Neuroscientists Beware! Here Come the Cardiologists!

DrRich | May 29th, 2010 - 10:24 am

Podcast:

Throughout the millennia, the characteristic that has distinguished robust barbarians from extinct ones is that, when forces beyond their control begin encroaching on their turf, they simply pick up and encroach on the turf of less aggressive people (generally, of people who are more advanced, both intellectually and culturally, than they are).

And so, when the Feds begin making noises about limiting some of cardiology’s favorite revenue-generating activities, the cardiologists – among the most robust of the medical barbarians – are quick to overrun the turf of other, less bloodthirsty and more civilized, medical specialists.

DrRich in the past has attempted to warn his medical colleagues about the predatory nature of cardiologists. He has told how the cardiologists have driven the formerly proud and powerful cardiothoracic surgeons into a sad state of underemployment, how they have usurped the formerly sovereign territory of diabetes specialists, and how they are currently laying siege to sleep medicine and bariatrics.

And now, continuing his public service to the less robust medical specialists (whose great achievements, like all cardiologists, DrRich admires), he must reluctantly extend his words of warning to his friends, the neuroscientists.

Cardiologists began encroaching on the field of neurology many years ago, but only surreptitiously, when they took to blaming imbalances of the autonomic nervous system (i.e., dysautonomia) on mitral valve prolapse. In more recent years, somewhat more blatantly, they have attempted to take ownership of migraine headaches. And now, just last week, in a full frontal assault, cardiologists laid claim to Alzheimer’s Disease.

Neuroscientists, nobody is safe! Hide your women and children!

The pattern of behavior employed by the invaders is easy enough to spot. First, cardiologists call attention to an alleged association between some cardiac condition (a condition they will manufacture if necessary), and a non-cardiac medical problem. Then, immediately, they will assert that (or at least begin behaving as if) the association proves a cause-and-effect relationship. Finally, since they have “proven” that the non-cardiac medical problem is caused by a cardiac condition, patients who have (or might develop) that non-cardiac medical problem need to be referred to cardiologists, who, lo and behold, have invented a well-paying procedure to treat it, or at least, to study it further.

The best known example is mitral valve prolapse (MVP), a congenital condition in which the mitral valve partially flops open when it should be closed, thus allowing blood to flow backwards (i.e., to regurgitate) across the mitral valve as the heart contracts. (For anyone interested, here’s a brief description of the heart’s chambers and valves.) Now, significant MVP can be a serious medical problem, and it often requires mitral valve surgery. Fortunately, however, significant MVP is a relatively uncommon condition.

The problem is that echocardiography (a non-invasive test using sound waves to create an image of the beating heart) has become so advanced that some degree of trivial MVP, it seems, can be found in almost anybody. According to some studies, as many as 25 – 35% of healthy individuals – people without any cardiac problems or any symptoms whatsoever – can be said to have some degree of MVP. In fact, whether you have MVP or not depends largely on what criteria the echocardiographer uses to make the call, and how badly the doctor wants you to have the diagnosis.

Over the years it has become customary to diagnose MVP in young, apparently normal people who have the temerity to complain about the highly disruptive symptoms of dysautonomia (such as fatigue, weakness, strange pains, dizziness, constipation, diarrhea, cramps or passing out), without supplying the kinds of objective physical or laboratory findings which, doctors insist, patients are always obligated to provide. Such thoughtless patients are now routinely sent for echocardiography, so that MVP can be diagnosed (since it can be diagnosed just about whenever it is looked for). The patient is then given the diagnosis of “mitral prolapse syndrome,” even though: a) the MVP is usually so trivial as to be nonexistent; b) the studies which claim to show an association between MVP and these sorts of symptoms are generally based on a gross over-diagnosis of MVP; and c) there is no credible theory based on actual physiology to explain how MVP – even real MVP, much less the trivial kind – might cause such symptoms.

But no matter. “Rule out MVP” has become one of the most common reasons for young, healthy people to be referred for echocardiography, and has become a staple source of income for cardiologists.

The story is similar for the association between patent foramen ovale (PFO) and migraine headaches. In the developing fetus, the foramen ovale is a hole that is present in the atrial septum (the thin structure that separates the right atrium from the left atrium). At birth, a flap of tissue imposes itself over the foramen ovale, causing it to close. In some people, however – people with PFO – the tissue flap is still capable of flopping open. In people with PFO, the foramen ovale can open transiently if the pressure in the right atrium becomes transiently greater than the pressure in the left atrium, such as with coughing, or straining during a bowel movement.

In rare instances, strokes in healthy young patients have been attributed to PFO. The supporting theory is that a stroke can occur when a blood clot happens to be coursing through the right atrium at the precise moment a person with PFO is coughing (for instance), allowing the clot to move into the left atrium, and on to the brain. And because this theory is at least plausible, in a young person who has an unexplained stroke and is then found to have a PFO, it makes at least some sense to close the PFO.

