World Health Organization (WHO?) Endorses DDT

MalariaGraphic.gif  Source of graphic:  online version of the WSJ article cited below.

 

The World Health Organization, in a sign that widely used methods of fighting malaria have failed to bring the catastrophic disease under control, plans to announce today that it will encourage the use of DDT, even though the pesticide is banned or tightly restricted in much of the world.

The new guidelines from the United Nations public-health agency support the spraying of small amounts of DDT, or dichloro-diphenyl-trichloroethane, on walls and other surfaces inside homes in areas at highest risk of malaria.  The mosquito-borne disease infects as many as 500 million people a year and kills about a million.  Most victims are in sub-Saharan Africa and under the age of 5.

 

For the full story, see:

BETSY MCKAY.  "WHO Calls for Spraying Controversial DDT To Fight Malaria." Wall Street Journal  (Fri., September 15, 2006):  B1.

Against Malaria “DDT Works in Weeks or Months”

Recently I highlighted hedge fund philanthropist Lance Laifer’s efforts to fight malaria in Africa.  Here is a letter-to-the-editor of the Wall Street Journal, in which a distinguished physician strongly endorses Laifer’s advocacy of the use of DDT against malaria:

Impoverished Africans should be grateful to philanthropist Lance Laifer for his effective outreach to reduce the tragic, needless toll of malaria in sub-Saharan Africa ("Malaria’s Toll" by Jason Riley, editorial page, Aug. 21).  For his attempt to focus complacent Americans, Mr. Riley also deserves thanks — such clarity is obviously desperately needed, as even with all the publicity accorded to the ravages of malaria, someone as educated and intelligent as Mr. Laifer remained blithely unaware of this scourge until last year.

Both Mr. Laifer and Mr. Riley note the lack of attention given by official organizations to the more widespread use of DDT as a malaria control method, despite its long and honorable history for this use.  Even with his money and other resources, Mr. Laifer has been unable to persuade Africans to utilize DDT.  African exporters legitimately fear economic repercussions from wealthy Western trading partners, who continue to demonize this lifesaving insecticide despite the lack of evidence of DDT’s adverse health effects in humans.

And where is the Gates Foundation’s massive resources in this ongoing struggle to save a half-billion from sickness and millions from death?  This organization asserts its devotion to reducing the toll of TB, AIDS and malaria — yet none of its funding is aimed toward the cheapest and most effective way to deal with malaria:  increased indoor spraying with DDT.  Maybe Warren Buffett can persuade his friends Bill and Melinda to target their contributions where they will do the most good, in the shortest time, for the most people.  Malaria vaccines are many years away — DDT works in weeks or months.

Gilbert Ross M.D.
Executive and Medical Director
American Council on Science and Health
New York

 

For the source of the letter, and for other letters, see: 

"Malaria Kills Millions — We Have the Cure."  Wall Street Journal  (Mon., August 28, 2006):  A13.

“DDT Saves Lives, Environmentalists Take Lives”

LaiferLanceMalariaFighter.gif  Connecticut hedge-fund trader, and malaria-fighting activist and philanthropist.  Source of image:  online version of the WSJ article cited below.

 

Inside of a year, and working with George Ayittey of the Free Africa Foundation, Mr. Laifer’s efforts have spawned five "malaria-free zones" in Ghana, Nigeria and Kenya.  Expansion to Ivory Coast and Benin is in the works.  He adds that he has the financing to roll out additional zones this year but — ever the searcher — first wants to assess what’s working and what isn’t.  If all is going well, "next year I see us doing something like 100 villages."

Mr. Laifer says a future focus will also be DDT, the pesticide used by Americans and Europeans in the 1940s to win domestic fights against malarial mosquitoes.  Indoor spraying of DDT is by far the cheapest and most effective way to control the disease.  One South Africa province employing DDT saw malaria infections and deaths drop 96% over a three-year span.

Yet Rachel Carson-inspired environmentalists have convinced many public health agencies that the chemical is dangerous.  African nations, fearful that lucrative European and U.S. markets might ban their agricultural exports, make do with less-effective DDT substitutes.  Though DDT, like any chemical, can be harmful in high doses, there’s no evidence that using it in the amounts needed to combat malaria has any ill-effect whatsoever on humans.

