Predicting heart attacks — the government study the media ignored

Most heart disease occurs in healthy people without traditional risk factors and who aren’t considered to be at risk. That has led healthy people without symptoms to feel vulnerable to this ‘silent killer’ and seek ways to see if they could be at risk. The biggest growth industry of preventive health screenings are tests for an array of “emerging” cardiac risk factors. While these tests are heavily marketed to the public and millions of people are lining up for them, do they have any credibility?

The results of a massive systematic review of the evidence for these nontraditional heart disease risk factors were released last week by the U.S. Preventive Services Task Force. This major government review — involving 42 years of published studies and 212 citations — as well as its recommendations for clinical practice, has extensive ramifications in preventive care for all Americans, as well as the clinical practice of medical professionals. These results should have been widely reported, offering information to help everyone make more informed decisions about preventive screenings. But, did you hear anything?

This is another example of mainstream media failing to report science that is politically incorrect. Amidst today’s popular “preventive wellness” movement, how many news stories reported this far-reaching government review last week?

Two.

There’s a good chance that you, like most people, missed them.

Emerging cardiac risk factors

You’ve seen the advertisements for scans to measure calcium scores, carotid intima-media thickness (CIMT) and other measures, claiming to be able to identify people who need treatment and to prevent heart attacks or sudden death. Offered by hospital radiology departments, for-profit heart hospitals and mobile test units in communities, they also claim that 90,000 deaths could be prevented and $21.5 billion of healthccare costs could be saved every year if people were screened.

As JFS readers have followed, clinical research has found that CIMT is not a measure of atherosclerosis or predictive of people who will have cardiovascular events, heart attacks or premature death. It is a measure of, and most closely related to, age, not to plaque or stenosis formation. As Dr. Jerome P. Kassirer, M.D., professor at Tufts University School of Medicine and former editor-in-chief of the New England Journal of Medicine, said, what appears to be behind the heavy promotion of these screenings, despite the fact even major professional organizations oppose them and no sound evidence supports their use, is a profit motive.

The U.S. Preventive Services Task Force had earlier found no credible evidence to support screenings for coronary heart disease. In fact, it specifically “recommend[ed] against routine screening with resting electrocardiography (ECG), exercise treadmill test, or electron-beam computerized tomography (CT) scanning for coronary calcium for either the presence of severe coronary artery stenosis or the prediction of coronary heart disease events in adults at low risk for coronary heart disease events.” It also found insufficient evidence to recommend routine screening “in adults at increased risk for coronary heart disease events.” Carotid artery screenings received a D recommendation by USPSTF, meaning they should be actively discouraged.

Despite what might seems intuitive, it found no evidence that these screenings improve health outcomes for most adults, but instead, that false-positive test results are likely to cause harm, “including unnecessary invasive procedures, over-treatment, and labeling, the USPSTF concluded that the potential harms of routine screening for CHD in this population exceed the potential benefits.”

Another increasingly promoted new risk factor is C-reactive protein (CRP) levels, but that correlation has also already been shown to not have a causal role in heart disease. Even so, based on the results of the JUPITER study (covered here), CPR is being marketed as another screening test which could increase statin sales to $14 billion a year for the study’s sponsor, AstraZeneca.

In this newly-released systematic review, USPSTF examined the evidence for nine such novel risk factors: CRP, coronary artery calcium score as measured by electron-beam computed tomography, lipoprotein(a) level, homocysteine level, leukocyte count, fasting blood glucose, periodontal disease, ankle–brachial index, and carotid intima–media thickness. Specifically, the researchers investigated the merits of these risk factors among people classified as being at intermediate risk using traditional risk factors (the Framingham Risk Model). This describes 23 million adults in the United States, who are told they have a 10% to 20% chance of having a heart attack or cardiac death over the next decade. Proponents have proposed that by adding these new risk factors doctors would be able to identify those people who could be reclassified as high-risk, and targeted for more aggressive interventions.

As the authors noted, more than one hundred emerging risk factors have been proposed to improve the predictive ability of risk assessments. Consensus conferences in 1998 and 2002, however, have recommended against them because of a lack of evidence to support their ability to predict cardiovascular events. For a new risk factor to be credible and have value, the authors pointed out, it must independently predict major heart disease events and be clinically useful for reclassifying intermediate-risk patients so that their clinical treatment would change. It must also offer a convenience, availability, cost and safety benefit over traditional risk factors with similar prognostic ability.

As the methodology of systematic reviews have been covered before, we’ll get right to the findings. The USPSTF reviewers found the evidence for these nine emerging risk factors lacking. Good-quality studies were sparse or the body of studies did not consistently find that the factor independently predicted major CHD events. Even while an index, such as CRP, may be associated with cardiovascular disease, there was insufficient evidence that changing the levels reduced cardiovascular events.

The USPSTF concluded: “The current evidence does not support the routine use of any of the nine risk factors for further risk stratification of intermediate-risk persons.”

The authors went on to remind us:

As Lloyd-Jones and colleagues recently pointed out, “assessments of new prognostic testsshould not rely solely on associations measured by relative risks.” Our results illustrate the importance of considering multiple criteria to evaluate whether a new risk factor should be incorporated into guidelines for coronary risk assessment in primary care.

But few of us heard about this study. Instead, we read hundreds of news stories marketing these preventive screenings and claiming, based on no or poor-quality evidence, that heart disease is preventable and that our risks can be measured and known ahead of time. Science isn’t what they're selling.

© 2009 Sandy Szwarc

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Penalties for bad behavior

Wednesday, the Senate Finance Committee approved a healthcare reform amendment that would penalize employees who are not following “healthy lifestyles” and participating in wellness programs. Employers will be allowed to raise healthcare premiums by as much as 50 percent for workers who are fat, smoke, don’t exercise, are noncompliant with preventive care, and not meeting certain health measures, such as lower cholesterol levels.

Blaming “skyrocketed healthcare costs” on weight gain and unhealthy lifestyles, he told media that weight loss programs, smoking cessation and preventive care could lower costs. Employees who are trim and living “healthy lifestyles” should be rewarded for their good behavior, said Senator John Ensign, and those who are not should pay. The Senate committee passed the bipartisan amendment by a vote of 19 to four.

This is why sound science matters.

People talk of personal responsibility, but it never seems to apply to taking responsibility to make sure that the popular claims and judgments they repeat, and act upon, are really supported by sound research evidence.

Personal accountability never seems to apply to hurting people and discrimination, especially against those who are politically incorrect.

Control over the personal behavior of others is the new public health ethic. It is not to be confused with medical ethics.

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

Your boss will weigh you now

According to Blue Cross Blue Shield of North Carolina’s Annual Report, claims in 2008 reached $10.7 Billion — half the entire budget for the state of North Carolina. Claims increased nearly three times the growth in health plan members. Claims also cost the State Health Plan more than $200 million over that budgeted. Politicians had believed that preventive wellness and managed care in the State Health Plan, administered by BCBSNC, would save the state money.

Participants in the State’s Health Plan pay more out-of-pocket expenses for medical care than those in any other major health plan in the state, and that’s about to go up even more for some of them. They believed that wellness care and healthy lifestyle benefits were free.

Employers will now perform random tests of employees for evidence that they’ve smoked outside of work and will weigh employees in the workplace and report their BMIs to the state. Employees deemed noncompliant with the State Health Plan’s employer wellness initiative, will pay one-third-more for health insurance. Employers believed that eliminating smokers and fat people would lower health costs.

Employers, politicians and participants believed the marketing. The results were easily predictable. When decisions work from false beliefs, rather than sound evidence, the end results aren’t likely to be very good.

Under the State

North Carolina State University employees, state employees, teachers, retirees and other members of the North Carolina State Health Plan received a mailing last week about changes to their benefits, effective July 1, 2009. The changes would affect their out-of-pocket expenses, deductibles and co-payments. As part of the state’s “Comprehensive Wellness Initiative” signed into law (Senate Bill 287) in April by Governor Beverly E. Perdue, everyone covered by the state plan must now complete an Attestation Form, stating that they, and their covered dependents, do not use tobacco products and that they have a BMI less than 40 or are participating in approved weight management and/or tobacco cessation programs. They must also agree to submit to random testing for the presence of nicotine and to be weighed and measured at their workplace. By July 2012, the BMI requirement will be lowered to less than 35.

The mailing included “the requirements for compliance and the consequences of noncompliance” to its weight management and smoking cessation policies. The consequences of noncompliance mean paying one-third higher insurance premiums, higher deductibles and out-of-pocket expenses, for themselves and all covered family members. Noncompliants will no longer be eligible for the 80/20 plan and will be automatically moved to a costlier 70/30 plan. Plus, “members will forfeit any coinsurance and deductibles already paid under the 80/20 Standard Plan.”

“But wait!”, a reader wrote. “This is a government health insurance, the state’s health plan. And, we were told that the State Health Plan’s Healthy Living Initiative is voluntary and free.”

It is… at a price.

This is what happens when people want something for free and to let someone else manage their health, rather than take care of themselves for regular upkeep and purchase insurance to protect themselves from unforeseen major medical expenses. Anymore, insurance is no longer actual insurance; it’s health management, because that’s where the money and politics are.

Skyrocketing claims

Years ago, the state had signed with BCBSNC for managed health care focused on wellness and prevention and “quality” measures (providers mandated to provide care that adhered to pay-for-performance measures). Like company benefit managers, politicians believed that it would not only save, but make them money. The recent audit of the State Health Plan revealed, however, that it lost $79.7 million in 2008 and that the higher number of claims and administrative expenses cost the state $200.1 million more than planned.

Why did claims rise so much? The reasons are not surprising, but admitting them goes against today’s political correctness.

The popular belief is that when people get low cost insurance benefits, they over-utilize medical services which raises costs. But, that doesn’t fully explain the growing numbers of claims filed under the State’s Health Plan and why these managed care plans actually cost employers and consumers more.

● Newly insured? No. These teachers and state employees have had health insurance, so they aren’t making up for years without medical care.

● New members? No. The surge in claims isn’t explained by more members, as claims increased three times over the increase in members, according to the 2008 BCBSNC Annual Report. In just 2008, the company processed 46 million claims, more than 10% over the previous year; while membership increased by only 130,000 members, 3.5% of the 3.7 million members.

● Cheap? No. The theory that low health insurance premiums are encouraging overuse doesn’t hold up. Premiums for an employee and family (non-Medicare) under the NC State Plan are $533 a month for the 80/20 plan and $450 for the 70/30 plan — this is well over the national average. According to the Kaiser Family Foundation and Health Research and Educational Trust study on Employer Health Benefits, the average worker paid $293 for family coverage each month.

● Suddenly sick? There is no evidence that, over the past three years, teachers and state employees are suddenly becoming ill in greater numbers than ever.

Preventive wellness initiatives and disease management, as holistic and intuitively helpful as they may sound, have been shown to raise healthcare costs, and not just because of the additional tests, treatments, diets and lifestyle interventions. Health risk assessments, the key element in employer wellness programs, and screening tests are the gateway to identifying more people for prescription drugs (and other diets, products and interventions offered through health partnerships). These make money for insurers managing healthcare for government- and employer-offered health plans, under the guise of managing health indices (risk factors).

Opportunities for insurers to generate revenue with employer wellness programs go beyond pharmacy benefit management. The personal lifestyle information members reveal are marketing gold mines. Yet, for instance, nowhere among the member information is there a cautionary note telling participants in the State Health Plan that its commercial workplace wellness program and online health risk assessment are not covered under federal Health Insurance Portability and Accountability Act (HIPAA) privacy protection. That means participants have no protections in how their personal health information is used or sold. Nor are members likely aware of advertising content that appears to be health information. And few members likely stopped to read the more than 5,700-word privacy and terms disclaimer* on the North Carolina Workplace Wellness site.

Wellness isn’t medical care

The State Health Plan’s wellness initiative mandated by the legislature and largely enacted through employers, is “wellness care” and healthy lifestyle interventions, rather than caring for sick people. It was sold to politicians and company benefit managers as saving costs and preventing aging-related diseases. These alternative beliefs, born of the new field of “lifestyle medicine,” are increasingly finding their way into popular culture, even though few are supported by the scientific and medical literature.

BCBSNC tells prospective group plan managers that the key to controlling healthcare costs is prevention. Calling obesity the public health crisis of the 21^st century, it blames “sedentary jobs, high-calorie diets and leisure time spend in front of the TV or on a computer” and claims that fat people in North Carolina are responsible for $83 million in medical costs that could be reduced by healthier lifestyles. It claims that expensive diseases - from heart disease, diabetes to cancers - can be prevented by regular check-ups, cancer and cholesterol screenings, cholesterol medications, diet and exercise counseling, blood pressure checks and treatment. It also blames fat people for raising everyone else’s health care premiums.

How many politicians and employer benefit managers do you know who go to the medical literature, let alone understand the research, to realize these claims are far from slam dunks and are not supported with good science? Employers and politicians also don’t weigh the health risks and safety concerns associated with wellness initiatives. Examinations of the scientific evidence behind employee wellness program recommendations; screenings; and diet, exercise and lifestyle behavioral interventions, find poor evidence for effectiveness, as well as numerous inconsistencies with U.S. Preventive Services Task Force recommendations, that they claim to be following.

In fact, there’s not even a link between degenerative diseases of aging or premature death and any of the health indices in preventive wellness programs.

Health discrimination

Ideal health risk indices — from BMI, blood pressure, blood sugars to cholesterol — are mostly euphemisms for thin and young. Those who believe that their own good health is because they eat “right,” exercise and have perfect numbers are often young and upper-income and not old enough to experience age-related changes. Their genetic good fortune is not evidence of good behavior, either. Evidence-based research to date has shown these health indices are primarily measures of aging, genetics and social stresses, and not significantly malleable with “healthful” diets and lifestyles. With aging, the “ideal” numbers of healthy 20-year olds cannot be achieved for most workers without taking controversial and risky prescription drugs or temporarily lowered by undergoing mostly ineffective weight loss measures.

Today’s healthism stigmatizes those who don’t follow culturally acceptable lifestyles, or look like they do. It is also accompanied by blaming victims of diseases, such as cancers, diabetes and heart disease, for having brought on their diseases themselves through bad behavior; and by growing age and class discrimination. Discrimination claims filed with the Equal Employment Opportunity Commission have jumped to the highest level since the agency opened in 1965, spokesperson David Grinberg told the media earlier this year. Just from 2007 to 2008, age discrimination claims grew nearly three times those of race and twice as fast as those of gender or religion.

Fat people and smokers are especially stigmatized and actively denormalized in our culture. Citing efforts to contain healthcare costs, it’s a short step from raising premiums on them to removing them from surgery waiting lists, denying them medical treatment, and refusing to hire them at all — all discriminatory practices that have been increasing over recent years. As Brian House, from the Dept of Sociology at the University of Washington in Seattle, and co-author Dr. Michael Siegel, M.D., Social and Behavioral Sciences Department, Boston University School of Public Health, cautioned in the January issue of Tobacco Control: “In recent years, a new trend in worksite smoking policies has emerged: a shift from ‘smoke-free’ workplace policies to what have been termed ‘smoker-free’ workplace policies.” House and Siegel found a lack of published evidence for the effectiveness of such policies, nor any evaluations of their far-reaching deleterious consequences that are putting people at increased risks.

Moreover, they wrote, “norms of other unhealthy behavior could also start to shift and socially justify barring employment to other groups.” They exampled Clarian Health in Indianapolis, which planned to begin “fining employees for smoking, having a body mass index greater than 30 and if their blood pressure, cholesterol and glucose levels are too high.” The war on obesity has become a war against the ‘obese’ and is far different than caring for them.

The State Health Plan’s healthy living initiative

The summary of the new benefit modifications that were mailed to members last week states: “NC HealthSmart, the State Health Plan’s healthy living initiative… is voluntary. Eligible members can use the program at no charge… The tools and services available through NC Health Smart include tobacco cessation and weight management programs.” The State’s healthy living initiative includes tobacco cessation support through a telephone quitline, health coaches, and smoking cessation medications; weight management in the form of nutrition counseling, weight loss medications and bariatric surgery as covered benefits, a web and telephone support line, health coaches, workplace diet and wellness initiatives, case management and personal health risk assessments.

It says its employer wellness program, called the “Eat Smart, Move More, Weigh Less,” encourages lifestyle management and “health-friendly policies” at workplaces.

The new benefits also include a Pharmacy Benefits section that’s been rewritten from last year’s plan, with new pharmacy drug exclusions for drugs not covered by the plan, prior approval requirements and quantity limits for some drugs, and a preferred drug list of drugs available through the plan with others subject to higher co-payments. Medications for chronic diseases, such as rheumatoid arthritis, multiple sclerosis, hepatitis C, and anemia, must be purchased through its contracted vendor or members will pay the total amount.

Participants in the NC State Health Plan noted that none of their wellness benefits were being reduced, even as the plan threatened to cripple employers and the state, and will cost taxpayers more than $300 million this year to keep solvent. BCBSNC saw profits of $186 million last year. In fact, in order to receive affordable health coverage, participation in preventive wellness is increasingly becoming mandatory, but not because it’s been proven to save medical costs or to be effective. According to the database on health plans kept by AthenaHealth, which manages electronic medical records and billing for more than 19,500 medical providers nationwide, BCBSNC sent out 250,000 reminders to customers last year who hadn’t complied with preventive health screenings.

While the State-provided health management comes with preventive wellness care, “free” health risk assessments and health “coaches,” and “free” case management — should recipients actually need medical care, that will cost them… increasingly more. Free isn’t really free. BCBSNC plan participants already have more out-of-pocket costs for medical expenses (12.1%) than any other major health plan in the state — 68% more than United, 60% more than Humana, 50% more than Aetna and 29% more than Cigna. This most hurts those who have real medical needs, especially older workers and those of lower socio-economic class and certain hereditary predispositions. The discriminatory aspects of preventive wellness mandates and the healthy lifestyle movement is the elephant in the room.

It is also yet to be seen if the State Health Plan will survive legal challenges for violating the Final Rules of the HIPAA, Nondiscrimination and Wellness Programs in Health Coverage in the Group Market. As ruled by the Department of Labor, these laws prohibit discrimination of employees in employee wellness programs based on hereditary features and health indices (measurements). It had also ruled that discrimination exemptions for wellness programs referred only to supplemental coverages and could not be those that are part of the primary health coverage.

Without an understanding of sound science, “for your health” can make discrimination seem acceptable … until it comes for you. Your boss will weigh you now.

© 2009 Sandy Szwarc

* North Carolina Workplace Wellness Privacy and Terms:

…The information we collect falls into two categories: (1) user-provided personal information such as information that you provide to us when you register to use our Web site, and (2) certain anonymous information that we collect as you navigate through the WorkplaceWellnessNC.com pages. You also provide personal information when choosing to participate in various activities on WorkplaceWellnessNC.com such as uploading videos, photos, posting messages on our site, entering contests or sweepstakes, taking advantage of promotions, responding to surveys, or subscribing to newsletters or other mailing lists… Once you register with WorkplaceWellnessNC.com and sign in to our site, you are not anonymous to us…

Please keep in mind that whenever you voluntarily make your personal information available for viewing by third parties on our site - for example, in a post, comment, classified ad, event listing or Yellow Pages review, or on other areas of our site - that information can be seen, collected and used by anyone who visits the site…

We may disclose your personal information to trusted partners who work on behalf of WorkplaceWellnessNC.com under confidentiality agreements. These companies may use your personal information to help us serve you…

We may disclose your personal information to conform to legal requirements or to respond to a subpoena, search warrant or other legal process received by WorkplaceWellnessNC.com, whether or not a response is required by applicable law.

We may disclose your personal information to enforce our WorkplaceWellnessNC.com Terms of Use Agreement, or to protect the rights, property or safety of members of the WorkplaceWellnessNC.com community, other visitors to our site, our advertisers and other customers, the public, or WorkplaceWellnessNC.com and its employees

As our business grows, we may buy or sell various assets. In the event that WorkplaceWellnessNC.com or some or all of our assets are acquired by another company, information about our users may be among the transferred assets…

No warranties: you agree that use of the workplacewellnessnc.com website and any material or information available through this site is entirely at your own risk. This site is provided by BCBSNC on an "as is" and "as available" basis. BCBSNC makes no representations or warranties of any kind, express or implied, as to the operation of this site or the accuracy, completeness, currentness, noninfringement, merchantability or fitness for a particular purpose of the information available through this site, nor do we guarantee that the site will be error-free, continuously available, or free of viruses or other harmful components… Indemnification by you: you agree to indemnify and hold harmless BCBSNC, its affiliates, agents, employees, representatives and licensors against any liability of any nature arising out of any content posted on the workplacewellnessnc.com site by you or by others…

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Who will speak out for you?

Two New Mexico nurses have paid a heavy price for following their consciences and the basic tenet of the nurse’s Code of Ethics — the ethical duty to protect and advocate for the rights, health and safety of patients. After unsuccessfully going up the chain of command at the Winkler County Memorial Hospital, a small West Texas hospital in Kermit, Texas, they made an anonymous report to the Texas Medical Board with concerns about a doctor selling his own sham herbal remedies to patients in the hospital’s emergency department and at a health clinic.

When the Texas Medical Board contacted the doctor to investigate him for poor quality of care, the doctor went to the Winkler County Sheriff who left no stone unturned to learn the identity of the nurses, including accessing confidential patient records and issuing a search warrant to seize their work computers. The whistle blower nurses were fired from their jobs, imprisoned and criminally prosecuted, and later let out on $5,000 bonds. They will finally face a jury trial next week for third-degree felony charges, carrying potential penalties of two-to-ten years’ imprisonment and maximum fines of $10,000.

Experienced nurses, whose only “crime” was to report to the appropriate medical agency something they felt was medically unsound and unethical, were imprisoned, their livelihoods taken, and criminally prosecuted.

In America.

The Court case

The court documents and exhibits (available in Plaintiff’s original complaint here), describe what has been described in an editorial published in the Austin American Statesmen as “a stunning display of good ol' boy idiocy and abuse of prosecutorial discretion.” The registered nurses, Ann Mitchell and Vickilyn Galle, had each been employed by the hospital for about two decades with good work histories. They were co-medical staff coordinators who worked in its quality improvement and utilization management department. Their responsibilities included credentialing physicians and reviewing patient quality issues and following patients throughout their hospital stay to ensure compliance with state and federal regulations.

