ARE MEDICAL MISTAKES THE #1 CA– USE OF DEATH?
''Within the last decade medical professional practice has become a major threat to health. Depression, infection, disability, dysfunction, and other specific iatrogenic diseases now cause more suffering than all accidents from traffic or industry. Beyond this, medical practice sponsors sickness by the reinforcement of a morbid society which not only industrially preserves its defectives but breeds the therapist's client in a cybernetic way.
Finally, the so-called health-professions have an indirect sickening power-a structurally health-denying effect. I want to focus on this last syndrome, which I designate as medical Nemesis. By transforming pain, illness, and death from a personal challenge into a technical problem, medical practice expropriates the potential of people to deal with their human condition in an autonomous way and becomes the source of a new kind of un-health.''
~ Illich I. Medical Nemesis. Lancet 1974; i:918-21
The above is from an article by Ivan Illich that was published over three decades ago in The Lancet, generally considered to be the world's leading independent general medical journal. Although its coverage extends to all aspects of human health, it is somewhat unusual to see articles authored by lay individuals unless they have been solicited. However, Illich was recognized as one of the most radical thinkers of his time and this article was actually an abstract from a forthcoming book that the editor felt was likely to attract wide attention.
Illich had become famous because of his Deschooling Society, a 1971 book that was severely critical of our educational system. Albert Einstein once described education as ''what remains after one has forgotten everything he learned in school.'' Illich similarly argued, ''For most men, the right to learn was curtailed by the obligation to attend school'' and that educational ''progress'' was measured by meaningless grades instead of the value of learning. However, the school system was simply one illustration of Illich's basic premise that it is the nature of most institutions to eventually wind up by performing in a manner that is the opposite of the original purpose because of corruption and greed. This inevitably followed when institutions and organizations became increasingly more powerful and particularly when they were governed by a self-perpetuating hierarchy subject to little external regulation or control. In his opinion, the practice of medicine was a perfect example of this.
Illich had studied theology and philosophy to prepare for the priesthood and his Ph. D. thesis was devoted to exploring the institutionalization of charity in the 13th-century Roman Catholic Church. He showed how this led to dishonesty that soon spread to other church activities. In addition, even when corruption was discovered and seemingly suppressed or eradicated, it eventually resurfaced in some different form or a more severe manner. He was fond of citing an old Latin adage ''corruptio optimi pessima'' (the corruption of the best is the worst) and history seems to bear this out. Massive malfeasance has repeatedly been uncovered in respected charities like the Red Cross, which was recently accused of misappropriating funds and holding back hundreds of millions of dollars donated to help victims of 9/11, tsunamis and other disasters like Katrina. The Catholic Church itself has also been rocked by numerous scandals involving priests, corruption, concealed crimes and cover-ups by higher authorities.
Illich believed that the medical care system's inability to improve health was an even more compelling example of how a noble and respected profession ended up achieving the opposite of its stated purpose. As he explained in his book, Limits to Medicine: Medical Nemesis, The Expropriation of Health, being healthy essentially means having the adaptive capacity to cope with such stresses of daily life as sickness, pain and death. He felt that modern medicine had gone too far in its godlike campaign to eradicate discomfort and illness and prolong life as long as possible regardless of its quality. In doing so, it had turned people into consumers or objects and impaired their ability to achieve health on their own. He wrote that, ''Better health care will depend not on some new therapeutic standard, but on the level of willingness and competence to engage in self-care.'' Self-care was defined as consisting of ''personal activities shaped and conditioned by the culture in which the individual grows up: patterns of work and leisure, of celebration and sleep, of production of food and drink, of family relations and politics.'' This view anticipated the current bio-psycho-socio-eco-logical model of health, which emphasizes the individual's interrelationships with his or her social environment and the stress reduction and other salubrious rewards of strong social support.
It was not that Illich was against schools, teachers, hospitals or physicians per se, but rather how they had become increasingly ineffective due to corruption. Once a certain threshold of institutionalization had been reached, schools and teachers tended to make students more stupid and hospitals and doctors made patients sicker. In addition, as such organizations become more powerful people become increasingly dependent on them and therefore fail to fully develop their innate potential. This was especially true with respect to preserving and promoting their health. Illich explained this Medical Nemesis hypothesis using this analogy from Greek mytholology.
