How does healthcare reform fit with your values and ethics?

The healthcare reform debate has become so discordant, it’s even been said to be a sign of a larger, irreconcilable ideological abyss growing in our country. In this environment, it can be hard to sort out the endless reports all claiming to debunk the myths surrounding healthcare reform proposals. There is one simple way to tell the difference between reports that are written to support an ideology from those giving us the facts. And increasing numbers of people are figuring out how: Go to the original source and read the healthcare reform legislation being proposed for themselves. It’s a lot harder to convince people that it doesn’t really say what is says when they’ve actually read it.

In truth, there is no easy answer to a perfect healthcare system. Every method of funding and providing healthcare is a struggle to balance access, costs, quality and patients’ rights and, while our healthcare is among the best in the world, all of us can spot areas that need improvement. The controversy comes in accurately identifying the problems and in how to address them: tackle what’s broken or have a massive government-centric overhaul. Healthcare reform to one means something very different to another. And ideological-based solutions are not the same as the consequences that play out in real life.

To sort out the proposals to decide what adheres to our own values and ethics starts with looking at what is being proposed and thinking about what “ethical” means to us.

In defining medical ethics, the guiding ethical principle that people around the world universally support is that patients should be the ones to make the most important decisions about their own bodies and health. It was born of devastating consequences and became part of the Nuremberg Code adopted internationally in 1947. It’s the basis for established medical ethical practices, such as informed consent, full disclosures and the rights of patients to refuse care or to participate in human experimentation. People no longer support having someone else, even a doctor, decide what’s best for them.

So, it might be helpful to examine healthcare reform proposals and how they will play out in real life and compare them to the fundamental guiding ethical principle of preserving people’s personal control over their own healthcare choices.

While there are variations of reform legislation, most are patterned after HR 3200, the one supported by the White House. Here’s the link to the Government Printing Office's authentic text of HR 3200. We don’t need to take anyone else’s word for what it does or doesn’t say. We can read it for ourselves. In doing so, we quickly see that “health care choices” means something very different to the government than it means to most of us. Follow along with a few examples:

Choice of plans

Section 141. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES COMMISSIONER (begins on page 41). — This establishes a new executive branch of the U.S. Government called the Health Choices Administration. It would be headed by a Health Choices Commissioner appointed by the President and confirmed by the Senate.

SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER. — The Commissioner would be given the power to decide the standards for qualifying health care plans, including the enforcement of its standards “in coordination with State insurance regulators and the Secretaries of Labor and the Treasury.” The standards the Commissioner would determine include premiums, how much providers are paid, covered treatments, drug coverage and administrative procedures.

As Sue Blevins, Editor of Health Freedom Watch explained in the latest newsletter, the Health Exchange Commissioner would have control over more than $700 billion federal dollars. “However, the Federal Acquisition Regulations (to promote competition and keep contractors ethical) would NOT apply to contracts between the Commissioner and insurance companies offering plans in the exchange.”

The Commissioner is given authority to enforce compliance with participation in a plan with qualified benefits, with remedies that include “civil money penalties” and “suspension of enrollment of individuals…until the Commissioner is satisfied that the basis for such determination has been corrected and is not likely to recur.” It can also suspend payment to providers participating in a nonqualifying plan.

The legislation defines “quality” later in Section 2410, as pay-for-performance measures, adherence to best practices established by the director and which incorporate electronic medical records that “provide for the dissemination of information and reporting.”

SEC. 201. ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE; OUTLINE OF DUTIES; DEFINITIONS (begins on page 72). — This establishes a Health Insurance Exchange under the direction of the Commissioner. It would have full control over what health plans we can legally have. It would determine the “variety of choices” to be part of quality health insurance coverage, different levels of required benefits, affordability and access of individual and employers.

The Commissioner “shall establish standards for, accept bids from, and negotiate and enter into contracts with” entities wanting to offer qualifying plans through the Health Insurance Exchange.

SEC. 202. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS (begins on page 73). — Unless people are enrolled in a Commissioner-determined qualified plan or other acceptable coverage, all eligible individuals are to be enrolled into a plan offered through the Health Insurance Exchange. “Other Acceptable Coverage” is defined on page 76 as being other government qualified health plans, Medicare or Medicaid, a member of the armed forces (including Tricare) or coverage under the veteran’s healthcare. In other words, health coverage and covered benefits for everyone would be determined by the government.

As described in SEC 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE (beginning on page 16), individual health insurance coverage is grandfathered in and current group health plans are also “Acceptable Coverage” only as long as “the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1 [January 1, 2013].” An employer-based plan must meet the same requirements as apply to a qualified health benefits plan, including the essential benefit package requirements. After January 1, 2013, all individuals must purchase health insurance from the government-run national health insurance exchange.

SEC. 204. CONTRACTS FOR THE OFFERING OF EXCHANGE PARTICIPATING HEALTH BENEFITS PLANS (beginning on page 88). — Entities offering plans allowed to participate in the Health Insurance Exchange must be licensed by the state and “shall provide for the reporting of such information as the Commissioner may specify…” The Commissioner will also determine what makes an acceptable provider network and enforce those standards. The Commissioner also “shall collect data for purposes of carrying out the Commissioner’s duties, including for purposes of promoting quality…”

How is the legislation comparing so far with the ethical principle of preserving individuals' control over healthcare choices?

Choice of providers

SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS (page 24) — The Commissioner is awarded the authority to establish the adequacy of network providers in terms of the services and treatments they may provide and their costs.

As ENFORCEMENT OF NETWORK ADEQUACY on page 92 describes, an individual who is enrolled in a plan or receives services from a provider that is not within such networks will be required to pay the same costs as if services were provided by a doctor within the government network. In other words, people will no longer be allowed to independently contract with a provider and pay them an agreed upon price for their services. The ability of doctors to have their own practices is virtually eliminated. The Commissioner may terminate a contract with any healthplan found to be noncompliant and to include providers who provide care outside the standards and costs established by the Commissioner.

Under OVERSIGHT AND ENFORCEMENT RESPONSIBILITIES, the “Commissioner shall establish processes, in coordination with State insurance regulators, to oversee, monitor and enforce applicable requirements… of entities offering Exchange-participating health benefits plans and such plans, including the marketing of such plans.” The Commissioner may terminate any contract if such entity fails to comply with any requirement.

Choice of benefits

SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE. — The benefits and premiums for qualified coverage would be established by a “private-public advisory committee” chaired by the Surgeon General called the “Health Benefits Advisory Committee.”

SEC. 203. BENEFITS PACKAGE LEVELS (beginning on page 84). — “The Commissioner shall specify the benefits to be made available under Exchange-participating health benefits plans during each plan year.” It will also enter into contracts with an entity offering a qualifying plan if it offers only one basic plan for the service area and if it offers an enhanced plan, it “may offer one premium plan for such area.” In other words, the Commissioner will restrict options available in each service area.

