Health – Page 92 – artdiamondblog.com

Empirical Science at Its Best

Source of book image: http://images.barnesandnoble.com/images/11460000/11468284.jpg

I have not yet read The Ghost Map, but from the review excerpted below, it sounds like a wonderful book. One lesson from the book appears to be that much good can come from a careful collection of evidence, and that much harm can come from sticking to a theory in spite of the evidence. It is also interesting that in this tale, the villain turns out to be the advocate of public works, whose good intentions resulted in much death and suffering.

(p. P8) The sociology of error is a wonderful subject. Some university ought to endow a chair in it — and then make Steven Johnson the first professor. Mr. Johnson last provoked the public with his counterintuitive polemic "Everything Bad Is Good For You," in which he argued that TV and videogames actually improve our cognitive skills. In "The Ghost Map" he tells the story of how for 30 years and more the medical establishment in Victorian London refused to accept what was staring them in the face, namely that cholera was a waterborne disease.

Thousands of Londoners died while doctors and public-health officials stubbornly clung to the view that the plague was an airborne miasma that hung in the foul atmosphere of the slums and was inhaled by the wretched creatures who lived there. Every kind of cure was proposed: opium, linseed oil and hot compresses, smoke, castor oil, brandy — everything but the simple, obvious remedy of rehydration, which reduces the otherwise fatal disease to a bad case of diarrhea.

The fact that the cholera toxin tricks the cells in the lining of the colon into expelling water at a terrifying rate (victims have been known to lose 30% of their body weight in a matter of hours) should surely have alerted someone to the possibility that putting this Niagara back into the body might be worth trying. Only one doctor, Thomas Latta, hit upon the answer, in 1832, just a few months after the first outbreak ever in Britain. His mistake was not to inject enough salty water, and his lone initiative was soon overwhelmed by the brainless babble of the quacks.

Chief among the villains of Mr. Johnson’s unputdownable tale was the man whom we were brought up to revere as the father of public sanitation, Edwin Chadwick. This dour, tactless, unpopular reformer laid the foundations for all the government interventions in public health that we now take for granted. Yet in this story he labored under not one but two illusions that proved catastrophic.

. . .

With the austere teetotaller and vegetarian Dr. Snow and his devoted helper in the Soho slums, the Rev. Henry Whitehead, "The Ghost Map" gains not one but two heroes. Patiently they mapped the patterns of victims and survivors and narrowed down the most likely source of the cholera plague to the Broad Street pump. But even after the pump handle was removed so that Londoners could no longer fill their buckets there and the illness subsided, the miasmatists were not convinced. Snow then tramped the streets of Battersea and Vauxhall to demonstrate that those who had their water from higher up the Thames, above the reach of the tide, remained unharmed, while those who took it from the foul tidewater perished in the hundreds. This was no easy task, since the pattern of water pipes under London’s houses was as tangled as the pattern of Internet service providers are today.

Why did it take so long? Because mapping epidemics was only in its infancy, though Snow’s famous map was not quite the first. Because the questions that Chadwick’s public-health board researched were self-fulfilling, all having to do with the smells and personal habits of the poor and not with the water they drank. The researchers mistook correlation for causation: Nobody died on the high ground of Hampstead, where the air was purer, therefore higher was safer — or so it seemed until a Mrs. Eley, who had retired thither, arranged to receive a jugful of water from her beloved Broad Street pump and got cholera.

But above all Chadwick and his crew were certain of themselves because the stench of the slums was so utterly disgusting and because smell acts so powerfully on our imaginations. Only the most careful and dispassionate investigators were free of the obsession with stench. Henry Mayhew, for example, noted in his "London Labour and the London Poor" (1851) that sewer-hunters, who scavenged deep underground knee-deep in muck, lived to a ripe old age. The Great Stink of 1858, which finally persuaded the government to commission Sir Joseph Bazalgette to lay down the magnificent network of sewers that have lasted to this day, did not kill a single Londoner — yet still Chadwick did not believe.

For the full review, see:

FERDINAND MOUNT. "BOOKS; Lost in a Time of Cholera; How a doctor’s search solved the mystery of an epidemic in Victorian London." The Wall Street Journal (Sat., October 21, 2006): P8.

(Note: ellipsis added.)

The reference to the book is:

Johnson, Steven. The Ghost Map: The Story of London’s Most Terrifying Epidemic – and How It Changed Science, Cities, and the Modern World. New York: Riverhead Books, 2006. 299 pages, $26.95

Dr. John Snow. Source of photo: online version of the WSJ article cited above.

Edwin Chadwick. Source of photo: online version of the WSJ article cited above.

Health Care Spending Increases Faster than Inflation, But Slower than Previous Year

Source of graph: online version of NYT article cited below.

WASHINGTON, Jan. 8 — Spending on health care in the United States increased in 2005 at the slowest pace in six years, mostly because of much slower growth in spending on prescription drugs, the government reported Monday.