Dr. Rolando Arafiles, Jr., M.D., had been hired by the hospital in April 2008 and at the time of hire was still subject to a three-year order by the Texas Medical Board prohibiting him from supervising or delegating prescription writing. Since then, two physicians at the hospital, and emergency room and clinic staff, had presented to the hospital’s administrator and Board of Control concerns about his standard of care and performance of medical procedures, but no action was ever taken. When the hospital’s chief of staff had requested a meeting with the doctor and hospital administrator and the nurses, the hospital administrator cancelled three meetings in a row and Dr. Arafiles was granted privileges. After three months of efforts, the chief of staff was able to present his concerns to the hospital board which included documentation and case reviews.

Finally, the nurses, believing they had an ethical and legal duty to report to licensing boards care that they had reasonable cause to believe exposed a patient to substantial risk of harm, filed an anonymous report to the Board with concerns about Dr. Arafiles selling herbal remedies that were not in the hospital formulary to patients. Afraid that if they signed their names the administrator would fire them, their letter was anonymous.

On April 15, 2009, the Texas Medical Board sent a letter to Dr. Arafiles, informing him that it had received a complaint and was investigating complains of quality of care and non-therapeutic prescribing or treatment and directed him to respond. The doctor took it to the Winkler County Sheriff, Robert Roberts.

Sheriff Roberts and Dr. Arafiles were business associates in an herbal supplement business, according to the court documents.

Sheriff Roberts sent the Texas Medical Board a letter requesting a copy of the complaint, stating he was conducting a criminal investigation of the complainants for the offenses of misuse of official information and harassment of the doctor. He then began an investigation and personally contacted every patient in the letter from the Texas Medical Board, trying to learn the identity of the nurses. When that didn’t work, he learned from their letter to the Texas Medical Board that they were female, over 50 years of age and had worked at the hospital since the 1980s, which helped him narrow down his search. On May 19^th, a search warrant was issued for their work computers and their computers were seized and the letter was found. The nurses were then fired on June 1^st by the hospital administrator for reporting a patient safety issue to the licensing authority. Not because of any unsatisfactory job performance.

By June 11^th, the nurses had been indicted for third degree felonies, charged with “misuse of official information,” with Sheriff Roberts as the only witness to the Grand Jury

Mari Robinson, Executive Director for the Texas Medical Board, sent a letter to the attorneys on June 17^th stating that all information provided to the Board was confidential and not subject to subpoena or other means of legal compulsion for release to anyone other than the Board and that the Board depends on reports from healthcare professionals to carry out its duty of protecting the public from improper practitioners. The Board supported the nurses in sharing chart numbers of patients to verify their concerns, stating that the Board is exempt from HIPAA and has the statutory access to hospital records and releasing any such information is not in violation of any laws. They also stated that the legal protections of the nurses and those who provide information to the Board, according to the Medical Practice Act under which the board is statutorily mandated, were being violated. She added:

It is our understanding that, as a result of your actions, the nurses who you allege provided information to the Board have been fired from their jobs at the hospital, have been indicted, been required to hire counsel, and each had to pay $5,000 bond. This action undertaken by your office has adversely impacted the Board’s investigation by its peace officers in this case. Further, it has potentially created a significant chilling effect on the cooperation of any other hospital personnel who might have been able to provide additional information needed by the Board in the completion of its investigation. This is of grave concern to the Board in its implications for this case, as well as other cases…

As part of its investigation of the complaint involving the licensee physician in question, a relevant inquiry will be whether that physician engaged in any activity that was designed to intimidate witnesses or complainants. Such activity is a violation of the Act and constitutes unprofessional and dishonorable conduct…

Ann and Vicky are fighting back and filed suit in federal court alleging they’ve been victims of retaliation for advocating for patients, as well as for violations of their civil rights and due process.

Why’d they do it?

While the court documents give a glimpse of the legal and professional nightmare these nurses have been enduring this year, they don’t reveal what was so troubling to them in the first place and what was going on at the hospital that they felt compelled to speak out. The media stories have glossed over that.

The court documents made passing reference to a prior disciplinary action against the doctor by the Texas Medical Board. The full story is on the Texas Medical Board’s website. Dr. Arafiles, who had received his medical degree from the University of the East, Quezon City in the Philippines in 1977, had been disciplined by the state licensing Board in April 2007. While working as a contracting supervising physician at a weight loss clinic, for months Dr. Arafiles had signed off on the prescriptions written by his physician assistant. The clinic protocol called for use of phentermine for obesity, even in patients whose BMI was under 30, as well as use of diuretics for potential side effects of hypertension, even in patients who weren’t experiencing hypertension or edema. The Board found that Dr. Arafiles had only reviewed his physician assistant’s files and was present at the clinic about 5% of the time the clinic was open, rather than the required supervision of his delegate a minimum of 20%. The Texas Medical Board took disciplinary action against Dr. Arafiles based on “unprofessional or dishonorable conduct that is likely to deceive, defraud or injure the public… because he, acting through his delegate, failed to practice medicine in acceptable professional manner consistent with public health and welfare.” He was prohibited from supervising physician assistants or nurse practitioners, assessed a $1,000 penalty, and made to complete continuing education on medical ethics, medical records and the treatment of obesity.

The nurses’ complaint expressed concern about his selling alternative herbal remedies to patients in the emergency department and a rural health clinic, but it’s easy to get a better understanding of the full extent of his medical practice that troubled them enough to speak out. Here are a couple of publicly-available examples:

Biotherapy. The February 17, 2000 issue of the Victoria Advocate advertised an Alzheimer’s Disease Support Group meeting presented by Dr. Arafiles, discussing nutritional therapy, screening for Alzheimer’s and dementia and offered a “biological terrain assessment.” He was the medical director at the BioTherapy Clinics of Texas, an alternative mind-body clinic offering “Immune System Restoration,” as well as ultra-darkfield microscopy, acupuncture, bio-terrain analysis, chiropractic, energy management, deep tissue massage, emotional therapy, bodywork, colonics, lymphatic drainage, hormone testing, nutritional and diet counseling , magnetic therapy, food allergy testing, human performance, metabolic programs, weight management, genetic marker testing, dendritic cell therapy, biologic response modifier concepts and more.

Alkaline-reduced water. Describing himself as the medical director of Texas Innovative Health Options and Wellness Center, he endorsed a water “alkanizer,” writing:

I know that you realize that unless we conscientiously find ways to protect ourselves from the barrage of xenobiotics in our food, environment, air and other aspects of life then we begine [sic] to lose whatever is healthy in our body. It is no secret today that the three leading causes of premature aging or degeneration are the uncontrolled activity of free radicals in the body, chronic dehydration and a chronic cellular acidity. I still am amused at the looks I see on my patient's face when I tell them that drinking 6~8 glasses of water may solve 50% of some of their ailments. You can thumb through the hundreds of peer-viewed medical literature and find that free radicals and its deleterious effects on the body are well documented. The acidic cellular pH is also now recognized as a hot bed too.

I would not have enough space to mention all the thousands of diseases but one in particular is cancer. Cancer thrives in an acid environment and changing that pH to neutral 6.5~7 may be one of the ways to inhibit cancer growth and/or even make it susceptible to the natural killer cells of the immune system. Fortunately the water from an Alkalizer™ covers these three causes.

I have been sharing this information with my patients. I have made the alkaline reduced water available in my office and treatment rooms… I personally have been blessed by drinking alkaline reduced water. I have reduced the number of supplements that I take. My allergies are less frequent. I have maintained my waist size at 34 inches since I dropped from 38 inches.

Keep up with the good work. together with the rest of health professionals that believe in the use of natural options to health we will keep touching more lives and helping people attain the quality of life they choose.

The website for the alkanizer claims that ionization makes water more hydrating, that its electrons make free radicals harmless, that drinking alkaline water will help flush the acidity and toxins out of your body, and that alkaline water balances today’s acidic diet and lifestyle and enable the body to heal naturally. Purportedly, the more alkalized water you drink, the healthier you’ll be. Among the numerous benefits of alkaline water claimed, are for treating:

Blood pressure

Osteoporosis

Constipation

Migraines

Urea stones

Faster healing

Acne

Fibromyalgia

Low energy/sluggishness

Morning sickness

Blood circulation

Diarhhea [sic]

Muscle aches after exercise

Water retention

Obesity

Acid reflux / heartburn

Arthritis

Nausea

Hyper-acidity

Colds

Hangovers

Body odor

Chronic fatigue

Cholesterol

Cancer

Stress

As covered at JFS repeatedly, all of this — ionized alkaline water, the need to drink lots of water for health, weight control or to flush toxins from the body and detox — is pseudoscience and quackery. You can learn more water pseudoscience at Dr. Stephen Lower’s H2O.con. The science on the other alternative modalities in his biotherapies can be researched by following the JFS links above and using the Google search tool on the right hand side bar of JFS. It is easy to understand why experienced medical professionals and these nurses might have been so concerned about the supplements and goodness knows what else patients in the emergency room were being sold.

Consequences

Medical professionals, especially nurses who are generally lower on the food chain, so to speak, are increasingly reticent to speak out when they see unsound, unethical or corrupt things going on in healthcare. It is hard to do the right thing. They know and see the consequences of following their consciences and the Code of ethics. This is not an isolated incident. Three California nurses were suspended after they reported a doctor who later admitted giving a lethal injection to a child and another nurse was threatened with firing after refusing to follow a doctor’s verbal order to administer morphine until a patient stopped breathing. A California nurse was threatened with firing for reporting unsafe patient care practices. A registered nurse in San Antonio was fired when she voiced concerns about unsafe staffing at a dialysis center. A San Antonio hospital posted a notice to employees that anyone who went outside the hospital with a report of unsafe or unethical practices violated the state’s “Safe Harbor Law” and would face discipline and even termination. This “violates the basic premise of whistle-blower laws — to free up an individual from the internal politics of the workplace,” wrote Linda R. Srungaram, RN, an experienced emergency room nurse.

Ann and Vicky courageously did the right thing and had the expertise to understand how patients could be harmed. Yet, they only came up against the interests of a single doctor. What do you think happens to nurses who might dare to report something unethical or corrupt that affects entire institutions, comes up against well-funded drug companies or counters powerful political interests?

If nurses following their professional ethics and good consciences are prosecuted for speaking out on behalf of patients, how many nurses will avert their eyes and shut their mouths when they see unsafe, unsound or unethical patient care or corruption, for fear of being hauled off on criminal charges?

All nurses and healthcare professionals will be watching what happens to these nurses in court next week.

But so should each of us.

© 2009 Sandy Szwarc

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

How some food can make us sick

Do you have friends who say that they feel physically sick and develop headaches, heart palpitations, nausea and dizziness when they eat sugar or anything with high fructose corn syrup? Do you know others who report feeling tired, bloated and nauseous when they eat meat or saturated fats, especially fatty meats processed with nitrates? Do you know people who say that they feel less energetic or alert when they eat processed foods or who feel nervous, shaky and irritable when they drink something with an artificial sweetener in it? Do you know people who develop rashes and congestion when they eat or drink various foods or who feel depressed and fatigued when they eat refined white flour or carbohydrates?

A reader recently wrote puzzled about a strange phenomenon she was seeing among a large and growing number of healthy, nondiabetic young women. They complain of feeling jittery, dizzy and sick the rest of the day after consuming “too much sugar,” she said. When she pins them down, they define “too much sugar” as the amount in a scoop of ice cream or can of soda — yet they say they have to “detox for a week because of ‘all that sugar’,” she wrote. “Detox … from sugar?” They’ve become so afraid of sugar that if they enjoy even the smallest treat, it ruins their entire day, she lamented. “What is going on here? Are all of these people losing their minds because of the hysteria they’re being whipped into? Could you shine a sane light onto this sucrophobia?”

There is a name for the ill health effects reported associated with our modern diet.

It’s called the nocebo effect and it’s far more widespread than many people realize.

Nocebo

The nocebo effect is negative stepsister of the placebo effect, where we feel good after eating foods, taking a remedy or doing something we believe is healthy.

With the nocebo effect, people can experience real and extraordinary physical and mental symptoms of illness, even paralysis, when they believe they’ve eaten or been exposed to something they think or fear could be harmful. The nocebo effect is behind most fears of unseen dangers lurking around us, especially in our food, and explains how people can sincerely believe that something is making them sick … even when there is no biological basis for their symptoms. When we’re told, or know, there is no scientific basis for what we’re experiencing, it’s still hard to believe that our minds can be that powerful.

Psychologists have cautioned that public health and nutrition information, or simply reading about scary diseases, triggers the nocebo effect. The growing trend to issue precautionary advice concerning health risks, even when there is no evidence for any credible risk to people’s health, can also feed the nocebo effect. Fears are not benign and the nocebo effect can have real and harmful effects and there are growing examples in the medical literature.

Dr. Nicholas Christakis, M.D., Ph.D., MPH, professor of medical sociology at Harvard Medical School, described the phenomena where healthy people develop anxiety about a perceived danger, then, being around others who are anxious, serves to heighten one’s own sense of fear. In other words, fear is contagious. “Mass hysteria,” also called “mass psychosomatic reaction” or “mass sociogenic illness,” is an epidemic of physical symptoms without biological basis that spread through a group of people, often young women, who share beliefs about their fears and symptoms. The Canadian Medical Association Journal noted that these events are common. Besides disrupting lives and communities, they can also place enormous burdens on emergency and public health services to care for people suffering from a mass psychosomatic reaction.

The preventive health movement, concerns over health risk factors, and being inundated by health information and health warnings has not only changed our entire concept of what it means to be healthy, it is transforming us into a nation of worried well. Although we have the greatest supply of nourishing food and we’re healthier and freer from serious illnesses than ever before, we’re more worried than ever about our health. Even benign aches and pains and symptoms that are part of normal human experience can be misinterpreted as signs of something wrong. The nocebo effects of healthism costs all of us, too. The worried well account for one-third of all primary care visits and incur healthcare costs 14 times higher than average.

Nocebo means “I will harm,” Jack Dini wrote in the Hawaiian Reporter last week. His article, “The Nocebo Effect — Think Sick and You’ll Be Sick,” gave a fascinating list of examples of nocebo. For example:

● In a study in the early 1980s, 34 college students were told an electric current would be passed through their heads, and the researchers warned that the experience could cause a headache. Though not a single volt of current was used, more than two-thirds of the students reported headaches.

● Drinking water fluoridation was first introduced in Grand Rapids, Michigan in 1945. Calls began coming in to city offices from people complaining of sore gums and peeling tooth enamel. One woman even claimed that all her teeth had fallen out. These calls arrived in early January, when some press reports had stated that fluoridation would begin, but some weeks before the actual advent of fluoridation on January 25.

● Call it fear of spraying. In one study researchers spewed distilled water from planes over residential neighborhoods without telling anyone what the spray contained. The intent was to gauge public phobia of chemicals. Sure enough, the experimenters were soon deluged with complaints from frightened folks who claimed the spray was causing cows to abort, dogs to shed and children to get sick…

● A Paris household blamed three installed cell phone antennas in their area for causing headaches, nosebleeds and a metallic taste in the mouths of some residents. The one problem with this complaint—the antennas were never activated.

Nocebo and healthy eating

Most troubling is how nocebo is used on unsuspecting consumers. The nocebo effect is not only well recognized in medicine and science research, it’s well-recognized by marketing professionals. Nocebo is why fear has become the most widely used political and marketing technique, especially when it comes to food and health. Fear sells. This natural human phenomenon has been the bread-and-butter for proponents of various alternative diets and nostrums over the decades.

Sadly, it’s hard for people to differentiate fear-based marketing from science and to see how the effects of nocebo and placebo have influenced what they’ve come to believe is food that is healthy and unhealthy for them. Nocebo-driven fears hurt people’s health and well-being, leave them less able to enjoy foods, and cost them normal relationships with food.

While there is no sound evidence that any food is actually harmful (excluding, of course, rotted, germ-ridden foods and people with severe allergies or rare metabolic disorders), from the age of two, people are being scared into believing that they’ll develop cancer or another chronic disease, get fat, and die prematurely if they eat “unhealthy” foods or are exposed to ‘chemicals’.

One of the most troubling and powerful examples of the use of the nocebo effect is in a food curriculum for elementary children across the country to scare them into believing that conventionally-grown foods, animal products, fats, sugars and processed foods poison their bodies and will give them cancer, heart disease and dementia, and cause them to be fat, have acne and deviant behaviors, and make them feel less energetic or able to learn.

What may be surprising is that these unsupported nocebo/placebo dietary tenets — such as metabolic typing, enzyme, healthy, macrobiotic or intuitive eating — are not really new. They resurface every generation, different renditions of the same basic fears, with new names and twists. And each new generation is largely unaware that these alternative beliefs are not grounded in science and have failed to hold up in clinical research time and again.

These tenets have in common the belief that chronic degenerative diseases of aging, such as cancers, type 2 diabetes and heart disease, are caused by unhealthy diets or processed foods and a build-up of toxins. Conversely, they hold that chronic diseases can be prevented and optimal wellness achieved by all-natural diets rich in antioxidants, “healthy” fats and fiber; whole foods made without added sugars, salts or preservatives; and flushing toxins from the body by drinking lots of water or detoxification.

Nocebo is also behind beliefs that each person should eat “in tune with their body and how foods make them feel.” The belief is that every body has different dietary needs for optimal health, maximum energy and mental clarity; to naturally control food cravings and maintain a healthy weight, strengthen immunity and slow down the aging process. The restrictive eating encouraged by the nocebo avoidance effects of ‘unhealthy’ foods are also weight loss techniques, and not surprisingly, eating intuitively is most intensely marketed to people concerned about their weight.

These nostrums, remember, have not been supported in scientific research. They are correct about one thing, though: there is no “one size fit all” diet. But that’s only because eating a certain way doesn’t matter as much as many think. People around the world have a wide range of diets with no consistent relationships to health or lifespans.The most common cause of poor nutrition and deficiencies isn’t eating “bad” foods, but eating too few calories and trying to restrict eating.

The origin of beliefs of diet and degenerative disease date back at least to the 1920s and 30s when a couple of dentists theorized that the “modern” diets of more developed countries were associated with degenerative diseases — diseases that were seldom seen among under developed regions of the world. Their theories have repeatedly failed to hold up to scientific scrutiny, however, which has noted they’d failed to account for the fact that people in more industrialized countries live longer and have different hereditary characteristics. Poor people in remote underdeveloped countries don’t live long enough to get degenerative diseases of aging.

By the 1950s, theories that eating according to one’s individual autonomic nervous system balance gave way to Dr. Roger Williams’ theory of optimal diets according to “biochemical individuality” and metabolic profiles. Another dentist, Dr. William D. Kelley, originated the metabolic typing diet by the 1960s. His assistant, William L. Wolcott, continued to develop metabolic typing in the 1980s, which promoted that every person had unique dietary requirements according to their metabolic type.

Through the use of questionnaires and other suggestive techniques, people are guided to think about how certain foods make them feel when they eat them, and to believe that this is their body telling them what they should eat. (Based on the answers to their “metabolic typing” profile, for example, people are divided into protein types, carbo types or mixed types, and told what type of personalities they have, their food cravings and what foods they should avoid and what foods are supposed to be best for them.) Invariably, of course, what foods their body is telling them they should eat is always ‘healthy’, based on the same underlying fears of modern diets as causing degenerative diseases and weight gain.

One holistic health counselor of “integrative nutrition” describes what can be learned by getting in touch with how your body feels when you eat certain foods and eating intuitively. Based on Wolcott’s 60 questions, carbo types, for instance, are described as characteristically having a “weaker appetite, higher tolerance for sweets, type A personalities, caffeine dependency” and should avoid foods high in fat (and use oils sparingly), heavy proteins, caffeine, sugar and “thyroid suppressing foods.” They are encouraged to eat whole grains, fruits and vegetables. For protein, they can eat “sustainable seafood, lighter chicken and turkey meats, pasture-raised eggs, low-fat dairy (if tolerated), tempeh, tofu and beans.” To feel more energetic and alert all day, she also advises drinking more water. “I don’t mean some water — I mean a lot of water. Eight 12 ounce glasses a day at least” to keep your system “healthier and better flushed.” And eat more fiber for more energy, she says, to lose that heavy feeling from food not processed effectively.

Nocebo and health frauds

These unsound dietary beliefs become even more dangerous when they become unsupported clinical guidelines or public health policies to prevent diseases. Or worse, when they’re used in treatments.

Kelley’s diet became part of a treatment regimen for cancer, as outlined in his Newsletter on Cancer Remedies in 1980. Kelley was convicted of practicing medicine without a license in 1970 and had his dental license suspended for five years in 1976, reported Dr. Saul Green, Ph.D., former professor of biochemistry at Sloane-Kettering Cancer Institute and a board member of the National Council Against Health Fraud. Still, Kelley continued to promote his methods through his “International Health Institute” in Dallas, where “certified metabolic technicians” administered his metabolic typing questionnaires and produced long computerized instructions for diets and supplements, detoxification and healthy lifestyle changes.

Kelley’s regimen was duplicated in the cancer regimen of Dr. Nicholas Gonzales, M.D., who has been found guilty of professional negligence and incompetence more than once. Proponents of the Kelly and Gonzalez regimen believe that toxins from sources such as processed foods and environmental pollution are responsible for human cancers, according to the National Cancer Institute. "If these toxins could be neutralized and eliminated from the body, proponents believe, both early and established cancers would be halted, and general health would be restored."

As Dr. Green explained, Kelley’s and Gonzales’ regimen was based on the discredited theory that cancer is caused by the growth of ectopic germ cells in the wrong place and a lack of digesting enzymes. Kelley invented a Malignancy Index based on a patient’s “metabolic classification as a sympathetic dominant, parasympathetic dominant or a balanced metabolizer,” and his cancer treatment was supposed to clear the body of toxins. Concerning his diet, wrote Dr. Green:

Kelley initially proposed a strict vegetarian diet, but later advocated that diet must be tailored to each patient's need. He developed ten basic diets with 95 variations. These ranged from pure vegetarian to exclusively meat. The diets forbade processed foods, pesticide residues, milk, soy beans, peanuts, food concentrates, white sugar and white rice. It allowed almonds, low protein grains and nuts, yogurt, "organic" raw vegetable and fruit juices, salads and whole grain cereals….

Kelley/Gonzalez diets are not unique and have been referred to variously as nutritional, enzyme, metabolic, holistic, macrobiotic, nontoxic and oxidative. Advocates of these diets also recommend "all natural foods" grown without pesticides or chemical fertilizers, and prepared without added sugar, salt, artificial coloring or preservatives. They also recommend large vitamin doses, mineral and glandular supplements and amino acids.