But the presence or absence of a PFO is a little like the presence or absence of MVP. Its diagnosis depends on how hard the echocardiographer looks for it, and on how much the doctor would appreciate the diagnosis. With modern echocardiographic equipment, at least some sign of PFO can be found in as many as 25% of normal individuals.

Being able to make this nifty diagnosis is of little use to cardiologists if the only clinical problem it may cause is a one-in-a-million chance of stroke. One cannot make a living, or even make a car payment, doing echocardiograms in young patients with cryptic strokes. They’re just too darned rare. So it didn’t take long for cardiologists to draw a more useful association – this time, between PFOs and migraine headaches.

While all the things that have to happen in order for a PFO to cause a stroke are very unlikely, it is at least possible that they could all occur simultaneously in a patient. This is not the case with migraine. No plausible theory has been advanced to explain how PFO might cause migraines. The only reason PFO is being invoked as a cause for migraine is that when patients with migraine have been carefully studied for the presence of PFO, an increased incidence of PFO was found. But (as we have seen) when PFO is carefully sought in any population of patients, it is more likely to be found. The only likely reason PFO has not been associated with cancer, red hair, type A personality, or difficulty in memorizing the multiplication tables is that cardiologists have not thought of looking for it (yet) in these conditions.

For cardiologists, the poorly-supported allegation that PFO causes migraine is particularly compelling, since not only can they get paid to look for PFOs in migraine sufferers, but also there is an invasive (and lucrative) procedure they can do to close PFOs, to “treat” the migraines. Studies to date have not been successful in showing that closing PFOs improves migraine headaches, but that hasn’t kept cardiologists from screening migraine patients for PFO, then offering them PFO closure as a therapeutic option.  This, again, is because an association implies cause and effect, at least when that implication can be helpful to someone.

Migraine sufferers are particularly vulnerable to this and many other unproven therapies, since they are often disabled by their condition, and in many cases medical science (or medical ignorance) offers them insufficient help. Consequently, anecdotal stories abound regarding unorthodox therapies that cure migraines. DrRich, himself a migraine sufferer for many decades, has heard all the stories. (He even has one of his own. If DrRich maintains a schedule of running at least 20 – 25 miles a week, he does not get migraines. If he quits running for a few weeks the headaches come roaring back. He has mentioned this decades-long and reproducible pattern to several neurologists and other specialists over the years. They conclude that DrRich – and this should not be a surprise to many of his readers – is nuts. But if cardiologists had a billable procedure that could make you exercise, you can bet they’d fold DrRich’s experience into their formal clinical guidelines.) In any case, merely performing PFO closures on a few migraine suffers was almost guaranteed to produce a patient here or there who would report a positive response. And despite the continued negativity of actual clinical trials so far, that’s what happened.

So, at least by anecdote if not by controlled trial, closing PFOs can cure migraines.

But now it gets even worse for the neuroscientists. Any neurologists who ignored the cardiologist’s usurpation of dysautonomia, and who may have felt only a little more concern when cardiologists began to lay claim to migraine headaches, had best sit up and take notice. Because now, cardiologists have a way of treating (at least preventing, if not actually curing) Alzheimer’s Disease.

This time it is DrRich’s own particular sub-branch of the cardiology tribe which is the culprit – the electrophysiologists.  In a way, it is a little disappointing for DrRich to see his EP brethren going in for the same, turf-grabbing sophistry used by lesser cardiologists. EPs are known for being more intellectually sophisticated than your typical heart doctor (who, after all, is a glorified plumber). Indeed (as he thinks he may have mentioned in the past), DrRich has a neurosurgeon friend who, when he wants to convey the idea that what he is doing isn’t quite as difficult as it appears, but at the same time what he is doing is, in fact, neurosurgery, will say, “It’s not exactly electrophysiology!” But of course, he may not say this anymore once he finds out what we EPs are up to.

Last week, at the Heart Rhythm Society Scientific Sessions, researchers presented a study suggesting that ablation procedures for atrial fibrillation are associated with a lower risk of Alzheimer’s disease. (Here’s some information on atrial fibrillation and its treatment for anyone who is interested.) The study was presented as an abstract only, so we know relatively little about the specifics.

But, really. Atrial fibrillation and Alzheimer’s are both disorders associated with aging, so it is not surprising that they are associated with each other – in the same way that atrial fibrillation is associated with gray hair, cataracts, and bunions. Ablation for atrial fibrillation is a relatively lengthy and difficult procedure, whose results are relatively middling, and which carries a substantial risk of some really nasty complications. So these ablation procedures are generally reserved for carefully selected, reasonably ideal candidates – usually, the relatively young, relatively healthy atrial fibrillation patients, who are less likely to get Alzheimer’s disease over the next few years whether they have ablations or not.

