaning that the diagnosed man was very unlikely to die from prostate cancer. So of the roughly 4 million men diagnosed from 1985 to 2005, half a million were over-diagnosed.
What about the fact that, as the Roswell Park urologists note, mortality rates have fallen since PSA testing began in the mid-80's? Doesn't that suggest that PSA is helping? The authors in this week's JAMA paper address this in their analysis. For that claim to be credible, we should be seeing a sharp fall in number of advanced stage prostate cancers, which is what would happen if screening was finding the "bad" cancers early, before they could reach an advanced stage. Although we have indeed seen a fall in advanced cancers it has been nowhere near as sharp as we would expect, given the many more cancers we are finding in the PSA era. We should thus probably look elsewhere to explain the fall in prostate cancer mortality, likely improvements in treatment.
So, given what we know about how well PSA testing performs as a screening test, how can it be advertised as one of medicine's great success stories? As potential explanations, I offer two themes that I believe also offer some larger lessons for why health care is less effective and more expensive than it should be.
Theme 1: Thinking about organs rather than people: If your focus is the prostate, then finding and removing cancerous prostates is the goal. This works well at the level of prostates, but not so well for whole men. With a test as imperfect as the PSA, a small or nonexistent reduction in the risk of dying from prostate cancer is sometimes traded for diminished quality of life, most commonly the incontinence and impotence that affect about 1/4 of men treated for prostate cancer.
Theme 2: Economic incentives favoring procedures. As the numbers above demonstrate, PSA has expanded the number of prostate cancer patients by about a third. The professional urology association has long recommended PSA screening even when the US Preventive Services Task Force, tasked with providing rigorous assessments for screening procedures, has consistently recommended against routine PSA screening.
Themes 1 and 2 intertwine. Greed is not what drives PSA testing. When a urologist can make a prostate cancer diagnosis and provide a "cure," doctor and patient alike perceive it as a valuable service. A life-saving intervention. That the service is well reimbursed appears justified when the stakes seem so high. It is only from the application of healthy skepticism and careful analysis -- of outcomes for people, not organs -- that we can reach better conclusions about the value of what we do.
The topic of PSA screening was previously addressed (if less well) in PSA Screening: What is the Value? March 21, 2009
[1] Anonymous. Health and Wellness Outlook Special Report: Cancer Treatment Options [advertising supplement]. New York Times Magazine, 11 October 2009. p. 33-46
[2] Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine. 2009a;360:1320.
[3] Andriole GL, Crawford ED, Grubb III RL, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009b;360:1310.
[4] Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. c;302:1686-1692.
[5] Welch HG, Albertsen PC. Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening: 1986-2005. J Natl Cancer Inst. 2009c;101:1325-1329
This topic was also addressed previously in PSA Screening: What is the Value? March 21, 2009
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Guest blog by Robert Ferrer, MD MPH
I spent 2 days at home recently with the H1N1 flu and caught up on some of my newspaper reading. In the Oct 11, 2009 New York Times Magazine, (p.38) was an advertising supplement, "Health and Wellness Outlook Special Report: Cancer Treatment Options," paid for by some of our finest cancer centers. [1] In the prostate cancer section, I found this interesting assertion, in big capital letters: "The PSA test for prostate cancer detection and management is one of medicine's great success stories." It goes on to say that 90% of prostate ca is now diagnosed when curable and that the death rate has declined by 40% since the PSA test began to be widely used in the 1980's. The source is the chair of urology and senior vice president for translational research at Roswell Park Cancer Institute in Buffalo, where the the PSA test was developed.
I found the assertion curious because this past March the New England Journal of Medicine published 2 long-awaited studies[2],[3] on whether PSA testing was effective: one found a modest benefit and the other virtually none. Both noted that a very large number of men had to be screened and treated for every one who benefited. These articles received extensive press coverage. And just as I was going to my laptop today to assemble this and other maybe-not-such-a-great-success-story evidence for PSA screening, this week's JAMA showed up with a terrific paper by Esserman, Shieh, and Thompson.[4] They have this to say about PSA screening:
"After 2 1/2 decades of screening for [breast and] prostate cancer, conclusions are troubling: Overall cancer rates are higher, many more patients are being treated, and the absolute incidence of aggressive or later-stage disease has not been significantly decreased. Screening has some effect, but it comes at significant cost, including over-diagnosis, overtreatment, and complications of therapy."