Section 122. ESSENTIAL BENEFITS PACKAGE DEFINED (begins on page 26). — The legislation lists the mandatory benefits a plan must include to be qualified, including prescription drugs, mental health and substance use disorder services, preventive wellness services, maternity care and other coverage, regardless of if they are needed or desired by the patients or of their efficacy and cost effectiveness. It sets essential minimum benefits at 70% of actuarial value, making high-deductible plans or traditional insurance — where people pay can pay for routine care themselves and purchase insurance just to cover major medical events — illegal.

Only managed care plans with preventive wellness interventions will be permitted. As SEC. 1711. REQUIRED COVERAGE OF PREVENTIVE SERVICES on page 764 explains, preventive services are required covered benefits.

SEC. 3121. NATIONAL PREVENTION AND WELLNESS STRATEGY (beginning on page 934). — As this legislation describes, key to healthcare reform mandates is a national strategy prioritizing preventive wellness activities headed by the Secretary. Under TITLE XXXI — PREVENTION AND WELLNESS (page 931+), the legislation funds $2.4 billion next year, increasing annually to $4.6 billion for fiscal year 2018 of taxpayer dollars to go for preventive wellness programs and infrastructures. **

Choice to opt-out or self insure

SEC. 311. HEALTH COVERAGE PARTICIPATION REQUIREMENTS (beginning on page 143 under Title III). — This section requires employers to offer a plan that qualifies according to the Health Insurance Exchange and to automatically enroll employees into the plan, unless the employer opts out.

SEC. 321. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT (beginning on page 152). — The Secretary is authorized to conduct regular audits of employers and plans to discover noncompliance with health coverage participation requirements and to report findings of noncompliance “to the Secretary of the Treasury and the Health Choices Commissioner. The Secretary shall take such timely enforcement action as appropriate to achieve compliance.

SEC. 410. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE (page 167+). — The Internal Revenue Code is amended to impose a tax on anyone caught without acceptable coverage.

SEC. 431. DISCLOSURES TO CARRY OUT HEALTH INSURANCE EXCHANGE SUBSIDIES. — This amends the Internal Revenue Code of 1986 to add a mandate for “disclosure of return information to carry out Health Insurance Exchange subsidies. The IRS “shall disclose to officers and employees of the Health Choices Administration or such state-based health insurance exchange, as the case may be, return information of any taxpayer is relevant in determining any affordability credit…”

SEC. 1801. DISCLOSURES TO FACILITATE IDENTIFICATION OF INDIVIDUALS LIKELY TO BE INELIGIBLE FOR THE LOW-INCOME ASSISTANCE… on page 819 also requires the Social Security Administration to disclose all return information to the Commissioner, benefits and retirement payments, “unearned income information and income information of the taxpayer from partnerships, trusts, estates, and subchapter S corporations for the applicable year,” and filing status, number of dependents, income from farming and from self-employment, if the individual is married and if the spouse filed a separate return.

How is the legislation comparing so far with the ethical principle of preserving individuals' control over healthcare choices?

Choice for coverage beyond government plan

SEC. 208. OPTIONAL OPERATION OF STATE-BASED HEALTH INSURANCE EXCHANGES (beginning on page 111). — This section gives the Commissioner control over any state-based Health Insurance Exchange, to approve them and determine requirements for approval, and to shut them down for noncompliance.

TERMINATION; HEALTH INSURANCE EXCHANGE RESUMPTION OF FUNCTIONS on page 114 explains, “in lieu of terminating such approval, the Commissioner may temporarily assume some or all functions of the State based Health Insurance Exchange until such time as the Commissioner determines the State-based Health Insurance Exchange meets such requirements.”

The Commissioner also retains enforcement authority and to specify the functions any state run insurance change may not provide. As Blevins explains, “state-mandated benefits (coverage beyond the essential benefits package) could only continue if states reimburse the Commissioner for continuing their regulatory regimes.” Any pretense that state co-ops could really be independent is unsupported in this legislation.

Choice over personal finances

The Commissioner would also be empowered to determine what each person can afford and to administer “individual affordability credits, including determination of eligibility for such credits.” The IRS tax code would be used to enforce compliance.

SEC. 242. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL (beginning on page 132). — The legislation defines any eligible individual to mean anyone enrolled under a plan in the Health Insurance Exchange, with a family income below 400% of the Federal poverty level (for example, $88,200 for a family of four in Virginia) and not Medicaid eligible.

SEC. 243. AFFORDABLE PREMIUM CREDIT (beginning on page 135). — The government will determine what premium individuals can afford to pay. As PROGRAM INTEGRITY; INCOME VERIFICATION PROCEDURES on page 139 explains, “the Commissioner shall take such steps as may be appropriate to ensure the accuracy of determinations and redeterminations under this subtitle.” This includes the Secretary of the Treasury disclosing to the Commissioner all such information as may be permitted to verify income, family size and composition. Also, the “Commissioner shall establish rules requiring an individual to report…significant changes in such income (including a significant change in family composition) to the Commissioner and requiring the substitution of such income for the income otherwise applicable.”

How is the legislation comparing so far with the ethical principle of preserving individual's control over healthcare choices? To preserve the appearance of freedom of choice, some have suggested that the public option be taken out of the legislation or repackaged as health insurance co-ops. But both suggestions are Trojan horses and ignore the underlying threats to people’s autonomy over their bodies, livelihoods, and healthcare choices that are found throughout legislation.

Simply eliminating the public option — Section 221 (page 116+) that establishes a public option, gives the Secretary unlimited authority to set payment rates and services and to determine what is sufficient and efficient care, exempts the public plan from review or recourse through the courts, authorizes the Secretary to devise policies and payment mechanisms under the medical home model to manage or prevent chronic illness and promote managed care pay-for-performance (“quality”) measures, and gives the Secretary the authority to establish the conditions and the pay for healthcare providers — won’t remove the fundamental concerns about healthcare reform legislation.

It does not eliminate the fact that the federal government, not individuals, would be given control over personal health care choices.

© 2009 Sandy Szwarc

** The proposed solution for reducing healthcare costs is foremost to put the nation on a weight loss diet. As the President said last week to the Organizing American National Health Care Forum:

If we went back to the obesity rates that existed back in the 1980s, the Medicare system over several years could save as much as a trillion dollars. I mean, that's how much our obesity rate has made a difference in terms of diabetes and heart failure and all sorts of preventable diseases. And so what we want to do is to, first of all, in health care reform, in the legislation, encourage prevention and wellness programs by saying that any health care plan out there has to provide for free checkups, prevention, and wellness care. That's got to be part of your deal, part of your package. And that way nobody has got an excuse not to go in and get a checkup.

It’s similar to the speech he gave to the American Medical Association on June 15^th (covered here), in which he claimed preventive health screenings, mammograms and management of health risk factors, like a “Healthy Measures” program, can prevent the costliest chronic diseases — cancer, cardiovascular disease, diabetes, lung disease and strokes. Most important of all under his plans is ridding the country of obesity. “It means going for a run or hitting the gym, and raising our children to step away from the video games and spend more time playing outside,” he said. “It also means cutting down on all the junk food that's fueling an epidemic of obesity which puts far too many Americans, young and old, at greater risk of costly, chronic conditions,” he said.