But no one has ever identified those supposed toxins in processed foods, said Dr. Green. Such beliefs are not grounded in science, but from fears of unseen and misunderstood chemicals. Nor has any credible evidence ever surfaced that they poison the body and lead to cancer, or that pancreatic enzyme deficiency is related to cancer, or that enzymes supplied from animal or vegetable sources can replace human enzymes, or that pancreatic enzymes seek out and kill cancer cells. Nor have Kelly or Gonzales every produced evidence that their regimens are more effective than placebo for cancer, he said. In fact, their claims are biologically implausible.

Memorial Sloan-Kettering Cancer Center has cautioned that nutritional metabolic therapies — such as Kelley’s metabolic typing based on claims that a “healthy natural diet” of whole foods, fresh fruits and vegetables, vitamins and detoxification practices to flush toxins from the body can help the body heal naturally — show no evidence of efficacy. They can, however, cause life-threatening complications while deterring people from seeking medical care that can help them.

National Center for Complementary and Alternative Medicine (NCCAM) actually put Gonzales’ pancreatic proteolytic enzyme treatment to the test in a clinical trial begun in November, 1999 at the Herbert Irving Comprehensive Cancer Center at Columbia University in New York. Because most patients refused randomization, the trial was changed in 2001 to a controlled, observational study with participants allowed to volunteer for the regimen. The results were just published in the Journal of Clinical Oncology and reported that those on the Gonzales enzyme regimen did considerably worse than those receiving chemotherapy, living one-third as long and with poorer quality of life. Even more troubling, the patients did worse than average patients with pancreatic cancer in the SEER Database. Regardless of the weaknesses in this study, the bottom line is that the dietary interventions were unable to demonstrate any benefits.

There have been a string of null studies recently published that disprove (again) many popular beliefs about healthful eating in tune with one’s body’s natural healing and that prevents degenerative diseases of aging. Since the media has largely ignored them, upcoming posts will take a look.

© 2009 Sandy Szwarc

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

The man who fed the world

You can't build a peaceful world on empty stomachs and human misery. — Dr. Norman Ernest Borlaug (1914-2009)

One man is credited with saving more lives than any other person in world history. Born to Norwegian migrant parents in his grandparent’s Iowa farmhouse, Dr. Norman Ernest Borlaug grew up during the Great Depression and the hunger he witnessed had a profound effect on him.

He devoted his life to ending the human misery of famine in destitute third world countries, often living and working in harsh, squalid conditions in remote regions of Mexico to Africa. He also understood that large numbers of miserable, hungry people contributes to world instability. He didn’t seek fame and fortune for himself, and few people outside of the scientific field have even heard of him.

Through his pioneering scientific work in plant pathology, developing fungus and disease-resistant crops, drought-resistant farming methods, and increasing crop yields, he saved an estimated one billion people from starvation. As the father of the Green Revolution, through this work, world food production doubled between 1960 and 1990, and quadrupled in India and Pakistan. He continued his work on world hunger well into his 90s and won the Nobel Peace Prize, the Presidential Medal of Freedom and the Congressional Gold Medal.

Dr. Borlaug died tonight at the age of 95. He embodied kindness, compassion, and a conviction to save the lives of fellow human beings, regardless of their race, creed and religion. No other man in human history can compare to his legacy of service to mankind.

“He made the world a better place,” said close friend Dr. Ed Runge, retired head of Texas A&M University's Department of Soil and Crop Sciences. "A much better place."

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A Day to Remember — September 11, 2001

America Attacked 911

Dedicated to the men, women and children who lost their lives, those brave people who gave their lives, and the heroes who responded to the emergency 11 September 2001. We will never forget you.

911 Phone Calls

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Reality check — How have scary predictions about swine flu held up to reality?

The flu season is winding down in Australia, where their winter is nearing end. How did the expert claims, speculations and predictions of the deadly pandemic hold up to the facts?

Three months ago, public health experts and even the President of the Australian Medical Association were warning that one-third of the population would get swine flu. As late as last month, the Australian government had ordered 21 million doses of swine flu vaccine, enough to vaccinate the entire population.

In reality, as of noon today, the Australian Department of Health and Ageing reports that Australia has had 35,775 confirmed cases of pandemic H1N1. The experts had overstated the numbers who would get sick by 203-fold. There have been 162 deaths — a fraction (5.4%) of the 3,000 Australians who typically die from the seasonal flu each year.

It’s a similar story here in the United States. In July, we were hearing projections that as many as 40 percent of Americans could come down with the flu over the next two years and several hundred thousand could die. The government ordered 160 million doses of vaccine.

In reality, the pandemic H1N1 variant has proven to remain far less virulent (to be milder) than the seasonal flu here, just it's been in Australia. As of last week, according to the U.S. Centers of Disease Control and Prevention data, the total number of influenza-related deaths in the United States — including from the H1N1 pandemic — have remained below epidemic levels and resulted in 2009 being the mildest flu year in more than a decade.

Despite perceptions among the public and portrayals in the media of extreme risks, medical professionals recognize that, while the H1N1 flu may spread easily, it causes a relatively mild flu in most people and there is no evidence that is has or is likely to mutate and become deadlier. “If we have to have influenza, I would clearly choose novel H1N1,” Dr. William Schaffner, an infectious disease expert at Vanderbilt University, just told the Wall Street Journal.

Fear Sells

The facts make the latest FDA and FTC consumer warnings about fraudulent H1N1 flu products on the market attempting to take advantage of people’s fears even more tragic.

Since May, when a H1N1 pandemic was declared, the U.S. Food and Drug Administration and the Federal Trade Commission have issued consumer warnings about fraudulent products being marketed claiming to diagnose, prevent, treat or cure H1N1 virus that are not approved, cleared or authorized by the FDA.

Yesterday, the FTC announced that CVS Pharmacy, Inc. has agreed to stop making false and deceptive advertising claims that its AirShield supplement boosts the immune system and can prevent colds and flu and to pay nearly $2.8 million.

On Monday, the FDA issued its latest list of 133 H1N1 products believed to be fraudulent and of criminal activity associated with the swine flu virus The list of fraudulent products include air purifying systems, body washes and shampoos, protective devices, masks and gloves, hand sanitizers and gels, inhaler products, herbal flu remedies, sprays, supplements and teas, and H1N1 tests.

Rather than let fears get the better of us and spend gobs of money and believe that spurious products are keeping us safe, the most effective thing we can all do to help protect from getting sick is use plain old-fashioned common sense and soap and water. Wash our hands. Not nearly as glamorous, but a whole lot more effective.

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

Look before we LEAP again

Clinical guidelines are used to measure the quality of care provided by physicians and are purportedly evidence-based. National childhood overweight and obesity policies in the United States, United Kingdom and Australia call for primary care physicians and pediatricians to monitor children’s BMIs and to counsel youngsters with BMIs ≥85^th percentile and their families on diet, physical activity, sedentary behaviors and adopting healthy lifestyles.

“Evidence supporting such an approach in primary care, however, is conspicuously lacking,” said pediatrician Dr. Melissa Wade M.D., associate director of the Centre for Community Child Health at the Royal Children’s Hospital and the Murdoch Children’s Research Institute in Melbourne, Australia, and colleagues.

To determine the effectiveness of screening and counseling for child overweight and obesity, a second Live, Eat and Play (LEAP) randomized controlled trial was launched. The long-awaited results were just published in the British Medical Journal.

As readers will remember, the first LEAP trial had been conducted at 29 Melbourne medical clinics and involved 3 months of interventions by primary care physicians to teach overweight children and their families healthy lifestyle changes, with 12 months of follow-up. The doctor-based weight management program failed to make any sustained changes in the larger children’s BMIs, failed to change obesity rates, and failed to make any difference in the children’s health status compared to the control group. Thinking a larger study, more training for the doctors and more intense interventions might be able to demonstrate a benefit, LEAP 2 was begun. This larger study began in May 2005 and was due to be completed in September 2007.

Overview of LEAP 2

This trial (registered ISRCTN 52511065), included 45 family practices and 66 general practitioners in Melbourne. From May 2005 through July 2006, nearly 4,000 children, aged 5 to 10 (average 7.5 years old), were screened and 258 who were overweight or obese, according to the International Obesity Taskforce definitions, were enrolled into the study. They were independently randomized, with 139 in the intervention group and 119 in the control group, and were well matched by every measure evaluated. The study investigators remained blinded to who was participating in the study, and the physicians were blinded to the children among their large patient base in the control group. The physicians received training on weight management counseling, which included five hours of instructions, role modeling scenarios and two simulated counseling session, and only those with high scores were allowed to participate.

The children and their families received targeted information on healthy behavioral changes (reducing sedentary time, increasing physical activity, increasing water consumption, improving family eating habits and making low-fat food selections) and agreed to change contracts. For three months, the parents were offered four physician consultations which reinforced family-focused healthy weight, diet and lifestyles changes, with an average of one counseling per month attended.

The family’s socioeconomic status was quantified using the Australian census based Index of Relative Socio-economic Disadvantage score, and the parents BMIs were followed. The parents completed 4-day food diaries on the children, and completed questionnaires on their physical activity and weight concerns. The children’s health status was followed by their pediatricians and graded on 23 quality measures; their weights, heights, waists and activity levels (measured by accelerometry) were followed at six and 12 months; and the children completed questionnaires to evaluate their body dissatisfaction, perceived physical appearance and self worth.

Findings

There was no statistical difference between the intervention and control groups after 6 months or after 12 months in the:

● children’s BMI

● children’s waist circumference

● either parents’ BMIs

● children’s physical activity (counts/minute on accelerometry) or percentage of time spent moderately to vigorously active or percentage of time spent in low activity

● children’s diets

● children’s physical or psychosocial health scores

● children’s degree of body dissatisfaction

● children’s positive/negative feelings about their appearance or self worth

There was no statistical difference in outcomes among children whose parents attended all the consultations and those who attended fewer. There was no statistical differences based on socioeconomic status. Healthcare costs were significantly higher in the intervention group, based on the costs of adhering to the intervention guidelines.

The sample size and consistent follow-up with their doctors for a full year, and the extremely high retention rates (92.8% and 96.6%), enabled the researchers to conclude that there was no clinically meaningful benefit from the diet and activity interventions — as called for in clinical guidelines and public health policies — on the children’s BMI trajectory, physical activity or nutrition.

These findings are at odds with national childhood overweight and obesity policies, including in Australia, UK and the US, the authors concluded. All childhood overweight and obesity policies and guidelines are similar (work to improve diets and increase physical activity) and have similarly been shown to be ineffective. Despite high political appeal, they said, recent systematic reviews of the evidence have been unable to support screening children for overweight or obesity because of the lack of weight management strategies that have demonstrated efficacy and the lack of evidence that benefits outweigh the harms. The authors were unable to find a clinical trial of primary care interventions and screening for child overweight and obesity that had been shown to be effective, as the few trials had all proven to be ineffective in reducing BMI compared to controls.

These findings concur with every other comprehensive intervention trial, including school, state and community based, as well as the findings of the U.S. Preventive Service Task Force, which reviewed nearly 40 years of evidence on screening and interventions for childhood and adolescent overweight — some 6,900 studies and abstracts. The USPSTF had concluded that there is no quality evidence to support that overweight or obesity in youth is related to health outcomes or predicts fitness, blood pressure, body composition or health risks. The USPSTF found insufficient evidence to recommend routine screening for overweight in children and adolescents as a means to improve health outcomes. It did, however, note potential harms of screening programs. According to the USPSTF Childhood Obesity Working Group, no scientific review has been able to find quality evidence that any program to reduce or prevent childhood obesity — no matter how well-intentioned, comprehensive, restrictive, intensive, long in duration, and tackling diet and activity in every possible way — has been effective, especially in any beneficial, sustained way. Nor has any program been able to demonstrate improved health outcomes or physiological measures, such as blood lipids (“cholesterol”), glucose tolerance, blood pressure or physical fitness. Nor has any diet or exercise intervention in children been shown to lead to better health outcomes in adulthood. Not only did the USPSTF find no evidence to support the effectiveness of counseling for healthy eating in young people, it also found no evidence to support low-fat diets in children and, instead, found growing evidence for harm. Politically popular childhood obesity interventions don’t work, of course, because they’re based on false premises about the causes of children’s sizes.

How many more years and how many more times does the evidence have to continue to show the same thing before the public and medical professionals say “enough” and demand evidence-based public health policies and clinical guidelines for our children?

How long before taxpayers begin to hold politicians and stakeholders accountable for the massive amounts of public moneys and resources spent in the name of a childhood obesity epidemic that could have gone towards improving educational opportunities and healthcare for children and families?

© 2009 Sandy Szwarc

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

A Labor Day health story

The health story for this Labor Day is the health of our labor force. The U.S. Department of Labor’s Bureau of Labor Statistics released its latest employment figures on Friday. The unemployment rate jumped to 9.7% in August — a 26-year high — as payrolls fell by another 216,000 jobs. A total of 14.9 million Americans are now listed as unemployed, with an additional 9.1 million working at part-time jobs rather than the full-time work they want. What does this have to do with health? Let’s look.

Civilian unemployment rates for the past decade from the United States Bureau of Labor Statistics reveal just how significant this year's rise in unemployment has been:

But looking at the Bureau’s data, layoffs haven’t been the primary impetus for the recent rising unemployment rates. Layoffs account for about 11 percent of the unemployed this year. [Below: number of unemployed due to layoffs and total unemployed from the Bureau of Labor Statistics.] People with jobs have also been far less likely to quit their jobs, which is understandable when job prospects are so gloomy. People aren’t losing jobs as much as businesses aren’t creating jobs, even while the work force grows.

Jobs don’t materialize out of the ether, of course. Businesses create jobs. When economic prospects for businesses are unfavorable and they can’t anticipate a reasonable return for the risks, they are less likely to invest in equipment and resources to expand or create new products … and create new jobs, entrepreneurs are less eager to take a risk to launch a new business… and create new jobs, and banks or investors are less likely to take a risk to provide the needed capital for business growth… and to create new jobs.

And what would you guess happens to jobs as taxes on businesses, especially those that show a profit, are raised?

Unemployment and job insecurity are not good for people’s health. A review of epidemiological evidence, led by Dr. Robert Jim, a specialist with the Workers’ Compensation Board of British Columbia, reported higher rates of overall mortality, deaths due to cardiovascular disease and suicides among unemployed adults than among either employed people or the general population, even after adjusting for smoking, alcohol use and dietary fat. Associations are not evidence of causation, but something associated with being unemployed has a role. Unemployed people also appear to be more likely than employed people to visit physicians, take medications or be admitted to general hospitals, they wrote. While unemployment and economic issues may not seem part of health care, these authors argue that medical professionals have an important role in furthering economic growth.

We are reminded that the greatest health risk factor is poor financial health and that social-economic disadvantage is associated with four times the risks of poor health outcomes, regardless of health insurance or access to health care.

So, if you’re among the 24 million Americans looking for a good job, or the countless others who are worried about the security of the jobs they have, which would you prefer?

● a government health insurance policy, made possible by raising taxes, notably on corporations, to cover a $1.6 trillion price tag, or

● a good job with long-term growth potential in a strong, thriving economy?

© 2009 Sandy Szwarc

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

Common sense about swine flu

The flu season has barely begun and yet the panic is already in full swing with 186,933 media stories about H1N1 and 47,159 news stories about the swine flu currently at Google News.* Do you know what is missing among the widespread pandemic alarm in the media and coming from government agencies, pharmaceutical and other stakeholders?

The scientific evidence being reported by medical professionals and in the medical literature.

The September 3 issue of the British Medical Journal published an analysis from MIT (Massachusetts Institute of Technology) about how public health responses to flu pandemics have not followed the scientific evidence and that public strategies, which are based on catastrophic epidemic scenarios, risk doing more harm than good.

BMJ even sent out an EurekaAlert press release — Eureka is the global news service provider of the American Association for the Advancement of Science that goes to mainstream media reporters and freelancers and even makes the original studies available to them free. Usually, stories written for reporters on Eureka are plastered across the media but a diligent search for this one found only three articles even mentioning it on Google News, among more than a quarter million news stories about the flu pandemic.

In the same BMJ issue was a report about physicians in Spain, including the Spanish Medical Association, representing around 200,000 physicians, who’ve launched a country-wide “Common Sense” flu communication initiative called Gripe A— Ante Todo Mucha Calma [“Influenza A, above all, very calm”]. It was endorsed by the Organización Médica Colegial [College Medical Association] and has been praised by the Spanish Minister for Health and Social Policy, Trinidad Jimenez. He described the pandemic of H1N1 mostly as an epidemic of fear caused by a ghost illness being fought by exaggerated responses.

The medical community — seeing the strong disconnect from the information politicians and public officials are giving the public, and the science — has been enthusiastically supportive of Common Sense. As one doctor commented: “With so much media morbid, with so many hoaxes on the net and, above all, with so many interests at stake, it takes a lot of information, education and common sense.”

On September 2^nd, forty medical professionals promoting evidence-based medicine also collaborated on an online blog project as part of the Common Sense initiative and simultaneously published the same article explaining the best scientific knowledge about the flu and stressing that there is no evidence to justify alarm.

There was no mention of these medical articles in the Google News, even specifically searching using pertinent search terms. And any mention of the blog project was only found by doing a word search of the participating Spanish medical blogs by name.

Google’s Health Advisory Council appears to have determined that mention of these medical articles is not “relevant for you.” Google has become such a transparent social media marketing venue, it’s impossible for those who follow science and research to miss how Google’s search results prioritize what government-private stakeholders want the public to believe, not what people may want or need to know. Consumers searching Google for information, however, are largely oblivious to the degree that Google’s firewall filters their news.

As a continuation of JFS’ swine flu coverage and efforts to offer balance with medical and scientific research that mainstream media ignores, let’s take a look at this issue of BMJ and the articles from MIT and physicians. The MIT article recapped the medical evidence and conclusions of infectious disease experts that has previously been reported at JFS.

From MIT

“Over the past four years, pandemic preparations have focused on responding to worst case scenarios,” wrote Peter Doshi. As a result, government officials have reacted to H1N1 as if it was “an unfolding disaster.” Their measures are alarmist, overly restrictive and unjustified, given what science knows about emerging infections and advanced laboratory surveillance, he explained. Our understanding of epidemics has changed.

Yet, an impression of the “seriousness of the threat” is underlined by officials spending large sums of public money on pandemic preparedness ($7 billion in the United States). And often repeated phrases — such as those by the U.S. Department of Health and Human Services stating “it’s not a question of IF a pandemic will happen, but WHEN” — characterize the next flu pandemic as a high probability event with extremely serious consequences. But the 2009 pandemic “bears little resemblance to the forecasted pandemic,” he pointed out.

“Pandemic A/H1N1 virus is not a new subtype but the same subtype as seasonal [influenza] A/H1N1 that has been circulating since 1977.”

The word “pandemic” doesn’t mean what the general public thinks it does and few people are even aware that the definition has been changed. In declaring a global pandemic of H1N1, the World Health Organization, as well as the U.S. Centers for Disease Control and Prevention and the Public Health Agency of Canada, changed the definition of “pandemic.” This pandemic wouldn’t be a pandemic with the old definition.

For years, Doshi explained, influenza pandemics were defined as occurring when a new influenza virus appears where the human population has no immunity, resulting in epidemics worldwide with enormous numbers of deaths and illness. That phrase was removed from the definition in early May, just after a phase 5 pandemic alert was declared. The definition of pandemic was changed to reflect how widely dispersed a virus has been detected, not how severe the disease. Yet, the response of public officials for what has largely been a clinically mild illness, as well as the impact on society, he wrote, proceeded based on long-standing assumptions of pandemic disaster scenarios.

Even Dr Margaret Chan, Director-General of the World Health Organization, acknowledged at the H1N1 Health Ministers’ meeting in Bangkok, Thailand, on May 8: “H5N1 has conditioned the public to equate an influenza pandemic with very severe disease and high mortality. Such a disease pattern is by no means inevitable during a pandemic. On the contrary, it is exceptional.”

Doshi also explained how laboratory testing is used to drive public fear and create misperceptions of huge increases in the numbers of cases of the disease. “On 26 April, with 20 cases and no deaths in the US, the Department of Health and Human Services declared a nationwide public health emergency. The subsequent increase in laboratory testing was unprecedented.” The week after the emergency was declared, testing increased nearly sevenfold.

Heightened testing and the “seek and ye shall find” phenomena does not mean there is a real increase in the prevalence of a disease, as JFS has explained. But it’s easy to mislead with statistics and create fears and perceptions of deadly epidemics in the minds of the public. People can even be led to fear something less serious than a common cold and the sniffles. As Doshi writes:

The sudden emphasis on laboratory testing for H1N1 in the first weeks of the outbreak, particularly in the US, produced what I call concern bias, in which concern and anxiety may drive events more than the disease itself. Concern bias confounds the interpretation of data in important ways. The rapid increase in virological testing amplified the perceived prevalence of A/H1N1 and simultaneously minimised the role other agents may have played in causing the same symptoms. After the declaration of a public health emergency, the percentage of respiratory specimens testing positive for influenza viruses increased for eight consecutive weeks to a peak of 40%. This increase, however, may only in part reflect a true increase in prevalence of influenza. It may also be due to behavioural changes in the way respiratory specimens were taken, tested, and reported on.

Laboratories were overwhelmed with a large volume of respiratory specimens, often from patients who under ordinary circumstances would not have had a specimen taken (an extension of the "worried well" effect)….The high concern also makes it difficult to determine whether this epidemic revealed itself or whether its presence came to light only because of heightened awareness triggered by official announcements.

Today’s advanced laboratory capabilities also allow us to track epidemics at a level of detail never possible before and media can present a confusing, frightening perspective that exaggerates the severity of the clinical illness and the number of people threatened by it.

The greatest failures of responses to infectious disease epidemics has been in not recognizing that there are four clinical-epidemiological variations to viruses and in not taking responsibility to ensure that the response is matched to be suitable to the virus. A single, one-size-fits-all public health strategy that assumes every epidemic results in widespread catastrophic and deadly disease (type 1) is not appropriate. Some epidemics affect very few people but the infection is serious (type 2), while type 3 affects many people but with mostly mild infections. But most new viruses, he stressed, are not type 1 threats. The 1957 and 1968 pandemics, for instance, went largely unnoticed by most people and the recorded deaths during both pandemics were similar to those seen an ordinary flu season today.