''Medical Nemesis is but one aspect of the more general'' counter-intuitive misadventures ''characteristic of industrial society. It is the monstrous outcome of a very specific dream of reason – namely, 'tantalising' hubris. Tantalus was a famous king whom the gods invited to Olympus to share one of their meals. He purloined Ambrosia, the divine potion which gave the gods unending life. For punishment, he was made immortal in Hades and condemned to suffer unending thirst and hunger. When he bows towards the river in which he stands, the water recedes, and when he reaches for the fruit above his head the branches move out of his reach. Ethologists might say that Hygienic Nemesis has programmed him from compulsory counter – intuitive behaviour. Craving for Ambrosia has now spread to the common mortal. Scientific and political optimism has combined to propagate. To sustain it, the priesthood of Tantalus has organized itself, offering unlimited medical improvement of human health. The members of this guild pass themselves off as disciples of healing Asklepios, while in fact they peddle Ambrosia. People demand of them that life be improved, prolonged, rendered compatible with machines, and capable of surviving all modes of acceleration, distortion, and stress. As a result, health has become scarce to the degree to which the common man makes health depend upon the consumption of Ambrosia.''
Why Iatrogenesis Is Now The Leading Cause Of Death And Is Getting Worse
Illich was not the first to suggest that physicians and the medications they prescribed might be doing more harm than good. The following quotation is taken from an address entitled, ''Currents and Countercurrents in Medical Science'' delivered to the Massachusetts Medical Society in 1860.
The truth is, that medicine, professedly founded on observation, is as sensitive to outside influences, political, religious, philosophical, imaginative, as is the barometer to the changes of atmospheric density. If the whole material medica, as now used, could be sunk to the bottom of the sea, it would be all the better for mankind, and all the worse for the fishes.
~ Oliver Wendell Holmes, Sr.
Oliver Wendell Holmes Sr. was a physician who coined the term anesthesia; he served as the first Dean of Harvard Medical School and was one of the leading figures in mid-nineteenth century American medicine. However, he was much more famous as a poet (Old Ironsides) and writer and it is believed that the British physician Arthure Conan Doyle named his fictional detective Sherlocke Holmes as a tribute to him. Holmes helped found the Atlantic Monthly in 1858 and for many years he contributed its popular feature ''The Autocrat and the Breakfast Table'', which provided witty and incisive commentary on societal problems, such as the above. By materia medica, Holmes was referring to the medical remedies being used at the time but his comments may still apply a century and a half later, especially with respect to drug safety.
Iatrogenic (from the Greek iatros for physician and genesis or origin) can be defined as illness induced in a patient as a consequence of a physician's activity, manner or therapy and usually refers to some injury resulting from ineffective, unsafe or toxic drug treatment. In addition to clinical iatrogenesis, such as giving someone the wrong type of dose of a medication, Illich so recognized the problem of social iatrogenesis, which occurs when more and more of life's routine problems come to be viewed as requiring medical interventions. As illustrated in our last Newsletter [see Stress.org], drug companies increasingly develop expensive products for non-diseases such as cholesterol and osteoporosis or exaggerate the significance of relatively trivial disorders like restless leg syndrome. Even more dangerous and pernicious was Illich's concept of cultural iatrogenesis that did away with traditional ways of dealing with distressful but inevitable things like sickness, pain or death. He believed that, ''A society's image of death reveals the level of independence of its people, their personal relatedness, self-reliance, and liveness…We have become a morbid society, where through the medicalization of death, health care has become a monolithic world religion…Society , acting through the medical system, decides when and after what indignities and mutilations the patient shall die. Healthy, or the autonomous power to cope, has been expropriated down to the last breath.''
Illich's prediction that iatrogenesis would be an increasingly major threat to health unless drastic changes were made in our medical care system has proved to be alarmingly accurate. However, there was little interest in this subject until Leape's 1994 JAMA paper, ''Error in Medicine'' two decades later. It cited a 1964 report showing that 20 percent of hospitalized patients suffered from some sort of iatrogenic injury and that 2- percent of these were fatal. A 1981 study found iatrogenesis in 36 percent of hospital patients largely from adverse drug reactions with a 25 percent fatality rate. Another reported that 64 percent of acute heart attacks in one hospital were also drug related and could have been prevented. Leape's review of New York State hospital records revealed that medical mistakes were frequently not reported and that error rates soared when they were specifically sought. Autopsy studies showed that 35 to 40 percent of deaths were due to diagnoses that had been missed. One intensive care unit had an average of 1.7 errors / day / patient, almost a third of which were potentially serious or fatal. Since each patient in the unit had an average of 178 daily ''activities'' (staff / procedure / medical interactions) 1.7 errors represented a 1 percent failure rate. While that may not seem to be too alarming, even 0.1 percent failure rate in other occupations would be equivalent to:
- 2 unsafe plane landings per day at O'Hare airport
- 16,000 pieces of lost mail every hour by the U.S. Postal Service
- 32,000 checks deducted from the wrong bank account every hour
Based on the hospital data he had personally collected, Leape estimated that there were at least 180,000 deaths / year due to medical mistakes. Although this was equivalent to three jumbo-jet crashes every two days without any survivors, nobody seemed to be concerned about the magnitude of the problem. He speculated that was probably because jumbo-jet crashes get instant national media coverage whereas hospital errors are spread out over the country in thousands of different locations and tend to be thought of as isolated and unusual events. However, the most important reason that the extent of iatrogenesis was not recognized is that medical mistakes are frequently not reported or are deliberately concealed for fear of malpractice litigation. Physicians have never been taught what to do when there is evidence of medical negligence and most would be reluctant to share any such failure with colleagues unless it is likely they would learn about it from other sources. Leape hoped his paper would encourage physicians and others ''to fundamentally change the way they think about errors and why they occur.''
