Podcast:

 

 How Fat People Reduce Global Warming [15:25m]: Play Now | Play in Popup | Download (64)

When DrRich was a little tyke, he always loved it when Uncle Harry came to visit. Uncle Harry was a large, rotund man with a ready smile and a jolly laugh, who was genuinely delighted to spend hours entertaining little DrRich and all the other children with his jokes, stories, magic tricks, and samples from the large stash of candies he always kept in his coat pockets. We all loved Uncle Harry.

But we were deceived.

Little did DrRich know, in his youthful innocence, that far from being the cheerful and beloved amateur prestidigitator delighting us with his his egg trick, Uncle Harry was actually a menace. For Uncle Harry was obese.

We now know, of course, that obese people, through their gluttony, sloth and lack of self-control, are causing untold harm to our society. They are unpleasant to sit next to on buses and airplanes. They use more than their rightful share of healthcare resources. They snore. They cause excessive tire wear (and if they sit in the same seat all the time, the tire wear will be asymmetrical, probably leading to an increase in automobile accidents).

And now, thanks to a recently published academic article, we know that the obese are largely responsible for global warming.

That global warming is taking place, and that it is being produced by mankind, of course, is a settled issue. DrRich is led to understand that a great council of hand-picked environmental scientists, taking a lesson from the Council of Nicaea, has met and has decreed it to be so. The entire body of scientific evidence has been formally considered, and like the Holy Scripture has been carefully locked down into its final form, and has been divided into orthodoxy (the study of which is holy) and heresy (the study of which leads to perdition). And having accomplished this task, the scientific community will hereafter countenance no dissension on the matter, and will admit no further debate or even any further data (unless it is corroborative data). For this is how science is supposed to work, at least for matters as critically important as global warming.

DrRich calls it Environmental Scholasticism, and believes it is about time we returned to a system of thought that was good enough for some pretty important Saints. The notion that scientific viewpoints should never be considered “closed,” and should always be open to challenge as new evidence and new ideas come to light, is a relatively recent invention initiated by the likes of Galileo and Newton, and has led to nothing but trouble (such as, for instance, global warming).

In any case, now that we know once and for all that global warming is man-made, it behooves us to figure out which men (and women) are causing it. And now, according to two eminent scholars at the Department of Epidemiology and Population Health, at the London School of Hygiene & Tropical Medicine, we know that among the chief culprits are the fat. That is, fat people, through the office of their obesity itself, are responsible for a significant degree of the carbon emissions that are unarguably (and officially) destroying our planet.

This fact, heralded by radio and newspaper reports proclaiming, “Fatties Cause Global Warming,” was revealed in a “scientific” paper written by Professors Edwards and Roberts and published by the prestigious Oxford Press in the International Journal of Epidemiology.

The paper really ought to be perused directly to appreciate the elevated level of scholasticism employed by the authors, which would make even Thomas Aquinas and Albertus Magnus themselves sit up and take notice. For this paper, which indicts a whole class of individuals with the supreme crime of global warming, a crime whose disastrous effect on our planet eventually will make the atrocities perpetrated by even Hitler and Stalin seem mere trifles in comparison, reaches its conclusions without ever offering even one tiny glimmer of actual data or evidence.

Rather, the authors rely (as true scholastics must) on the approved body of scientific work, choosing from that body an array of assumptions based on bits of sanctified data from physiology here (e.g., Basal Metabolic Rate = 11.5 X body weight in KG + 873kcal), and behavioral science there (e.g., that the average daily activities of humans consists of 7 hours sleeping, 7 hours of office work, 4 hours of light home activities, 4 hours sitting, 1 hour standing, 30 min of driving and 30 min of walking at 5 km/h), then applying these bits to an incredible chain of assumptions and estimations, to demonstrate that the negative impact of the obese on our society goes far beyond what we currently think. Indeed, through such machinations it can be concluded that the obese are melting the ice caps, killing polar bears, flooding the seacoasts, and turning our farmland, forests and fields into hot, dry, desert.