So there is a lot to be cautious about in interpreting a preliminary study like this one. For a well-presented, comprehensive treatment of why the results of this study should be largely ignored for now, see Dr. John M’s blog. (It sounds like John M is as embarrassed by his fellow EPs in this instance as is DrRich).

But such objections as DrRich and John M may express are just quibbles. The headlines are already blaring: “Ablation Procedures For Atrial Fibrillation Prevents Alzheimer’s.” Whatever the details and limitations of this study, cardiologists can now treat Alzheimer’s. Mission accomplished.

Having duly (and humanely) called this problem to the attention of his neuroscience friends, DrRich would like to finish by emphasizing a larger point.

You can’t fight the Feds. When the sovereign authority, at the point of a gun, decides to reach down into the world of the medical specialists, and dictate which medical services are no longer going to be feasible (all for the noblest of purposes, of course – to maximize quality and efficiency and the collective good), the affected medical specialists have a limited range of possible responses. And fighting the Feds is NOT among these available responses.  Better to fight the change of seasons.

So the affected specialists can contract their horizons, take what’s left, and try to make the best of it. Or, they can do what the Visigoths did when the people of the steppes displaced them. Strike out against other, weaker specialists, and take what’s theirs. If you can’t grow the pie anymore, then take the other guy’s piece.

DrRich is not passing any judgment on his cardiology brethren here. He is just describing what’s happening, as a public service. You neuro-types, he believes, have a right to be told what’s happening. You can do with the information as you see fit.

In the meantime, DrRich remains supremely confident that his cardiology colleagues can find a nearly unlimited supply of plunder in this brave new world. They are very robust barbarians.

Just Say No to Public Health

DrRich | May 19th, 2010 - 12:04 am

Podcast:

Many thanks to a loyal reader, Ivan from Montreal, for calling DrRich’s attention to a recent editorial in the New England Journal of Medicine, arguing for more dollars to go to “public health,” as opposed to “healthcare.” The editorial is by David Hemenway, Ph.D., director of the Harvard Injury Control Research Center of the Harvard University School of Public Health.

By “public health,” Hemenway appears to mean that branch of academics that deals with promoting the overall health of a community through organized societal efforts. Some effective public health efforts have included vaccination programs, improved sanitation, motor vehicle safety, draining the swamps, limiting public smoking, and the chlorination of drinking water. A few of these efforts have even been advanced by actual public health experts, such as those to which Hemenway refers.

Hemenway’s main argument is that society gets more bang for the buck with money spent on these kinds of public health efforts, than on money spent on healthcare for individual Americans, an argument which is almost certainly true.

But his conclusion, that the distribution of healthcare dollars should be adjusted accordingly, is spurious. All four of the specific arguments he gives to bolster his claim that public health is underfunded are insubstantial, and more importantly, the folks who have given us most of the wonderful public health benefits we all enjoy are actually not the public health experts whom Hemenway wants to fund.

First, Hemenway claims public health is under-funded because people are just too stupid to understand the importance of public health. Specifically, they are incapable of valuing and thus implementing actions whose benefits lie in the future (such as those provided by public health). Hemenway is quick to say that it is not peoples’ fault; they are built that way. He even gives a complex neuroanatomical explanation for the innate inability of folks to plan for the future.

So: This must be why Americans have never landed on the moon, and why they refuse to invest in cancer research, or to fund their 401(k) plans. As Ivan from Montreal points out, this must be why the great cathedrals were never built. Hemenway’s point here is so spurious on its face that DrRich must wonder if it reflects that baseline contempt for the mental capacity of the proletariat, which is so fundamental to Progressive thinking.

Secondly, Hemenway points out that the beneficiaries of public health (being the public) are not identifiable as individuals, and so we (the bovine masses) cannot bring ourselves to care about them, as we care about individuals such as, he suggests, Baby Jessica falling down the well. This additional deficiency of the proletariat puts public health at a major disadvantage.

It is indeed true that humans have more capacity to identify with individual stories than with “populations.” But this issue is not unique to the field of public health. Those raising funds for heart disease research, for instance, deciphered this mystery long ago – since statistics only gets you so far, you need to tweak potential donors’ emotions by advancing the story of the 12-year-old heart transplant recipient. If the academics in public health haven’t been able to figure this out – using the Baby Jessica story to advance their latest theories on well safety, for instance – whose fault is that? (If what Hemenway says is true – that the field of public health “relies almost exclusively on government funding,” that’s where the fault is. Being on the public dole greatly dulls one’s perceptiveness and creativity.)