It was the third consecutive year of slower growth in the nation’s medical bills. Total health spending reached nearly $2 trillion in 2005, growing only a bit faster than the economy as a whole, officials said.

But with new medical technology becoming available every month and with a generation of baby boomers approaching old age, federal officials made no bold claims about having tamed health costs.

“It is unclear whether this phenomenon is temporary or indicative of a longer-term trend,” said Aaron C. Catlin, the principal author of the government’s annual report on health spending, published in the journal Health Affairs.

For the full story, see:

ROBERT PEAR. "In ’05, Medical Bills Grew At Slowest Pace in 6 Years." The New York Times (Tues., January 9, 2007): A13.

The Mere Threat of “Hillary-Care” Reduced Investment in Drug R&D

CEO of drug company Eli Lilly. Source of image: online version of WSJ artcle cited below.

NEW YORK — Is the future of your health riding on what happens in Washington? Sidney Taurel thinks it might be. The Eli Lilly CEO ticks off a list of former "death sentences" being cured or turned into chronic conditions — "AIDS, leukemia, Hodgkins, hopefully solid tumors within the next few years. The potential for medical research is unlimited. We just need to make sure we don’t interdict it by the wrong policies."

And what might those "wrong policies" be? Anything, it would appear, that reduces the financial incentives for drug companies to invest in research and development. Mr. Taurel points without hesitation to the mere threat of HillaryCare in the early 1990s as an episode that reduced investment in R&D, as drug makers, including his own, redirected money toward the purchase of pharmacy benefit management companies. As another example, he offers the anti-drug industry crusade of Sen. Estes Kefauver in the late 1950s and early ’60s:

"At that point companies started to diversify. We bought Elizabeth Arden, we went into animal health and agricultural chemical products, later on in medical instruments and so forth. All other companies did similar things. And for a while after that we saw fewer new products. When this threat subsided the companies focused again on R&D and we saw a golden era in the ’80s and ’90s with a lot of new products and breakthroughs."

For the full interview, see:

ROBERT L. POLLOCK. "THE WEEKEND INTERVIEW with Sidney Taurel; Of Politics and Pills." The Wall Street Journal (Sat., December 2, 2006): A8.

Hugely Wasteful Health-Care Spending

Source of book image: http://www.encounterbooks.com/books/cure/

Milton Friedman is gone now, but the new book reviewed below, includes a forward written by him. Friedman can be praised for many reasons; a minor one is that he was tireless and generous in offering praise and support for others who were seeking to better understand free markets.

About 10 years ago, I broke my leg playing basketball. After I came out of surgery, with a cast stretching from my ankle to the top of my leg, an orderly asked me whether I had ever used crutches before. I hadn’t, so he showed me what to do, swinging through them from one end of the room to the other. The whole lesson lasted about 90 seconds. When I got my hospital bill, I saw that I had been charged $150 for "gait training on crutches." I did what all insured Americans do: I forwarded the bill to my insurance company. Why should I care? I wasn’t paying for it.

One of the problems with American health care, as David Gratzer notes in "The Cure," is precisely a payment system that takes the patient out of the equation. In the early 1960s, the average American paid out of pocket one of every two dollars that he spent on health care; today the figure is one dollar in seven. The inevitable effect is hugely wasteful spending (and inflated hospital bills like mine). In fact, per-patient costs have gone up almost exactly in inverse proportion to the share of spending borne by the consumer.

Dr. Gratzer cites a remarkable Rand Corp. study that tracked health-care spending by 2,000 families over eight years. The families who got free health care spent 40% more than the families with cost-sharing arrangements. And yet the health outcomes for the two groups were the same. The lesson: Market-based health insurance systems, such as health savings accounts, cut out inefficiencies and lower costs without compromising quality.

. . .

. . . : America is clearly at a crossroads in medical care. Within the next decade we will get either some version of Hillary-care or more free-market medicine, starting with universally available health savings accounts. Let’s hope that our nation’s policy makers read "The Cure" before they decide. They will learn that the government route flattens costs only by holding back the pace of technology, artificially controlling its price and rationing its use. That is not a prescription for better health.

For the full review, see:

STEPHEN MOORE. "BOOKS; The Market and Its Medicine." The Wall Street Journal (Tues., By December 5, 2006; Page D6.

The reference to the book under review, is:

Dr. David Gratzer. The Cure: How Capitalism Can Save American Health Care. Encounter Books, 2006. (233 pages, $25.94)

Standard Heart Therapies Do Little to Fight “Vulnerable” Plaque

Most people have of a clear image of how atherosclerosis, popularly known as hardening of the arteries, causes a heart attack — fatty deposits called plaque build up in a coronary artery until the day the blood flow that sustains the heart is blocked.