However, the dozen years since then things have gotten worse rather than better. According to a 1995 study, ''Over a million patients are injured in U.S. hospitals each year, and approximately 280,000 die annually as a result of these injuries.'' A landmark 2000 JAMA ''Commentary'' by Barbara Starfield a Johns Hopkins Professor, reported that the number of deaths caused directly or indirectly by physician error made iatrogenesis the third leading cause of death. Contribuiting to this were 80,000 deaths / year from hospital – acquired infections and 106,000 deaths / year from adverse effects of drugs correctly prescribed. A subsequent review of 37 million records revealed that an average of 195,000 people died due to potentially preventable in-hospital medical errors in 2000, 2001 and 2002. And an April 2006 Patient Safety in American Hospital survey reported that such incidents had significantly increased since then. Starfield warned that her estimate of 22,500 physician related deaths / year was conservative since hospital records did not always list iatrogenic errors as the cause of death nor is this ever reported in the federal accounting of leading causes. In addition, these estimates are for deaths only and do not include negative effects that are associated with disability or discomfort. [Starfield B. Is US Health Really the Best in the World? JAMA 2000 ; 284 : 483 – 485]. In commenting on this average of 616 daily deaths due to physician error, Larry O'Brien, a retired health care executive asked, ''How many people would ever purchase an airline ticket if, everyday of every year, two airliners each carrying three hundred passengers crashed with no survivors?'' [O'Brien LJ. Absurdity in Conventional American Medicine. BMJ 2003 : March 9]. Florence Nightingale's reinforcement of Hippocractic dictum that ''the very first requirement in a Hospital is that it should do the sick no harm'' seems to have been forgotten. As my good friend, the late Norman Cousins noted, ''The hospital is no place for a sick person.''
Floyd Bloom, President of the American Association for the Advancement of Science, told members at the 2003 annual meeting that the U.S. health system was sick itself and required an immediate national effort to nurse it back to health. His focus was on soaring health premiums, paperwork burdens, and archaic methods of information management. He noted that elderly patients often saw several doctors who did not know about each other and who were prescribing drugs that were often mutually antagonistic or toxic. In addition, the number of drugs available to treat an increasingly elderly population had already passed the 10,000 mark and many had hidden and dangerous interactions not seen in younger patients. Stress in infancy was another unrecognized cause of serious problems in later life for millions of Americans.
Stress is the name we give to a natural reaction our bodies generate when we encounter a situation that is unbeknownst to us,'' he said. '' We activate our autonomic nervous system, and as a result our blood pressure goes up, or heart rate goes up, our blood glucose goes up, and our blood lipids go up. All of which is a great advantage if you are trying to flee from a threatening situation. But if stress is maintained, what results is a change in our metabolism which permanently results in hyperglycemia down-regulation of insulin receptors, deposits of lipids from those high lipids in the blood into the endothelial cells of the capillaries. And, prolonged stress of itself is a major factor in the onset of type 2 diabetes, hypertension, cardiovascular illness, and various problems of modern society.
He argued for more preventive medicine rather than our ''reactive'' health care system.
We wait until somebody is sick, and then we try to do something about it. Preventive medicine has a great deal to offer. Socioeconimc status has important proclivities for a host of illnesses in our country, including osteoarthritis. The lower you are in the socioeconomic status scale, the more likely you are to have osteoarthritis, or asthma or other kinds of pulmonary illnesses. We can't declare poverty to be gone. But, we can recognize what the factors are and try to apply what we have today – instead of waiting for molecular discoveries to tell us how we might tailor drugs at some point in the future. Unless we do something now, all of the doubling of the NIH's research resources will have a difficult time making it through the pipeline to reach the bedsides of the patients.