As HHS Secretary Kathleen Sebelius said at last month’s Weight of the Nation, the government’s preventive wellness policies to transform our healthcare system plan “to put the nation on a weight loss diet.” At the heart of President Obama’s healthcare reform is fighting obesity, she said, which is why the government has made preventive wellness one of its top priorities.

As covered previously, the long-term effectiveness of weight loss diets has yet to be supported after nearly half a century of research. And beliefs of cost savings from preventive wellness and treating risk factors and incentivizing healthy lifestyles, along with integrated electronic medical records, have also failed to be supported in the medical literature. The cost-savings argument for most health promotion and disease prevention measures cannot be supported “because the evidence is simply not there,” concluded a review of the research by the Canadian Health Services Research Foundation based in Ottawa. “An ounce of prevention buys a pound of cure” is a myth, it stated. Benefits of mammograms, for instance, have been repeatedly found in the medical literature to be more controversial than the public realizes, with some expert bodies concluding they fail to be a justifiable use of public funds because of their marginal benefits, substantial harm and significant costs.

The Congressional Budget Office has calculated that healthcare reform legislation, depending on the version, would add $1 to $1.6 trillion to the national debt over the next ten years. Doug Elmendorf, director of the CBO, stated in an August 7^th letter that “researchers who have examined the effects of preventive care generally find that the added costs of widespread use of preventive services tend to exceed the savings.”

While the lack of evidence for preventive wellness and treatment of health risk factors has been covered at length at JFS, Charles Krauthammer’s editorial in Investor’s Business Daily last week emphasized the mythology of prevention:

A study in the journal Circulation found that for cardiovascular diseases and diabetes, "if all the recommended prevention activities were applied with 100% success," the prevention would cost almost 10 times as much as the savings, increasing the country's total medical bill by 162%. Elmendorf additionally cites a definitive assessment in the New England Journal of Medicine that reviewed hundreds of studies on preventive care and found that more than 80% of preventive measures added to medical costs...

[Prevention] is not the magic bullet for health care costs…. remember: It's nonsense — empirically demonstrable and CBO-certified.

Commentary: Dr. Obama Plans to Put You on a Diet.

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Online social media — marketing in disguise

Millions of Americans have received emails and read blogs and commentary on social media sites and never realized that what they were reading was carefully crafted marketing messages from the government — paid for with their tax dollars and manipulating them to support government agendas, programs and legislation.

Today’s news exposed that the White House had hired a private social marketing firm to distribute mass emails and unsolicited spam to sell President Obama’s health care plan. The firm, GovDelivery.com —“the email and digital subscription management company for the government” — hired last January by the White House, has handled social marketing emails to sell the administration’s campaigns on a range of issues, including its Supreme Court nominee and healthcare reform.

This is not news, of course. JFS has been cautioning for years that social media marketing sites and blogs are inundated by entities who are not who they seem, even as they’ve skyrocketed to popularity. GovDelivery has also made no secret of its success and the fact that it has been hired by more than 250 government agencies and sent out more than 118 million emails in January alone. People weren’t paying attention.

In a March 10^th press release, the St. Paul, Minnesota company, said it expected the government to send out more than 1.5 billion emails this year through its service. Earlier this week, Inc. Magazine rated GovDelivery as one of America’s fastest-growing private companies, with a total of 300 government entities, including over half of all federal agencies, state, county and city governments.

Scott Burns, co-founder, was quoted in Washington Technology in July, saying: “To me, technology is the biggest opportunity we have to make citizens better citizens and government better government.” But concerns have been raised about how the government is gathering the emails of private citizens and when does government “communications” to citizens cross the line to propaganda and monopoly on information, squelch debate and steer public discussions? Can citizens critical of the government have an effective voice against 1.5 billion emails, armies of online trolls and social media marketing paid for with unlimited government funds?

Swine Flu, The Brand. One of the most unsettling examples of GovDelivery being used by the government has been the social media marketing campaign by the CDC to build panic over a “swine flu” pandemic. GovDelivery said it helped “brand” swine flu and grow the CDC’s email lists by 103,000 in just two weeks. The U.S. Department of Health and Human Services has used GovDelivery to spread “awareness” of a “H1N1 pandemic emergency” through a combination of email, social media, compelling content, and creative marketing approaches, as it explained at a Federal Consulting Group seminar on May 28^th. It’s been effective in raising fear and media coverage far beyond the science and evidence that’s shown the virus to not be particularly dangerous. It has helped to build support for the CDC’s pandemic recommendations for businesses that will risk shutting down businesses and the economy; its plans for mass vaccination of half the country's population within months; and its recommendations for H1N1 vaccinations, even though the clinical trials to determine effectiveness, dosage and safety and side effects aren’t due to be completed until mid- to late-October.

As JFS has examined, it’s easy to manipulate public opinion. Saturating the media, giving more attention to a scare and increasing “public awareness” serves to heighten perceptions that the danger is real and the threat is significant. We see that with all types of disease mongering, camouflaged as health education. We see it with messaging about healthcare reform that counters what’s in the actual legislation if anyone took the time to read it.

As Peter Wason’s research showed nearly half a century ago, few people test their beliefs. Most people resort to social consensus to judge the truth of a belief, as research at the Institute for Social Research at the University of Michigan, Ann Arbor, showed. If a lot of “people” around them appear to believe something, most people think there must be something to it. Most people want to be accepted and don’t want to seem different from the group to speak out or to think for themselves.

Marketing professionals understand the psychology of disinformation and fallacies of logic better than most consumers, which is why social media is the fastest growing marketing venue. According to the Association of National Advertisers, two-thirds of marketers use social media and it’s expected to grow to a $3.1 billion industry over the next five years.

Please be careful out there. Do your own research, go to original sources and think for yourself. The source of a belief and its popularity are never measures of its credibility — some of the greatest pseudoscience and falsehoods have been wildly popular and issued from reputable institutions and sources. Learn about the fallacies of logic and psychology of disinformation being used to sell you something. Don’t wait to see what’s popular among your online “friends.”

© 2009 Sandy Szwarc

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The sky is not falling … again

Once again, the biggest health story of the year has found that we are healthier and living longer than in the history of our country.

The latest vital statistics data from the CDC National Center for Health Statistics was just released. It is based on statistics representing 91 percent of the demographic file and 87 percent of medical records for all deaths in the United States in 2007. This data is compiled each year to guide public health resources.

Just like last year, life expectancy hit another record high. “Life expectancy at birth for the total population in 2007 reached a record high of 77.9 years,” the CDC report stated.

Despite those continuing to make that doomsday prediction that “today’s children are destined to be the first generation to have shorter lifespans than their parents — unless drastic action is taken to slim them down” — the facts continue to show the opposite. Every year, in fact, the government’s actual health data has shown that our children are living longer and healthier lives than ever. There’s not even a hint to indicate that that could change. Babies born in 2007 can expect to live to 75.3 years for boys and 80.4 years for girls.

Life expectancy has been increasing for more than a century. By comparison, babyboomers born in 1950 had a life expectancy of 65.5 and 71 years, men and women respectively. And our grandparents born in 1900 had a life expectancy of a mere 48 and 51 years, respectively.