Mr. Laifer’s been unable to spray DDT in any of his malaria-free zones.  "It’s the best thing in our arsenal," he says.  "We have a prodigious supply, it’s cheap and we know it works.  Our world leaders need to legalize DDT, and people in America need to get mad about this. . . . We need to have people walking around with signs that say, ‘DDT saves lives, environmentalists take lives.’"

 

For the full commentary, see:

JASON L. RILEY.  "Malaria’s Toll."  Wall Street Journal   (Mon., August 21, 2006):  A11.

 

(Note:  the ellipsis is in the original.)

Distorted Incentives in Medicine


  Source of book image:  http://www.harpercollins.com/books/9780061130298/The_End_of_Medicine/index.aspx

 

The problem right now, as Mr. Kessler sees it, is that we fight the "big three" — cancer, stroke and heart attack — with treatment rather than early detection.  Cancer cells and blood-vessel plaque can be handled much more easily in the early stages, but we spend most of our money on the later ones.  More than 80% of health-care dollars are paid by insurance companies and the government, and neither is especially interested in detecting disease when it first appears.  Doctors, regulators, researchers and payers of all kinds are locked into what Mr. Kessler calls — a bit ungenerously — the "cholesterol and cancer conspiracies."

A complicated system of mutual dependency distorts the incentives.  "The FDA is like the FCC and Big Pharma is like the regional Bells" is what Mr. Kessler hears from Don Listwin, a former Cisco executive who now heads the Canary Foundation, a Silicon Valley-based effort to promote preventive medicine.  In other words, in medicine as in telecom, the big players end up exploiting regulations more than opposing them, if only to preserve their monopolies.  The Food and Drug Administration — understandably but narrow-mindedly — wants "cures" for cancer and other diseases.  Thus tens of thousands of chemicals are screened, only a handful make it even to Phase I trials, and by the time a new drug is approved a billion dollars has been spent.  Even then the new drug may help only 10% of patients.

Yet if someone were to invent a device with a wide, preventive usefulness — say, a nanotech implant that would spot the proteins that indicate the first minute presence of cancer — it would have to go through the same process of billion-dollar testing.  Since the government and insurance companies are reluctant to add anything to their repertoire of coverage — and since such a device would be targeted at the much broader pool of people who are not sick — research might well stall in its earliest phases for lack of reimbursement-funding.

 

For the full review, see:

WILLIAM TUCKER.  "Bookshelf; The Art of Navigating Arteries."  Wall Street Journal (Tues., July 18, 2006):  D6.

 

A full reference to the book reviewed, is:

Kessler, Andy.  The End of Medicine:  How Silicon Valley (and Naked Mice) Will Reboot Your Doctor. HarperCollins, 2006.

 

“Financial Incentives Can Change the Way Medicine is Practiced”


        An angioplasty being performed in Eyria, Ohio.  Source of photo:  online version of the NYT article cited below.

 

Medicare patients in Elyria receive angioplasties at a rate nearly four times the national average . . .

. . .

. . . some outside experts say they are concerned that Elyria is an example, albeit an extreme one, of how medical decisions in this country can be influenced by financial incentives and professional training more than by solid evidence of what works best for a particular patient.

“People are rewarded for erring on the side of an aggressive, highly expensive intervention,” said Dr. Elliott S. Fisher, a researcher at Dartmouth Medical School, which analyzed Medicare data and found Elyria to be an outlier.

Medicare pays Elyria’s community hospital, EMH Regional Medical Center, about $11,000 for an angioplasty involving use of a drug-coated stent.

The cardiologist might be paid an additional $800 for the work.  That is well above the fees for seeing patients in the office.  And with the North Ohio doctors performing thousands of angioplasties a year — about 3,400 in 2004, for example — the dollars can quickly add up.

Some medical experts say Elyria’s high rate of angioplasties — three times the rate of Cleveland, just 30 miles away — raises the question of whether some patients may be getting procedures they do not need or whether some could have been treated just as effectively and at lower cost and less risk through heart drugs that may cost only several hundred dollars a year.