Thirdly, Hemenway says, “in public health, the benefactors, too, are often unknown.”  That is, whereas medicine has its great public heros – Hemenway suggests DeBakey and Barnard – the great heroes of public health do not get their due. There are doubtless many heroes of public health – the inventor of the flush toilet comes immediately to mind – but unfortunately most of them remain anonymous. The flush toilet’s inventor, for instance, based on current archeological evidence, died in the Indus valley 4600 years ago. Indeed, many if not most of the truly impactful public health advances took place outside the ivory towers of the modern academy.

Hemenway struggles mightily to come up with an unsung hero for modern, academically-based public health, and – and undoubtedly wishing not to remind us of certain well-known, early20th century heroes of the academy who espoused eugenics as the most effective means of achieving public health  – offers up one Maurice Hilleman, who saved countless lives with his development of more than 30 vaccines. Now, DrRich completely agrees that Hilleman was one of the most important scientists of the 20th century, and probably was responsible for preventing more premature deaths than any other person in history, and, certainly, that he is an unsung hero. But it is a bit of a stretch for Hemenway to claim him for one of his own. Hilleman did his vaccine development as an employee of E.R. Squibb, and then, of Merck. That is, his research was funded by private industry, whose primary motive was filthy lucre. If Hilleman is a hero of public health (and DrRich agrees that he is), then his career is an argument for unleashing the capacity of the private pharmaceutical industry, rather than an argument for more government funding.

Fourth, Hemenway laments that public health efforts often meet with fierce opposition from well-placed interests. This is true. Limiting smoking in public places, for instance, required a sustained battle against powerful interests for decades. But here, Hemenway tips his hand a bit too much. He cites a study showing that having a firearm in the house is a risk factor for gun death, and offers up this rather obvious result to illustrate the important work which academic public health can offer, and to decry efforts to de-fund that kind of important research. Now, DrRich does not diminish the importance of research whose aim is to improve gun safety. But he does wonder why Hemenway could only come up with an example of productive research which is just a little more helpful than, say, a study revealing that automobile deaths are more frequent in the U.S. than in Romania (where ox-carts remain a chief mode of transportation). If DrRich were grading this editorial request for funding as a formal grant proposal, he would take points off for the effectiveness of the applicant’s (that is, academic public health’s) prior work.

Hemenway’s fundamental sin is conflating “real” public health with whatever the people with degrees in “public health” are doing. “Real” public health consists of flush toilets, water treatment, draining swamps, pest control, well-lit streets, and the like, and tends to have a lot more to do with good civil engineering and fundamental medical research than with “academic” public health.

Some of what the modern experts in public health are doing, DrRich suspects, is quite important and is worthy of funding. But just because the schools of public health split off from medical schools in the 20th century, and established their own academic fiefdom, and commandeered the name “public health” as their exclusive domain, they ought not commandeer the credit (as Hemenway does here) for inventing and building sewage treatment plants, vaccines, or side airbags. Most of the actual “stuff” that makes public health so effective comes from somewhere else. If there’s to be more funding, give it to the people and enterprises that actually invent and develop that stuff.

Call DrRich a cynic, but he suspects that schools of public health really want more money so they can publish academic papers that will justify – or demand – more invasive governmental action to control private behavior, for the good of the collective. For instance, while DrRich does not know anything about Hemenway himself, he notices that a major interest of his Injury Control Research Center is firearm injury. Nothing wrong with that. But he also notices that the Injury Control Research Center gets a big chunk of its funding from the Joyce Foundation, an organization with a strong, self-professed “anti-gun” (and not merely gun safety, or gun control) agenda. One might be forgiven for wondering whether one of the “public health” agendas of the Injury Control Research Center in this regard might be to help justify stiffer anti-gun legislation. Whatever you may think of stricter gun legislation, diverting healthcare dollars to support one side or the other of a fundamentally political issue does not seem like a good precedent to set.

Let the public health experts get their own funding. Dollars that people pay for health insurance – whether through direct premiums to insurance companies or through tax dollars to Medicare, Medicaid, and whatever else is coming down the pike – ought to go for individual healthcare, and not to any interest group that can assemble an argument that whatever it is they are doing benefits the overall health of the collective. After all, anybody – from gym owners to grocers to game manufacturers to medical bloggers – can do that.

Healthcare Reform For The Unwashed Masses

DrRich | May 18th, 2010 - 9:20 pm

Sure, nobody’s read the bill, and even if they had, what Nancy said is true: To find out what’s in the bill, they first had to pass it (so the bureaucrats could translate it into the hundreds of thousands of regulations that would finally determine its meaning). But there’s no need to wait for the regulators to sort it all out. DrRich can tell you what you need to know about our new healthcare system right now!