Anyone with a cheap telescope can conclude from all this that Martians, when they existed, must have been really fat.

This information, of course, will come in very handy when we are forced at last to reduce our healthcare costs, and we find we need somebody to blame. We can already discriminate against smokers with a clear conscience. And now discriminating against the obese can be accomplished not only with a clear conscience, but with a sense of duty. For, far from merely costing the healthcare system a lot of money, they are killing us all and ruining our planet.

Indeed, DrRich himself was sharpening his pitchfork, when a thought occurred to him.

The paper in the International Journal of Epidemiology comports to the classical scholastic practice of “lectio,” whereby a learned person expounds on a certain interpretation of the approved texts, and allows no dissension or questioning. But scholasticism also offers a process for “disputatio,” whereby alternative interpretations of the approved texts are permitted to be offered, and the two viewpoints are then subjected to logical analysis through which the truth is determined. (Though in classical scholasticism, the “truth” is ultimately determined by the scholar who delivered the original lectio, and the disputant is put in his/her place.*)

So in the spirit of Environmental Scholasticism (but for the ultimate purpose of discovering whether the healthcare system ought to cure, ignore or euthanize the obese), DrRich would like to propose an alternative interpretation of the argument that the obese are causing global warming. That is, he will offer a disputation.

The logic of the two eminent scholars Edwards and Roberts, once you wade through the incredible morass of scientific-sounding language they have produced, essentially rests on two arguments. First, that the obese require more food energy for their basal metabolic requirements, and second, that because they are so fat they travel in cars (and very big cars at that) much more than normal people do. For these two reasons the obese produce way more carbon emissions than they are supposed to. The authors go on to calculate the excess carbon emissions produced by the obese via the aforesaid impressive chain of assumptions and estimations, and the magnitude of that excess shows us plainly that the fat are largely to blame for global warming.

This is when it occurred to DrRich that both of the basic arguments of Professors Edwards and Roberts can be easily countered, well within the bounds of the scholastic arts, using only the approved texts and without introducing any new (which is to say, heretical) data.

So, to their lectio, DrRich advances this disputation:

First, DrRich asserts that while the basal metabolic rates of the fat are indeed higher than those of the thin, one reason the thin are thin is that their non-basal metabolism is high. That is, often they habitually engage in exercise, even running marathons and triathalons, which burns many calories and produces much CO2. Scientific studies have shown that the obese tend to be still, serene, relatively inanimate. On the other hand thin people are fidgety, they pace about, wave their hands, bounce their legs, and excrete much CO2 through largely habitual and non-useful activity. Perhaps we should punish the calorie-burning thin rather than the fat. At least when the obese burn calories they are generally doing something useful.

Second, while thin people do ambulate more than the obese (indeed, this is DrRich’s first point), the assumption that the obese must make up that mileage by driving cars is entirely ridiculous. The thin actually drive far more than the obese, because they have places to go and things to do, and they’re in a hurry to get there and do it. In contrast the obese are efficient in their movements, they preserve their energy. Thus, they do not drive to the grocery for a pint of milk on a whim. They plan their trips carefully, and shop for the entire week with one trip. There is no evidence that the obese require more support from internal combustion engines than do the thin, and simple observation in fact suggests the opposite.

DrRich could, with some effort, produce a paper just as scientific-sounding as that of the Professors to “prove” his points, but will not do so here. Instead, he will just state his points as bald assertions – which (despite all the fancy math they attached to it) is just what his opponents have done.

DrRich maintains that his two assertions – which entirely counterbalance those of his opponents – make his argument equally compelling to theirs. So thus far we have a draw. But DrRich’s third assertion, which follows, wins the day.

To wit: The obese are unarguably sequestering carbon.