The 2007 mortality rate was 8.03 per 1,000 people — half of what it was just 60 years ago (15.32 per 1,000 in 1947).

For the first time, life expectancy for black males reached 70 years.

Nearly 3 out of 4 deaths (72%) occur in the elderly. Yet, even the oldest among us are fairing better. Mortality dropped 2.7 percent among those 65-74 years of age and dropped 2 percent for both those 75-84 years of age and those 85 years of age and over. [And the CDC reports that about two-thirds of seniors age 75+ report being in good to excellent health, see below.]

The highest rates of deaths among those 15 to 44 years of age were due to accidents (largely motor vehicle). And among those under 24 years, the second largest cause of death is homicide. These are clearly largely unrelated to healthcare or today’s pop wellness movement. In fact, when Dr. Robert L. Ohsfeldt, professor of Health Management and Policy at the University of Iowa and Dr. John E. Schneider, with the VA Medical Center in Iowa City, IA, compared health statistics of the United States with other countries, they found that when they controlled for homicides and traffic accidents, the United States ranked #1 in the world for life expectancy.

The new CDC report also found that death rates from the major causes of death among Americans continue to fall: Heart disease is down 4.7 percent from the previous year; cancer deaths have fallen 1.8 percent; deaths from strokes have fallen 4.6 percent; diabetes is down 3.9 percent; influenza and pneumonia down 8.4 percent; hypertension and hypertensive renal disease down 2.7 percent. In fact, 12 out of the 15 main causes of death have gone down or remained stable.

The exceptions are from diseases associated with the most advanced aging, such as Alzheimer’s, lower respiratory disease and Parkinson’s disease.

Once again, no matter how much the actual data about the state of our health continues to getter better every year, “preventive wellness” and government bureaucrats continue to try to paint the facts as doom and gloom — perhaps, hoping that we won’t put the incongruent pieces together. Dr. David Katz, M.D., MPH, director of the Yale University School of Medicine Prevention Research Center and the Integrative Medicine Center, for example, told media “I suspect we may be living longer not because of improvements in health, but thanks to the ability of high-tech, high-cost medicine to forestall death despite a growing burden of chronic disease. That means we may be adding years to life while reducing the life and vitality in those years, a very dubious bargain.”

We’ll set aside all of the public hype about how awful our healthcare system is supposed to be, and point out that this negativity ignores the other government health report that just came out: The Vital and Health Statistics, 2008. This is the National Health Interview Survey data conducted by the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics to give an ongoing picture of the health of U.S. adults.

Over 90 percent of Americans (90.2%) reported being in good to excellent health! This is even higher than last year’s report, when the figure was 88%.

That is pretty remarkable, especially given the nonstop drumbeat trying to convince us that we’re all fat, diseased and doomed by unhealthy foods, air and water.

The sky is still not falling.

© 2009 Sandy Szwarc

Click here for complete article (and single page version).

Our shared humanity

“Diversity” and “acceptance” have become politically correct ideas and appear in countless employee policy manuals and mission statements of nonprofit groups. As well-intentioned as they may be, they also hold a troubling side.

As we’ve seen, advocacy for stigmatized groups can disguise and foster prejudices of the very same group. Seldom recognized is that behind “diversity” and “acceptance” can also hide disturbing prejudicial and racist beliefs. Like all prejudices, they can lead to greater divisiveness, and be used as a technique to keep discriminated people even more oppressed and separated.

When it comes to acceptance of individuals who look and live in ways that are different from ourselves or who don’t conform to what society views as correct, our acceptance, even tolerance, of others is put to the test. If we look closely, our society really isn’t tolerant of those who are autonomous and independent. The evidence comes in how our society or social group defines “diversity.” We say we support diversity — but have we thought about what it really means?

Philosophy professor Bert Olivier at Nelson Mandela Metropolitan University in Port Elizabeth, South Africa, wrote a thought provoking article in the Mail & Guardian this week examining diversity. His article is a continuation of one he wrote last week on the importance of understanding what it means to be autonomous. That definition is critical to understanding his description of how today’s concepts of diversity and acceptance manipulate and divide us. As he explained:

Why is this important for understanding what it means to be autonomous? If all human beings are shaped by discourse — which includes not only the languages they use, but the actions they perform, too — the widespread hold that dominant discourses have on people’s actions can be resisted in only one way: a person has to claim for him or herself a different discourse, one of what Foucault (in his study of ancient Hellenistic, that is, Greek and Roman societies) refers to as “self-mastery”.

Importantly, self-mastery does not depend on “information” as much as on the difficult, painstaking development of the ability to distance oneself from those agencies that constantly tend to “infantilise” people, by treating them as if they are children, incapable of thinking and acting as (relatively) autonomous beings. Such agencies are all around one, even more so than during the Hellenistic era, given the “bio-power” that governments, the media, economic institutions like corporations and churches wield over people’s lives today.

But don’t make the mistake of thinking that it is easy to adopt a radically different discursive stance in the face of the dominant discourses that surround one and have shaped the actions of the vast majority of people on Earth today. It is very difficult, especially because it requires nothing less than systematically changing the way in which one thinks and — even more important — acts in society… that stands in stark contrast to everything that we have inherited from Christianity as well as from Western modernity (all of which, by large, exhort one to be “obedient” — whether to the church, the state, or more subtly, to the behavioural models promoted by the media — rather than to think and act “autonomously”).

Being your own self is hard. Being accepted, even while being different, is even harder. What does acceptance of diversity mean? “Diversity” is bandied about as if its meaning is self-explanatory, he wrote, but it’s not. As he explained:

Ostensibly “diversity” denotes first and foremost … diversity of people in terms of race and we should add — because these cannot be separated — culture. And to respect such diversity or differences is surely a good thing. But should we respect diversity for its own sake or is there something tacit, unspoken, behind the exhortation to respect diversity or differences in this context? Surely apart from the wonderful richness imparted to experience by racial, cultural (and natural) diversity, the tacit implication is that there is something more fundamental that makes diversity something valuable, not merely from a cultural perspective but also from a moral one.

And how far should we go in our respect for diversity? ONLY as far as racial and cultural differences? Most people would probably say no to this question because one cannot forget gender differences or disability as a mark of diversity, especially when it comes to different needs. But once gender differences and disabilities have been included, is that how far our consideration of diversity should go?

We mark our acceptance of diversity by choosing what we won’t discriminate against, such as race, gender and disability. And we itemize them in anti-discrimination and diversity policies, but does that really mean our society accepts diversity? How far are we willing to go towards acceptance of differences, beyond the aesthetic? Are all differences equally valuable?

As he walked readers though these questions, Professor Olivier pointed out: “Again we are confronted by the implication, that, at least at a moral level, there is something more fundamental than mere diversity that demands our respect, and that diversity, or individual as well as cultural differences themselves, should be judged in terms of this ‘something’.” He argued that if we truly accept diversity and do not discriminate against people, we should value diversity further.