If only they were right. In reality, severe coronary artery blockages almost always cause chest pain known as angina and other symptoms as they form. But among those who suffer heart attacks, half of the men and two-thirds of the women report never experiencing a warning symptom. And autopsies of such victims frequently show blood clots jammed into arteries that have been only modestly narrowed.

Standard atherosclerosis therapies include bypass surgery to route blood around blockages, angioplasty and stenting to clear blockages from inside the artery, and drugs like statins that reduce cholesterol levels to slow the formation of plaque. But they have not been enough to prevent 200,000 to 500,000 American deaths annually from what doctors refer to as coronary artery disease.

As a result, many researchers have turned their attention from atherosclerosis in general to the tendency of some patients to develop a form of plaque prone to inflammation and rupture, which can spill a stew of cells into the bloodstream that can incite rapid clotting. Such plaques have been called ”vulnerable” plaque.

For the full story, see:

BARNABY J. FEDER. "In Quest to Improve Heart Therapies, Plaque Gets a Fresh Look." The New York Times (Mon., November 27, 2006): C1 & C3.

Doctors Earn More When They Rush Colonoscopies

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

For years, patients and many doctors assumed that a colonoscopy was a colonoscopy. Patients who had one seldom questioned how well it was done. The expectation was that the doctor conducting the exam would find and cut out any polyps, which are the source of most colon cancer.

But a new study, published today in The New England Journal of Medicine, provides a graphic illustration of how wrong that assumption can be, gastroenterologists say. The study, of 12 highly experienced board-certified gastroenterologists in private practice, found some were 10 times better than others at finding adenomas, the polyps that can turn into cancer.

One factor distinguishing the physicians who found many adenomas from those who found few was the amount of time spent examining the colon, according to the study, in which the gastroenterologists kept track of the time for each exam and how many polyps they found.

They discovered that those who slowed down and took their time found more polyps.

. . .

The Rockford study was preceded by other signs that colonoscopies are by no means foolproof. But as problems have been pointed out, they have all too often been met with disbelief among doctors, Dr. Rex said.

The first indication that colonoscopies were not as effective as widely believed came with two studies, one in 1991 and a larger one, in 1997, in which patients had two colonoscopies on the same day. Those studies showed that doctors were missing 15 to 27 percent of adenomas, including 6 percent of large adenomas.

Then, in the last few years, two studies of so-called virtual colonoscopies, which use a CT scan to view the colon, found that the rate of overlooked adenomas in traditional colonoscopies was even higher. Patients in those studies had traditional and virtual colonoscopy on the same day. Traditional colonoscopies missed 12 to 17 percent of the large adenomas detected in the virtual colonoscopies. But many doctors dismissed those findings, saying — if they believed them at all — that they applied to other doctors, not to themselves, Dr. Rex said.

Dr. Schoen, for one, said he was a believer. The conclusions of the adenoma detection studies were reinforced, he said, by studies finding that colonoscopies missed not just polyps but actual cancers.

That finding emerged from studies testing ideas about how to prevent polyps, like taking beta carotene or calcium pills or sticking to a low fat, high-fiber diet.

The patients in all the studies had at least one adenoma detected on colonoscopy but did not have cancer. They developed cancer in the next few years, however, at the same rate as would be expected in the general population without screening.

. . .

The study by the group in Rockford suggests a way to improve colonoscopy: by slowing down. “If you rush things, you miss things,” Dr. Schoen said.

That happens in part because reimbursement rates for colonoscopies have fallen in recent years, and some doctors are doing the exams faster than ever, Dr. Schoen and others say.

“I have heard of people who do it in 30 seconds,” Dr. Schoen said. “Whoosh, and it’s out.”

For the full story, see:

GINA KOLATA. "Study Questions Colonoscopy Effectiveness." The New York Times (Thurs., December 14, 2006): A23.

Feynman: Nothing in Biology Requires Us to Die

Source of book image: http://stochastix.wordpress.com/files/2006/08/the-pleasure-of-finding-things-out.gif

(p. 100) It is one of the most remarkable things that in all of the biological sciences there is no clue as to the necessity of death. If you say we want to make perpetual motion, we have discovered enough laws as we studied physics to see that it is either absolutely impossible or else the laws are wrong. But there is nothing in biology yet found that indicates the inevitability of death. This suggests to me that it is not at all inevitable, and that it is only a matter of time before the biologists discover what it is that is causing us the trouble and that that terrible universal disease or temporariness of the human’s body will be cured.

Source:

Feynman, Richard P. The Pleasure of Finding Things Out: The Best Short Works of Richard P. Feynman. New York: Perseus Books, 1999.

Incentives Influence Doctors’ Choice of Prostate Therapy

(p. A1) The nearly 240,000 men in the United States who will learn they have prostate cancer this year have one more thing to worry about: Are their doctors making treatment decisions on the basis of money as much as medicine?