Floyd Bloom had previously directed the neuropharmacology laboratory at NIH and had served as editor in chief of the journal Science and it is significant that he chose to open the largest public science conference in the U.S. to emphasize what he viewed as the most serious problem facing the scientific community – a dangerous and worsening health crisis. On the other hand, nobody really knew just how bad this really was, especially with respect to iatrogenic injuries and deaths. All the available studies seriously underestimated the total number of physician-related deaths and injuries because the data was derived solely from hospital death records. As a result, it is difficult to estimate how much pain, suffering and disability results from medical mistakes in outpatient facilities and private practice or unnecessary procedures that are primarily profit-motivated.
That was confirmed by a 2003 report that stated, ''The American medical system is the leading cause of death and injury in the United States''. It found that the total number of iatrogenic deaths / year was 783,936 far greater than deaths from either heart disease or cancer. In addition, each year 8.9 million people were exposed to unnecessary hospitalization, 7.5 million needless medical and surgical procedures were performed and 2.2 million patients suffer in-hospital adverse reactions to prescribed medication. These statistics come from a very detailed and extremely well-referenced report entitled, ''Death By Medicine'' by Gary Null and other researchers that is available at http://www.ourcivilisation.com/medicine/usamed.htm. It pointed out that although we are spending more and more on health care, things have gotten progressively worse. In 1975 the United States spent $95 billion on health care or 8.4% of the Gross National Product (GNP), up from 4.5% in 1962. By 2001 it had escalated to 14% of the GNP ($1,600 billion) and is predicted to be $2815 billion, or 17% of the GNP in 2011. As the report noted,
Considering this enormous expenditure, we should have the best medicine in the world. We should be reversing disease, preventing disease, and doing minimal harm. However, careful and objective review shows the opposite. Because of the extraordinary narrow context of medical technology through which contemporary medicine examines the human condition, we are completely missing the full picture. Medicine is not taking into consideration the following monumentally important aspects of healthy human organism: (a) Stress and how it adversely affects the immune system and life processes (b) Insufficient exercise (c) Excessive caloric intake (d) Highly processed and denatured foods grown in denatured and chemically damaged soil (e) Exposure to tens of thousands of environmental toxins. Instead of minimizing these disease-causing factors, we actually cause more illness through medical technology, diagnostic testing, overuse of medical and surgical procedures, and overuse of pharmaceutical drugs. The huge disservice of this therapeutic strategy is the result of little effort or money being appropriated for preventing disease.
This report also cited numerous studies confirming that deaths and injuries due to medical errors are far greater than reported. Only five percent of adverse side effects from drugs are reported to either hospital administrators or the FDA and there are probably 5 million medication reactions each year. This implies that if the annual iatrogenic death rate is higher than 800,000, that at least six jumbo jets are crashing with no survivors everyday. While the pilots go down with their planes, the perpetrators of these deaths live on to keep repeating their mistakes. There is little doubt things could improve dramatically if medical errors were reported more accurately so their causes could be identified and corrected. In December 2004, Donald Berwich, a Harvard professor and Director of The Health Care Improvement Institute, challenged hospitals and health care executives to prevent mistakes and improve care by launching a ''100,00 Lives Campaign.'' He set a June 14, 2006 deadline to signup at least 2,000 U.S. hospitals in the effort and implements six types of changes that might help prevent hospital deaths. The effort was endorsed by federal health officials, health insurers, hospital industry leaders, the American Medical Association and others. The roughly 3,100 hospitals that signed up represented about 7.5% of the nation's acute-care beds. Dr. Berwick announced the preliminary results of the campaign at a recent conference. About 86% of hospitals sent in mortality data, roughly a third said they were implementing all six measures, and more than half committed to at least three. However, even without full compliance, it was estimated that 122,300 lives had been saved over the past 18 months.
Antibiotic Resistance, Superbugs, Tequin And Ketek
Antibiotic resistant bugs are out of control and nosocomical or hospital based infections are largely responsible for this growing epidemic. According to the Centers for Desease Control & Prevention, over 100,000 Americans die each year from hospital-bred infections, more than from breast cancer and AIDS combined. Nearly 2 million patients get hospital infections, two-thirds of which are now resistant to antibiotics that were previously effective. Almost 60% of hospital staphylococcal infections are now resistant to antibiotics compared to only 2% two or three decades ago. Some, like methicillin resistant staphaureus (MRSA) can cause lung, bone or skin infections so toxic that they prove fatal within a few days because an effective antibiotic is not available. Just two or three years ago these and other pathogens would have responded to any of the ''cillin'' or cephalosporin antibiotics but now the only resource is vancomycin, a powerful antibiotic that is usually reserved as the drug of last resort. The problem is that as vancomycin in use has sky-rocketed, MRSA and other pathogens are becoming increasingly resistant to this as well as anything else.