[C]ategories such as race, culture, gender and (dis)ability are broad, descriptive categories under which innumerably many individual differences are subsumed. It is so easy — too easy — to stop thinking at that point where diversity of race, culture, gender and “able-bodied-ness” has been invoked for political correctness’ sake. In a sense, that was the mistake (a huge mistake) made by the architects of apartheid. I recall debates where, against my claim that it is wrong to discriminate (with detrimental consequences that is) on the basis of race, defenders of apartheid claimed that they were not “discriminating” but simply showing a respect for racial differences (that is, diversity). Hence the policy of “separate development.” They were merely (they claimed) creating the political circumstances where racial and cultural differences could flourish.

Needless to emphasise, such racially charged rhetoric hides a more fundamental “racism.”

Mandela recognized the limits of recognizing diversity in terms of race. “Here we encounter one of the most important considerations in the pursuit of (the valorization of) diversity,” wrote professor Olivier. The slippery slope is evidenced in today’s growing movement among advocacy groups to exclude, censure and create dissent and distrust of those who aren’t white enough or fat enough or disabled enough to understand their discrimination. Those who are privileged, must atone for their accident of birth. As he recognized in the apartheid movement, discriminatory charged rhetoric hides more fundamental prejudices. He cautioned:

In other words, today, too, one should be very careful in promoting the notion of diversity. Not to do it to the point where the shared humanity of all people, regardless of cultural and racial differences, is simply ignored. It is so easy to classify someone as NOT belonging to one of the categories of people who should be privileged and prioritised in certain ways in the current political dispensation (justifiable as such privileging may be to a certain degree, in view of past disadvantages) and then to discard such a person as not being worthy of the epithet “human.” Given the individual differences among people, the talents and abilities of such individuals are often much needed for making extant society a “better” one.

One sometimes encounters a view such as the one referred to above among those people who, given the past wrongs committed in the name of patriarchy, believe that men — particularly white men — should be sorry and apologetic about the fact that they are men. By implication men do not really make the grade as “human.” Such a prejudice overlooks the fact that the only way to improve society is to work towards a non-patriarchal society — something that cannot be done without men, that is, without changing men’s attitudes. But this means that they ought to be given a chance to do so. “Men” are unavoidably part of a diverse society. The same could be argued about any other group of individuals with a distinct “group-identity”, whether it is a race, cultural or religious group — all of these diverse groups should be recognised as adding to the diversity of society. Tolerance of any such group’s activities is therefore also required of everyone else, although it is important to acknowledge that the limits of tolerance lie in the ability of others to tolerate or be sensitive to one’s own unique difference. In brief: intolerance should not be tolerated.

We cannot afford to ignore that the “policy of separate development (apartheid) was ultimately irreconcilable with the very democratic tradition of the West,” he wrote. Racial differences came to be viewed as sufficient reason to exclude some races from the family of humans. Before we fragment ourselves into countless special interests as we look for concepts to define our differences, each intolerant of the other, we need to see that we’re overlooking the most fundamental concept of all. That is our humanity.

“We should not make a similar mistake again: the recognition and promotion of diversity and difference should not blind us to what we have in common,” he said.

© 2009 Sandy Szwarc

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The scientific process in action — Where is the evidence for governmental efficiency?

Scientific literacy isn’t the stuff found in a science textbook. That’s science literacy — and, while understanding the principles of science is important too, it’s not as important as knowing how to think and reason. Scientific literacy means the scientific process — also known as thinking critically and logically. It’s a way to carefully look at information, question ideas and test them, and make decisions based on the best information and evidence. It’s what protects us from being taken in by unsound things or letting the fallacies of logic* get the better of us. What might feel intuitively correct to us, and everyone around us, often isn’t.

The scientific process is what ordinary people do — no fancy degree required. According to Dr. Jon D. Miller, Ph.D., director of the Center for Biomedical Communications at Northwestern University Medical School in Chicago, has tracked scientific literacy for more than thirty years and said that only 20-25 percent of Americans are “scientifically savvy and alert,” and that most of rest of us “don’t have a clue.” The National Science Foundation estimates that 70% of Americans don’t understand the scientific process, or how to think.

Metacognitive research has also shown that the more emotional and the more emotionally involved people are in an idea, the harder it is to apply the scientific process and question or test their beliefs. That’s what makes the exception being seen in the debates over healthcare reform so remarkable. Growing numbers of ordinary people are questioning things they hear, going to original sources, and trying to reason through the information for themselves. Most interestingly, the questions they raise are often better than anything the experts can answer.

Thought-provoking questions and missing answers

One writer whose questions best showed the thinking process in action said that after reading everything he could find, he found a “giant morass of conflicting claims” about healthcare and that the answers to good questions never really answer the questions. “In short,” wrote Robert S. Siegel, “I have seen no evidence that would cause me to believe that either of these approaches [a government health insurance option or single payer government run health insurance] will improve health care, but good evidence that both options will become major barriers to making real improvements to health care.”

See if his questions don’t jolt us all into looking beyond the media and to think through claims more critically for ourselves, too. As he begins:

1. How do we pay for all of this now and long term?...And costs will rise. What is the plan? I don’t accept that we just have to do this and can’t slow down to figure it out. Do supporters really understand how much this will cost? Convince me that you do.

2. What are these “Cost savings” that Obama talks about? Are we relying on one big negotiating entity to drive down costs? That has worked so well for military spending over the years (that was a satirical statement). The efficiencies that are supposed to come from this plan sound unrealistic, as though no one worked through the tactical details to see if there really are efficiencies to be brought out.

a. The plan to save money by fighting obesity is cruel and unrealistic…

3. If we move to single payer health care that means one entity will directly manage all health care spending and as a result, indirectly manage the entire health care industry. Do you know of any examples where one entity, public or private, runs something as large as 20% of the U.S. economy, and does it successfully?

a. What causes people to think that a government takeover of the bureaucratically complex business of medicine is going to make it less complex?...Better? How?...

4. If government health care does not work, do we have an exit strategy?...

My fundamental question, the summation of the above ten question is this: Will the plans currently under consideration improve health care or make the system worse than it is today? If you think it will be an improvement, can you please explain why, rationally and with facts and not hyperbole?

Show us the evidence

A Wall Street Journal article also asked healthcare reform advocates to “show us the evidence.” The author shared questions being raised by seniors, based on “experience and common sense.” Seniors have “exposed a fundamental truth about what Mr. Obama is proposing: Namely, once health care is nationalized, or mostly nationalized, rationing care is inevitable, and those who have lived the longest will find their care the most restricted.”

The existence of rationing is the argument being used to support universal health coverage. Because “rationing” exists in the free marketplace, it is argued that a government healthcare system is needed. The ability to pay is being called “rationing” when it comes to health care. “Yet no one would say we ‘ration’ houses or gasoline because those goods are allocated by prices,” it said. In a free market economy and a world of finite resources but infinite wants, every good and service could be said allocated by ability to pay.

But there’s an ocean of difference between coverage decisions made under millions of voluntary private contracts and rationing via government, the author wrote. “The problem is that governments ration through brute force—either explicitly restricting the use of medicine or lowering payments below market rates. Both methods lead to waiting lines, lower quality, or less innovation—and usually all three.”