Among several widely used treatments for prostate cancer, one stands out for its profit potential. The approach, a radiation therapy known as I.M.R.T., can mean reimbursement of $47,000 or more a patient.

That is many times the fees that urologists make on other accepted treatments for the disease, which include surgery and radioactive seed implants. And it may help explain why urologists have started buying multimillion-dollar I.M.R.T. equipment and software, and why many more are investigating it as a way to increase their incomes.

. . .

(p. C7) The one certainty about I.M.R.T. is that for doctors who own the technology, it can be much more lucrative than alternative treatments. Medicare and other insurers typically pay urologists only $2,000 or less for performing surgery to remove the prostate or for implanting radioactive seeds. The insurers say the much higher I.M.R.T. payments, which in some cases exceed $50,000, are based on the technology’s cost.

For the full story, see:

STEPHANIE SAUL. "Profit and Questions as Doctors Offer Prostate Cancer Therapy." The New York Times (Fri., December 1, 2006): A1 & C7.

Ignoring the Elephant in the Stent Hearing Room

A stent. Source of photo: online version of the 3/27/07 NYT article cited below.

(p. C1) See, there was an elephant in the hearing room last week that went almost entirely ignored. One study after another has found that whether or not a stent is coated, angioplasty — the process of opening up an artery before a stent is inserted — and stenting do not actually reduce the risk of heart attack or extend life span for most patients.

“There’s a much more liberal use of angioplasty and stenting than there needs to be,” Dr. Eric J. Topol, a member of the panel, told me last week.

Dr. Calvin L. Weisberger, the top cardiologist at Kaiser Permanente, said, “A large pool of angioplasties and bypass surgeries are being done without scientific evidence.”

. . .

Angioplasty dates back to the 1970s, and stents became a part of the process in the 1990s. Doctors have assumed, sensibly enough, that blocked arteries caused heart attacks by preventing blood from reaching the heart. Opening those ar-(p. C14)teries would keep the blood flowing.

But when researchers tried to prove the theory, they kept coming up empty. The reason seems to be that heart attacks aren’t generally caused by a big buildup of plaque that blocks an artery. They occur instead when a small piece of plaque bursts, causing a cascade that can suddenly clog an open artery. The best way to reduce the risk of that is through cholesterol-lowering drugs, diet and exercise, rather than by opening up a couple of clogged arteries.

Yet stent use keeps growing. “Cardiologists just believe that if you open up a blockage, you’re going to help someone,” said Dr. Judith S. Hochman, director of the cardiovascular clinical research center at New York University. “And they make money from these procedures.”

Ah, yes — money. Medicare typically pays $12,000 to $15,000 for a coated stent procedure, according to Thomas Gunderson of Piper Jaffray. Angioplasty and stenting have accounted for almost 10 percent of the increase in Medicare spending since the mid-1990s, Jonathan S. Skinner, a Dartmouth economist, estimates.

For the full commentary, see:

DAVID LEONHARDT. "ECONOMIX; What Money Doesn’t Buy in Health Care." The New York Times (Weds., December 13, 2006 ): C1 & C14.

Added on 3/22/08: For a later, related story, see:

BARNABY J. FEDER. "In Trial, Drugs Equal Benefits of Artery Stents." The New York Times (Tues., March 27, 2007): A1 & A13.

Your Tax Dollars at Work: Government Protecting Us from Bling-Bling

A dental grill, one form of the hip-hop jewelry sometimes called "bling-bling." Source of image: http://www.thesmokinggun.com/archive/0410062teeth1.html

If all you want for Christmas is to gild your front teeth, you may have to buy the bling-bling somewhere other than the Gold Plaza II kiosk at Crossroads Mall.

That’s because an employee of that shop, Bhavin Dalal, faces a felony charge of practicing dentistry without a license. He’s accused of helping customers fit their teeth for glittering mouthpieces known as grills.

It’s the first such case in Nebraska involving the hot hip-hop fashion accessory. And Dalal and his attorney, James Martin Davis, plan to fight it tooth and nail.

Dalal entered a not guilty plea Friday in Douglas County Court. Davis blasted the Nebraska Health and Human Services System for its investigation of Dalal and the charge that resulted.

"It’s overzealousness on the part of a bunch of bureaucrats" who don’t want people to wear grills, Davis said.

For the full story, see:

CHRISTOPHER BURBACH. "Dental Grill Seller Feels State Law’s Bite." Omaha World-Herald (Saturday, December 2, 2006): 1A & 2A.

(Note: the slightly different online title for the article is: "State puts bite on grill seller")

Distinguished Physician: “I Hate Hospitals”

Dr. James Armitage is a leading lymphoma physician. His honesty in the passage below, is refreshing. But instead of it being viewed as a personality quirk of the physician, it should be viewed as one more reason to reform how our medical system is organized.