MRSA infections are often confused with necrotizing fasciitis a more serious disorder due to ''flesh-eating'' bacteria that can cause death within a day. The usual culprit is Streptococcus pyogenes often found in common infections like strep throat and impetigo that respond readily to antibiotics. Drug resistant strains of this and other streptococci produce toxins that destroy the soft tissue beneath the skin and the infection quickly spreads through the blood to the lungs and other organs. Although rare, necrotizing fasciitis is fatal in around 30% of those who develop it. Clostridium difficile, an intestinal bug previously regarded as a minor nuisance that was easy to eradicate has also mutated into a killer. C. difficile infections usually occur in hospitals when antibiotics given for other disorders wipe out normal intestinal flora leaving this organism to thrive and produce toxins that cause severe diarrhea and destruction of colon cells. The difficile refers to the fact that it can be very difficult to culture and since an accurate diagnosis is delayed, patients are given antibiotics to treat the diarrhea, which worsens the problem. A new mutation circulating in hospitals and clinics in North America produces 20 times as much toxin and can destroy the colon in less than a week. One outbreak at hospitals in Quebec infected 1,700 patients and the organism was so virulent that 33 patients had to have their colons removed and 117 died. Vancomycin resistant strains of this organism and other enterococci are increasing.
More dangerous, drug-resistant forms of tuberculosis, gonorrhea and pneumonia are also emerging along with bacteria responsible for childhood ear infections. These growing problems are largely due to the widespread and indiscriminate use of antibioitics. Of the 150 million prescriptions written annually in the U.S., 90 million are for antibiotics and 50 million of these are absolutely unnecessary or inappropriate. It is estimated that last year, 6 to 8 million unnecessary antibiotic prescriptions for ear infections were written because many are not aware that over 85% of patients with this complaint recover spontaneously and simply require analgesics for symptomatic relief. There were 20 million needless and ineffective prescriptions for colds and other viral infections and two out of three babies received antibiotics by their first birthday beause of anxious parents and pediatricians who acquiesce to their demands. These infants never get a chance to fully build up their immunity to bacterial pathogens and since therapy is often stopped when symptoms subside, the remaining bacteria are apt to be resistant to antibiotics. Antibiotic resistance also comes from food contamination. Over 40% of the antibiotics produced in the U.S. annually are administered to chickens, cows and pigs to promote growth and up to 75% of these feed antibiotics pass unchanged into manure. Some 57 billion pounds of animal manure sprayed on crops or some 575 billion pounds of animal manure are sprayed on crops or farmland and the runoff can carry antibiotic resistant microbes into rivers and ponds that are often sources of drinking water. Serveral outbreaks of serious infections due to drug-resistant bacteria have been linked to such livestock waste. Antibiotics are present in fruits and vegetables grown with fertilizer developed from animal stools and you can buy antibiotics for animals in any pet store including tetracycline for fish. Antibiotics are available without prescription in many foreign countries and in some they can even be bought on the street. It is important to emphasize that the greater the use of antibiotics the more likely you are to develop a resistant strain that eventually can result in a new generation of superbugs.
Attempts by drug companies to develop different or more powerful antibiotics have been disappointing and in some cases disastrous. Tequin is a quinolone type of antibiotic made by Bristol-Myers Squibb to treat upper respiratory and urinary tract infections. Last February, the FDA required the company to list increased safety warnings on the label stating that it may be particulary dangerous for diabetics, the elderly or patients with kidney disease. The FDA has also been petitioned to withdraw Tequin because of links to at least 20 deaths and over 150 hospitalizations. Although the company has agreed to stop making it, currently available stocks will not be recalled. If Tequin is banned, it will be the fifth of 13 previously approved quinolone antibiotics to be taken off the market because of safety problems. Ketek, a macrolide antibiotic made by Sanofi-Aventis, was approved by the FDA two years ago for the treatment of sinusitis, bronchitis and pneumonia acquired outside of a hosptital by an adult. Prior requests for approval had been rejected because of concerns about liver damage and other side effects and the agency asked for an additional large clinical study comparing it with amoxicillin. This was performed in 2001 but the FDA found so many flaws that the data was unreliable. However, Sanofi-Avientis, the world's third-largest drug company with annual revenues of $34 billion, persisted. They pointed out that Ketek had been approved in Europe in 2001, had been used about four million times as an important and effective treatment for stubborn respiratory infections and reports of safety problems were minimal. More than 5 million prescriptions have been written in the U.S. since it was approved but a recent FDA review cited growing evidence that Ketek may be unusually toxic. Twelve patients suffered liver failure resulting in four deaths and there were 23 reports of serious liver injury. Some suggested that the agency should consider withdrawing the drug or severely restrict its use and add a prominent warning about potentially fatal side effects. In addition, current clinical trials in children should be stopped pending further investigation. While the results of the flawed study were not released, a New England Journal of Medicine article stated it showed that Ketek was as safe as other antibiotics. However, five of article's six authors disclosed that they received consulting fees from Sanofi-Aventis, and the sixth was an Aventis employee at the time of the study.