Rationing isn’t a logical reason for universal health reform. As the author points out, rationing is found in universal health care throughout Europe, which restricts access to health care to control costs. And Medicare already rations care, refusing to pay for certain drugs, procedures and care. So, it asks, why would the President want to add to our financial burdens by expanding a Medicare-like program to everyone?

A similar question was posed in another Wall Street Journal article. The author, Alan B. Miller, is a hospital service administrator, but he pointed out what the general public may not know, although it’s well-known among medical professionals: The existence of private health insurance and private pay options is what has kept public plans possible.

“Medicare works because hospitals subsidize the care they provide with revenue received from patients who have commercial insurance,” he said. “Without that revenue, hospitals could not afford to care for those covered by Medicare.” Medicare payments to hospitals only cover about 93.1% of what hospitals spend when caring for Medicare patients, according to an independent congressional advisory, MedPAC.

“In effect, everyone with insurance is subsidizing the Medicare shortfall, which is growing larger every year,” Miller wrote.

Myth of government efficiency

There is no evidence that, as the claim goes, “by eliminating duplication, reigning in millionaire doctors, wasteful medical corporations, and gouging insurance companies, national healthcare will be better and more affordable.” There is no evidence that putting healthcare in the hands of the federal government and increasing the size of government, makes for more cost-effective healthcare or reduces healthcare spending. Far from it.

As James Simpson, an economist and former university instructor, was with the White House Office of Management and Budget (OMB) 1987 to 1993, wrote today in American Thinker, since the creation of Medicare and Medicaid in 1965, these programs have grown to cover increasingly more people and programs. Today, more than a third (36%) of all healthcare spending in the United States goes to government programs, Medicare and Medicaid. “Corrected for inflation, total federal and state government spending on healthcare has increased by 1,791 percent since Medicaid and Medicare funding began in 1967. That is a real annual growth rate of 44 percent, over 10 times the annual rate of economic growth for the same period!

Growth of public health care spending has far outpaced private spending, both in real dollars and per person. According to Centers for Medicare & Medicaid Services data, total private healthcare expenditures (in billions of dollars) increased 58% between 1960 and 2007, while public expenditures have increased 152.31%. Per capita, private healthcare expenditures increased 35.95%, while public healthcare spending per person increased 95.25% — nearly three fold more. Despite nearly 50 years of evidence, there is no support for claims that government managed healthcare is more efficient.

Using historical government data from the Office of Management and Budget, here is what the growth in government spending on healthcare since 1950 looks like, in billions of dollars:

Or, to see the growth in government healthcare spending as a percentage of the entire gross domestic product, which includes all industries in the nation:

It’s not unlike the Massachusetts’ experiment of the healthcare reform measures now being proposed for all of our country. Massachusetts’ plan is increasingly being propped up by federal funds (that’s us, the nation’s taxpayers), as it falls into insolvency. Government healthcare expenditures on free and subsidized insurance have doubled in just the past two years, while denying claims for medical care at nearly four times the rate of private insurers, cutting benefits, and raising premiums. With the state’s universal coverage program threatening to bankrupt businesses and patients, last month, the Massachusetts’ Special Commission on the Health Care Payment System proposed capitation and a complete restructuring of the healthcare system trying to contain costs, including a new executive branch that will decide how much money will be allotted to each type of patient.

The National Health Services in the UK is currently facing its most severe financial crisis in its history.

Canadian doctors with the Canadian Medical Association have been speaking out for years about the plight of its healthcare system, with expenses quadrupling in the last twenty years, more than one million people on waiting lists for care and five million with no access to a family doctor, and shortage of doctors with Canada ranking 26^th out of 28 countries in doctors per population. “We have one of the most costly and least efficient health systems of any industrialized country,” said Dr. Robert Quellet last year when he was elected to head the CMA.

Today’s news reports that the new incoming president of the CMA says the entire Canadian medical profession agrees that their system is imploding, that patients are getting less than optimal care, and that things are more precarious that even many Canadians may realize. “They have to look at the evidence… and realize what Canada’s doctors are trying to tell you,” Dr. Anne Doig said. At their annual meeting in Saskatoon today, the solution they are proposing is a move to more private health care delivery.

There is no evidence to support that the massive nationalized healthcare reforms being proposed will work to save costs or improve healthcare for all.

The evidence doesn’t exist.

© 2009 Sandy Szwarc

* There are a lot of fallacies of logic at work that make reasoned discussions about healthcare reform darn near impossible. But Mr. Miller touched on one of the biggest. “It is important that we take the time to fix only the parts of our system that need repair,” wrote Mr. Miller.

Did you guess the logical fallacy?

It’s the straw man fallacy. As Dr. Michael C. Labossiere explains, the straw man fallacy is committed when the actual situation is ignored and substituted by a distorted, exaggerated or misrepresented version. An example is overstating the number of uninsured and using it to call for a complete restructuring of our entire healthcare system, put the entire healthcare industry and everyone’s insurance under the federal government, and nationalize over 17 percent of the GDP — rather than accurately identify the uninsured and find a way to help what turns out to really be about 4 percent of the population.

As we’ve examined, the number of uninsured people is exceedingly smaller than popularly claimed. Nor is there any credible evidence to support claims predicting that tens of thousands of Americans are dying every year because they don’t have health insurance. In fact, a 1994 study by researchers at the National Heart, Lung, and Blood Institute at the National Institutes of Health found that people on public programs had higher mortality than either the uninsured or those with private insurance. But if the problem of the uninsured weren’t exaggerated, how likely would the country support a massive government takeover of their healthcare system?

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The myth of unhealthy belly fat

Before continuing with the obesity paradox series, one of the most important null studies of the year deserves mention… especially since the media universally ignored it. As the body mass index (BMI) is finally being recognized as an uncredible measure of health or predictive of premature death, other measures of body fat are being promoted because everyone “knows” that fat is unhealthy.

It’s inconceivable to contemplate that our condemnation of our body fat and of fat people might be little more than vanity, profit and prejudices. That increasingly seems to be the case, though, when we stop to think about why we remain so intent on finding a reason to condemn fat even when the null studies are far stronger than any others.

One of the most popularized new measures is waist circumference or waist-to-hip ratio, as an indicator of belly fat. It’s based on the belief that there is good and bad body fat, and that visceral fat — the fat that accumulates inside the abdomen — is the unhealthy, dangerous fat.

Null studies: No link, don’t blink

It’s not science itself that we can’t trust, it’s the stuff that often becomes pop science and cults masquerading as science.

Popular culture is topsy turvy when it comes to understanding science. Many people mistakenly believe that the strength of science comes in proving something. It’s actually the exact opposite. Science doesn’t prove anything. The ability of a carefully designed study to disprove a hypothesis is what sets science apart from pseudoscience. Those null findings that are unable to support a hypothesis or belief are the most important. Yet, we almost never about them and few people realize that those are the ones we should be paying attention to.