So, we have pandemic preparedness strategies that are based on a catastrophic (type 1) epidemic and which result in public health responses that are improperly calibrated to the threat and risk doing more harm than good. They are also seen as alarmist and erode the public trust.

Common Sense physicians speak out

It was this understanding of the need for more common sense and rational communications to the public about swine flu that led the Spanish physicians and medical professionals to begin their “Common Sense” communication efforts. The information they have been providing could help people around the world understand what the medical evidence actually supports.

For instance, they explain that swine flu produces the very same cold-like symptoms as seasonal flu, people get it the same way as the seasonal flu (from droplets as people cough or sneeze), and that people can help avoid getting sick by following the very same basic recommendations of hand washing, covering their coughs or sneezes, and avoiding contact with sick people. Those quick laboratory tests to see if you have swine flu are accurate only about 35% of the time and are not useful, they explain. They add that despite the scary misinformation, swine is no more dangerous for pregnant women than the seasonal flu: “Being pregnant does not increase the risk of suffering from swine flu.” Ideally, all pregnant women receive good prenatal care and contact their doctor for all infections.

Just because the virus is infectious and spreads easily, however, does not mean that it is more serious. This virus has proven to cause mild or moderate flu and to be less severe than the ordinary seasonal flu. Most people have mild symptoms and will get no benefit from going to the doctor, the physicians stress. Most importantly, the advice for taking care of the swine flu is the same as in all types of colds and flu. Most people can care for themselves at home, just as they would any cold or flu, with keeping themselves hydrated and nourished.

“Previous flu pandemics do not produce high mortality since we have had antibiotics to cure pneumonias which complicate flu,” explained Dr. Juan Gérvas, a general practitioner and public health professor at the School of Medicine at Autonomous University in Madrid. Historically, flu pandemics also do not have “second waves,” he wrote, and if they occur, they are not likely to be more severe. “It’s absurd to panic about swine flu, especially since it won’t cause severe disease in many people. The current WHO messages, which are increasing fear of swine flu is a form of disease mongering.” And the media’s focus on worst case speculations and giving detailed accounts of every case or every death is irresponsible. While keeping death rates low should not be a problem for medical professionals because of the low severity of the virus itself, he wrote, avoiding social chaos “calls for a strong policy of calmness and accurate information for both professionals and the public.”

If you get sick, the physicians repeat the old adage: ‘The flu lasts 7 days with treatment and one week without it.”

Anti-viral medications do not do much to limit the infections and have proven to have very small benefits, and their routine use is not recommended, the doctors advise. “Anti-virus drugs have not proven effective in infections by seasonal flu; at most they decrease symptoms in less than one day. And considering the swine flu, we even lack any probe of efficiency,” they write. The drugs also have side effects and “in previously healthy people the risk of side effect can be bigger than the benefits.” We know nothing about the safety or effectiveness of new vaccinations specifically for swine flu that are not yet on the market.

Finally, they urge that using health care services because of fear about flu symptoms is unwarranted. Just like any illness, those with severe symptoms should see their doctor (such as trouble breathing, chest pain, fainting, sudden worsening of symptoms, or symptoms during more than seven days), as well as children under 6 months or who have trouble breathing or a fever that lasts more than 3 days. But during any flu pandemic, there will still be people who need medical care for serious conditions such as heart attacks, appendicitis, heart failure, diabetes, asthma attack, hip fractures, accidents, etc.

“It is important that patients suffering from swine flu do not panic and overwhelm the system, so hospitals and doctors can continue to treat all patients,” they concluded. That’s why it is essential to keep calm and have common sense and self-control — and that means everyone including “patients, health professionals, decision makers, politicians and the media.”

Given that it’s unlikely the enormous political and financial interests behind flu pandemics will come to a screeching halt, that leaves medical professionals and consumers to be the responsible ones and get the facts, keep calm and practice common sense.

© 2009 Sandy Szwarc

* As of 7 pm EST on September 6, 2009

Blue cartoons are from the comic book “No Ordinary Flu” funded by the CDC and National Association of County & City Health Officials.

(Click on any image to see larger.)

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Blame, compassion and science

On August 14^th, mainstream media was reporting that osteoporosis-linked fractures have dramatically increased over the past decade. Among 723 news stories, not one questioned the study behind the news. The public not only lost an opportunity to learn the facts, but a valuable take-home lesson.

According to a syndicated Reuters Health story, the number of Americans hospitalized for osteoporosis-related fractures and other injuries have increased 55 percent since 1995, accounting for 254,000 hospitalizations in 2006. According to a study by the Agency for Healthcare Research and Quality (AHRQ), such hospitalization rates had been 55/100,000 people in 1995 and 85/100,000 in 2006. "This is a fairly alarming increase," Anne Elixhauser, Ph.D., a social science analyst with the AHRQ, was quoted saying.

Most of the osteoporosis-related hospitalizations were among older women, with 89 percent of the patients women and 90 percent over age 65. The news article negated aging of the population as fully accounting for the increase, however, and instead suggested that lack of exercise and inadequate calcium and vitamin D intake, as well as medications to treat high blood pressure, such as diuretics, were the “culprits.”

Professor Elixhauser said everyone should start thinking about osteoporosis prevention and adopt healthy lifestyles, eating more calcium and vitamin D in foods, and using supplements as necessary, exercising, not smoking and drinking only in moderation. “Doing so may also make a difference in terms of healthcare dollars,” the story said, adding that osteoporosis-related injuries carried a price tag of $2.4 billion in hospital costs in 2006.

Notice how readers were led to view the elderly victims as being to blame for costing society billions of dollars and to believe that, had the women adopted healthy diets and lifestyles, they could have prevented their problems?

This type of subtle messaging, couched as research, is everywhere today and can lead us to come away believing that popular beliefs are supported by science, when there is no science at all. The only way to prevent being misled is to think questionably about everything, go to the original source and look for the solid evidence.

This story gave us every reason to question it, too. Notice the leaps. There was no attempt to see if there was even a connection between diet and exercise and the osteoporosis-related hospitalizations; no effort to see if there was a link between bone density or calcium levels and osteoporosis-related hospitalizations; and, certainly no attempt to look at medication usage. Readers were left to assume that this study validated the popular beliefs about osteoporosis.

The explanations for the “alarming trend” and the recommendations being given didn’t add up, based on the evidence already in the medical literature:

● Osteoporosis risk is primarily determined by advancing age and by genes. Hip fractures increase with age, with rates doubling every decade after age 50 years.

● Yet, low bone mineral densities don’t predict who will develop fractures. More than half of women who have hip fractures don’t have osteoporosis.

● Despite common beliefs that lifestyle factors — exercise, calcium intake, protein, salt, etc. — hold critical roles in bone density, none of the risk factors used to predict osteoporosis have been shown to make much difference. Even the AHRQ 2002 Evidence Report found no evidence that screening for risk factors or bone mineral density predicts fractures or improves actual clinical outcomes. Nor is there credible support for claims that older women are less active today than they were a decade ago. And NHANES “What We Eat in America” data shows that calcium intake among women of all ages has even been slightly increasing — from a mean of 746 mg/day in 2001 to 858 mg in 2006, for example.

● Repeated studies [reviewed here], including the Women’s Health Initiative which followed 36,000 women for seven years, have also found no evidence that calcium supplements prevent fractures. As the Australian Fracture Prevention Summit’s summary of randomized controlled clinical trial evidence concluded, there remains no evidence that calcium or vitamin D supplementation can reduce osteoporotic fractures among the population.

● It’s widely recognized in the medical literature that osteoporosis rates among fat people are about half that of the general population, with osteoporosis exceedingly rare among obese women who’ve not had bariatric surgeries, and that bone fractures are highest among thin elderly people. But those facts wouldn’t support the government’s healthy diet and lifestyle policies and are rarely mentioned.

● Why was no attempt made to investigate a possible iatrogenic link due to prescription drugs, even though prescription records are readily available in more than 80 percent of hospitalization records, according to the AHRQ authors? According to the CDC’s Health US 2007 [covered here], the number of prescription drugs taken by Americans has increased by 71 percent just since 1996, with the greatest usage among women and rising with age.

Antidepressants make up the largest percentages of drugs prescribed for Americans, for example, tripling just between 1988-97 and 1999-2002. Medco Health Solutions, Inc, the nation’s leading pharmacy benefit manager (PBM), reported that since 2001, nearly half of all women are taking prescription drugs with one in five on anti-depressants [covered here]. Yet the most-used antidepressants, known as selective serotonin reuptake inhibitors (SSRIs, such as Lexapro, Prozac and Zoloft), are known to be associated with increased fractures and osteoporosis, doubling the risk for fractures in older adults in the Canadian Multicentre Osteoporosis Study, for instance.

Going to the study

The source of the news story was a Statistical Brief #76 published in July by the AHRQ as part of is Healthcare Cost and Utilization Project (HCUP). It was authored by professor Elixhauser and colleagues at the AHRQ. These briefs have used the HCUP Nationwide Inpatient Sample database — hospital discharge records on a sampling of 1,000 civilian hospitals, using ICD-9 billing codes (International Classification of Diseases, Ninth Revision, Clinical Modification)* — along with U.S. Census data. Specifically, the authors looked at hospitalizations in 2006, where the condition of “osteoporosis” and “injury” or “fracture” had been checked on the billing claims.

How many readers thought the study had shown there to be more hospitalizations for bone fractures due to osteoporosis? Those who read the actual report would have learned that, in truth, among the hospitalized patients who also reportedly had osteoporosis, the paper had included all sorts of “injuries” that were unrelated to fractures, including superficial injuries and bruises (10%), external caused conditions and injuries (8.2%), sprains and strains, open wounds of extremities, etc. All together, one-fourth (25.1%) of the hospital stays were unrelated to fractures at all.

More telling, while the news reported the patients had been hospitalized for osteoporosis-related fractures, the report reveals that the patients had been hospitalized and received treatment for all sorts of things, including 8.1% for hip replacements. Only 21.9% of the hospitalized patients had received any treatment for fractures or dislocation of hips or extremities.

The AHRQ report also claimed that osteoporosis is a “preventable condition” and that a diet rich in calcium and vitamin D, regular exercise and bone mineral density screenings and treatment “can prevent, improve and slow the progression of the condition.” It said barriers to care, such limitations in insurance coverage for screening tests, could reduce early detection and create a “substantial strain on the healthcare system.”

The footnoted support for this claim was legislation (HR 1894: Medicare Fracture Prevention and Osteoporosis Testing Act of 2009) that had been introduced, and a reference from the National Osteoporosis Foundation about Medicare laws to pay for bone density screenings. This foundation lobbies public policy on behalf of its corporate contributors, and whose corporate partners sell calcium supplements.

This example reminds us of the new role of the AHRQ and its U.S. Preventive Services Task Force — away from its founding purpose as a leading source for objective, systematic reviews of the medical research to its new political role redirected by Congress to build consensus between government health agencies and outside stakeholder partners and to produce information that will support preventive wellness guidelines and pay-for-performance measures.

Going to the original source

The raw HCUP statistics are available directly, so next, we go to the original source: the “HCUP Facts and Figures, 2006” report on hospital stays for 2006 and trends from 1993. HCUP reports have specifically tracked the principle diagnoses and procedures for hospital stays in the United States. Fractures and dislocations of the hip and femur don’t even appear as a frequent diagnosis for hospitalizations until the 85+ age group. This type of fracture is also the most significant type of fracture that medical professionals hope to avoid among adults reaching advancing ages because it is so strongly associated with death and long-term disability.

In fact, just this week, another study was published showing just how significant the connection is between fractures and mortality. The 5-year Canadian Multicenter Osteoporosis Study of a randomly selected cross section of the Canadian population found that hip and vertebral fractures more than tripled the risk for death.

But an interesting fact appears on page 24 of the HCUP report: hip fractures are the only principle diagnosis among the oldest ages that has decreased since 1997, with a nominal drop of 5 percent. The actual HCUP data negates the AHRQ claims. The HCUP report states: “Hospital stays for hip fractures, a common diagnosis among adults 85 and over, changed very little between 1997 and 2006.”

Exhibit 2.2 in the report, which gives the most frequent principle diagnosis by age for all hospital stays shows hip fractures among the 85+ age group were 12.5% of discharges in 1997 and 11.9% of discharges in 2006. Looking at Exhibit 3.2, which lists medical procedures by age, the HCUP statistics reveal that among this age group, 8.7% of hospital patients were treated for fractures or dislocations of hip and femur in 1997 and 2005, and 8.45% in 2006.

Body of evidence

The fact that rates of fractures have been relatively unchanged and have even slightly dropped over the past decade — not experiencing the “alarming increase” as the AHRQ claims — is not a surprise. In fact, that’s been the case for decades across North America.

Health US 2007 and Health US 2008, issued by the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, are our government’s reports of the health of the population. They show that rates of hospitalizations for all types of fractures for every age group have dropped, but most significantly among older women.

● Among men 65-74 years of age, rates were 0.45% in 1990; 0.45% in 2005 and 0.41% in 2006.

● Among men aged 75+, rates were 1.37% of hospitalizations in 1990 and 1.34% in 2005.

● Among women 65-74 years of age, rates were 0.84% in 1990; 0.80% in 2005 and 0.76% in 2006.

● Among women 75+, rates were 3.15% of hospitalizations in 1990 and 1.49% in 2005.

● Among the oldest of all adults, those 85 years and over, fracture rates were 4.39% in 1990 and by 2006 had dropped to 4.03%.

Canadian health statistics, from the Canadian Institute for Health Information database, also show age-adjusted hip fracture rates have steadily declined since 1985 and most rapidly since 1996. The figures compiled by the Osteoporosis Surveillance Expert Working Group were published in last week’s Journal of the American Medical Association. They reported a drop in age-adjusted hip fracture rates of 31.8% in women and 25% in men.

Lost lesson

Because no one thought to question this news story, investigate the original sources, and think about the evidence, the myth was perpetuated that chronic diseases of aging and heredity are largely preventable if everyone followed the government’s recommended healthy diets and lifestyles.

Because no one thought to question this news story, investigate the original sources, and think about the evidence, the belief was reinforced that elderly people who develop age-related conditions are to blame for their conditions.

Because no one thought to question, go to the original sources, and to think about the evidence, viewing seniors needing medical care as unnecessarily raising healthcare costs for everyone else was encouraged.

Information that comes from the government or seems to confirm what we believe to be true, does not make it factual. Marketing rarely comes in the form of an obvious advertisement. Yet, whether it’s to move us to think a certain way, to believe certain things or to act in certain ways, it is still selling us.

To help prevent ourselves from being misled, it’s never been more important to question things we hear, go to the original sources and look for the sound evidence, and to think.

Think about the consequences of a populace that fails to question or think. Think about why the re-emergence of the preventive wellness and healthism movement, and its anti-science, is so important to understand.

© 2009 Sandy Szwarc

* ICD-9. As reviewed previously, the ICD-9 released in 1984, is an enormous, complex system that gives a number to every disease and medical procedure. The medical literature is filled with documentations of its inaccuracy in reflecting actual patient disease rates. Over recent years, healthcare providers have also been encouraged to check off these codes in order to receive reimbursement from third party payers, and the use of ICD-9 codes has increased. Caution is warranted in extrapolating more billing codes to mean that there were actually more cases of any condition.

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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

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

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

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

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?

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

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.

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

Medical Grand Rounds 5.47

Dr. Rich hosts this week’s issue of Medical Grand Rounds. The topic is cost containment in healthcare reform.

The commentary was true to his reputation for sharp, stinging humor. Good sarcasm is hard to do because if the audience doesn’t understand the issue, it can be taken all wrong.

In the introduction, Dr. Rich (retired cardiologist Dr. Richard N. Fogoros, M.D.) reminded readers that critics of healthcare reform legislation have been formally serviced notice that they are under surveillance should they be caught making errors in describing the proposed plan and risk being reported to Linda. He welcomed visitors on such important surveillance work, though, and assured them that they would find no malefactors here and that they could safely move on…

For readers who weren’t sure what he was talking about, it was a commentary about last week’s citizen informant news when the White House asked people to report to the government anyone saying or writing anything “fishy” about the Administrations’ healthcare reform legislation — whether rumors, casual conversations or emails. Of course, it’s raised privacy concerns and parallels to past governments that have used citizen informer techniques. Since then, bloggers have responded in droves, turning themselves in.

Medical news JFS readers may find especially interesting is that Dr. Nicholas Christakis has taken his social networking model (which he'd used to support a theory that fat is catching) to matchmaking.

A medical blog post Dr. Rich missed including in Grand Rounds was his own. Last week he talked to patients who believe greedy doctors using expensive technology and insurance companies are finally going to have it stuck to them in healthcare reform. They tell you that “once they take care of the evildoers, you, the patient… will be left with full, efficient, timely, and effective healthcare.” But this is where you are wrong, he wrote.

“If you believe that you patients are not, in fact, the primary target of the healthcare reformers, you have not been paying attention,” he wrote. “If you would like to get a preview of how you are going to be treated under the new healthcare regime, consider the growing plight of one relatively small subset of your number - the obese.” He went on to talk about “obesity as a health risk factor now marked for particular excoriation” under the plan. If patients and doctors don’t get this stuff, he wrote, then we are all “truly screwed.”

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

Equitable isn’t always ethical or compassionate

If more medical professionals shared with the public what it’s like to care for patients covered by managed care plans, the reason most doctors find it incompatible with medical ethics would be more widely understood. By controlling what care is available, managed care rations care and decides which lives are worth expending money to save. But government rationing is quiet, behind the scenes and often invisible to the public. It isn’t to doctors who understand how it works.

Dr. Zane F. Pollard, M.D., who’s at the only pediatric ophthalmology practice left in Atlanta, Georgia, that still accepts Medicaid patients, explained why most doctors oppose government-managed care. Dr. Pollard wrote:

For example, in the past 6 months I have cared for three young children on Medicaid who had corneal ulcers. This is a potentially blinding situation because if the cornea perforates from the infection, almost surely blindness will occur. In all three cases the antibiotic needed for the eradication of the infection was not on the approved Medicaid list.

Each time I was told to fax Medicaid for the approval forms, which I did. Within 48 hours the form came back to me which was sent in immediately via fax, and I was told that I would have my answer in 10 days. Of course by then each child would have been blind in the eye. Each time the request came back denied. All three times I personally provided the antibiotic for each patient which was not on the Medicaid approved list. Get the point — rationing of care.

Over the past 35 years I have cared for over 1000 children born with congenital cataracts. In older children and in adults the vision is rehabilitated with an intraocular lens. In newborns we use contact lenses which are very expensive. It takes Medicaid over one year to approve a contact lens post cataract surgery. By that time a successful anatomical operation is wasted as the child will be close to blind…

Read the full article here.

People who need medical care beyond the basic benefit coverage — like premature babies, elderly, disabled and those with chronic diseases — find their special care needs an uncovered benefit. Under healthcare reform, managed care is to be focused on “wellness” not sick care. Medical care for those with special needs will be even less attainable. Such people are already being described as burdens on the system, costing everyone else and not cost effective to spend money on under the comparative analysis formula being used to prioritize healthcare spending.

That’s what actual, active rationing of care means.

With Medicare already paying doctors and hospitals 20-30% less than comparable plans, and Medicaid 30-40% less, growing numbers of doctors and hospitals can't afford to care for the poor and those with special needs. Out of necessity, care for them is increasingly restricted to what the government will cover. Those needing care beyond the government’s basic “equitable for all” coverage, have to find a way to pay for it themselves or suffer. Discrimination can be disguised as equitable and fairness. Equitable isn’t always ethical or compassionate.

© 2009 Sandy Szwarc

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

No American can ever say they didn’t know…

An ongoing debate has been unfolding among the public and medical professionals about whether the healthcare reform bill really requires mandatory counseling for every senior that will steer them to make advance healthcare decisions that could end their lives sooner, perhaps in order to lower healthcare costs.

While quick reactions have come from both sides of the issue, few people have read the bill and understand what it says or what the words really mean. Even fewer know the history and objectives of the stakeholders behind this section of the bill. In talking this weekend with other nurses who’ve worked in intensive care and faced ethical questions surrounding life and death for much of our careers, the repeated comment was how few people even know what’s happening, even though they will soon find their ethics put to the test in ways they never imagined. The issue is far too big to cover comprehensively in a single blog post, but links to historical perspectives and a few resources will hopefully give all of us cause to pause and think.

Beginning with the legislation

Let’s first look at the source of this debate: Section 1233 “Advance Care Planning Consultation.” It’s on pages 424-434 of the Health Care Bill (H.R. 3200). Then, we’ll begin to decipher some of the doublespeak:

SEC. 1233. ADVANCE CARE PLANNING CONSULTATION.

(a) Medicare-

(1) IN GENERAL- Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended

(A) in subsection (s)(2)—

(i) by striking `and' at the end of subparagraph (DD);

(ii) by adding `and' at the end of subparagraph (EE); and

(iii) by adding at the end the following new subparagraph:`(FF) advance care planning consultation (as defined in subsection (hhh)(1));'; and (B) by adding at the end the following new subsection:

`Advance Care Planning Consultation

(hhh)(1) Subject to paragraphs (3) and (4), the term `advance care planning consultation' means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following:

`(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to./p>

`(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses./p>

`(C) An explanation by the practitioner of the role and responsibilities of a health care proxy./p>

`(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965)./p>

`(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title.

`(F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include—

`(I) the reasons why the development of such an order is beneficial to the individual and the individual's family and the reasons why such an order should be updated periodically as the health of the individual changes;

`(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and

`(III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decision maker (also known as a health care proxy)./p>

`(ii) The Secretary shall limit the requirement for explanations under clause (i) to consultations furnished in a State—

`(I) in which all legal barriers have been addressed for enabling orders for life sustaining treatment to constitute a set of medical orders respected across all care settings; and/p>

`(II) that has in effect a program for orders for life sustaining treatment described in clause (iii)./p>

`(iii) A program for orders for life sustaining treatment for a States described in this clause is a program that—/p>

`(I) ensures such orders are standardized and uniquely identifiable throughout the State;/p>

`(II) distributes or makes accessible such orders to physicians and other health professionals that (acting within the scope of the professional's authority under State law) may sign orders for life sustaining treatment;

`(III) provides training for health care professionals across the continuum of care about the goals and use of orders for life sustaining treatment; and

`(IV) is guided by a coalition of stakeholders includes representatives from emergency medical services, emergency department physicians or nurses, state long-term care association, state medical association, state surveyors, agency responsible for senior services, state department of health, state hospital association, home health association, state bar association, and state hospice association.