Since Ketek is approved only for adults, it is being tested as a treatment for ear infections and tonsillitis in nearly 4,000 infants and children in more than a dozen countries. This includes the United States, where there were four FDA approved clinical trials in children ages 6 months to 13 years. Internal FDA memos indicate that officials asked the company in May to stop studies in children because of safety concerns. However, nothing happened until a scathing June 8 expose by Gardiner Harris who had obtained copies of the FDA memos and other information for the New York Times. One safety official wrote, ''How does one justify balancing the risk of fatal liver failure against one day less of ear pain?'' The major 24,000 patient study that allegedly confirmed the safety of Ketek was ''marred by fraud.'' The doctor who treated the most patients in the study was in federal prison after pleading guilty to fabricating data and defrauding the company and another who treated the third-most patients had his license revoked because of gross negligence and failing to keep adequate records. Another doctor who participated in the study, agreed to stop doing research after the FDA accused him of backdating consent forms and failing to properly record which drug his patients were taking. In addition to the FDA reports of liver damage and deaths cited there were 110 spontaneous reports of MedWatch from consumers complaining of Ketek associated liver damage ''most of which occurred in otherwise healthy people''. There were also reports of blurred vision and loss of consciousness but what was most troubling is how anyone could justify subjecting infants and children 6 months to 13 years of age to a drug described as ''unusually toxic'' for a trivial condition that resolves by itself in almost nine out of ten such cases. The day after the Times report, Sanofi-Aventis suspended the trials in children. The FDA has still taken no action and simply indicated it would continue its investigations and discussions with the manufacturer.
Considerable concern has been expressed about how the U.S. would respond to a bioterrorism attack that used superbugs or others like anthrax for which most drugs are not effective. There are few if any promising new antibiotics in the pipeline and little financial incentive for pharmaceutical manufacturers to develop them based on the experience with Tequin and Ketec. One proposal was to extend the patents on billion-dollar drugs like Zoloft or Zithromax provided those extra profits were ploughed back into antibiotic research. However, the drug companies would prefer a solution similar to President Bush's proposal called Bioshield, which would give them $6 billion outright to come up with new anti-toxins in case of a bio-terror attack. It would seem that in any event, they will continue to reap exorbitant profits that the public pays for in one way or another.
Medical Bankruptcies & How Doctor Supply Increases Demand And Deaths
Of the 2 million patients who get hospital infections each year due to medical mistakes, two-thirds have a bug that is resistant to at least one drug. This costs consumers $30 billion a year and contributes to the phenomenal increase in bankruptcy due to inability to pay physician and other medical expenses. Over 2 million Americans are financially ruined each year because of health related debt and a very recent report from Harvard confirms that medical problems are responsible for about half of all bankruptcies. Most of those who declared bankruptcy had health insurance and were middle class workers and more than three-quarters were insured at the start of the bankrupting illness. Often illness led to job loss, and with it the loss of health insurance. David Himmelstein, the lead author of the study and an associate professor of medicine at Harvard commented: ''Our study is frightening. Unless you're Bill Gates, you're just one serious illness away from bankruptcy. Most of the medically bankrupt were average Americans who happened to get sick. Health insurance offered little protection. Families with coverage faced unaffordable co-payments, deductibles and bills for uncovered items like physical therapy, psychiatric care and prescription drugs. And even the best job-based health insurance often vanished when prolonged illness caused job loss precisely when families needed it most. Too often, private health insurance is an umbrella that melts in the rain.'' A Commonwealth Fund survey found that 41 percent of young and middle aged adults with incomes between $20,000 and $40,000 a year were without health insurance for all or part of 2005, up from 28 percent in 2001. Many of the uninsured reported spending their entire savings on health care and/or that they were having difficulty paying for basic necessities. Most reported cutting corners on medical care to save money by failing to fill prescriptions, skipping medications and doing without preventive care. The Institute of Medicine estimates that lack of health insurance leads to 18,000 unnecessary American deaths – the equivalent of a 9/11 disaster every other month. Elderly patients, although covered by Medicare, who have to take multiple costly medications, are also faced with choosing the most important ones or cutting down on dosages so they can buy food or pay rent.