"As a scientist you are taught not to answer questions, but to question answers." — Anonymous

Null findings enable true scientists to know they’re looking in the wrong direction and that it’s time to go back to the drawing board and develop a different hypothesis. They also enable us to stop needlessly worrying about something that doesn’t matter. Null results are most vital to the progress of science and are the source of Albert Einstein’s famous saying: “No amount of experimentation can ever prove me right; a single experiment can prove me wrong.”

In fact, a big earmark of junk science and pseudoscience — or science being misused to sell us something or advance a special interest — is continuing to test and retest a belief long after it’s been disproven in well-designed studies. Building a body of research can lead unsuspecting consumers to believe that there’s a body of evidence in support of a belief. All studies are not created equal and the weight of the evidence does not come by tallying up the number of studies on one side or another.

Another common earmark of the misuse of science is trying to make the science appear conflicting and undecided, when it really isn’t, by burying us in an overwhelming number of conflicting studies. Unfortunately, these techniques can be quite effective when people don’t understand how to recognize a well-designed, strong study of merit versus a poorly-designed weak one.

The problem is accentuated when people aren’t armed with scientific literacy and fall back on fallacies of logic, especially the top five. When people don’t know the difference between studies that can be trusted from those that can’t, they get taken advantage of.

When scientists talk about a strong, sound study, they are referring to one that’s been well-designed to be a fair test of a hypothesis. That means one that has carefully controlled for biases. In science, “bias” doesn’t refer to the motives of a study’s author, but to specific aspects of study designs that can lead to faulty conclusions. Biases “stack the deck” and can be imposed in all sorts of ways, such as how the groups being compared are selected (randomized or cherry-picked, representative samples of the general population or from the Land of Ignognita); the quality of the data being measured (actually measured data or self-reported, recalled information or measured in real-time); and failing to control for confounding factors (contributing factors to mortality that could go along with the one you’re looking at, such as age or social-economic status).

Epidemiological (observational) studies — which use computer models to dredge through a chunk of information on a group of people to find correlations — are most rife with misinterpreted statistics, errors and biases, and are most easily manipulated to arrive at whatever conclusions researchers set out to find. That makes them especially helpful for marketing, too. Epidemiological studies make up the bulk of what’s funded, published and reported nowadays because they’re done in a computer and are cheap and easy to do. These are the studies most popularly reported as the health scare of the week and the health miracle of the week. They also cause epidemiological whiplash — coffee is bad for us one week and good for us the next.

They’re also the source of today’s never ending efforts to link our lifestyles, foods or the environment to some horrible disease.

The most common blunders when interpreting epidemiology are using correlations as evidence of causation and thinking that the findings are meaningful when they’re no greater than chance, computer error or random coincidence. In other words, failing to acknowledge a null study. No matter how popular, impressive or intuitively correct it might seem, a correlation to a disease is not evidence that it’s the cause. A correlation big enough to suggest a true link, and one that deserves our attention, is also much bigger than most people would guess. But it’s easy to trick people with statistics and lead them to believe that random chance findings mean something.

All studies are not created equal in another way, too. Each type of study is designed to answer specific questions and cannot credibly be used to conclude things it wasn’t designed to answer. When we hear about an epidemiological study finding something linked to higher risks for a disease, for example, it means the scientific process has barely begun to investigate a potential cause, let alone a treatment. Finding a correlation is just the first step in narrowing down potential factors in a disease. If a strong link is found, then an hypothesis about a potential cause is thought up and tested in a series of randomized, controlled clinical intervention studies. Only after an intervention has been tested in humans to see if it’s effective and if the benefits outweigh the harms does it suggest something we or our doctors might want to actually do.

In other words, when you hear about an association, don’t blink, sit back and wait for a study that actually tests something. Don’t YOU be the one who falls for the fallacy of correlations as evidence for causation. Even more importantly, look for those null studies. When a well-designed epidemiological study can’t even find a strong correlation, then that variable can’t possibly be the cause and you can relax and move on.

That’s why those null studies are so important for us.

The health risk factors said to be associated with obesity — high blood sugars and insulin resistance, high blood lipids (cholesterol and triglycerides) — and said to lead to diabetes, heart disease and premature death — are all blamed on visceral fat. These health indices have been lumped together and called the metabolic syndrome. The entire metabolic syndrome theory — which is being used to support endless preventive health screening tests and surveillance, "healthy eating" plans, exercise programs and prescription drugs (that are costly for us, but make gobs of money for those who want to manage our health) — is held up by beliefs about visceral fat.

This theory is evidence of the failure to understand risk factors and of how a belief can be built and take on a life of its own by ignoring null studies — in this case, layers of null studies.

Null link: BMI; waist, hip, and arm circumference; waist-hip ratio; waist-height ratio; skinfold thickness; and body fat — and all causes of death

Among the many studies showing no link, the most recent null studies were two independent analyses of the most precise measurements of body size, measurements and body composition available on a large representative sample of the U.S. population conducted by the Third National Health and Nutrition Examination Survey (NHANES III, 1988–1994) of the Centers for Disease Control and Prevention (CDC). As senior scientists at the National Center for Health Statistics at the CDC and the National Cancer Institute reported, the data shows that no higher measurement of body shape or size — BMI; waist, hip or arm circumference; waist-hip ratio; waist-height ratio; skinfold thickness or body fat composition measured by bioelectrical impedance — is predictive of higher risks of dying from all causes.

Nor was there a net benefit of using BMI versus another measurement. The data also found that NONE of the 21 diseases popularly attributed to obesity — those “obesity-related” diseases, including: cardiovascular disease, cancers (colon cancer, breast cancer, esophageal cancer, uterine cancer, ovarian cancer, kidney cancer, or pancreatic cancer) and diabetes or kidney disease — are actually associated with excess deaths at any BMI category, including obese.

Null link: waist circumference, waist-hip ratio, and visceral fat — and mortality, type 2 diabetes or cardiovascular disease

A second group of researchers examined the data using different statistical methods and reached the same results. They found no significant correlation between BMI, waist circumference or waist-hip ratio and risks for death from all causes among younger adults, while higher BMIs and waist measurements were associated with lower risks for dying among older adults. Tummy fat was not even linked to greater risks for premature death.

As they also noted in their review of the medical literature, while waist circumference has been more highly correlated with visceral fat than waist-hip ratio or waist-thigh ratio, studies to date have not consistently supported a correlation between abdominal fat or body fat distribution as predictive of mortality. Nor has waist circumference been consistently shown to be more strongly associated with type 2 diabetes, cardiovascular disease or mortality than waist-hip ratio.

Null link: visceral fat — and health outcomes or mortality or obesity or belly fat

Regardless of the fact that no association has been found between visceral fat and actual health outcomes or mortality, these null studies continue to be ignored. The visceral fat theory, which was first created by lumping together metabolic health risk factors, is now hanging its hat on a purported correlation with another surrogate measure for heart disease: carotid artery intima-media thickness.

We’re now really getting into risk factor (correlation) squared. Risk factors are being defined based on correlations with other risk factors based on other risk factors. All the while, ignoring the null studies.