(2) A practitioner described in this paragraph is--`(A) a physician (as defined in subsection (r)(1)); and `(B) a nurse practitioner or physician's assistant who has the authority under State law to sign orders for life sustaining treatments.

`(3)(A) An initial preventive physical examination under subsection (WW), including any related discussion during such examination, shall not be considered an advance care planning consultation for purposes of applying the 5-year limitation under paragraph (1).`(B) An advance care planning consultation with respect to an individual may be conducted more frequently than provided under paragraph (1) if there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal diagnosis or life-threatening injury, or upon admission to a skilled nursing facility, a long-term care facility (as defined by the Secretary), or a hospice program.

`(4) A consultation under this subsection may include the formulation of an order regarding life sustaining treatment or a similar order.

`(5)(A) For purposes of this section, the term `order regarding life sustaining treatment' means, with respect to an individual, an actionable medical order relating to the treatment of that individual that—

`(i) is signed and dated by a physician (as defined in subsection (r)(1)) or another health care professional (as specified by the Secretary and who is acting within the scope of the professional's authority under State law in signing such an order, including a nurse practitioner or physician assistant) and is in a form that permits it to stay with the individual and be followed by health care professionals and providers across the continuum of care;

`(ii) effectively communicates the individual's preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual;

`(iii) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary); and

`(iv) may incorporate any advance directive (as defined in section 1866(f)(3)) if executed by the individual.

`(B) The level of treatment indicated under subparagraph (A)(ii) may range from an indication for full treatment to an indication to limit some or all or specified interventions. Such indicated levels of treatment may include indications respecting, among other items—

`(i) the intensity of medical intervention if the patient is pulse less, apneic, or has serious cardiac or pulmonary problems;

`(ii) the individual's desire regarding transfer to a hospital or remaining at the current care setting;

`(iii) the use of antibiotics; and

`(iv) the use of artificially administered nutrition and hydration.'.

(2) PAYMENT- Section 1848(j)(3) of such Act (42 U.S.C. 1395w-4(j)(3)) is amended by inserting `(2)(FF),' after `(2)(EE),'.

(3) FREQUENCY LIMITATION- Section 1862(a) of such Act (42 U.S.C. 1395y(a)) is amended—(A) in paragraph (1)—

(i) in subparagraph (N), by striking `and' at the end;

(ii) in subparagraph (O) by striking the semicolon at the end and inserting `, and'; and (iii) by adding at the end the following new subparagraph:

`(P) in the case of advance care planning consultations (as defined in section 1861(hhh)(1)), which are performed more frequently than is covered under such section;'; and (B) in paragraph (7), by striking `or (K)' and inserting `(K), or (P)'.

(4) EFFECTIVE DATE- The amendments made by this subsection shall apply to consultations furnished on or after January 1, 2011.

(b) Expansion of Physician Quality Reporting Initiative for End of Life Care-

(1) Physician’s QUALITY REPORTING INITIATIVE- Section 1848(k)(2) of the Social Security Act (42 U.S.C. 1395w-4(k)(2)) is amended by adding at the end the following new paragraphs:

`(3) Physician’s QUALITY REPORTING INITIATIVE-

`(A) IN GENERAL- For purposes of reporting data on quality measures for covered professional services furnished during 2011 and any subsequent year, to the extent that measures are available, the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted or endorsed by a consensus-based organization, if appropriate. Such measures shall measure both the creation of and adherence to orders for life-sustaining treatment.

`(B) PROPOSED SET OF MEASURES- The Secretary shall publish in the Federal Register proposed quality measures on end of life care and advanced care planning that the Secretary determines are described in subparagraph (A) and would be appropriate for eligible professionals to use to submit data to the Secretary. The Secretary shall provide for a period of public comment on such set of measures before finalizing such proposed measures.'.

(c) Inclusion of Information in Medicare & You Handbook-

(1) MEDICARE & YOU HANDBOOK-

(A) IN GENERAL- Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall update the online version of the Medicare & You Handbook to include the following:

(i) An explanation of advance care planning and advance directives, including—

(I) living wills;

(II) durable power of attorney;

(III) orders of life-sustaining treatment; and

(IV) health care proxies.

(ii) A description of Federal and State resources available to assist individuals and their families with advance care planning and advance directives, including—

(I) available State legal service organizations to assist individuals with advance care planning, including those organizations that receive funding pursuant to the Older Americans Act of 1965 (42 U.S.C. 93001 et seq.);

(II) website links or addresses for State-specific advance directive forms; and

(III) any additional information, as determined by the Secretary.

(B) UPDATE OF PAPER AND SUBSEQUENT VERSIONS- The Secretary shall include the information described in subparagraph (A) in all paper and electronic versions of the Medicare & You Handbook that are published on or after the date that is 1 year after the date of the enactment of this Act.

Did you get all that? Of course not. It’s mostly gobblety goop and legalese, with repeated edits and references to other laws that makes it next to impossible for most anyone to comprehend. But, as the Bioethics Defense Fund has concluded, this broad and vaguely written bill is wide open to being interpreted as giving the government the power to require all Medicare recipients to receive advance care consultations and giving the government the unprecedented authority to define exactly what such counseling must include, who can deliver it, and when it must be given.

More importantly, it is clearly an effort to coerce seniors to sign such an order. There are multiple loopholes that open doors for its misuse, and abuse of the elderly, while also including no protections for these patients.

Claims that it is not mandatory are most obviously not supported by the bill’s language. It directs healthcare providers that they “shall” ensure every Medicare patient receives such counseling every five years. “Shall” means must. Those directives are to become part of the patient’s medical records. The most telling evidence that it will be mandatory is the Expansion of Physician Quality Reporting Initiative provision that makes advance care planning a reportable Pay for Performance measure for every professional providing services to Medicare patients. “Such measures shall measure both the creation of and adherence to orders for life-sustaining treatment.” Worse, those measures reportable to the government will be defined and determined by the Secretary of Health and Human Services. Electronic medical records will enable governmental oversight of physicians’ and patients’ adherence and identify those who are noncompliant.

It says that at each counseling session, the healthcare provider must provide patients and their families with a list of outside advance planning organizations and resources, and explain the benefits of their end-of-life services and why signing an order is beneficial to them. The end of life discussions at the initial preventive physical exam, mandated for every Medicare recipient upon enrollment, doesn’t count towards the five years. And anytime there is a change in their health, a diagnosis of a chronic, progressive or life-limiting disease, or diagnosis of a terminal illness or life-threatening injury, or admission to a nursing care or long-term care facility, they may receive the counseling again. Note: This would define all chronic diseases of aging, which means seniors could receive relentless counseling about the benefits of and need to plan their deaths.

Every consultation can result in an actionable medical order about life-sustaining treatment, says the bill, one that is signed by the doctor. Note: It makes no provisions that the patients must consent to these orders or that the doctor writing these orders must be the patient’s own personal healthcare provider.

If these counselings are really not mandatory, whether for doctors or patient, then it would be very simple to correct any confusions, according to Wesley J. Smith, Senior Fellow in Human Rights and Bioethics at the Discovery Institute, associate director of the International Task Force on Euthanasia and Assisted Suicide, and a special consultant for the Center for Bioethics and Culture. In fact, it is even more disturbing that no patient protections are included in the legislation, such as his suggestions to:

● Add a provision stating that the counseling is entirely voluntary–both for the patient and the medical provider. In that way, the regulations–that will be thousands of more pages–promulgated by the agencies to further the purpose of the law won’t be able to require counseling.

● Add a provision stating that the patient will not lose benefits if he/she refuses counseling or does not sign an advance directive.

● Add a provision that no service provider will lose compensation for not providing counseling.

● Add a provision prohibiting the counseling from being directed toward refusing or accepting care…

Look at those closely. In other words, this legislation leaves the door wide open for the government to deny seniors medical care or take away their benefits if they don’t sign a directive and it gives the government the authority to withhold a doctor’s compensation. Intimidation of seniors at the most vulnerable times of their lives? Clearly.

But the most critically important provision — and what should be the most deeply concerning to every American — are the compulsory referrals of patients to outside organizations that not only may, but do, have strong ideological agendas. THIS is why it is so important for medical professionals and every consumer to understand this legislation and its history and what is included in these counseling sessions. The outside groups that have positioned themselves as the end-of-life experts and that have been doing the end-of-life education at academic centers across the country have been being closely followed and opposed by medical ethicists for decades. These are the ones who will (and already have) become the outside counselors and providing the approved counseling materials and registries, as mandated by this legislation.

The history behind the “Lives not worth living” campaign

This legislation is the culmination of efforts since 1938 to change what the public would once have viewed as morally repulsive into something accepted. There are a number of papers that have documented this history in detail. Let’s first look at the report that formed the basis for this legislation, and then at a paper which helps decode the terminology.

The report this legislation was written from was “Advance Directives and Advance Care Planning: Report to Congress,” published last August. It was written by RAND Health, a division of RAND Corporation, and the HSS. RAND Health is under the direction of Dr. Robert H. Brook, M.D., who heads the Robert Wood Johnson Clinical Scholars Program at UCLA, and is sponsored by Robert Wood Johnson Foundation, along with other foundations, pharmaceutical companies, managed care companies and governmental agencies.

This report was commissioned to map out how to promote advance directives and planning for end-of-life care on a national level and to identify the barriers and legal issues. As it noted, legal cases during the 1970s and 1980s surrounding withdrawing life support resulted in the increasing adoption of state laws. Since the 1990s, efforts have ensued to create a national model and legislation requiring all health care facilities receiving Medicare or Medicaid funding to provide information on advance directives and to incorporate those directives into the medical records.

Among adults, those “with dementia would appear to be a group for who advance care planning and advance directives would be particularly useful,” said the report. “About 5 percent of those age 71-79 have evidence of dementia; the figure rises to 37 percent of those 90 years and older. In long-term care facilities, the prevalence of dementia among residents approaches 50 percent.”

The report noted that disability rights activists have raised concerns “that advance directives and withdrawal of life-sustaining care, when combined with ‘biased and inaccurate views of many disabled patients’ quality of life held by the non-disabled, encourage less aggressive care and withdrawal of life-sustaining treatment, permitting persons with disability to die earlier then warranted.” A history of social and economic discrimination of persons with disability contribute to these concerns. The strongest concern, however may be the view that the quality of life of some disabled person is less preferable than death or “at least not worth using life-sustaining treatment to achieve or preserve,” said the report. “The disability community also raises concerns that biases about quality of life translate into reduced clinician efforts to maximize patients’ quality of life, which in a self-fulfilling manner causes patients to accept less aggressive care.

Disability doesn’t have a uniform definition, noted the report, and it’s generally defined as a physical or mental impairment that substantially limits one of more life activity. Read this language carefully, as you will see it again:

Major life activities include seeing, hearing, speaking, walking, breathing, performing manual tasks, learning, caring for oneself or working. Examples of disability so defined include a seizure disorder, paralysis, HIV infection, substantial hearing or visual impairment, cognitive developmental disability, or a specific learning disability.

Based on this definition, 20 percent of the United States population — more than 50 million people — has a disabling condition that interferes with life activities.

The report looked at various approaches to promote advance directives and end-of-life planning. It recommended the behavioral change model that includes motivating the behavior, providing an opportunity to change and enabling the change through education and social marketing efforts. “Legislative or policy intervention may help someone who lacks motivation and particularly those without ability or opportunity.”

Social marketing, it explained, is designed to bring about social change using concepts from commercial marketing and has proven effective in achieving widespread acceptance of behavioral changes in other health issues. It recommended using social marketing to make a public case for advanced care planning. It exampled the 1995 national social marketing campaign, Last Acts, funded by RWJF, that included more than 1,000 groups across the country. It worked to build coalitions and change the culture in healthcare institutions and change cultural attitudes about death and dying. Another social marketing campaign exampled was the Hawaii state program, Kokua Mau, also funded by RWJF together with foundations, the state and insurance companies.

The report also examined the benefit of Health IT (electronic medical records), including electronic prompts, computer-generated reminders and forms, to influence physician practices and increase compliance. At roundtable discussions of legal and social marketing initiatives, held in Washington, DC on October 22-23, 2007, it specifically recommended end-of-life planning be incentivized by making it a pay-for-performance (“quality”) measure. Hospitals would be graded on their adoption of measures and it even recommended that poor advance care planning be seen as a medical error, in violation of standards and requiring “remedy.” Any doctor who fails to comply could jeopardize their license.

The Hawaiian Kokua Mau program, funded by a RWJF grant of $450,000 between January 1999 and August 2003, continues to give seniors an advanced planning booklet, called Making Choices Known to help them “ease their families’ burden.” It begins with “Understanding Life-Sustaining Treatments” and describes them (mischaracterizing them) as including:

● food and nutrition (as in an IV and tube feeding) that, it said, can prolong life

● blood transfusions

● surgical and other procedures to relieve suffering and provide comfort (it asks if there are not “other, less invasive procedures that can increase comfort and reduce pain?)

● CPR

● breathing machines

● and antibiotics. “Pneumonia used to be called ‘the old person’s friend,” it said, and for “persons nearing the end of life, symptoms of an infection may be effectively managed without the use of antibiotics.”

It then asks three simplified questions about their desired end-of-life care: if they want to have their life prolonged, if they want food and fluids, and if they want treatment to relieve their pain even if it hastens their death. If you’ve ever watched someone die of starvation and dehydration, or from hypoxia and unable to breath with fluid-filled lungs, it is not a swift or painless death, hence the use of drugs to “relieve their pain even if it hastens their death.”

According to RWJF, the University of Hawaii Center on Aging, a member of Kokua Mau, reported that the number of advance directives completed by seniors in Hawaii had increased by 10 percent between 1998 and 2000. Most notably, hospice admissions increased 20 percent from 1999 to 2001, and referrals at the state's largest hospice increased 48 percent during 2002. The program had effectively led those seniors to forgo medical treatment, saving managed care providers an undisclosed amount.

As RWJF explained, between 1997 and 2003, it funded a national program called Community-State Partnerships to Improve End-of-Life Care, authorizing $11.5 million for the program. That was after its earlier Last Acts coalition and its $28 million project in 1995 called Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT), which had claimed “most Americans die in hospitals, often alone and in pain” and was used to garner support for assisted suicide programs.

As RWJF said, states had been the focus of the physician assisted suicide debate during the 1990s after the headline case of Dr. Jack Kevorkian, and it had funded programs in Maryland, Florida, Colorado and elsewhere, before deciding it didn’t want to fund more ad hoc efforts and preferred a national program to bring cohesiveness to their efforts.

The Art of Verbal Engineering

This article was first published in the Duquesne Law Review in the fall of 1996 and may be one of the most important things you’ll read to help better understand the verbiage used in the Healthcare Reform bill, as well as in media on this issue. Words can often mean something very different from what we think they do, and even from what they meant a few years earlier. Not understanding how words are used can do more than hurt, authors Rita L. Marker and Wesley J. Smith wrote, they may kill.

Regardless of one's views about assisted suicide and euthanasia, an understanding of the words used when they are discussed is vitally important. This importance is underscored by a changing relationship between patients and health care providers, a relationship increasingly characterized less as a patient-physician relationship and more as a consumer-provider transaction. In practice, the consumer/patient and the doctor/provider are often placed in a position subordinate to that of the managed care bureaucrat. Health care consumers deserve and desperately need to know how definitions have changed, and they have a right to know that these changes can affect them profoundly.

“Slowly, quietly — but inexorably — the previously appalling is transformed into the presently appealing,” they wrote. The story begins on January 27, 1938, in a New York Times article by the president of the Euthanasia Society of America that called for the legalization of killing. Euthanasia was described bluntly at first. “The public was horrified,” wrote Marker and Smith, “when Dr. Foster Kennedy, president of the Euthanasia Society of America, explained that the primary purpose of his group's legislative proposal was to eventually legalize euthanasia for ‘born defectives who are doomed to remain defective, rather than for normal persons who have become miserable through incurable illness.’”

During the six decades after this first legislative attempt, “euthanasia proponents have learned a lot about public relations,” they wrote. “One lesson is that all social engineering is preceded by verbal engineering. If words or their meaning can be changed, the quest to change hearts and minds will be achieved.”

This important article, traces how the meanings of words have shifted, forming new patterns of thinking — words like ‘terminal’ (which laypeople wrongly think means that death is unavoidable and very close); ‘treatment’ (which has morphed from care given in efforts to cure or ameliorate a medical condition to come to mean prescribing fatal overdoses and lethal injections); and ‘comfort care’ (where a prescription for a “drug overdose, legally prescribed” is now called “comfort care” and, according to Oregon’s Medicaid director, is covered under Oregon’s Health Plan).

Considerable verbal engineering, they explained, has transformed foods and fluids that had been sustaining life to be called a ‘treatment’, and removal for nonmedical reasons with the intent of causing death called 'withdrawing treatment'. The simple procedure of providing foods and water by a gastrostomy tube has been around for more than a century, they wrote, and at least 848,100 people a year in the United States are on these feedings for a period. “Yet, in the debate over food and fluids, this simple procedure has been described [by proponents of assisted suicide] as one which is highly invasive and highly risky,” they said. By the time the 1990 case of Nancy Cruzen had been decided, right-to-die advocates had already expanded the withholding foods and fluids to include any oral feeding, by spoon or on a lunch tray. “A tray of food is considered treatment,” according to the 1996 guide to end-of-life options by the Euthanasia Educational Council (now called Choice in Dying).

So today, euthanasia is “couched in euphemisms — words of gentleness or the language of rights,” said Walker and Smith. “Titles of euthanasia advocacy groups contain words like ‘compassion’, ‘choice’, and ‘dignity’. Even the Euthanasia Society of American has undergone name changes to present a more positive image.”

“Words only mean what the speaker intends them to mean, regardless of the understanding of the listener,” they concluded. “Terms like ‘killing’ and ‘suicide’ which have precise definitions but negative connotations have become outcasts, replaced by subjective, feel-good, meaningless phrases...Thus, the ongoing revolution in ethics and values was preceded by a radical shift in the use of language, all intended to beckon us to embark on a journey to radical social change.”

There are several articles that have chronicled the evolution, money and people behind the assisted suicide and death with dignity organizations. It’s especially helpful is to see the various mergers and changes in the names of the groups between 1938 and today; the changes in the arguments used to slowly bring the populace to accept killing even of babies born with disabilities, terminally ill and elderly; and to follow the legal and legislative efforts that have brought us to this point.

Karen Ward, RN wrote a long article in the March 29, 2006 issue of North Country Gazette that described the findings of researchers such as Rita Marker, a Steubenville, Ohio, lawyer who has extensively examined the foundations that have funded euthanasia and assisted suicide groups in the United States. In addition to RWJF, she described another major foundation that has provided billions of dollars in funding, the Soros Open Society Institute of George Soros. She also chronicled the name changes and mergers of the groups it supports, and noted how these major funders “have also embedded themselves in every level of health care, government, and society.”

Euthanasia Society of America — the Society for the Right to Die — Euthanasia Educational Council — Concern for Dying — Hemlock Society— Americans Against Human Suffering — Californians Against Human Suffering — Death with Dignity Education Center — World Federation of Right To Die Societies — National Council for Death and Dying — Choice in Dying — Euthanasia Research & Guidance Organization ERGO — Americans Against Human Suffering — Californians Against Human Suffering — Compassion in Dying formed — Caring Friends— Partnership for Caring: America’s Voices for the Dying — End of Life Choices — Final Exit Network — Last Acts Partnership — Compassion and Choices…,

These groups all preach dignity, choice, rights, compassion, mercy, but the common denominator is their origins in the Hemlock Society and Euthanasia Society, including legalization of euthanasia. Marker, along with many others, believes the assisted suicide and euthanasia movement often refers to the "right-to-die" or "death with dignity" and that this movement seeks legalization of mercy killing via a two-step process: the acceptance of assisted suicide, and then, a shift to active euthanasia.

She also condemned the verbal engineering. In order to gain acceptance among the public, she wrote, euthanasia is “cloaked using phrases such as death with dignity, compassionate care, and choices, as in autonomy, and thereby creating a deceptive power or right of self governance or control for those allegedly on their death bed. Taking advantage of people’s ignorance with word play is deceitful.”

Most troubling was her question: “[W]ill policy changes and laws shade and transform our moral beliefs whereby we accept this incremental moral decline within our society, not truly aware, until it has already happened?” Will be become a society “indifferent to killing; people without a heart and without a conscience?”

Another must-read article detailing the history of assisted suicide organizations, their name changes, spin-offs and mergers, was published by the International Task Force. “After sixty-six years, and after using many different names and approaches, euthanasia organizations in the United States could point to Oregon as the only state where their goal had been met.” This article also explored ethical debates that have taken place over the years. At a 1994 debate, for instance, the murder of a disabled girl by her father was excused by the director of Choice in Dying and used to support the need for physician assisted suicide.

Amici

Amici are physicians, philosophers, and law professors involved in studying and teaching bioethics. In Issues in Law & Medicine, they documented the history and consensus of the medical profession that has always maintained that assisting suicide is not a legitimate medical purpose and that it “undermines the foundational commitment of medicine to healing and the promotion of human health.”

Their primary argument was: “The proper end of medicine is restoration and preservation of health and relief of suffering, not termination of life.” The Amici stated “that condoning the ‘quick fix’ of physician-assisted suicide will undermine society's commitment to the more difficult but infinitely more rewarding task of meeting patients' real needs.”

This is not to negate their strong support for pain management and palliative care (as traditionally defined) for terminally ill patients, they added. That is inherent in the ethical and compassionate care of patients by all doctors and nurses.

This medical ethics historical is important to read. It’s valuable to remind ourselves of what our society could repeat if we forget these most fundamental principles. The Hippocratic Oath, as Sir William Osier said in 1913, has been the ‘credo’ of the profession and the high water mark of professional morality for 25 centuries. The Hippocratic Oath was born in response to requests to provide lethal drugs to patients to facilitate suicide, the paper explained. “In responding to such requests Hippocrates (c. 450-377 B.C.) formulated his oath for physicians, providing in part: ‘I will give no deadly medicine to anyone if asked, nor suggest any such counsel.’”