In that regard, the 2005 Medicare trustees' report estimates that providing promised Medicare benefits over just the next 10 years could require over $2.7 trillion in new tax revenues. Yet, Medicare is far less expensive than private insurance since it spends 98% of revenues on actual health care compared to less than 80% by Aetna and other insurers because of administrative and advertising expenses. Many authorities believe that covering the 46 million Americans currently uninsured with a Medicare type program would actually save money since the uninsured already receive some medical care at public expense. For example, much of their treatment in emergency rooms, because they have no place else to go, would be far less expensive and more effective if provided in doctors' offices. It would also reduce administrative expenses for doctors and hospitals. Dr. Benjamin Brewer, who writes a weekly column for the Wall Street Journal, recently commented on the excess expenses he incurred trying to deal with 301 different private insurance plans. He currently employs two full-time staff members for billing, and his two secretaries spend half their time collecting insurance information; he wrote ''I suspect I could go from four people in the paper chase to one with a single-payer system.'' A few months ago, General Motors reported a $1.1 billion loss for the first quarter, its largest quarterly loss in more than a decade, which was largely attributed to the increased cost of providing health care coverage for employees. Health expenditures increase the price of each GM car by $1525, more than the cost for steel. This may explain why GM sales were down 19% and Toyota's sales jumped 23%. GM's health care costs are $4 billion more than Toyota's because almost all health care in Japan is provided by the government rather than employers.
Although we spend 2? times as much as any other country per person on health care, middle-aged Americans are in far worse health than their British counterparts who spend less than half as much because they practice less intensive medicine. There is a great deal of evidence that getting more medical care as well as paying more for it is likely to make your health worse. The average longevity for Medicare beneficiaries is significantly reduced in those areas of the USA that have a higher-than-average supply of physicians in so-called ''supply sensitive'' medical specialties. Situations in which suppliers of medical care regulate the demand for their own service have been proven to result in adverse effects on health status, quality of life, and length of survival for the affected patients. As Dr. O'Brien also noted, ''In its final report before shutting down operations in January 2000, the Pew Commission on the Health Professions, chaired by Senator George S. Mitchell, found that the nation had more than twice as many active physicians as would be optimal for the society as a whole. Since then, the numbers have increased, with most of the newly licensed physicians joining the ranks of 'supply sensitive' specialists. If you can situate yourself in a position to determine the level of demand for your own services, this is obviously where the big money can be made. What else can be expected? Conventional American physicians now consider their profession to be just another business in which 'market forces' can be counted on to resolve all problems. The trouble is that there can be no legitimate market force at work when supply regulates demand, instead of the converse.''
A recent Dartmouth study confirmed that the amount spent per person on health care varies dramatically in different parts of the country. Southern California is high cost, for instance, while Northern California is low cost. Spending is high in the Boston area, and lower in Western Massachusetts and Minnesota. And while it was initially suspected that people in areas with more health care would be healthier and live longer, the reverse was true. A major reason is that our health care system is structured to offer doctors, hospitals, and companies enormous financial incentives to provide more and more treatments. Surgeons get paid if they do bypass operations, insert ear tubes in children, or take out prostates but not if they recommend waiting or considering some interim drug treatment. Hospitals get higher revenues if they put more patients in their new catheter labs or operating rooms. Americans and their doctors want access to any new treatments such as bone marrow transplants for breast cancer even if it has not been shown to prolong life. Insurers who refused coverage usually lost in court until clinical trials proved that the treatment, costing $50,000 to $150,000 per patient didn't work. The choice of therapy for prostate cancer may also depend on profit, motive and geographic location. A Cincinnati urologist who does many brachytherapies (implanting radioactive seeds) said, ''If you drive one and a half hours down the road to Indianapolis, there is almost no brachytherapy. Head to Loma Linda, Calif., where the first proton-beam treatment are far higher than in most other parts of the country. Go to a surgeon, and he'll probably recommend surgery. Go to a radiologist, and the chance are high of getting radiation instead.'' The study also found startling differences in what happens in the last six months of life at 77 top hospitals. The average number of days spent in the hospital during the last six months of life was 10.1 days at Stanford University Hospital compared to 27.1 days at New York University Medical Center. The average number of paid doctors' visits ranged from 17.6 to 76.2, with NYU at the top.
Another recent report, ''Will More Doctors Increase or Decrease Death Rates'' conducted by the Center for Health Program Evaluation in Australia, helps to explain the reasons why an increase in the doctor supply is associated with poorer health and increased mortality. It has also been well established that death rates decrease when doctors go on strike, one example being Israel physicians in public hospitals who were protesting a proposed contract several years ago. Over the three or four-month period of the dispute, thousands of visits to outpatient clinics and tens of thousands of elective operations were postponed. To find out how this affected death rates, the Jerusalem Post interviewed the non-profit burials societies that perform funerals for the vast majority of Israelis living in Jerusalem. According to an article in the British Medical Journal, the director of one said, ''The number of funerals we have performed has fallen drastically.'' The manager of another larger, facility declared with much more certainty: ''There definitely is a connection between the doctors sanctions and fewer deaths. We saw the same thing in 1983 when the Israel Medical Association applied sanctions for four and a half months.'' A similar trend was noted in Tel Aviv. Readers who responded to the article emphasized that this was hardly a new observation. Death rates fell during strikes only to return to prelevels after strikes in Los Angeles, Canada and Columbia and Israel in the 1970's. According to the Jerusalem Burial Society, doctors reduced their daily patient contact from 65,000 to 7,000 during the one-month 1973 strike. The death rate dropped 50% during those four weeks.