. . .

Experts know that changing the financial incentives can change the way medicine is practiced.

For example, Kaiser Permanente, the big health system that employs its own doctors, says its patients in Ohio, including some in Elyria, are slightly less likely than the national average to undergo the type of cardiac procedures the North Ohio Heart Center doctors perform so prolifically.

Kaiser’s cardiologists, who work on salary instead of being paid by the procedure, typically treat patients in that region at the Cleveland Clinic, where they have hospital privileges.  And they follow established protocols about when a patient should undergo an angioplasty, when drugs might suffice and when bypass surgery might be the best resort.

“It’s not just individual doctors making up their minds,” explained Dr. Ronald L. Copeland, the executive medical director for Kaiser’s medical group in Ohio.  With no financial reason to perform expensive procedures, the Kaiser doctors frequently choose to manage the patients’ heart disease with drugs only.  “Our doctors have no disincentive to do that,” Dr. Copeland said.

. . .

For many cardiologists, the natural tendency when they see a patient with heart disease is to perform a procedure to try to clear arterial blockages.  And patients, cardiologists say, tend to rely on their doctors’ judgment.

“It’s sort of like, you go to a barber and ask if you need a haircut,” said Dr. David D. Waters, chief of cardiology at San Francisco General Hospital, who is currently studying the effectiveness of different kinds of treatment for heart disease.  “He’s likely to say you do.”

. . .

Experts say it can be difficult to detect cases in which doctors cross a medical line and are clearly performing unnecessary treatments.

“A lot of decisions are discretionary,” said Dr. Harlan M. Krumholz, a cardiologist and professor at Yale.

“It’s about where the thermostat is set,” he said, arguing that doctors in a particular geographic area tend to be unaware if the way they are treating their patients is markedly different from the practices of their peers in other areas.

Traditional measures of medical quality are not set up to detect whether patients are being treated too much, he said, unlike the kinds of safeguards that prompt credit card companies to call their customers to discuss unusual spending activity.  “Right now there are no ‘smart’ systems in place,” Dr. Krumholz said.

In the absence of any real monitoring or oversight, doctors in most places, including Elyria, have few incentives not to favor the treatments that provide them the most reimbursement.  Dr. Waters, the San Francisco cardiologist, said that the way physicians are typically paid — more money for more procedures — results in too many decisions to give a patient a stent.

“You can’t be paying people large sums of money to do things without checks and balances,” he said.

 

For the full story, see:

REED ABELSON.  "In Ohio City, a Heart Procedure Is Off the Charts; SIDE EFFECTS; A Stent Epidemic."  The New York Times  (Fri., August 18, 2006):  A1 & C4.

 

Source of graphic:    online version of the NYT article cited above.

Perverse Incentives Lead to Useless Heart Surgeries


The old idea was this:  Coronary disease is akin to sludge building up in a pipe.  Plaque accumulates slowly, over decades, and once it is there it is pretty much there for good.  Every year, the narrowing grows more severe until one day no blood can get through and the patient has a heart attack.  Bypass surgery or angioplasty — opening arteries by pushing plaque back with a tiny balloon and then, often, holding it there with a stent — can open up a narrowed artery before it closes completely.  And so, it was assumed, heart attacks could be averted.

But, researchers say, most heart attacks do not occur because an artery is narrowed by plaque.  Instead, they say, heart attacks occur when an area of plaque bursts, a clot forms over the area and blood flow is abruptly blocked.  In 75 to 80 percent of cases, the plaque that erupts was not obstructing an artery and would not be stented or bypassed.  The dangerous plaque is soft and fragile, produces no symptoms and would not be seen as an obstruction to blood flow.

That is why, heart experts say, so many heart attacks are unexpected — a person will be out jogging one day, feeling fine, and struck with a heart attack the next.  If a narrowed artery were the culprit, exercise would have caused severe chest pain.

Heart patients may have hundreds of vulnerable plaques, so preventing heart attacks means going after all their arteries, not one narrowed section, by attacking the disease itself.  That is what happens when patients take drugs to aggressively lower their cholesterol levels, to get their blood pressure under control and to prevent blood clots.

Yet, researchers say, old notions persist.