Physicians profess devotion to human health and healing… This devotion to health and healing necessarily requires the cultivation of particular virtues, such as self-restraint, patience and sympathy. More to the point, devotion to health and healing sets certain limits on the physician's conduct, chief among which is the prohibition against physicians killing or helping to kill their patients.

The prohibition against killing patients, the first negative promise of self-restraint sworn to in the Hippocratic Oath, stands as medicine's first and most abiding taboo... The deepest ethical principle restraining the physician's power is neither the autonomy and freedom of the patient nor the physician's own compassion or good intention. Rather, it is the dignity and mysterious power of human life itself, and, therefore, also what the [Hippocratic] Oath calls purity and holiness of the life and art to which the physician has sworn devotion. A person can choose to be a physician but cannot simply choose what physicianship means…

The international medical community rejects physician-assisted suicide as well. Physician-assisted suicide, like euthanasia, is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically.

The nursing profession has long been bound by similar medical ethics. “Historically, the role of the nurse has been to promote, preserve and protect human life,” they wrote. “The Code for Nurses states that respect for persons extends to all who require the services of the nurse for the promotion of health, the prevention of illness, the restoration of health, the alleviation of suffering and the provision of supportive care of the dying. The nurse does not act deliberately to terminate the life of any person,” according to the 1994 American Nursing Association, Position Statements: Assisted Suicide.

Yet, assisted suicide advocates are also finding their way into nursing journals and nursing associations, such as a troubling article in the August 2008 issue of the American Journal of Nursing, where Judith Schwarz with Compassion and Choices, told nurses that when “patients wish to hasten their dying, nurses can and should help.” She distorted the American Nurses Association’s policy to add: “But the ANA did not include taking appropriate palliative measures in its definition of assisted suicide.” She said nurses must be encouraged to inform their patients about palliative options, “including those that might hasten dying: forgoing life-prolonging interventions, refusing food and fluids, and receiving high doses of opioids or palliative sedation that causes unconsciousness.” By providing support for such “palliative” measures, she claimed, nurses “aren’t assisting in suicide.”

What isn’t widely understood is that hospice care and existing legislation, not to mention medical ethics, already call for pain management and measures to reduce patient suffering, ensure their comfort, and that their wishes are followed. Palliative care as is being used in legislation has become a broad term that can mean something quite different. As Stanton J. Price, a health lawyer and member of the Los Angeles Country Bar Association’s Bioethics Committee, wrote last August in the Los Angeles Times, legislation by Compassion and Choices is a legally confusing solution to a nonexistent problem and is merely a way to open the door to assisted suicide.

The California legislation he was referring to was AB 2747, which had mandated doctors to discuss the most gruesome end-of-life decision with patients, upon any diagnosis of a terminal illness with potentially one year to live. Even the term “terminal illness” was so vague, it could refer to any condition that could lead to death without treatment. “Requiring an oncologist to tell a woman who has just been diagnosed with breast cancer all about end-of-life palliative care would only frighten and be extremely inappropriate,” he wrote. “It is far better to leave it up to the discretion of the doctor and patient to determine when information about end-of-life care is given.”

The Amicus also reviewed the history of legislation regarding assisted suicide, saying that it supported legislation to explicitly ensure that assisted suicide would never be misconstrued as a legitimate use of medical professionals or medicines that are paid for by the federal government. Doctors must never be forced into the position of having to answer to the government when it comes to ending lives. “Physicians entrusted by the federal government with the privilege of using these potentially dangerous drugs in their practice should be the first to understand the need for laws ensuring their proper use,” wrote former U.S. Surgeon General, C. Everett Koop, M.D. “Their own ethical code instructs them always to use medications only to care, never to kill.”

If you don’t think that a government counselor could ever advocate that elderly people should end their lives because they are a burden on the government’s healthcare system and have a duty to die, then you may want to read the advise given by Lady Warnock, who became Britain’s leading moral advisor and chaired the landmark Government committee on fertility treatment in the 1980s. Last September, in a Church of Scotland’s magazine, she said “pensioners in mental decline are ‘wasting people's lives’ because of the care they require, and should be allowed to opt for euthanasia even if they are not in pain.” Because of the strain they put on their families and public services, she said, they should consider ending their lives.

“If you're demented, you're wasting people's lives – your family's lives – and you're wasting the resources of the National Health Service,” she said. She added that she hoped people will soon be “licensed to put others down” when they are unable to look after themselves. Her suggestions received widespread condemnation by medical professionals. What was disturbing was to read some readers writing in support of her ideas.

Why fears about the Healthcare Reform bill are warranted

As Wesley Smith explained again on Saturday in a troubling article, the legislation “laid bare a realistic fear that compensated counseling under Medicare could easily become subtle (or not so subtle) persuasion to refuse treatment — particularly since the primary point of the clause is to cut costs.”

“In the wrong hands,” he wrote, “end of life counseling could easily be subtly or overtly outcome directed.” It all depends on how it is done. If it’s done by a counselor who thinks seniors or sick and disabled people are burdens on the healthcare system and wasting resources for everyone else and should be helped to die, it gives a very different take on whether it is benign.

And who are the groups that have positioned themselves as end-of-life experts and service providers, and have been creating the end of life academic curriculums for medical professionals across the country? The groups funded by the Older Americans Act of 1965 and most likely to also be on the list of those resources to be given seniors and their families to assist them with advanced planning. They will be those counselors for us and our loved ones.

Smith exampled the advance planning workbook published by the Center for Practical Bioethics, called Caring Conversations.

What I found disturbing is the emotional manipulation evident in it. Caring Conversations begins by asking seniors to envision their ideal death and last day of life. It asks them how important it is to their quality of life and wellbeing to be able to see, taste and touch. As Smith writes, “the lexicon of the document is far from neutral and presumes that people will not want their lives sustained if they are in a dependent state.” He pointed out that the “quality of life” examples that are suggested to be listed by the document signer were the ability to “take care of myself, feed myself and be responsive to my environment.”

As he explains, and you can see for yourself here, it includes boilerplate instructions for seniors to sign that would become their “Healthcare Treatment Directive.” Those state:

● I always expect to be given care and treatment for pain or discomfort even if such care may affect how I sleep, eat, or breathe.

● I would consent to, and want my agent to consider my participation in federally regulated research related to my disorder or condition.

● I want my doctor to try treatment/interventions on a time -limited basis when the goal is to restore my health or help me experience a life in a way consistent with my values and wishes. I want such treatments/interventions withdrawn when they cannot achieve this goal or become too burdensome for me.

● I want my dying to be as natural as possible. Therefore, I direct that no treatment (including food or water by tube) be given just to keep my body functioning when I have: a condition that will cause me to die soon, or a condition (including brain damage or brain disease) that I have no reasonable hope of achieving a quality of life that is acceptable to me…

This is the default directive and to disagree requires the patient to “draw a line through the statement and put their initials at the end of the line,” he said.

It’s even worse than that. An entire second page lists these default directives again and says that if you only want to name a Durable Power of Attorney for Healthcare Decisions, you have to draw a large X through the entire page, then sign the back of the page even if you don’t want to appoint a Durable Power of Attorney for Healthcare Decisions. But there is no place to sign on the back of the page. Confusing? Misleading? You bet.

Is this what we want for ourselves, our parents, grandparents and loved ones? As an ethical society and compassionate people, we have a responsibility to educate ourselves, understand history, and consider the consequences of what we allow to happen or choose to condone.

When I first read Karen Ward’s article, several years ago, the passage that most affected me was when she said that against major foundations with billions of dollars and that have “embedded themselves in every level of healthcare, government and society…the average American, you and I, has no such advantage to change policy. Our only tools are our telephones, computers and the U.S. Postal Service.” All we have is our strength in numbers and our voices.

As hard as all of this is to believe, what is happening isn’t wacko conspiracy theories — this is in our own governmental legislation, in our medical and nursing journals, in public reports from foundations, and in mainstream media that every citizen can read for his or her self. No American can ever claim that they didn’t know what was happening — only that they didn’t care enough.

© 2009 Sandy Szwarc

To read the other articles in this series on medical ethics and healthcare reform:

Prioritizing lives

He who controls the medical profession, controls life

Today's changing medical ethics

Remembering the care in healthcare

Comparative effective research

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

Weight of the Nation — “We have a plan”

If anti-obesity news coverage has seemed to get a shot in the arm the past few days, you might want to know why. The Centers for Disease Control and Prevention’s Division of Nutrition, Physical Activity, and Obesity has literally given it an injection of media stories, even down to free graphics and banners, with its inaugural obesity conference, Weight of the Nation, held in Washington, D.C. on July 27-29^th.

The conference, funded by a grant from Robert Wood Johnson Foundation and partnered with preventive wellness, chronic disease councils, and disease management and public health organizations, was announced a couple of months ago, saying its objectives will be to set policies and environmental strategies to overcome barriers to obesity prevention and control in communities, healthcare, schools and workplaces… set specific policy and environmental initiatives impacting obesity; and highlight the use of law-based efforts to prevent and control obesity (e.g., legislation, regulation and policies). The agenda is all politics, not a single examination of the science.

How many know what the CDC’s Division of Nutrition, Physical Activity, and Obesity (DNPAO) does? It’s the arm of the agency directing the development of the government’s regulations, economic strategies and laws to impose changes in the country’s infrastructure and society — at the community, state and national levels. “For your health,” and more specifically changing the “obesogenic environment,” is being used as the grounds. As its website explains, the CDC has “collaborated with policymakers, partners and stakeholders in these leadership activities” — which have included some frightening programs if anyone stops and thinks about them for a moment, such as “Legal Preparedness for Chronic Disease Prevention” and “Legal Preparedness for Obesity Prevention and Control.”

Its website openly describes its partnerships. To change medical settings, for example, the CDC is “creating partnerships with commercial health plans.” For changing communities, its partnerships include the Healthy Eating Active Living Convergence Partnership, to change transportation and food systems; and the Common Community Measures for Obesity Prevention (Measures Project), which works to change local governments' policies. Few people likely know about these groups, or that those seeming grassroots movements of non-government, nonprofit groups in their communities and states are actually funded by the CDC to put the goals of the government and its partners into action. As the website explains:

Twenty-three states are currently funded through CDC's Nutrition and Physical Activity and Obesity (NPAO) Cooperative Agreement Program which coordinates statewide efforts with multiple partners to address obesity. The program's focus is on policy and environmental change initiatives. These initiatives help support the following behavioral targets: increasing physical activity; the consumption of fruits and vegetables; and breastfeeding initiation, duration, and exclusivity; and decreasing television viewing, the consumption of sugar-sweetened beverages and the consumption of high-calorie/low-nutrient foods. The program seeks to address health disparities and requires a comprehensive state plan.

The Common Community Measures for Obesity Prevention Project is a Robert Wood Johnson Foundation program in collaboration with the Kellogg Foundation, Kaiser Permanente and the CDC Foundation. The Healthy Eating Active Living Convergence Partnership, as its website says, “is a collaboration of funders who have come together with the shared goal of changing policies and environments to better achieve the vision of healthy people living in healthy places.” It’s also a partnership of the Robert Wood Johnson Foundation, Kellogg Foundation, Kaiser Permanente, California Endowment and the CDC. Any industry or stakeholder, even the largest drug company in the world, can set up a foundation to lobby for its interests yet those receiving foundation money aren't seen as having any conflicts of interests to report or as having any industry ties.

According to this week’s Weight of the Nation program, the NPAO expects two outcomes of this conference, besides a media blitz:

First, in collaboration with partners, CDC will synthesize lessons learned from the conference to identify the challenges to obesity prevention and control, identify setting appropriate policy and environmental strategies to overcome these challenges and determine indicators of progress in implementing these strategies, and then disseminate policy and environmental best practices for obesity prevention and control. Then, CDC will utilize this information to produce its “National Road Map for Obesity Prevention and Control”; guidelines for investing in integrated obesity prevention and control initiatives.

Stakeholders are setting national policy. Worse, we’re funding them.

Background — “CDC says” doesn’t mean science says

Before we take it as a given that science has proven obesity to be a deadly crisis requiring a massive reorder of our society, it’s critical to understand the difference between science and marketing. Few consumers realize that most of what we hear coming from the CDC isn’t from the scientists at the CDC’s National Center for Health Statistics (NCHS), but from CDC’s various marketing divisions. It’s important to understand the difference.

As regular readers remember, in 2005, after CDC scientists published the CDC’s own national data and nearly brought down the government’s entire war on obesity, a press conference was hastily called to, as then director Dr. Julie Gerberding said, “translate our science more effectively so that we avoid this kind of communication in the future.” [The CDC’s evidence had shown that, instead of being deadly, obesity (BMI 30 to <35) was associated with a 24% lower risk for premature death than those of ‘normal’ weight, and that even most fat people outlive those of normal weight.]

It was at this conference, the public first learned that the CDC had been massively restructured to create what its director called, “the new CDC.” It created the National Center for Health Marketing and a second center on public health informatics, as well as four new coordinating centers. “At the new CDC, we are engaging the entire agency in the development of our strategies around obesity,” said Dr.Gerberding.

Dr. Edward Sondick, director of the NCHS, said that the bottom line is the NCHS was to be placed within the Coordinating Center for Health Information, along with the National Center for Health Marketing and the National Center for Public Health Informatics. In other words, the NCHS (and its problematic science) was put behind several layers of political firewalls. Thereafter, all communications to the public would come through CDC communications and marketing departments. The CDC directors would have first access to NCHS data before it is released to the public to ensure that the scientific data was released as “actionable” points based on the government’s Healthy People goals.

The org chart just approved looks little different from that first one after the reorganization, with coordinating centers of health information, under which you’ll find the National Centers for Health Statistics, along with the new one for Public Health Informatics, and for Health Marketing; the new National Center for Chronic Diseases Prevention and Health Promotion is under the Coordinating Center for Health Promotion. [Click on any image to see enlarged.]

You may also remember that there was a mass exodus of the top CDC scientists during 2004-2006, who were concerned with the honesty and integrity of science and the information reaching the public. By the end of 2006, in addition to more than a dozen leading scientists, all but two of the directors of CDC’s eight primary scientific centers had left.

When Dr. Gerberding said that every activity of the CDC would be engaged in its strategies around obesity, she meant it. And it continues to be evident today, as in the CDC’s latest budget for fiscal year 2010. Its total $10,101,606,000 budget includes $6,389,000,000 in discretionary spending authority for the CDC and another $1,000,000,000 from the stimulus bill. The changes in this year’s budget reveal its dissolute priorities, such as cuts in Vaccines for Children by $54.1 million, while increasing funding for REACH (Racial and Ethnic Approach to Community Health) by $4 million, and gives $18.54 million more for Health Promotion.

● The budget for obesity programs under the Nutrition, Physical Activity and Obesity department totals $44.4 million; which includes “developing innovative partnerships,” such as with the Healthy Eating Active Living Convergence Partnership and with the Produce for Better Health Foundation (where the CDC co-chairs the National Fruit and Vegetable Alliance). PBH was honored at the Weight of Nation conference, by the way, with an award for its work “advancing policies and environmental strategies to prevent and control obesity.”

● The $62.47 million budget for REACH, which targets minority communities for intervention, is part of its Healthy Communities Program which, it says, is an integral part of CDC’s response to the epidemics of obesity and chronic disease.”

● $7.3 million is for the Behavioral Risk Factor Surveillance System.

● $12.3 million for Genomics is described as “opportunities for public health and preventive medicine, which support the President‘s Healthier U.S. Initiative and the Secretary‘s Personalized Health Care Initiative.”

● $65.99 million is budgeted for diabetes surveillance, prevention and education (such as its Diabetes Primary Prevention Initiative which is “focused on approaches that identify people with pre-diabetes... to adapt lifestyle behaviors aimed at reducing modiable risk factors for type 2 diabetes” – i.e. obesity).

● $341 million is for cancer prevention and control programs, such as WISEWOMAN (Well-Integrated Screening and Evaluation for Women Across the Nation, which targets low-income women “to improve diet, physical activity, and other lifestyle behaviors to prevent, delay, and control cardiovascular and other chronic diseases”) and NCCCP (National Comprehensive Cancer Control Program, which “provide a blueprint to encourage healthy lifestyles, promote recommended cancer screening guidelines and tests,…[and] education programs about cancers or their associated risk factors”).

● The $62.78 million budget for School Health is focused on physical activity, nutrition and tobacco use prevention and other priority health risk behaviors, most notably obesity and type 2 diabetes (which it says “has become increasingly prevalent among children and adolescents as rates of overweight and obesity rise”) and funds 22 state agencies “to focus on reducing chronic disease risk factors such as tobacco use, poor nutrition, and physical inactivity” and funds 29 NGOs (non-governmental organizations) to “promote healthy behaviors for the nation’s youth.”

● $22.8 million is for its Healthy Communities program for “community leaders and public health professionals to equip these entities to effectively confront the urgent realities of the growing national crisis in obesity and other chronic diseases in their communities.”

And there's much more, but you get the idea. As the sampling of links above show, the scientific evidence, often from CDC statistics itself, fails to support any of these programs. That’s why it’s never been more important for us to remember those fallacies of logic and to think and look deeper than the headlines.

The speakers at this week’s Weight of the Nation conference came from these extensive partnerships. For example on Monday, Dr. Thomas Frieden, M.D., MPH, alongside the acting Surgeon General, Steven K. Galson, M.D., MPH, and the Senior Vice President of Robert Wood Johnson Foundation, James S. Marks, M.D., MPH, opened the conference. Dr. Frieden’s proposals to tax sugary drinks and salt to prevent obesity and diabetes didn’t have any science behind them when he was New York City’s Health Commissioner and didn’t become any better when he became the new Director of the CDC.

Tuesday, HHS Secretary Kathleen Sebelius spoke about moving the CDC’s preventive wellness policies forward and “transform our healthcare system from a sickness system to a wellness system.” If you thought her speech, which was also issued in a press release, sounded like it was written by RWJF, you would be right. All of the oft-repeated, and unsupported, claims about the deadly crisis of obesity were there, with RWJF even cited as the source. The government’s solutions are based on the pop beliefs about the causes of obesity: bad eating and sedentary lifestyles. Not what obesity researchers have long recognized.

Before she told audiences “about some of the exciting plans the administration has in this area,” she talked about the children. She cited a list of health problems caused by childhood overweight, according to RWJF, even down to the oft-repeated claim that this might be the first generation to have shorter lives than their parents. “The share of children that are overweight has quadrupled in the last 40 years,” she said. “Type 2 diabetes used to be called ‘adult-onset’ diabetes. Now doctors don't use the term because so many kids are getting it.” This is coming from the leader of the nation’s health agency.

But, Secretary Sebelius said “we finally have a plan” to put the nation on a weight loss diet. Thanks to research, she said, “we don’t just have good ideas, we have ideas that are tested and whose success can be measured.” She was right that every proposal she described has been tested — and they’ve all failed to show any effect on reducing obesity over time and improving actual health outcomes. And every independent examination of the evidence has concluded diet and behavioral changes are ineffective.

So, the government proposes to throw more money at them:

President Obama and I are committed to delivering a health care system that provides all Americans with better quality and lower costs. And fighting obesity is at the heart of both of these goals. That's why the President and the First Lady have made investing in prevention and wellness one of their top priorities.

It's why we're going to require health insurance plans to cover preventative services like the kind of counseling and care that can help people lose weight or keep the weight off in the first place. It's why as part of health reform, we'll also be investing in programs like the ones highlighted in the CDC report… President Obama and I don't think this issue can wait. And neither does Congress, which is why they appropriated $1 billion for prevention as part of the American Recovery and Reinvestment Act.

Part of this money will go to immunizations and another part will go to prevent patients from getting infections during surgeries and other medical treatments. But most of the money is going towards a prevention initiative that was developed by the CDC and the Office of Public Health and Science with input from many of the groups that are here today.

We aren't ready to officially announce this initiative, but we expect that a significant amount of the money will go to help states and communities attack obesity and other public health challenges.

This Weight of the Nation summit was carefully staged to correspond to the release of policy papers also funded by RWJF and CDC’s partners. Tuesday afternoon, the Urban Institute hosted a media event called “Ousting Obesity: Strategies from the Tobacco Wars” where it released its policy paper for combating the obesity epidemic. It proposed fat taxes, as Dr. Frieden had, purportedly to reduce consumption of foods they want the public to believe are fattening (based on Britain’s traffic light system that judges the health value of food according to its sugar, fat and salt content). Their policies included other food regulations, such as calorie counts on menus, bans on advertisement and marketing of “fattening food,” and subsidies of fruits and vegetables. The tables and text in the last half of the report revealed what it was really about. They calculated the revenue that state governments could bring in with fat taxes, even after funding fruit and vegetable initiatives to appear to support healthy eating.

The Urban Institute describes its Health Policy Center as devoted to examining the social, economic and government problems affecting health insurance. This report was funded by WellPoint Foundation, the foundation for Wellpoint, a family of health insurance companies that includes the Blue Cross and Blue Cross Blue Shield licensee in 14 states, pharmacy benefit managers and managed care services. WellPoint Foundation has been spending $30 million over three years to lobby for mandatory health insurance to cover the uninsured and $16 million to market health management programs. Last Monday, on July 20^th, the Urban Institute hosted its “Step One: Pass Health Reform Legislation. Step Two: Administer Reforms” to correspond with another policy paper it released, funded by RWJF. It covered policy initiatives that really need no further explanation:

● structuring a health insurance exchange [which determines what government-approved plans people will be allowed to purchase]

● administering individual mandates and subsidies

● subsidizing health insurance premiums and cost sharing

● regulating health insurance

● restructuring health insurance markets

● simplifying administration and controlling costs (electronic medical records)

Retrospective

More than two years ago, a Dr. Miguel A. Faria, Jr., M.D., made troubling observations in the journal Surgical Neurology about the misuse of statistics and epidemiology surrounding most of the studies associated with the Healthy People 2010 agenda. There is a worrying trend in academic medicine, he said, that “equates statistics with science, and sophistication in quantitative procedures with research excellence.”

The corollary of this trend is a tendency to look for answers to medical problems from people with expertise in mathematical manipulation and information technology, rather than from people with an understanding of disease and its causes…

Much of CDC-funded research and Healthy People 2010 initiatives, he explained, “are generally geared toward promoting social engineering and enlarging the scope and collective role of government in the lives of citizens… than with making genuine scientific advances and improving the health of humanity.”