Epilogue: Colossal Corruption And Conflicts Of Interest
In his famous 1910 report on the satus of American medicine that resulted in closing down most of the existing medical schools, Abraham Flexner warned against ever allowing ''the commercial point of view'' to influence the world of medicine: ''In modern life the medical profession is an organ differentiated by society for its own highest purposes, not a business to be exploited by individuals according to their own fancy. The physician is a social instrument and the medical school is a public service corporation.'' Sir James Bryce noted in a 1914 address, ''Medicine is the only profession that labours incessantly to destroy the reason for its own existence.'' And George Merck, who founded the company that is currently defending itself in thousands of Vioxx and Fosamax lawsuits said, ''Medicine is for the patient. Medicine if for the people. It is not for the profits.'' If these individuals were alive today, their opinion might be that medicine's top priority appears to be to perpetuate itself and its profits in any way possible. Commercialism rather than professionalism now predominates in a continuous attempt to provide maximal financial rewards for drug and device manufacturers, specialty physicians and various entrepreneurs.
Corruption and conflicts of interest are so rampant, outrageous and often cleverly concealed that space constraints preclude any thorough discussion here. It is not unusual to read weekly accounts of how physicians have bilked Medicare, Medicaid, and insurance companies and received millions of dollars for services to fictitious patients over several years. Others have been convicted of accepting kickbacks for using certain expensive devices or drugs. As pointed out in previous newsletters [see Stress.org], prominent physicians who determine government recommendations, standards and treatment guidelines for different disorders have a greater allegiance to drug companies that often pay them several hundred thousand dollars annually than the public they are supposed to protect. One example is the lowered definition of ''normal'' blood pressure to increase sales of antihypertensive drugs. As the New York Times recently reported, the physicians largely responsible for this received $700,000 just to invite doctors around the country to attend promotional dinner lectures at a Ruth Chris or similar high scale restaurant. While doctors must report income from speaker fees, consultancies and stock gifts, payments are often made to wives or others so that the total reimbursement is probably much higher. The latest ploy according to a June 28 New York Times article is to donate the funds to a non-profit organization that has been setup by a physician to benefit the public by allegedly engaging in medical research or education. As the article points out, ''No one knows precisely how many of these doctor-run charities exist. Although each one files with the federal government as a tax-exempt entitiy, they are hard to discern among other health-related charities. And because in many cases each has no more than a few hundred thousand dollars in annual revenue, they tend to escape the attention of the federal and state regulators who oversee charities.'' The above activities are often detrimental to patient health and safety and to add insult to injury, patients are the ones who are largely footing the bill for their abuses. Ivan Illich was not the only one who believed that corruption and greed had turned medicine into something that was the exact opposite of its original purpose. Mahatma Gandhi also tried to ''show that there is no real service of humanity in the profession [of medicine] and that it is injurious to mankind.''
I am hardly a therapeutic nihilist and fully appreciate the life saving value and other benefits of certain medications. Nor do I wish to imply that all doctors are motivated by monetary concerns. There are many caring and compassionate physicians who continue to make the patient's best interest their only priority. However, in the more than half century I have been in practice, my impression is that medicine has become much more of a commercial trade than a caring profession. What used to be a very personal doctor-patient partnership now includes the participation of countless anonymous individuals who can determine the appropriateness of therapy, which drugs to use, how long a hospital stay should be, etc. Our ''health care'' system does little to enhance health or prevent disease because its focus is on treating sickness, which is much more remunerative. What we call ''health insurance'' has nothing to do with insuring health. It is really sickness insurance, since it primarily pays costs only when people are sick. And it is becoming increasingly expensive because more of us are getting sicker than ever before. I'm not sure what can be done to get things back on track, but as others have suggested, a proactive emphasis on prevention and developing healthy lifestyles and reducing stress would be a very cost effective way to start. Continuing to search for new drugs in a reactive attempt to relieve signs and symptoms that may be Nature's early warning signals that something is amiss is not the solution.
Copyright ? 2006 by the American Institute of Stress. All rights reserved.
Health and Stress