Storing fat, in fact, is simply a relatively efficient way to store carbon. The obese consume massive amounts of carbon in the form of food, and then they fail to burn it off (unlike thin people, who convert their food to CO2 immediately through their habitually wasteful activities). Instead, the obese store their carbon intake in massive reservoirs of fatty tissue, taking it out of circulation forever, and removing it from the carbon cycle which (we find) is so fatally damaging to the earth. Indeed (at least according to the zero-sum crowd for whom redistribution is invariably the answer to all problems), the more food consumed by the obese, the less food remains available for the thin people who would just go ahead and metabolize it, with all their jogging and whatnot, excreting lots of excess CO2 in the process.

When we finally institute our cap-and-trade economy, the obese should get a tax break based on their weight.

Carbon sequestration, of course, is one of the holy grails for environmentalists. Lots of methods for sequestration have been proposed, but none seem particularly practical. One method that has been considered is called “Biomass Burial,” in which we would take some form of biomass (plants have been the main source proposed) and bury it under the earth. The carbon from the buried biomass will stay in the ground, and will not contribute to global warming, at least not for a long time. (This is how fossil fuels were formed in the first place.)

As long as we insist that fat people are buried (preferably after they die), and make cremation of the obese illegal, then putting the obese into the ground will constitute the much-sought biomass burial. When we bury deceased fat people, it is plain to see that we are removing tons and tons of carbon from the carbon cycle and thus from the atmosphere, and instead sequestering it in the ground. It brings a tear to DrRich’s eye to imagine that his king-sized Uncle Harry, gone now for the better part of three decades, by virtue of all that carbon he took with him under the earth continues to make the world a better place for all us former kids he used to delight with his card tricks and his stupid jokes.

And finally, this happy conclusion at which we have arrived – that the obese actually reduce global warming – at last informs those of us who are interested in healthcare how we ought to behave toward the obese. As long as fat people are maintaining (or better yet adding to) their weight – that is, as long as they continue to remove large amounts of carbon from circulation – we should encourage their continued good health. If, however, they start exercising or in some other fashion begin to burn off their large carbon deposits, then of course we might logically withhold medical care from them, or even encourage euthanasia.

But please, for the love of our precious planet and for the sake of our polar bear citizens, let us not discriminate against the obese, or discourage them from their important work.

*This, of course is where Martin Luther went wrong. The 95 Theses he nailed to the church door at Wittenberg was essentially an offer to engage in a classical scholastic “disputatio.” He was merely inviting a debate, like any other scholastic debate, and nothing more. The clergy, however, proved a bit too easily offended, and Luther proved a bit too tetchy, and the intended academic exercise turned into 300-years of bloodshed. DrRich sincerely hopes to avoid such a result here.

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

Podcast:

 

 More Arguments for Withholding Crestor [21:30m]: Play Now | Play in Popup | Download (93)

DrRich’s last post addressed a recent issue of the Archives of Internal Medicine which, strikingly, was largely dedicated to trashing the JUPITER study.

The JUPITER study was a landmark clinical trial in which giving the statin drug Crestor to apparently healthy individuals who were at increased risk of cardiovascular disease (and most particularly, had high CRP levels) resulted in a significant improvement in outcomes. In particular, within two years, individuals taking the statin had a 20% reduction in overall mortality, a 54% reduction in heart attacks, a 48% reduction in stroke, and a 40% reduction in venous thrombosis and pulmonary embolism. All these findings were highly statistically significant.

DrRich attempted to show that the criticisms of JUPITER recently offered by the Archives were sufficiently spurious to raise the question of what the authors and the editors were really trying to accomplish, and for him to suggest that perhaps they were auditioning for appointments to the government’s expert medical panels, which will soon begin determining who gets what, when and how. Indeed, DrRich will actually be quite surprised if none of these individuals end up with such an appointment. They have clearly demonstrated they have the right stuff.

Still, as DrRich also pointed out, the JUPITER study, while a reasonably straightforward clinical trial whose results seem impressive, was anything but air-tight. No clinical trial is air-tight, however, and if medicine were still practiced the way it should be, the JUPITER trial could be smoothly incorporated – with all its limitations – into clinical practice without a hitch.