In some cases, these [CDC] grant proposals (many of which are actually funded) use or misuse statistics, collect data of dubious validity, and even use “legal strategies” to reach social goals and formulate health care policies that the public health researchers believe may achieve “social justice.”… The reader will be surprised to learn that I found probably as many lawyers and social workers as practicing physicians and nurses applying for public health “scientific” research grants!

Public health is no longer about people’s health, but about preventive wellness and efforts to change behaviors for the good of society. It redefines medical ethics to mean a collective act of healthism. A leading organization in the government’s preventive wellness movement and promoter of the Healthy People 2010 goals is Partnership for Prevention, funded by RWJF and GlaxoSmithKline, along with Prescription for Health, a five-year initiative funded by RWJF.

When Dr. Faria wrote this a few years ago, it may have sounded extremist, but it doesn’t sound so much so today:

Frankly, money is being squandered by public health, politicized, pre-conceived research toward collectivist agendas, while the government (and the insurance companies follow suit) keeps cutting reimbursement for the physicians and nurses who are actually ministering care to patients with real, individual medical problems. It's not only a question of squandering money and misallocation of finite health care resources, but also, in the end, a question of population-based ethics versus the reinstitution of the individual-based ethics of Hippocrates.

© 2009 Sandy Szwarc

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

Prioritized lives

We can never be allowed to hear good news about our health. The government won’t allow it. “Such is the strength of cultural miserabilism today that even the most smile-inducing good news stories can swiftly be turned into doom-laden tales about the terrible future humanity faces,” wrote Brendan O’Neill, editor of Spiked.

Reporting on the latest U.S. Census Bureau report, finding that advances in science, safe food production, healthcare and prosperity have allowed people, worldwide, to live longer, healthier and wealthier lives, Brendan’s article had a much deeper message. It examined our prejudices, our compassion for others and how our society is coming to view the value of human life.

His thought-provoking article, titled “Older people are more than food for worms,” was about aging, but could just as easily have been about fat people, handicapped people and everyone deserving of our kindness. It was a reminder of our shared humanness and the need for ethical behavior.

As he wrote, rather than being seen as good news, the Census Bureau’s report was treated as worrying, if not bad news:

The growth of the older population will have ‘formidable consequences’ and pose ‘widespread challenges’, we were told. There was talk of an ageing ‘tipping point’, ‘burdens’ on social services, and the need to ‘sound the alarm’ about how the presence on Earth of all these old folks might provoke ‘intergenerational conflict’. In one fell swoop, we went from the revelation that mankind has successfully extended life beyond birth-work-death to warnings of burdensome old people sucking up all of our health and social resources and possibly launching a war of attrition against the young. Nothing better captures the downbeat nature of public life today... The new fear of the old springs from today’s tendency to treat social policy challenges, which an ageing population no doubt is, as insurmountable demographic nightmares – and more fundamentally from our inability to give meaning to human life and see it as something more than a bovine, biological thing.

An ageing population is an unadulterated good thing. Throughout history we have sought to extend human life in order that people – and humanity more broadly – might realise their potential…

But when we do enjoy longer life expectancies, suddenly success is treated as a sign of doom and older people as little more than burdens.

They’re no longer thought of as wise people whose experience of life counts for something important but as individuals with ‘outdated and irrelevant’ views: they’re grumpy, a bit racist, hell they don’t even believe in global warming. The treatment of older people as burdensome and irrelevant speaks to Western society’s increasing estrangement from, and its fear and suspicion of, the ageing process…

Our fetishisation of youth is a way of erecting a barrier against the future, keeping everything in an innocent childish state in order to avoid having a grown-up debate about our potentially grown-up futures. Today’s ambivalent or outright hostile attitude towards the ageing process really reveals our inability to give meaning to human existence today.

Rather than seeing older people as an integral part of some social fabric… we see them as a drain on society’s apparently limited resources. Rather than seeing older people as individuals with hopes and aspirations like the rest of us, we see them increasingly as little more than bovine creatures with a long list of burdensome medical needs. Many now ask: ‘Who wants to live to be old when you’ll only be sick and slow and incapacitated?’ – revealing our inability to see the profounder side to life behind any health problems individuals might have to endure.

“Quality of life” as seen through the eyes of a youth-oriented society does not mean the lives of older people are any less meaningful. When older lives are no longer valued by society, at what age do they become “too old” to get medical care and use public healthcare resources that could go to healthier, younger people?

If you’re too old, no care for you

This week, news in Sweden reported a woman had been left to endure incredible pain due to a treatable condition for four years from the age of 79; then had to wait more than a year to see a specialist in the public healthcare system before being told she was too old to get a surgery she needed. She was given pain pills and turned away. ‘I can understand that the county feels it is expensive to 'fix' us elderly, there more and more of us,” she told Östgöta Correspondente, “but in general, I am healthy. We end up paying for healthcare for younger people, but we don’t get anything ourselves.”

That happened in Sweden’s government-managed healthcare, but could never happen here… could it? Readers deserve to know about Dr. Ezekiel Emanuel, M.D., Ph.D., who serves as the director of the Clinical Bioethics Department at the U.S. National Institutes of Health. He's a key creator of Obama’s healthcare reform plan and his bioethics advisor. He’s also the brother of White House Chief of Staff Rahm Emanuel.

Dr. Emanuel has been appointed to two key positions by the Administration: health-policy adviser at the Office of Management and Budget and a lead member of the Federal Council on Comparative Effectiveness Research, deciding how healthcare resources will be rationed. [After reading this, what comparative effectiveness research is really doing and its resulting spending priorities, covered here, may be clearer.]

His ex-wife, Linda Emanuel, by the way, headed the American Medical Association’s Institute for Ethics, launched in 1997, focused on assisted suicide, terminal care, genetics and managed care. One of its initial projects, was to educate doctors on end of life care, funded by Robert Wood Johnson Foundation with $1.5 million to start and which went on to fund it ($5.3 million between 2000-2003, alone). Its real purpose and disconcerting messages may help to explain why the AMA’s promotion of a new medical ethics that displaces the Hippocratic Oath has resulted in widespread rejection among practicing doctors of the AMA, as well as government-managed care. She spoke at an aging conference at RWJF two months ago, on May 21^st, on reducing healthcare costs “without causing a panic by introducing explicit rationing of care.”

The Journal of the American Medical Association published a paper funded by Robert Wood Johnson Foundation and Blue Shield of California Foundation on June 18, 2008. Dr. Emanuel and co-author Victor Fuchs, Ph.D. of Stanford University, examined “overutilization” of healthcare and increases in the costs. They attributed four factors to doctors:

First, there is the matter of physician culture. Medical school education and postgraduate training emphasize thoroughness. When evaluating a patient, students, interns, and residents are trained to identify and praised for and graded on enumerating all possible diagnoses and tests that would confirm or exclude them… In medical training, meticulousness, not effectiveness, is rewarded.

This culture is further reinforced by a unique understanding of professional obligations, specifically, the Hippocratic Oath’s admonition to “use my power to help the sick to the best of my ability and judgment”…

The Hippocratic Oath, the very foundation of medical ethics and the one that the Nazi doctors abandoned, is seen as a problem because it raises healthcare costs. To contain costs, Dr. Emanuel and Fuchs recommended “many more experiments [of] pay for performance, bundled payments, partial capitation, value-based payment or other payment methods that promote prudent use of resources.”

Specifically, how medical care is planned to be allocated (rationed) in the United States was described in the January 31^st issue of the journal Lancet in “Principles for allocation of scarce medical interventions” by Dr. Emanuel and colleagues. In making rationing decisions, they recommend an alternative triage system they called “the complete lives system, which prioritizes younger people who have not yet lived a complete life.” Their ‘complete life’ principle also purportedly includes prognosis, lottery and instrumental value principles.

They first rejected caring for the sickest people first, writing:

Preferential allocation of a scarce liver to an acutely ill person unjustly ignores a currently healthier person with progressive liver disease, who might be worse off when he or she later suffers liver failure… [However], when interventions are persistently scarce, saving the progressively ill person later will always involve depriving others.

What is instrumental value? It “prioritizes specific individuals to enable or encourage future usefulness,” they wrote. “Responsibility-based allocation—eg, allocation to people who agree to improve their health and thus use fewer resources—also represents instrumental value allocation.”

Youngest first, they explained, directs resources to those who’ve had “less of something supremely valuable—life-years.” Their proposed ‘complete lives’ principle modifies the youngest-first principle, they wrote, by prioritizing adolescents and young adults over infants. “Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments.” They supplied an age graph, showing how healthcare resources will be prioritized:

The ‘complete lives’ system also considers prognosis, since its aim is to achieve complete lives. “A young person with a poor prognosis has had few life-years but lacks the potential to live a complete life… When the worst-off can benefit only slightly while better-off people could benefit greatly, allocating to the better-off is often justifiable,” they wrote. In conclusion:

When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated… the complete lives system justifies preference to younger people… Age can be established quickly and accurately from identity documents.

Remember, in the United States, the government now forces every citizen at retirement age into government managed care, Medicare. The only way to opt out is to relinquish all of the social security benefits you’ve paid into your entire life. The first proposal from the administration to “save healthcare costs” was to cut $313 billion from Medicare, which cares for seniors and disabled people. Didn’t anyone wonder how they really proposed to do that?*

The government, our government, is already working on deciding what lives are more valuable based on their usefulness and burden on the state, how long we will be allowed to live, and which of us will die.

Sixty-eight years ago, the appeals for compassion and ethical principles, and public condemnation of what was happening, sounded somewhat like O’Neill’s article, but with considerable more urgency. What is deeply disturbing is that the words spoken by Clemens von Galen at Münster Cathedral on August 3, 1941 in an effort to stop the Final Solution (ordered that fall) feel so imperative for us today:

[T]he doctrine is being followed, according to which one may destroy so-called “worthless life”… because, in the opinion of some department, on the testimony of some commission, they have become 'worthless life' because according to this testimony they are 'unproductive national comrades.' … of no further value for the nation and the state…

[W]e are dealing with human beings, our fellow human beings, our brothers and sisters. With poor people, sick people, if you like unproductive people. But have they for that reason forfeited the right to life? Have you, have I the right to live only so long as we are productive, so long as we are recognized by others as productive? ... then woe betide us all when we become old and frail!... then woe betide the invalids who have used up, sacrificed and lost their health and strength in the productive process… then woe betide loyal soldiers who return to the homeland seriously disabled, as cripples, as invalids. If it is once accepted that people have the right to kill 'unproductive' fellow humans—and even if initially it only affects the poor defenseless mentally ill—then as a matter of principle murder is permitted for all unproductive people, in other words for the incurably sick, the people who have become invalids through labor and war, for us all when we become old, frail and therefore unproductive.

Then, it is only necessary for some secret edict to order that the method developed for the mentally ill should be extended to other 'unproductive' people, that it should be applied to those suffering from incurable lung disease, to the elderly who are frail or invalids, to the severely disabled soldiers. Then none of our lives will be safe any more. Some commission can put us on the list of the 'unproductive,' who in their opinion have become worthless life. And no police force will protect us and no court will investigate our murder and give the murderer the punishment he deserves.

Who will be able to trust his doctor any more? He may report his patient as 'unproductive' and receive instructions to kill him. It is impossible to imagine the degree of moral depravity, of general mistrust that would then spread even through families if this dreadful doctrine is tolerated, accepted and followed.

© 2009 Szwarc

* That’s also why, in part, it was important to understand economics and the facts of who the uninsured really are in this country. Instead of finding a way to help the 7% of Americans who actually need our help and rather than caring for seniors at the time in their lives when they most need medical care, healthcare reform will have taxpayers pay for managed care for 18 million generally healthy young adults, 9.5 million illegal aliens, and 17 million with incomes over $50,000.

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

He who controls the medical profession, controls life

As hard as some are trying to make healthcare reform to be about political sides, it is really about human lives. Sadly, because the general public largely doesn’t understand what healthcare reform is really about, the very people who are most likely to be harmed by it — older, fat, disabled, poor and the most vulnerable — are the ones being most led to believe that it’s about taking care of them. Even sadder, experienced medical professionals have seen where we’re being led for well over a decade, but the information hasn’t reached patients and people.

The debate, especially the one in the media, is centered on emotional, intuitively-correct arguments and anecdotes, rather than careful examinations deeper than the headlines to understand the facts, economics, history, medical evidence and, most of all, the ethics of the issue. It’s uncomfortable and hard to think about things that are unpopular to question, including our own beliefs.

As difficult as it is to contemplate, the emotional perspectives on healthcare reform are largely driven by whether one thinks individuals are basically good, caring people who try to do the right thing and will help those in need, or if one thinks everyone is looking out for themselves and what’s in it for them. The ethical questions come in when those looking at what’s in it for themselves try to convince themselves and others that they are acting more ethically.

“Evil acts can be given an aura of moral legitimacy by noble-sounding… expressions,” wrote Walter E. Williams last November when he explained the difference between laudable charitable acts done by caring people to help their neighbors versus forcible use of one person to serve the purposes of another.

The second perspective in this debate comes from whether one thinks individuals are too dumb and irresponsible to decide what’s best for themselves, to choose their own doctors and make their own lifestyle choices, and that doctors are incapable of making sound clinical judgments or do their jobs — or if you believe that you have the right to decide what’s best for someone else; to make others pay for and comply with treatments, diets and lifestyles you believe are best for the common good; to prevent other people from seeing the doctors or seeking the care they want; and to mandate the care doctors must provide. The ethical questions come in when those looking to take away the choices and control the actions of other people, including doctors, try to convince themselves and us that what they want is not only right, but a right.

“There can be no such thing as a ‘right’ to products or services created by the effort of others, and this most definitely includes medical products and services,” explained Yaron Brook, managing director of BH Equity Research, in a recent Forbes article. “Rights, as our founding fathers conceived them, are not claims to economic goods, but freedoms of action…The rights of some cannot require the coercion and sacrifice of others.” This entitlement idea, he said, has been the key driver of the expansion of government medicine in America and led to the growing unaffordability of healthcare. Prior to the government’s entrance into medicine, basic health care was affordable for virtually all Americans, “while those few who could not were able to rely on abundant private charity.” Had this system been allowed to continue, he wrote, “Americans’ rising productivity would have allowed them to buy better and better health care, just as, today, we buy better and more varied food and clothing than people did a century ago.” The history was described in more detail by one reader, who noted the immorality of government mandates that have caused everyone’s medical costs to skyrocket to among the highest in the world and created more problems with healthcare access. “No amount of ‘need’ on the part of one man entitles him to initiate the use of force to take another man’s property.”

Taking our information from mainstream media and social marketing venues can lead us to believe that those voices we most hear also represent what most people think, including most doctors and medical professionals. Over the past fifteen years, increasingly what we hear from media and spokespersons leads us to believe there’s a new medical ethics that is displacing our doctors' Hippocratic Oath to do what’s best for patients and replaced it with a duty to act foremost for the common good and based on costs to society. But are most of the doctors and nurses — the ones caring for you and me — really embracing the new medical ethics?

What do our doctors and medical professionals think?

When we are sick and entrust a doctor with our lives, most of us want to feel we can trust that the care we are receiving is based on our doctor’s years of experience and clinical judgment, that medical ethics and the personal and private relationship we have with our doctor are guiding our doctor to do what he/she believes will be best for us, and that our care is in accordance with our own choices. It’s a terribly frightening thought for most people that, instead, the medical marketplace and its bottom line is calling the shots and that our doctor could be being forced to answer to a growing hoard of government regulators; politicians; lawyers; policy makers; pharmaceutical, healthcare industry and insurance companies; and oversight agencies.

Before we let the media scare us into believing that most doctors are following this new medical ethic and no longer care most what’s best for us. Before we let the media scare us into believing that most doctors are so incompetent and corrupt they need governmental oversight and mandated clinical guidelines in order to provide safe, ‘quality’ care. Before we let the media convince us that only a few uncaring, uninformed people with political motives are opposing healthcare reform… We should listen.

The voices rarely heard in mainstream media are those of the medical professionals who are providing the hands-on care we receive. The general public doesn’t realize that what experienced doctors and nurses have been discussing for years is far different from what we hear from doctors on TV and in academia. It turns out that most doctors do care, very much, for their patients and they have not abandoned the medical ethics that brought them to medicine. Their opposition to third-party managed care is because it violates the most fundamental medical ethics.

“What the public does not know,” wrote Dr. Sean Khozin, M.D., MPH, in a post on Sermo, “is the pervasive hypocrisy of the [healthcare] system and how it has diminished the authority of the only true advocates of patients: physicians.”

Sermo is the world’s largest online medical community with more than 100,000 registered licensed physicians in 68 specialties and in all 50 states who collaborate on difficult cases, share clinical research and work towards better patient outcomes. It has been active since 2006. This past week, it released the results of a survey of a nearly 10,000 doctors representative of the U.S. physician population in regional distribution, urban and rural locations, age and nearly all specialties. These doctors were all verified to have valid, active licenses to practice medicine in the United States, with a median 25 years of practice experience.

It reported that 94% of the physicians do not endorse the healthcare reform bill in the House [which is soon to be melded with the Senate’s similar version] or government managed care. Not one of the healthcare issues cited by practicing doctors as being most important were addressed in the legislation. In fact, practicing physicians believe it reinforces and will worsen what they described as the “insurance industry’s undue authority and oppressive control over healthcare,” the “excessive and misguided government administrative costs” and regulations that require doctors to spend more time on documentation than with their patients, while giving non-medical professionals oversight and decision-making authority over the care they can provide.

Nor do most practicing physicians support the American Medical Association’s recent endorsement of such healthcare reform. For years, opposition to the American Medical Association (which has been steadily moving towards promotion of those new medical ethics) has grown among doctors and the AMA’s membership is now estimated at only 15-20% of doctors. As the CEO of Sermo said of the healthcare reform legislation, it perpetuates the AMA’s core revenue streams and puts its own financial interests ahead of doctors and patients.

What isn’t grasped by laypeople who support healthcare reform, is that most doctors and medical professionals do believe healthcare reform is needed, but what medical professionals know is necessary to deliver the best care to their patients and in the most cost-effective manner bears no resemblance to the current system and to any managed care healthcare reform legislation, in the House or Senate, in this Administration or any previous. “We do not believe, ”said Dr. Todd Williamson, M.D., president of the Georgia Medial Association, “that increasing the federal government’s control over the practice of medicine is the best way to heal our ailing system.”

The concerns of doctors and medical professionals and what they’ve been seeing happening to medicine and healthcare for years has been well-documented in thousands of discussions in medical forums and journals that the public, sadly, never sees. Last year, in an effort to get information to the public, doctors wrote an open letter from America’s Physicians, which has been signed by more than 13,000 doctors so far. It shows that most doctors do hold dear their Hippocratic Oath and the traditions of medical ethics. As it stated:

[O]ur healthcare system has lost focus to the point where patient well-being is placed after politics, profits and special interests. Healthcare costs are on the rise and patients have lost their freedom of choice. These trends are hurting our economy and compromising the doctor-patient relationship. As a result, it has become difficult for physicians to deliver the best possible care... You are paying a lot for healthcare and not receiving enough in return. Your insurance premiums continue to increase while your healthcare options are dwindling. Gatekeepers, insurance networks and restrictive regulations limit your choice of doctors and your access to care. You have been made dependent on complicated and expensive health insurance plans. Employers are forced to take money out of your paycheck to purchase health coverage. If you lose your job, you are left with no safety net and the money you have paid for health coverage vanishes. The time you spend with your physician has become remarkably brief due to regulatory hurdles requiring doctors to spend more time on documentation than with you.

We believe the following factors have made our current healthcare system unsustainable:

The insurance industry's undue authority and oppressive control over healthcare processes

Excessive and misguided government regulation

The practice of defensive medicine in response to a harmful and costly legal environment

We, the physicians of the United States, will no longer remain silent. We will not tolerate a healthcare system where those without medical expertise or genuine interest in our patients' health have absolute control...

The medical ethics of managed care

This isn’t about politics. This is about the ethics of forcing medical professionals to do what third party payers— government Medicare, Medicaid and private insurers — order. With the medical home model that’s been under planning for years, electronic medical records and pay-for-performance measures will give the government, insurance, pharmaceutical and medical industry unprecedented surveillance, control and oversight over patient care, leaving doctors unable to provide the care they feel best and patients unable to have a choice. Most medical professionals recognize that many of the clinical guidelines, regulations and performance measures they will be compelled to follow are, as covered at JFS for years, not based on sound science, have not been shown to improve health outcomes for patients, and will harm large numbers of patients — most especially those who are aging, fat and socioeconomically disadvantaged.

Under nationalized managed care, those with bad numbers (health indices that the evidence shows are not measures of health or risks of chronic disease or premature death, but of age, size, heredity and social-economic status) or special needs will be targeted as costing society too much. We've already seen the "costs" of obesity and chronic disease of aging used to support all manner of public policies, interventions and surveillance. Those not seen as complying with prescribed diets, lifestyles, exercise regimens, screening tests, weight loss, counseling and taking medications will be blamed for failing to take responsibility to stay healthy and, therefore, undeserving of care when they get sick. We've already seen these beliefs in preventive wellness widely circulated, too. This has become serious really fast. We can no longer afford to just worry about trivial things like if someone thinks we look too fat.

We’ve already examined the concerns of medical professionals with managed care, as well as the proposed rationing of care based on comparative effectiveness that target those who are older, fat, disabled and the most vulnerable in need of care. The unthinkable consequences are closer than we might want to even think about. You’d have to live under a rock, too, to not know that Obama’s Science Czar has proposed some of the most unconscionable acts of eugenics, based on radically unsound beliefs, and his appointment sent shock waves through the scientific community that understands the science surrounding population control. But never before in the history of our country, have we been this close to making federal law that formalizes withholding of care to certain groups of people.

“Never before have we been this close to adopting a system that will tell certain citizens to forego treatment for the good of their country,” John Griffing poignantly wrote this morning in American Thinker while explaining Section 1233 of the health reform legislation. “Today’s Medicare recipients could be the first to experience our government’s new solution to America's ‘useless eaters’,” he wrote. “When all is said and done, the ultimate result of the proposed bill is to transfer to government the unprecedented power of determining who lives and who dies.”

Healthcare reform may prove to be the most expensive and deadliest consequence of the public’s scientific illiteracy, prejudices and inability to understand sound science. Healthcare reform may prove to be the most costly and deadly consequence of people failing to learn history and realize what is being reenacted and the unconceivable place it’s taking us. [Yet few people have read the more than a thousand pages of the legislation, let alone read Ominous Parallels, The Nazi Doctors and War Against the Weak.]