”There is just this embedded belief that fixing an artery is a good thing,” said Dr. Eric Topol, an interventional cardiologist at the Cleveland Clinic in Ohio.

In particular, Dr. Topol said, more and more people with no symptoms are now getting stents.  According to an analysis by Merrill Lynch, based on sales figures, there will be more than a million stent operations this year, nearly double the number performed five years ago.

Some doctors still adhere to the old model.  Others say that they know it no longer holds but that they sometimes end up opening blocked arteries anyway, even when patients have no symptoms.

Dr. David Hillis, an interventional cardiologist at the University of Texas Southwestern Medical Center in Dallas, explained:  ”If you’re an invasive cardiologist and Joe Smith, the local internist, is sending you patients, and if you tell them they don’t need the procedure, pretty soon Joe Smith doesn’t send patients anymore.  Sometimes you can talk yourself into doing it even though in your heart of hearts you don’t think it’s right.”

Dr. Topol said a patient typically goes to a cardiologist with a vague complaint like indigestion or shortness of breath, or because a scan of the heart indicated calcium deposits — a sign of atherosclerosis, or buildup of plaque.  The cardiologist puts the patient in the cardiac catheterization room, examining the arteries with an angiogram.  Since most people who are middle-aged and older have atherosclerosis, the angiogram will more often than not show a narrowing.  Inevitably, the patient gets a stent.

”It’s this train where you can’t get off at any station along the way,” Dr. Topol said.  ”Once you get on the train, you’re getting the stents.  Once you get in the cath lab, it’s pretty likely that something will get done.”

 

For the full story, see: 

GINA KOLATA.   "New Heart Studies Question the Value of Opening Arteries."  The New York Times   (Sun., March 21, 2004). 


Doctors Face Perverse Incentives and Constraints

Kevin MD’s blog provides an illuminating discussion of how hard we make it for good people to practice medicine.  The case discussed involves an MD who is successfully sued for not performing a heart cath on a patient, even though two previous treadmill tests did not reveal any problems.  (The heart cath procedure itself has a nontrivial risk of death and other serious complications.)   

The discussion in the Kevin MD illustrates the difficult incentives and constraints faced by the conscientious physician. In terms of a patient’s health, a cost/benefit analysis may imply that a medical test should not be performed, but in terms of an MD’s income, and legal liability, a cost/benefit analysis may imply that a medical test should be performed. 

Something is wrong with our reward structure and legal institutions, when MD’s who make the right medical call for the patient, are "rewarded" by earning less, and by increasing their chances of being sued.

 

Read the full discussion at:

http://www.kevinmd.com/blog/2006/06/liable-for-not-doing-heart-cath-on-49.html

 

For convenience, here is the opening entry in the discussion:

Continue reading “Doctors Face Perverse Incentives and Constraints”

“When Beds Are Available, Physicians Figure Out a Way to Fill Them”

HospitalStayLength.gif Source of graphic:  online version of the WSJ article cited below.

 

(p. D1)  The Dartmouth investigators say there is no evidence that higher amounts and greater intensity of care lead to better outcomes for patients.  They note past studies done at Dartmouth — looking at Medicare patients with heart attacks, hip fractures and colon cancer — that suggest centers with the most high-intensity care actually have slightly higher death rates than those with a lower intensity of care.  As a result, the researchers say, the bills for patients with similar illness may be two or three times higher at some prestigious institutions, with no apparent additional benefit — and perhaps some risk of harm.

. . .

(p. D4)  John E. Wennberg, principal investigator for the Atlas project, has pioneered research into variation of medical services.  He says the differences among academic medical centers are particularly striking since the medical community depends on these institutions to develop effective treatment strategies.  "If the academic medical centers don’t know how to do it, nobody will," Dr. Wennberg says.

He says his research suggests the primary reason for the differences is the capacity of services, such as hospital beds, intensive care units and specialist physicians, within communities.  There isn’t any evidence that people are sicker in the markets of high-intensity services than in low ones, says Dr. Wennberg, but when beds are available, physicians figure out a way to fill them.