Healthcare Reform Explained – An Updated Guide For The Perplexed

PCP’s: Here’s All You Need To Know About Our New Healthcare System

Why the Health Insurers Saved the Day

The Individual Mandate Will Stand

The Audacity of Perpetuity

Some Powers of the Immutables

Defending the Anti-Obesity Movement, Again

DrRich | May 15th, 2010 - 12:15 am

(A Heartfelt Plea To Certain Authors Of The Health Care Renewal Blog)

Podcast:

The other day, President Obama gave a commencement speech in which he pointed out one of the downsides of living in a new age of electronic communication:

“Meanwhile, you’re coming of age in a 24/7 media environment that bombards us with all kinds of content and exposes us to all kinds of arguments, some of which don’t rank all that high on the truth meter. . . .[I]nformation becomes a distraction, a diversion, a form of entertainment, rather than a tool of empowerment. All of this is not only putting new pressures on you; it is putting new pressures on our country and on our democracy.”

In other words, too much information can be bad (since it can be untruthful, and places pressure on our country and democracy). Clearly implied in this statement is the idea that something ought to be done about all that extraneous information out there. Presumably, disinterested truth-tellers in our unbiased government bureaucracies ought to sort out fact from fiction, and take the necessary steps to get rid of the fiction. This is not the first time the White House has offered to monitor the utterings of wrong-thinking Americans, and to do what is needed to correct their misapprehensions. Rather, it is simply another reinforcement of a consistent theme under our current administration.

We had best take it seriously.

And so, it is with some reluctance that DrRich finds it necessary at this time to perform an intervention. He does so with the kindest of motives, namely, to protect two people he greatly admires from finding themselves on the wrong side of a Federal disinformation bust.

DrRich speaks, of course, of Dr. Roy Poses and his colleague MedInformaticsMD (who had best not rely on an easily-decoded pseudonym for protection), two of the principle authors of the excellent Health Care Renewal blog. Both of these highly respected physicians and bloggers have posted articles this week which are critical of individuals who have spoken out against obese Americans.

Dr. Poses started it, pointing out that certain high-profile executives who have made recent public statements decrying obesity, and ridiculing (and offering to discriminate against) the obese, are pontificating on an issue about which they have no professional expertise.

MedInformaticsMD upped the ante by referring to these same executives as obesity bigots, and pointing out (rather colorfully) that such a person “talks stupidly and discriminatorily out of his anal orifice about how much people put in the other end of their GI tracts.”

Now, DrRich does not know how likely it is that Federal truth-tellers will stumble across these offensive posts. Given the stuff DrRich himself has said about healthcare reform and our government, he hopes it is unlikely indeed.

But Gentlemen of the HCR blog! Whereas DrRich habitually employs enough irony in his writings that most stone-witted bureaucrats (he hopes!) will have trouble discerning what he actually thinks, your prose is uncomfortably straightforward, and leaves no room for interpretation. If they find it, you are screwed.

And so, DrRich begs you to allow him an opportunity to set you straight on American obesity, and the importance of the anti-obesity movement.

To understand this, one must understand the underlying premise: Under any soup-to-nuts universal healthcare system (which, DrRich submits, is the ultimate goal), our central authorities, in the name of controlling costs, have got to be able to restrict, control and tax virtually any human behavior they can claim may lead to an increased risk of healthcare expenditures – which, really, encompasses virtually any human behavior you can think of.

Such power on the part of our central authorities will feel “unnatural” to many if not most Americans, if not developed judiciously. And so, it makes sense to develop such power – to set precedents which, once set, will be impossible to stop – by demonizing the obese, and making it not only OK, but imperative, for the government to control their unutterably selfish behavior, and, failing that, to punish them.

It is not difficult to demonize the obese. In literature and films the obese have long been portrayed as unreasonably jolly, slovenly and lazy, or just plain evil. (Hello, Newman!) Nobody likes to sit next to them on airplanes or buses. They block the aisles at the grocery store (their favorite haunts), and they reduce miles-per-gallon (and cause excessive tire wear) when they ride in our cars. On humid days, they sweat (and thus smell) more than you and I. So, with rare exceptions (and it is unfortunate that you two Gentlemen comprise one of these), nobody complains when the obese are criticized and attacked.

Given the current hypersensitivity to anything smacking of criticism of various races, ethnic groups, professions, political movements, sexual orientations, immigration status, victims of certain diseases, and scores of other categories of Americans, the obese present us with a refreshingly – and indeed the only – safe target. As the authors of the HCR blog point out, prominent and respected figures feel no compunction whatsoever against making the most offensive public statements against the obese, and when they do they receive (with rare exceptions such as provided by you HRC Gentlemen) applause rather than condemnation.