Sure, there are some bad doctors out there who are incompetent or follow greed rather than creed, and others who are guilty of looking the other way. But it’s reassuring that medical ethics is not dead and so many doctors have been trying to speak out, even at risk to their careers. Most doctors and nurses made medicine their vocation because they care about people and love helping people, and still do. What ethical oath have government appointees, politicians and corporate executives pledged?

What’s really behind healthcare reform

Most practicing doctors believe medicine can return to caring for patients and address the problems with the healthcare system without losing the things that make it among the best care in the world. But, as cardiologist Dr. Westby G. Fisher, M.D., said, “we can’t do that and continue to fund the gravy train. And that gravy train is the multi-billion dollar health insurance industry with executives who made over $24M annually in 2007, the $800B pharmaceutical industry with executive compensations of over 25 million dollars the same year, the over $24 billion spent in one year in our country on new hospital construction, the nearly half a billion dollars in political campaign contributions from health care special interests a single year (2008), and the 55-80% increase in malpractice insurance premiums that your doctors have paid over the past 5 years.”

What most consumers don’t realize is that healthcare reform chiefly isn’t about helping people, covering the uninsured or addressing health disparities, but about increasing the private-public medical industry and making money for them. Doctors have been watching the evolution of medicine and healthcare depart from caring for patients to caring for its bottom line and expanding the system’s sphere of power and control. “One only has to look at the diagram of the recently-proposed health care system interconnections,” he wrote, “to realize that the health care providers and consumers are on opposite sides, separated by so much regulation and oversight, we wonder who stands to win.”

Do those who are leading seniors, fat people or minorities to support managed care, healthy lifestyles and medicalization — whose script is right out of the pages of Nazi healthism — realize that they are really working to advance the agendas of the pharmaceutical, medical supply and insurance industries and their government agency partners? Do they understand what they are supporting?

While all eyes have been focused on the weight of the latest Surgeon General nominee, for example, few know that she is a Robert Wood Johnson Foundation Trustee, having serviced on its national advisory committee of prescription drugs for health. As she told media on her election to the RWJF Board of Trustees, “I am proud to be a part of accomplishing significant and lasting social change.”

But the most important person in government overseeing healthcare reform, is Nancy-Ann Min DeParle, who President Obama appointed as director of the White House Office of Health Care Reform in March. Also known as the Healthcare Reform Czar, this position is above Cabinet-level and answers only to the President and has been given the authority to make or influence decisions for Cabinet-level agencies. The Healthcare Reform Czar position, as readers may remember, was originally slated to go to Tom Daschle in addition to serving as Secretary of Health and Human Services, until his vast conflicts of interests came out during the Senate confirmation hearings for Secretary of the HHS and put him out of the picture. In his place, Ms DeParle was quietly appointed the Healthcare Reform Czar, which is not subject to Senate confirmation.

It is doubtful that the general public knows much, if anything, about the person behind healthcare reform. Ms DeParle holds a law degree from Harvard Law School, not a medical degree, according to whitehouse.gov — which provides few details on the corporate boards she’s served on, saying only that she “brings a unique industry perspective from her work in the private sector.” Most of her positions have been administering and serving on the boards of major medical companies. Shortly after her Czar appointment, she stepped down from the corporate boards of Cerner, Medco Health Solutions (a pharmacy benefit manager), Boston Scientific (medical devices manufacturer), CareMore Health Plan and Legacy Hospital partners, as well as from CCMP Capital Advisors LLC, a private equity firm whose interests include a Medicare managed care plan. She is also a trustee of the Robert Wood Johnson Foundation, receiving earnings not only in that position, but $7,500 a speech for Johnson & Johnson.

According to an in-depth investigative report by the Investigative Reporting Workshop and msnbc.com, and SES filings, she has earned more than $6.6 million since early 2001 for her work for major medical companies. Details of her income from the medical industry were released on July 2^nd, here. “[T]he public wasn’t told that much of that corporate career was built at companies that have frequently had to defend themselves against federal investigations,” the report added. “After leaving government, DeParle accepted director positions at half a dozen companies suspected of violating the very laws and regulations she had enforced for Medicare. Those companies got into further trouble on her watch as a director.” Five of those corporations have paid a total of $566 million since 2003 to settle fraud or product liability cases, often involving tax dollars paid by Medicare.

Her Czar appointment will no doubt have significant impact for the corporations she formerly served, said the report. While promoting electronic records, for instance, no one mentions that she served on the Board of Cerner Corporation, a major manufacturer of electronic medical records software, from May 2001 until the day after her White House appointment, earning at least $680,000 in compensations. Cerner has boasted that it is well-positioned to take advantage of the stimulus bill, which provided $19 billion for electronic medical records.

Yet, many consumers still don’t understand what healthcare reform is mostly about, even though it was clear long ago just by examining the science and evidence. They want to believe that it’s about helping them.

What do experienced medical professionals advocate for healthcare reform? To return medicine to the ethical, caring practice it once was that puts patients and people first, not profits and politics.

Let’s put the patient in control, with the doctor as trusted adviser. Let’s not lose the liberty that is our right as Americans. — Dr. Donald Palmisano, M.D., July 22, 2009, National Press Club in Washington, D.C.

© 2009 Sandy Szwarc

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

From the cognitive disconnect pages

Our thoughts go out to our friends across the pond today and to parents with sick children there. The King's Fund and the Institute for Fiscal Studies released a new analysis of National Health Services and found healthcare spending in England has more than doubled in real terms just since 1999/2000. “Our analysis shows that the NHS is facing the most significant financial challenge in its history,” said John Appleby, chief economist at the King’s Fund.

Yet, even with these realities, stories on other pages of the papers today demonstrate that government often has nonsensical spending priorities.

The King's Fund and the Institute for Fiscal Studies report on the financial prospects for the NHS from 2011 to 2017, examined the government’s plausible options and the consequences of each, stating that the “prospects for future funding now look bleak.”

The financial crisis is estimated by the Treasury to have dealt a permanent blow to the size of the UK economy, with a significant knock-on impact on the strength of the public finances. Given this, it is hard to see how the next spending review…could unveil further real terms increases in the NHS budget without significant reductions in spending elsewhere, or the introduction of tax-raising measures.

As the Times wrote, the report found that “even under the most optimistic funding scenario, the NHS will struggle to meet people’s healthcare needs without significantly increasing its productivity after 2011.” The productivity of government-provided services, according to the Office for National Statistics, however, has fallen every year between 1997 and 2007 (by an average of 0.4%), while it has grown in the private sector by 2% per year. The King’s Fund and Institute for Fiscal Studies report said that “even if the NHS budget is not cut in real terms, future funding is likely to fall short of the population’s healthcare needs by more than £30 billion [$49.55 billion in U.S. dollars].

While facing cuts in services, the report said, if the NHS freezes it budget, it still needs to bring in about “£10.6 billion — equivalent to an extra £340 per family” in additional revenue (taxes). According to the news, Niall Dickson, the chief executive of the King’s Fund, said: “The scale of what is about to hit the healthcare system is unprecedented. It would be a grave mistake to underestimate the challenge ahead.”

Is the government reading the news?

The Wales Western Mail reported on a report from the charity Sands which said funding pressures and shortage of qualified maternity care providers was contributing to nearly 300 infant deaths a year in Wales. Calling the situation a “national tragedy,” Neal Long, Sands’ chief executive, said that for far too long, the rate of infant deaths and stillbirths have been ignored “and yet there is a growing body of evidence to suggest that many babies’ lives could be saved.” This situation has been well-documented for years, while worsening.

The report echoed earlier work by the charity Bliss [covered here], which last year found that minimum staffing standards are still not being met in Wales and that units regularly have to close to new admissions due to lack of staff. It said that mothers and babies are being transferred between units, in some cases very long distances, which puts and intense strain on families at a critical time.

Health Minister Edwina Hart was reported as responding to concerns about neonatal service by announcing a £4million [$6.61 million] cash injection over two years for neonatal transport service. With the average cost of a transport helicopter alone about $5 million, let alone transport isolettes and trained medical professionals to transport critically ill babies, the money isn’t likely to go very far. The senior nurse manager of neonatal services at Gwent Healthcare NHS Trust said that all Welsh neonatal services are still facing chronic funding problems. The all-Wales review of neonatal services, she said, had found that services were in crisis and needed £12million just to sustain them, and that there was a shortage of 170 neonatal nurses just in Wales. Nothing, however, was ever done.

The RAND Europe study on neonatal services released last year was not mentioned in the news. It found that neonatal intensive care increases the survival rates of newborns, especially those with low birth weight or gestational age. “Effective neonatal care also improves morbidity rates, improving the long-term health prospects and quality of life for premature or low birth weight babies. In doing so the long-term burden on state sponsored health and social care systems is reduced.” As it explained:

Low staffing levels is a pervasive problem in UK neonatal services: all three regions of the UK fall short of the recommended staffing levels laid down by the British Association of Perinatal Medicine (BAPM). Scotland is well-staffed at consultant level, but lacking in neonatal nurses. Northern Ireland has a particular deficit of nurses, and staffing levels in Wales are critical at both the consultant and specialised nursing levels. In particular, there is evidence that the absence of dedicated neonatal transport teams produces staffing problems on neonatal wards. Across the UK as a whole in 2006, 78 pe cent of neonatal units had to turn babies away because of lack of capacity. This figure is eight percent higher than in 2005.There was little evidence of shortages in staffing or cots in the non-UK neonatal networks [United States, Canada, Australia, etc.] considered in this report… the evidence suggested that the infrastructure supporting neonatal services in Wales is less developed than in Scotland or Northern Ireland…

It’s almost inconceivable the frustration and heartache neonatal nurses and parents of critically ill newborns under NHS must feel. For years, they’ve tried to get needed medical care that all evidence shows can greatly improve babies’ survival and future health and well being, as well as to lower long-term medical expenses for the healthcare system. Meanwhile, the government continues to spend countless millions of pounds (dollars) on frivilous programs with no evidence they work in order to address a nonexistent health crisis.

The Edinburgh Evening News reported another government program is spending “apparently £23 billion [$37.99 billion U.S. dollars]” to offer free holidays, called an “outdoor education,” to Scotland’s children to get them moving and build character. It plans “to send every 11-year-old on a five-day adventure break, kayaking, climbing and abseiling among other things… [and] free swimming for all children, at least two hours of PE a week and more outdoor activities, most of which are meant to tackle childhood obesity levels.”

The Scotsman reports that the money NHS Lothian spends each year on weight loss and anti-obesity interventions grows. “In Scotland there has been a massive rise in the number of free medicines being requested to fight obesity – 25 times higher than a decade ago and up six percent alone in 2007.”

Calling it a “record government investment,” the government has also invested £56million [about $92.5 million U.S. dollars] over the next three years to encourage children to eat “healthily,” the news said.

Remember that Scottish Diet Action Plan launched in 1996, aimed to get everyone in Scotland to eat healthier to lose weight and prevent “obesity-associated” diseases? This massive initiative included every popular healthy eating idea that’s probably ever been proposed. Hungry for Success, part of the Action Plan geared to school children was well-funded, with $126.09 million (US dollars) committed to its first three years and more for the next three.

It was a flop. After a decade of intense interventions, it showed no effect on children’s’ consumption of fruits and vegetables. It also failed to have any impact on reducing children’s rates of “overweight and obesity.” The results were not at all surprising to medical professionals because the interventions were based on flawed premises on the causes of children’s diversity in sizes.

Not only does the government’s own data show that none of its massive anti-childhood obesity programs are based on evidence, it also shows the money has been spent on an unsupportable crisis. When the Scottish government developed its massive Hungry for Success program to eradicate childhood obesity, there was no epidemic of childhood obesity.

As we know, by reporting only the percentages of growing children crossing new arbitrary definitions for “overweight or obese,” it’s easy to create the illusion of skyrocketing obesity rates. But that doesn’t reveal the changes in actual heights and weights among children. It only gives half of the story.

As readers remember, researchers at the Department of Public Health, UMDS, St. Thomas’ Campus in London, had tracked the growth of English and Scottish children from 1972 through 1994, recording actual heights and weights measured each year among representative samplings of children, ages 5 - 10, as part of the National Study of Health and Growth study. By every test of health examined, the government found children were healthier. The most notable sign that Scottish children were growing healthier and better nourished was a steady increase in their heights over the decades.

Instead of an epidemic of children popping out like obesity balloons about to burst, their weights (the other part of the BMI equation, and the only one heralded) grew almost exactly matching the growth in heights.

Which would you choose to spend taxpayers’ scarce healthcare money on: medical care for critically-ill babies or free vacations and fruit? The choice might be clear to us, but we’re not from the government.

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

Today’s changing medical ethics — where it’s taking us

There’s no such thing as a kindler, gentler capitation. — Pamela K. Mulligan, Ph.D., Canadian Family Physician, 2002

Last week, the Massachusetts’ state commission proposed a radical restructuring of how doctors, hospitals and healthcare providers will be paid in an effort to keep the state’s model universal coverage program from bankruptcy. Their proposals give us even more disturbing insights on what is being envisioned for all of us with health care reform.

If you are older (or think you might get older sometime), have a disability or any condition that needs medical care (or think you might ever need medical care), or have a lifestyle that the government doesn’t think is healthful, you will want to know what is being planned. You’ve just been thrown under the bus.

As the Special Commission on the Health Care Payment System said, healthcare spending has been rising by more than 8 percent a year in Massachusetts, faster than anywhere else in the country and at a pace that far exceeds the rise in the cost of living; and by their projections, will double by 2020. The costs of the state’s universal coverage program is threatening to bankrupt businesses and patients, they noted. The commission’s next move to try and keep universal coverage afloat are being closely followed in Washington, according to the news.

What are the commission’s latest recommendations? The state commission has proposed paying providers a flat fee for each patient, forcing healthcare providers to coordinate all of the patient’s care within that budget. This payment system, called capitation, likely sent shock waves through the hearts of experienced medical professionals. That’s because capitation isn’t anything new. We’ve been down this road before, with results so devastating to the practice of medicine and welfare of patients, even while failing in its goal of lowering costs, it was largely abandoned.

Members of the state commission vowed that this time capitation, which they’ve renamed a “global payment” system, will be different.

It’s worse. And not just because capitation will be universally mandated and patients will have no other choices of other types of plans. As they described in the 74-page Recommendations of the Special Commission on the Health Care Payment System, they state they will use financial incentives to force doctors into acting as care coordinators consistent with the medical home model and purportedly costs would be contained through Pay-for-Performance (P4P) measures which will offer financial rewards to providers who comply with specified quality measures. [The P4P measures the commission recommends are those created by the same interests preparing our medical homes. New readers can follow the links for decoded background information and disclosures.]

Their global payment system would involve completely restructuring the healthcare system. Providers (primary-care and specialist doctors, hospitals and home health agencies) would have to form large Accountable Care Organizations, with the ACOs to receive the annual fee-per-patient from the state to divide among them all. This effectively eliminates private, independent doctor practices.

The commission’s scheme also establishes another new authority, an Executive Branch agency, that will decide how much money will be allotted for the care of each type of patient.[See "Comparative effective research-what it means for us" to learn how the healthcare reform movement is deciding how resources and care will be allocated (i.e. rationed), and “Vision for our healthcare” for what the federal government is already doing.] This new government agency will also be charged with robust monitoring and oversight of compliance.

Despite these far-reaching proposals, the commission acknowledged that there is scant evidence that P4P, the medical home model or global payments have positive effects, improve quality of patient care or patient outcomes, or that they reduce healthcare costs. But correlations suggest that they might work, they wrote. “Medical homes are generally in an early stage of development,” according to their supplemental documentation, so “evidence of their effectiveness as currently implemented is limited.” There is also limited evidence for making evidence-based spending decisions, they wrote, with the largest and longest example in the country being the Oregon Health Plan which famously took on the task of prioritizing state expenditures based on comparative effectiveness analysis. [Covered here and here].

Reports to the State

As outlined in the July 1^st report, Recommendations for the Massachusetts Health Care Quality and Cost Council’s Three Year Reporting Plan,the state mandates not only integrated electronic medical records, but also wants to increase the number of reportable conditions each year. “Patients must be attributed to physicians who will be held accountable for the quality and cost of care provided to them,” they wrote.

And accountable to the State.

Starting next year, doctors and hospitals must report patients with hip and knee replacement, lower back pain, diabetes, cardiovascular disease, respiratory disease; adherence to screening tests including mammograms and colonoscopies; and prenatal care. In 2011, reported conditions will include depression, hypertension, kidney disease, pediatric conditions, GI disorders, urinary tract infections, female genital disorders and contraception use. In 2012, the state recommends adding home health care, hospice and dental to its reporting requirements; along with conditions such as skin disorders, influenza, glaucoma and cancer treatment. For 2013 and beyond, they want the conditions reported to the state to include connective tissue disorders such as systemic lupus, nutritional disorders, thyroid disease, cataracts, headaches and more; along with adherence to obesity prevention and tobacco cessation interventions.

Healthcare reform advocates believe you want the state to know this information about you, and to monitor you and their doctors’ compliance with interventions it determines best — interventions developed by stakeholders, interventions that are not based on sound scientific evidence. Is that really what you want?

History lessons unlearned

“Those who cannot remember the past, are condemned to repeat it.” — George Santayana (1863 – 1952)

For nonmedical or younger readers who may be unfamiliar with capitation and what this new payment proposal means, here is a glimpse of what doctors were talking about in the medical literature when it was first widely promoted when managed care was failing to reduce costs. It may help you better understand the news spin this past week. It may also help to better understand the concerns that medical professionals have with all of this. It's long but more important to know than ever.

As Dr. Patrick C. Alguire, M.D., Director of Education and Career Development with the American College of Physicians explained, capitation payments are part of the efforts of some managed care plans to control costs. Capitation is a fixed amount of money per patient paid in advance for the delivery of health care services for a certain period of time. Capitation includes a list of specific interventions the provider must provide, with most including specific preventive screenings, diagnostic services and treatments; lab tests; health education and counseling and medications. Healthcare providers risk losing money if they provide care that goes over their budget, or if they make referrals to specialists or for expensive diagnostic tests or treatments; or if they fail to comply with the care mandates; while they can keep more money for themselves if they spend less.

You can guess the end results of this idea. If you are unlucky enough to have been born with any condition that requires ongoing care or is expensive to treat — or have a condition like normal aging, or obesity that the government has mandated must receive screening tests, labwork and interventions — fewer doctors will be able to afford to care for you and risk you costing them money. Nor will they want to bring more government oversight and scrutiny onto their practices. And if you develop a symptom that could be serious, doctors will have a financial incentive to downplay it and not treat it aggressively in order to keep more state money for this year.

Plus, how quickly will you be labeled as a noncompliant patient and be unable to find a doctor, if you don’t want to undergo the screenings, labwork and interventions, including diets, counseling and medications, that the government mandates?

During the 1990s, the medical literature was filled with ethical discussions and loud protests by American medical professionals who were experiencing capitation as part of healthcare reform and managed care. Similar discussions were taking place among Canadian doctors when capitation was proposed in 1997 as part of Ontario’s Health Services Restructuring Commission’s reform recommendations for its struggling healthcare system. Resistance was so intense during the 1990s among doctors and consumers, that it may help all of us to remember some of those ethical concerns. It’s also helpful to remember that, after decades, evidence of benefits of capitation and managed care remains lacking.

Experience of cost containment reforms

The United States has been blessed with abundant resources over the last half of the 20^th century. While the healthcare system has meant limited access and poorer health outcomes for some, wrote Dr. Charles K. Francis, M.D., “for the majority of the population, however, health care in the U.S. has been characterized by an abundance of technology, physician manpower, pharmaceutical advances and an environment of nearly unlimited support for research and discovery.” The perception sold to the public was that the health care system was “guilty of unbridled spending and profligate resource allocation.” This effectively built support for “healthcare reform” and the advent of managed care.

“Managed care was envisioned as a system that would reduce expenditures on inappropriate or unnecessary health care and thus increase the availability of funds to improve the overall health of society,” he said. “Managed care, in a wide variety of iterations, has become the dominant health care delivery system in the U.S… However, as experience with managed care has grown over the last several years, patients and physicians have expressed a litany of concerns. These have included sub-standard quality of care, denial of necessary diagnostic or therapeutic procedures, adverse effects on the patient-physician relationship, improper financial incentives for physicians and restriction of information to patients regarding service limitations.”

Rather than address the specific issues affecting healthcare for some, reform affected the delivery of healthcare for all. And the evidence has failed to support the claimed benefits, as he explained:

The hypothesis that managed care would ultimately improve the health care system for all has been tested and not proven. Despite great economic prosperity, health care costs are increasing, employers are cutting back on coverage, the numbers of uninsured are growing, and the rights of patients are threatened. The imposition of economic incentives in the clinical decision making of physicians has undermined patients trust in their physicians and in the medical profession…

Arguments that managed care helps in meeting social needs because resulting health care cost savings may be transferred to other socially responsible functions or programs are, at a minimum, disingenuous. Experience has shown that much of the early benefit of the new health care paradigm accrued to share holders and company executives rather than the general public.

Since managed care has become the dominant health care delivery system in the United States, the number of uninsured persons in the population has increased… Real progress toward removing racial and ethnic disparities in access to health care remains a largely unfulfilled promise. Numerous examples of racial disparities in access to care and health outcomes have been described. For example, in a study of Medicare recipients [covered under government managed care] the rate of mammography use was lower in black women compared to white women and lower in less affluent women than in more affluent women regardless of race… Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America, and especially its role in access to health care and the delivery of medical services.

Dr. Francis went on to describe numerous studies showing disparities in health outcomes among minorities and socially disadvantaged, as JFS has also examined, regardless of whether or not they had health insurance or government provided coverage and access to healthcare. Managed care and healthcare reform, while seemingly to equalize access to healthcare to disadvantaged, marginalized and discriminated groups, doesn’t address the core prejudices and social-economics behind health disparities. And the ethical issues it brings to the practice of medicine doesn't make it a more ethical way to deliver healthcare.

Naturally, people are nervous about the effects of profit motives on the quality of their medical care. But when medical professionals strongly hold the traditional medical ethics that place their duties first and foremost to the best interests of the patients in their care, patients can trust their doctors to make ethical decisions on their behalf. But beliefs that managed care would reduce profits for those providing medical care se