With visceral fat found to have no association with obesity or belly fat, the theory now claims that even thin people with small waistlines are at risk from visceral fat based on a correlation with carotid IMT measurements. But this ignores the null studies that have found that carotid IMT measurements are not a measure of atherosclerosis, either. As Japanese researchers reported in the April 2001 issue of the journal Stroke found, “that increased intima-media thickness is a physiological effect of aging that corresponds to diffuse intimal thickening, especially in very elderly persons, and that IMT is distinct from pathological plaque formation.” Rotterdam Study researchers, using different methodology, found IMT added nothing to predicting coronary heart disease and cerebrovascular disease.

Null link: Metabolic syndrome — and cardiovascular disease or premature death

Even more significantly, while the metabo syndrome and all of its health indices are being used to promote a plethora of preventive health interventions and pills, none of the metabolic risk factors being attributed to visceral fat in the first place has been shown to have a meaningful correlation to cardiovascular disease or premature death.

Fallacy of looking for causal role where there’s not even a link

Abdominal fat and metabo. So, we have null studies that have found no tenable correlation between any “obesity-related” metabolic risk factor and waist circumference or any body measure or abdominal fat. But those null studies were ignored and the search for a causal role has continued to look where no link has even been found. That’s not how good science works.

So, what do you think researchers at Washington University School of Medicine in St. Louis and the Istituto Superiore di Sanità Rome in Rome, found when they performed a clinical study to test the hypothesis that abdominal fat was the cause of “obesity-related” metabolic risk factors and that reducing abdominal fat could lower those risk factors?

They recruited 15 obese women with abdominal obesity (average BMI 35.1) willing to have extensive liposuction to remove 28-44 percent of their abdominal fat (an average of an astounding 22 pounds of abdominal fat from each of them). Over the next four months, the women were clinically monitored. As the researchers reported in a June 2004 issue of the New England Journal of Medicine, even after physically removing a significant amount of abdominal fat they found no effect on any metabolic lab measure (insulin sensitivity of muscle, liver or adipose tissue; glucose; C-reactive protein; interleukin-6; tumor necrosis factor {alpha}; and adiponectin) or other risk factor for heart disease or diabetes (blood pressure, plasma glucose, insulin, and lipids).

This research had been led by Dr. Samuel Klein, M.D., who was actually medical director of the Weight Management Program at Washington University School of Medicine and at that time was president of the North American Association for the Study of Obesity (now the Obesity Society). With grant and research support from a range of pharmaceutical companies, he also served on the Consensus Conference Panel of the American Society of Bariatric Surgery (now called the American Society for Metabolic and Bariatric Surgery), in their 2004 Consensus Statement recommending bariatric surgery as “the most effective therapy available for morbid obesity and can result in improvement or complete resolution of obesity comorbidities.”

But as he admitted in a Clinical Cornerstone, the failure of liposuction to reduce metabolic risk factors and the seeming favorable effects of bariatrics on those metabolic risk factors has not been shown to be due to reducing fat, but by “inducing a negative energy balance.”

While bariatric surgery and diet and weight loss is said to resolve “comorbidities associated with obesity” and to cure type 2 diabetes, high cholesterol and high blood pressure, as JFS has examined at length, these health claims are based on temporary drops that occur in these health indices during any period of caloric restriction, starvation and weight loss — even before much weight or fat loss has occurred at all. It’s not about fat.

As examined here last year, when you stop eating, eat insufficient calories, or suffer from malabsorption, what happens to your blood sugars? They drop, of course. Does that mean the underlying disease pathology of diabetes has been cured or arrested? Of course not. Blood sugars are a symptom, a health index, not the disease of diabetes itself. Dr. Francesco Rubino, now at New York Presbyterian Weill Cornell Medical Center, and Dr. Jacques Marescaux, M.D. at the University Louis Pasteur in France, wrote in the 2004 issue of Annals of Surgery that claims “a direct antidiabetic effect of bariatric surgery... is not supported scientifically.” As they explained, “it is admittedly impracticable to rule out that the rapid normalization of plasma glucose and improved insulin resistance after these surgeries be simply the effect of decreased caloric intake.”

Despite the null studies, the belief that belly fat and metabo are bad have continued virtually unchecked.

Visceral fat and metabolic syndrome. The “obesity is deadly” belief still rests on visceral fat as being “particularly pernicious to health” because of its purported causal role in the metabolic syndrome. The metabolic syndrome theory mistakenly attributes obesity-related risk factors (including blood sugar, insulin resistance, blood pressure and blood lipids) as causing diabetes, heart disease and premature death. Visceral fat is largely genetic, as well as appears greater with aging, yo-yo dieting and emotional stress.

Yet, the strongest, well-controlled null epidemiological studies have found no correlation between visceral fat itself and “obesity-related” metabolic risk factors, adverse health outcome or premature death. The importance of null studies hasn’t been understood.

So, what do you think researchers found when they conducted the definitive study (a randomized clinical trial, the gold standard) to confirm once and for all if visceral fat has anything to do with metabolic health risk factors?

If visceral fat had a real link to metabolic risk factors, then surgically removing it would change those metabolic measures and finally settle the question of whether the visceral fat theory has any merit. As Dr. Klein had written: “The true test needed to determine whether visceral fat is deleterious is to surgically remove visceral fat and see if that results in a beneficial metabolic effect.” The largest portion of visceral fat in our bodies is found in the omentum, a large apron of fat inside the abdomen.

Incredibly, 70 adults (average age 37) agreed to participate in a randomized clinical trial at the University of Chile in Santiago, where half would have their visceral fat (the entire omentum) surgically removed and half would have surgery without removing the omentum. The study results were published in the April issue of Obesity Surgery.

The study participants were all obese, with an average BMI of 43. Were the participants told that their risks of premature mortality are no different than people with “normal” BMIs or did they agree to participate in such an extreme clinical trial, and a surgery that even the bariatric surgeons admitted was difficult, because they believed their obesity put them at greater risk for dying? All of the participants otherwise received that same treatment, gastric bypass, and all had their metabolic risk factors — weight, blood pressure, blood sugar, insulin, serum cholesterol and triglycerides — evaluated before the surgery and two years afterwards.

Two years later, there was no significant difference in percentage of weight loss between the groups, or in changes of blood pressure, blood sugar levels, insulin levels, and cholesterol or triglyceride levels. Visceral fat proved unrelated to metabolic risk factors. As the authors, led by Dr. Attila Csendes, M.D., concluded, there is no scientific basis for removing visceral fat and the theoretical benefits were not supported in this clinical trial.

How long do you think it will take for the importance of the null findings of even the most radical clinical trial every conducted on visceral fat to be recognized? How long will people continue to be frightened that their belly or having bad numbers or not eating "healthy" means they’re at risk for type 2 diabetes, heart disease and premature death? How long will these fears be used to compel heightened monitoring of metabolic lab indices in fat and older people, and interventions to get their numbers increasingly lower, under the belief they’ll reduce their risks for developing chronic diseases of aging or dying prematurely? There is no evidence to suggest it will happen anytime soon.

Until more people understand the importance of null studies and risk factors, how to recognize strong studies, and what makes science they can trust, entire belief systems can be built on things other than the soundest evidence.

© 2009 Sandy Szwarc. All rights reserved.

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