Obesity is a condition which is immediately visible to all – and from a great distance – and which immediately labels one as being selfish and lazy, and, now, as entirely unconcerned that their bad behavior is costing the rest of us our healthcare dollars, and thus, potentially our lives. Hating the obese has become nearly a patriotic imperative.

Fully government-funded and government-controlled healthcare (by whatever subterfuge we finally get there) permits – nay, demands! – that we declare to the obese that their unsightly physiques are no longer a matter of personal choice, but are now a matter of legitimate public concern. The choices they are making – that is, their gluttony, sloth and all other manner of self-indulgence – are placing unwanted and unsustainable demands on us purer, svelter, fellow-citizens, not to mention placing us in danger of not receiving the healthcare which we (in contrast) actually deserve.

It is already far too late, Gentlemen, to appeal to mere reasonableness, rationality, or, especially civility.  We are well past that stage. Observe: It has become acceptable to write, and accept for publication, “scientific” papers claiming that the obese are the chief cause of global warming. Observe again: It has become acceptable to write, and accept for publication, “scientific” papers claiming that obesity is contagious, and that – never mind associating with the obese themselves – it is risky associating with the very friends of the obese. (That is, even those who like, or tolerate, fat people are to be shunned.)

By their own selfish actions, actions which threaten the collective far more than merely themselves, the obese have become fair game for whatever manipulations our government can devise to cause them to either lose weight, or pay for their sins. Such maneuvers may begin with simple taxes on foodstuffs favored by the obese, but the sky’s the limit. A special “carbon tax” based on their BMI would be legitimate, for instance, since it will always cost a lot of energy to move a fat person from point A to point B, whatever the mode of transportation. The periodic mandatory public “weigh-ins” such a tax would justify would serve the useful purpose of public humiliation, an important incentive to weight loss. And it goes without saying that the ultimate censure – already employed in more enlightened cultures such as Great Britain – would be simply to withhold certain healthcare services if one is deemed too fat.

Demonizing the obese provides several important precedents to our central authorities. That it sets an important precedent – and establishes the mechanisms and techniques – for controlling the private behaviors of American citizens is obvious. But it also allows us to place the blame for a medical condition, which largely depends on genetic predisposition, solely on the chosen behavior of its victims. Discriminating against those who have genetically-mediated conditions thus becomes possible.

Discriminating against obesity also sets a precedent for discriminating against the lower economic classes (since obesity, rather than starvation, is the chief nutritional problem of the poor in America). This will prove a useful tool when we set future behavioral standards to reduce healthcare spending, since so much of that spending is for the economically disadvantaged.

And so, Gentlemen of the HRC blog, it ought to be painfully clear that successfully demonizing the obese is a vital pillar of our new healthcare system. And when you express the unfortunate ideas the two of you have published this week (namely, that discrimination against the obese is somehow unhelpful), you are placing a large target on yourselves, and on your otherwise excellent blog. (And by extension, you may be placing more innocent blogs, like this one,  under more official scrutiny than might be comfortable.)

DrRich sincerely hopes you will take these comments in the communal spirit in which they are intended.

Black Market Healthcare – A Few Concrete Suggestions

DrRich | May 10th, 2010 - 8:27 pm

Podcast:

In his previous post, DrRich offered some general issues to consider before one dives into black market healthcare, and reminds his readers why this will not be an endeavor for the faint-hearted. In this post, we will get into some specifics.

DrRich must first assure his readers (and any government officials who may inadvertently stumble upon this blog) that he is a law-abiding citizen, and does not condone illegal activities. So he will suggest here only activities for black market healthcare which, strictly speaking, will not be illegal under American law; though not so much by complying with the law, but by avoiding it.

DrRich trusts that his readers can think up the more illegal kinds of black market activities for themselves, and thus they do not need his help with this aspect of the endeavor. Many of these more obvious illegal forms of black market healthcare (e.g., “medical speakeasies,” located in back alleys for the proletariat, and in swanky office buildings for public officials; rolling surgical suites hidden in semi-trucks; smuggling rings for drugs and medical equipment; an “underground-railroad-style” transport system for itinerant physicians who need to ply their illicit trade while on the move; etc.), can be established by individuals, or by relatively small groups of entrepreneurs, and with relatively little up-front capital or lead time – and with no coaching from DrRich.

But the varieties of black market healthcare which DrRich has in mind – certain “less illegal” activities, which will drive the U.S government into states of apoplexy but over which it will have little legal jurisdiction – will require a much larger scale, and a significant investment in time and energy.  So anyone who is interested ought to get started with the necessary organizational activities right away.