So how do we get from "great success story" to "troubling"? How can diagnosing cancer early not be a good thing? The answer lies in the kind of cancers we can detect with screening. Slow growing cancers, the kind unlikely to kill you, grow... slowly and so are around for a long time to be detected by screening. On the other hand, fast growing cancers can go from undetectable to lethal even in the year between cancer screenings. So the cancers we detect through screening are more likely to be the non-lethal kind. Well, isn't that still a good thing? Can't cancer harm without killing?
Yes, but the issue here is what we call "cancer." Our screening tests can detect collections of cells that are, by pathologists' standards, "cancer" when viewed under the microscope, yet not every collection of such cells is destined act like cancer; that is, to grow or spread (metastasize) to other parts of the body. Some are destined to remain dormant until the person eventually dies of something else. And therein lies the problem with PSA screening. It detects many of the ones destined to be dormant or slow growing for every one destined to be lethal. The exact number is uncertain, but the large European study in the NEJM this March estimated 1410 men needed to be screened and 48 cases of prostate cancer treated to prevent 1 death. [2] The American study released in parallel found the benefits to be even smaller. [3]
What this means, is that the consequence of PSA testing for many men is adding 6-12 years of life diagnosed -- and often treated -- as a cancer patient, without actually living any longer.
Just how much over-diagnosis can we attribute to PSA? In the August 2009 issue of the Journal of the National Cancer Institute, H. Gilbert Welch and Peter Alberson calculate than in the first 19 years of the PSA era, 1987 to 2005, about 1.3 million additional cases were diagnosed and 1 million more men treated.[5] They estimate that about half of these extra cases represent over-diagnosis, meaning that the diagnosed man was very unlikely to die from prostate cancer. So of the roughly 4 million men diagnosed from 1985 to 2005, half a million were over-diagnosed.
What about the fact that, as the Roswell Park urologists note, mortality rates have fallen since PSA testing began in the mid-80's? Doesn't that suggest that PSA is helping? The authors in this week's JAMA paper address this in their analysis. For that claim to be credible, we should be seeing a sharp fall in number of advanced stage prostate cancers, which is what would happen if screening was finding the "bad" cancers early, before they could reach an advanced stage. Although we have indeed seen a fall in advanced cancers it has been nowhere near as sharp as we would expect, given the many more cancers we are finding in the PSA era. We should thus probably look elsewhere to explain the fall in prostate cancer mortality, likely improvements in treatment.
So, given what we know about how well PSA testing performs as a screening test, how can it be advertised as one of medicine's great success stories? As potential explanations, I offer two themes that I believe also offer some larger lessons for why health care is less effective and more expensive than it should be.
Theme 1: Thinking about organs rather than people: If your focus is the prostate, then finding and removing cancerous prostates is the goal. This works well at the level of prostates, but not so well for whole men. With a test as imperfect as the PSA, a small or nonexistent reduction in the risk of dying from prostate cancer is sometimes traded for diminished quality of life, most commonly the incontinence and impotence that affect about 1/4 of men treated for prostate cancer.
Theme 2: Economic incentives favoring procedures. As the numbers above demonstrate, PSA has expanded the number of prostate cancer patients by about a third. The professional urology association has long recommended PSA screening even when the US Preventive Services Task Force, tasked with providing rigorous assessments for screening procedures, has consistently recommended against routine PSA screening.
Themes 1 and 2 intertwine. Greed is not what drives PSA testing. When a urologist can make a prostate cancer diagnosis and provide a "cure," doctor and patient alike perceive it as a valuable service. A life-saving intervention. That the service is well reimbursed appears justified when the stakes seem so high. It is only from the application of healthy skepticism and careful analysis -- of outcomes for people, not organs -- that we can reach better conclusions about the value of what we do.
The topic of PSA screening was previously addressed (if less well) in PSA Screening: What is the Value? March 21, 2009
[1] Anonymous. Health and Wellness Outlook Special Report: Cancer Treatment Options [advertising supplement]. New York Times Magazine, 11 October 2009. p. 33-46
[2] Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate-cancer mortality in a randomized European study. New England Journal of Medicine. 2009a;360:1320.
[3] Andriole GL, Crawford ED, Grubb III RL, et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med. 2009b;360:1310.
[4] Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA. c;302:1686-1692.
[5] Welch HG, Albertsen PC. Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening: 1986-2005. J Natl Cancer Inst. 2009c;101:1325-1329
This topic was also addressed previously in PSA Screening: What is the Value? March 21, 2009
.
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