But, since medicine is now practiced by guidelines, JUPITER poses a major problem. In fact, it has led to major and contentious debates between those who insist its results must be incorporated into formal clinical guidelines, and who insist they should not. On one hand, many point out that JUPITER is an important clinical trial which has demonstrated a vital clinical benefit (prevention of heart attack, stroke and death) with a high degree of statistical significance, which meets the high standards demanded by evidence-based medicine, and which therefore obviously demands a change in the clinical guidelines. But on the other hand, many others insist that the JUPITER trial simply does not demonstrate enough of a benefit with Crestor to justify changing the guidelines.

DrRich’s position – that the results of the JUPITER trial are striking and important but incomplete, and ought to change the conversation between, but not dictate the actions of, doctors and patients – simply does not obtain in the modern era.

So, unable to side with either party, DrRich observes with great interest the debate between those who want to change the guidelines, and those who believe that changing the guidelines would be the greatest of travesties.

Those who want to change the guidelines have, in their favor, the virtue of consistency. For, if one insists that every action by physicians must be supported by evidence-based medicine, then one is pretty much obligated to fully embrace legitimate clinical trials like this one that give clear-cut and statistically significant results. Unfortunately, the evidence-based strict-constructionists have painted themselves into a corner when it comes to JUPITER. They will not be able to say, for instance, “Statins are pretty much alike, so we’ll make the guidelines say ‘statins’ instead of ‘Crestor.’” For JUPITER did not study “statins,” it studied only Crestor, the most expensive statin on the planet. Expanding the results to all statins (despite a large body of experience that suggests this would be just fine) does violence to the whole concept of evidence-based medicine. It’s just not possible. The strict constructionists have therefore boxed themselves in to advocating a new, multi-billion dollar annual expenditure.

It is even more amusing to observe those who do not want to change the guidelines.

These people fall into two general camps. First, and easier to dismiss, are those who believe that drug companies are the embodiment of evil, and that any clinical trial sponsored by a drug company must be dismissed out of hand, particularly if the drugs which are being promoted are statins. (This, in fact, is the level of argument on which the main article in the recent issue of Archives relies.)

DrRich simply notes, once again, that the advancement of clinically useful medical science – in America and in the world – is almost entirely dependent on drug companies and other corporate dens of iniquity. That companies must pay for our medical research is the system we’ve invented. Furthermore, our total capitulation to the dictates of evidence-based medicine means that companies must fund large, expensive clinical trials like JUPITER before they are allowed to sell a new product, or to create a new indication for an old product. This evidence-based paradigm is inherently a double-edged sword. Sure, it creates a huge barrier to the development and adoption of expensive new therapies (which is the covert rationing dividend of evidence-based medicine), but it also creates opportunities, for companies who manage to successfully complete such trials, to create iron-clad indications for their products. For, once a product has been “proven” in a randomized clinical trial, there is no easy way to legitimately keep that product out of the guidelines and off the shelves. The makers of Crestor have simply figured out the rules. One can whip up anti-corporate emotions by criticizing the sponsor for playing the game well, but the fact that the sponsor stands to gain does not negate in any way the results of a well-designed study.

That the anti-pharmaceutical and anti-statin crowds vociferously object to the results of the JUPITER trial is, of course, entirely expected and cheerfully acknowledged. DrRich will merely observe that their position is one of default. It is not dependent on the scientific merit of JUPITER (or any company-sponsored study), and thus it adds no useful information to the debate. We can only note their objections and move on.

The second group of people who object to changing the guidelines are less dogmatic and more open to reason, and indeed (and very interestingly so) claim to be proponents of evidence-based medicine, and thus claim to be willing to follow the data to where it will lead. It seems pretty clear (to DrRich, anyway), that the chief concern of these individuals, as it relates to JUPITER, is cost. That is, this group feels strongly that the implications of the JUPITER trial are simply too costly to follow to their logical conclusion. This, indeed, is a very reasonable position to take.