DrRich has three such suggestions. With all three of them, DrRich envisions that implementation would be driven by a major private healthcare organization (or a consortium of them) which has a record of innovative thinking, as well as access to significant financial resources through their own holdings, or through their connections with rich benefactors from around the world. He is thinking of organizations like the Cleveland Clinic, the Mayo Clinic, or the Kaiser system.

For the sake of mankind, DrRich offers these suggestions free and clear. They may be taken up, with his blessings, by any institution or organization that wishes to employ them, with no obligations or strings attached whatsoever.

1) Floating Off-Shore Medical Centers. In this scenario, the Cleveland Clinic (say), with the help of their friends in Abu Dhabi, buys or leases a mothballed former Soviet aircraft carrier (nuclear power preferred), and refurbishes it into a floating, world-class medical center. The ship will ply the international waters off the American coasts, providing regular helicopter transport to and from major cities. There’s a lot you could do with an aircraft carrier, of course, to make it an attractive destination aside from medical care, including (for instance) establishing a world class hotel, food services, casinos and other entertainments. But the chief attraction would be that Americans will be able to buy the best healthcare services in the world, without fear of being arrested.

The fact that this floating medical center will be based on a former warship may turn out to be an advantage. Obviously, it would be useful to maintain at least some weaponry on board, if only to repel “pirates” But given the anger this ship will generate among American government officials, the Cleveland Clinic (or whoever) might be wise to remain intentionally ambiguous about just how much firepower the ship has retained. Just sayin’.

2) Native American Medical Centers. There are two things about the current state of Native American culture which make this approach to black market healthcare at least feasible, if not compelling. First is the recognized “sovereign status” of Native American reservations, the same status which has allowed various tribes across the land to open gambling casinos, even in states which otherwise do not allow such establishments. If their sovereign status justifies casinos (establishments of mere entertainment, which, in fact, encourage bad behaviors of all sorts such as alcoholism, prostitution, smoking and – gasp!- obesity), then surely the same sovereign status would justify establishing advanced institutions of healing.

Second is the deep guilt that Americans rightly feel about the treatment Native Americans have suffered over the years, much of which was arranged by the U.S. government. Note, in particular, that one of the ongoing claims which Native Americans have against the larger American culture is the chronically substandard state of the healthcare services they are provided. So, who will dare stand in the way of these oppressed peoples, when they propose to dedicate a portion of their pitiful remaining sovereign lands (with the help of, perhaps, the Mayo Clinic and its benefactors) to the development of world-class medical centers?

One advantage of the “Native American Strategy” for black market healthcare is that it would allow medical centers of various sizes and emphasis to be established in numerous convenient tribal locations around the U.S., as the need and logistics allow. Within a decade or two, if they play their cards right, Native American tribes may even find themselves controlling nearly 20% of the American economy – which would be justice at its finest.

3) Medical Centers Across the Mexican Border. There are several potential benefits to this suggestion. Converting Tijuana, Nogales, Laredo and Juarez from hotbeds of human and drug smuggling into hotbeds of illicit healthcare would probably be a boon to the local populations on both sides of the border. It would create tens of thousands of good jobs in Mexico, for Mexicans. The heavily-armed gangs of Mexican drug-runners along the border could be hired by the Cleveland Clinic Juarez, or the Mayo Clinic Nogales, as security guards, thus absorbing their “talents” into a more legitimate economy. (Being located so close to the border of a powerful nation which will badly want to terminate these medical centers would, one must understand, create a certain need for security.)

If nothing else, world-class medical centers just across the Mexican border would reverse the flow of illicit border crossings. Americans (and Canadians, who, bless them, would now have to travel much farther south for their healthcare) would suddenly be streaming across desert border crossings into Mexico in the dark of night – and Mexicans would be staying put. And its desperate need to get rid of black market healthcare would, at long last, give the U.S. government a compelling reason to control the borders once and for all. We would suddenly see American troops all along the Mexican border, supported by such features as a “no-man’s land” seeded with land mines, and constant surveillance by drone aircraft armed with cluster bombs.

And before long, Californians wanting to go to the Kaiser Tijuana Medical Center would have to get there by way of Cuba.

Some Considerations for Black Market Healthcare

DrRich | May 5th, 2010 - 8:33 pm

Podcast:

DrRich recently finished a four-part series describing our government’s attempt to prohibit individual Americans from spending their own money on their own healthcare. He believes that any open-minded person who reads this series, what with its numerous, well-documented and specific examples, related in DrRich’s own engaging and erudite prose, will become convinced that our government is very serious about, and much dedicated to, affecting this harmful prohibition.

DrRich’s critics have insisted that he is simply making too much of this. Our government, they insist, whatever its tendencies, will not really act in this way, for the simple reason that Americans would never put up with such limitations on their individual freedoms. And in fact, DrRich fundamentally agrees with his critics, at least to this extent: Americans – many of us, anyhow – just won’t put up with it.