 

For the full story, see:

RON WINSLOW.   "Care Varies Widely At Top Medical Centers; Utilization of ICU for Sickest Patients Is 5 Times Higher at Some Than Others; NYU Vs. Mayo."  The Wall Street Journal  (Tues. May 16, 2006):  D1.

 

  Source of graphic:  online version of the WSJ article cited above.

Entrepreneur Found Creative Way to Save Thousands of Babies

(p. 1)  The babies were lined up under heaters and they breathed filtered air.  Few of them weighed more than three pounds.  They shared the Boardwalk there on Coney Island with Violetta the Armless Legless Wonder, Princess WeeWee, Ajax the Sword-Swallower and all the rest.  From 1903 until the early 1940’s, premature infants in incubators were part of the carnival.

It cost a quarter to see the babies, and people came again and again, to coo and to gasp and say look how small, look how small.  There were twins, even, George and Norma Johnson, born the day before Independence Day in 1937.  They had four and a half pounds between them, appearing in the world a month too soon because Dorothy Johnson stepped off a curb wrong and went into labor.

All those quarters bought a big house at Sea Gate for Dr. Martin A. Couney, the man who put the Coney Island babies on display.  He died broken and forgotten in 1950 at 80 years old.  The doctor was shunned as an unseemly showman in his time, even as he was credited with popularizing incubators and saving thousands of babies.  History did not know what to do; he was inspired and single-minded, distasteful and heroic, ultimately confounding.

. . .

(p. 31)  He displayed incubators developed by his mentors at the Berlin Exposition of 1896, and though they caught on in Europe, acceptance was slower in the United States.

Using babies from New York hospitals that lacked the facilities to care for them, Dr. Couney mounted a display at Luna Park, a Coney Island amusement park, in 1903, soon adding another at a second Coney Island park, Dreamland.

. . .

At least 8,000 babies passed through the incubators, and the doctor was credited with saving at least 6,500, according to news reports of the time.  The Johnson twins made it off the Boardwalk and grew up strong and tall. George Johnson found work, and a sense of freedom, driving trains up and down the coast for the Pennsylvania Railroad.  Norma Johnson married a man named Coe.  Between the twins there are nine children, 13 grandchildren and one great-grandchild.  George and Norma attended Dr. Couney’s induction ceremony yesterday.  "My father didn’t have any money, and this doctor says you can use our incubator for free, but you have to put them on display on Coney Island," Mr. Johnson said, sitting next to his sister on the porch at the Sheepshead Bay Yacht Club the other day.  "It was us and a lot of other people, too."

The twins will turn 68 the day before Independence Day, old enough to enjoy the seaside air on an idle weekday morning.

Down the Boardwalk, the beach is open.  Pretty girls and seagulls play their games.  For a few dollars, you can watch a baseball game, shoot paint pellets at a hungry young dude or become a tattooed lady.

The likes of Martin A. Couney nobody has seen in 60 years.

 

For the full story, see: 

MICHAEL BRICK. "And Next to the Bearded Lady, Premature Babies."  The New York Times, Section 1 (Sun., June 12, 2005):  1 & 31.

(Note: ellipses added.)

JohnsonTwins.jpg  The Johnson twins who were displayed, and whose lives were saved, by Dr. Couney.  Source of photo:  online version of NYT article cited above.

 

Life Has Improved; And Can Continue to Improve

 Source of graphic:  online version of the NYT article cited below. 

 

(p. 1)  New research from around the world has begun to reveal a picture of humans today that is so different from what it was in the past that scientists say they are startled.  Over the past 100 years, says one researcher, Robert W. Fogel of the University of Chicago, humans in the industrialized world have undergone “a form of evolution that is unique not only to humankind, but unique among the 7,000 or so generations of humans who have ever inhabited the earth.”

. . .

(p. 19)  . . .  stressful occupations added to the burden on the body.

People would work until they died or were so disabled that they could not continue, Dr. Fogel said. “In 1890, nearly everyone died on the job, and if they lived long enough not to die on the job, the average age of retirement was 85,” he said. Now the average age is 62.

A century ago, most people were farmers, laborers or artisans who were exposed constantly to dust and fumes, Dr. Costa said. “I think there is just this long-term scarring.”