Where he quibbles is in the specifics. DrRich’s critics insist that our government (presumably, taking American character into account) would never actually try to limit the freedom of Americans in such an egregious way. In contrast, DrRich (having carefully demonstrated for his readers that the government will indeed use every means at its disposal to make it illegal, infeasible, or both, for Americans to spend their own money on their own healthcare), finds, sadly, that the many Americans who “won’t put up with it” will find themselves having to act counter to the wishes of their government. That is, Americans who insist on exercising their natural right to become “the proper guardians of their own health,” will have to do so extra-legally.

To say it even more bluntly, Americans wishing to enjoy the individual liberties which our Constitution promises us will, in this instance, need to engage in black market healthcare. DrRich has talked about this before, but finds this a propitious time to discuss it again, and to offer some words of wisdom and caution to anyone who might be inclined in this direction.

Black markets develop naturally whenever a society’s controlling authority attempts to prevent its citizens from acquiring an otherwise available good or service which they very much want (or need). In fact, it is a law of nature that, wherever a group of people exists who badly desire a certain product, and another group of people exists who very much want to provide that product, there is no force in the universe – governmental or divine – which can keep those two groups from engaging in commerce.

To see what is likely to happen when the government institutes its healthcare prohibition, we ought to think about what happened when that same government instituted its alcohol prohibition (i.e., Prohibition). The 18th Amendment (one of the big triumphs of the Progressive Era, and one which, quite typically, relied for its ultimate success entirely on a fundamental change in human nature), went into effect at midnight, January 1, 1920. By noon that day, an entirely new industry had sprung up. This industry – the alcohol black market – eventually employed hundreds of thousands of Americans in various capacities, such as distillers, alcohol “re-naturizers,” bootleggers, rum-runners, speakeasy proprietors, accountants, individuals who today might be called “lobbyists,” and various species of “muscle.”

DrRich’s own dear grandfather, who had only recently arrived from Eastern Europe to work in the steel mills, found more profitable employment instead, through the ’20′s and into the Great Depression, as a gun-toting rum-runner. Each weekend he filled the hidden tank under the back seat of his big Buick sedan with 250 gallons of prime home-made spirits, and would place DrRich’s young grandmother (wearing an impressive hat)  next to him, and seat their three innocent little children (among them DrRich’s toddler mother) over the hidden contraband in the back – the very picture of a happy young family out for a Sunday drive – and in this guise would make his deliveries across northeastern Ohio. DrRich will never understand why, at the end of Prohibition, Grandpa ended up as a laborer for the city street department, instead of the filthy-rich Ambassador to England like his fellow bootlegger, Joe Kennedy. (But on second thought perhaps it is better this way. If Grandpa had ended up like Ambassador Kennedy, DrRich today would be spouting the Progressive mantra, like all those other guilt-ridden souls burdened by unearned wealth.)

In any case, the government took great issue with the new industry that had been created, overnight, by Prohibition, and attempted to end the new black market by employing the ultimate expression of any sovereign authority – the legal exertion of violence. (The enforcers, it happens, were Treasury Agents, the very same enforcers who now will be ensuring compliance with certain mandates being imposed by our new healthcare system.) This effort on the government’s part led to an organized response, and resulted in the maturation of American organized crime. (Interestingly, this organized crime effort happened to be centered in Chicago, a happenstance which resulted in a persistent and evolving thugocracy within that city, whose ultimate ramifications – some say – are now affecting current events on a much broader scale).

When its concerted application of force against the the bootleggers failed to end the black market, our government turned to applying a different kind of force, this time to the consumers. The recalcitrant consumers of illicit alcohol were, after all, guilty of failing to change their behavior, despite all the heroic efforts which were being made to educate them about the pitfalls of demon rum.  The understandable frustration this caused finally led our government resort to deadly force against the obstinate public itself. Author Deborah Blum has recently documented how the U. S. government caused poisonous substances to be added to the alcohol supply, an act that is estimated to have eventually killed 10,000 people. The chief medical examiner of New York City at the time called this action “our national experiment in extermination.” And in 1927, the Chicago Tribune said, “It is only in the curious fanaticism of Prohibition that any means, however barbarous, are considered justified.” It was partly the revulsion against such official atrocities that forced the end of Prohibition in 1933.

DrRich relates this little-remembered episode merely to illustrate the lengths to which our government will go when its attempts to control human nature through legislation fail. It is worth keeping in mind as we conjure up ways to establish what he hopes we will not need, but fears we’ll not be able to avoid, namely, a black market in healthcare.

Black market healthcare will not be for the faint of heart. But then, no great human endeavor ever is.

In his next post, DrRich offers some concrete suggestions for black market healthcare.