 

For the full story, see:

Health1860s1994.gif Source of graphic:  online version of the NYT article cited above. 

HealthCivilWarAndNow.gif EscapeFromHungerAndPrematureDeath1700-2100BK.jpg  Source of graphic:  online version of the NYT article cited above.  Source of book image:  http://www.cambridge.org/us/catalogue/catalogue.asp?isbn=0521808782

 

Fogel’s book is a primary academic source for much of what is interesting in the New York Times article.  Fogel predicts that if we don’t screw things up, half of today’s college students will live to be 100.  He shows that academics in the past have consistently and significantly underestimated the maximum lifespans that would be attainable in the future.

The full reference for the Fogel book is:

Fogel, Robert William. The Escape from Hunger and Premature Death, 1700-2100, Cambridge Studies in Population, Economy and Society in Past Time. Cambridge, UK: Cambridge University Press, 2004.

 

Medication Errors Harm 1.5 Million a Year


The report described below documents an incredibly high rate of errors in the administration of medications.  Notice that one of the recommended practices is for patients to bring with them to each doctor’s visit, a complete listing of all of their medicines.  It reminded me of accompanying my mother and father while my father was being treated for melanoma at one of the top cancer hospitals in the country.  We were shuttled from doctor to doctor.  And at each stop we were asked to give a full account of the medicines that Dad was taking.  It gradually sunk in to me that the doctors at this prestigious hospital did not even know which drugs Dad had been prescribed, from within the hospital itself

The Institute of Medicine has identified a problem, but has not identified a cure.  If we really want to reduce medical errors, the key is not just to push isolated practices.  The key is to change the system so that medical practitioners and institutions are rewarded when they do a better job of reducing errors.  If the system provided the right incentives, then the practitioners themselves would be competing to invent and learn the practices that would be most efficient at improving patient health and well-being.

(p. A12) WASHINGTON, July 20 — Medication errors harm 1.5 million people and kill several thousand each year in the United States, costing the nation at least $3.5 billion annually, the Institute of Medicine concluded in a report released on Thursday.

Drug errors are so widespread that hospital patients should expect to suffer one every day they remain hospitalized, although error rates vary by hospital and most do not lead to injury, the report concluded.

The report, “Preventing Medication Errors,” cited the death of Betsy Lehman, a 39-year-old mother of two and a health reporter for The Boston Globe, as a classic fatal drug mix-up.  Ms. Lehman died in 1993 after a doctor mistakenly gave her four times the appropriate dose of a toxic drug to treat her breast cancer.

Recommendations to correct these problems include systemic changes like electronic prescribing and tips for consumers like advising patients to carry complete listings of their prescriptions to every doctor’s visit, the report said.

. . .

Drug computer-entry systems, which are supposed to ensure that hospital patients get the right drugs at the right dose, are used in just 6 percent of the nation’s hospitals, said Charles B. Inlander, president of the People’s Medical Society, a consumer advocacy group, and an author of the report released Thursday.

Electronic medical records can help ensure that patients do not receive toxic drug combinations.  The 1999 report urged widespread adoption of these systems.  Thursday’s report called for all prescriptions to be written electronically by 2010.

Just 3 percent of hospitals have electronic patient records, said Henri Manasse, chief executive of the American Society of Health-System Pharmacists.  Few doctors prescribe drugs electronically.

Even simple medication safety recommendations — block printing on hand-written prescription forms — are widely ignored.

. . .

Thursday’s report said that in any given week, four out of five adults in the United States took at least one medication.  A third take at least five different medications.  As the use of medications has soared, so, too have medication errors, Dr. Manasse said.

Effective strategies to prevent such errors have, however, been known for years, Mr. Inlander said.

“This is not rocket science,” Mr. Inlander said.  “It’s simple.  The key is having the will to make these changes in an organized and uniform way.  And it’s not that expensive.”

 

For the full story, see: 

GARDINER HARRIS. "Report Finds a Heavy Toll From Medication Errors." The New York Times  (Fri., July 21, 2006): A12.

For a link to the full "Preventing Medication Errors" report from the Institute of Medicine, see:  http://www.nap.edu/catalog/11623.html#toc