Unfortunately, the only legitimate way to turn aside the results of a costly but statistically definitive, evidence-based study is by rationing healthcare. (To ration, remember, is to withhold at least some useful medical services from at least some people who would be likely to benefit from those services.) But we can’t do that, because, well, it would be rationing. Because members of this second group are unable to invoke the “r” word, they are therefore forced to find other “reasons” for keeping the guidelines unchanged. This unfortunate situation leaves them little choice but to discover ways in which to impugn the legitimacy of the JUPITER trial.

In short, they find themselves forced to engage in statistical legerdemain in order to diminish the significance of the JUPITER trial. There are several useful statistical arguments they can employ.

From what DrRich has seen, many of the arguments that have been ginned up to this end have not come directly from the JUPITER trial itself, but instead from an editorial accompanying this study, written by Dr. Mark A. Hlatky.

Most of Dr. Hlatky’s editorial is measured and reasonable. But he threw in a key summary sentence that has been greedily grasped by the anti-alter-guidelinetarians, to wit: “The proportion of participants with hard cardiac events in JUPITER was reduced from 1.8% (157 of 8901 subjects) in the placebo group to 0.9% (83 of the 8901 subjects) in the rosuvastatin [Crestor] group; thus, 120 participants were treated for 1.9 years to prevent one event.”

This statement, at least taken at its face value as a stand-alone analysis, is statistically naive and wrong. DrRich realizes that one or two of his readers might not enjoy statistical arguments, so if you do not wish to wade through the reasons why, simply skip the next two indented paragraphs.

In a long-term clinical study in which the endpoints are events that can occur at any time (such as heart attack, stroke or death), then the probability that an enrolled patient will reach an endpoint in the trial increases the longer he/she has been enrolled in the trial. But in virtually all clinical trials, the length of time different people are enrolled varies greatly. This is because it often takes years to enroll people in clinical trials, so that when the trial ends, some will have been in the trial for many years, others for only a little while. This means that the risk exposure of each research subject is different, and is proportional to the total time they were enrolled. Not uncommonly, the enrollment process is not smooth – there are periods of more rapid enrollment, and periods of slower enrollment – so if all you do is average the enrollment time (as was done by Hlatky – 1.9 years) you are likely to get skewed results. So it is simply not statistically legitimate to do so.

There is a legitimate way of analyzing such longitudinal outcome statistics, and it’s called the Kaplan-Meier method. And indeed, the authors of the JUPITER trial presented in their paper a complete Kaplan-Meier analysis of their data (see Figure 1 of their paper), and the results look quite a bit different from Hlatky’s summary statement. The Kaplan-Meier analysis reveals that the risk of heart attack, stroke, and death all increase steadily through at least 4 years (5 years was the longest time anyone was enrolled in this study), so that at 4 years, the risk of reaching one of the “cardiovascular event” endpoints was about 8% (not 1.8%). Further, the Kaplan-Meier analysis shows that the protection imparted by Crestor persists through at least 4 years, and that indeed the magnitude of protection (i.e., the difference in outcomes between the treated group and the placebo group) increases throughout that entire duration. So, at 4 years, the placebo group had roughly an 8% event rate, compared to roughly a 3% event rate for the Crestor group – an absolute difference of about 5% (not 0.9%). This is a far greater benefit than is suggested by Hlatky’s shorthand summary.

Suffice to say, then, that Hlatky’s summary statement apparently ignores the appropriately analyzed data which is clearly presented in the JUPITER paper itself, and which documents that the clinical benefit of Crestor was substantially more impressive than his widely-quoted summary statement suggests.

But as illegitimate as this summary statement may be, let us accept it at face value for a moment just for the sake of discussion, since that’s the data the anti-alter-guidelinetarians have latched on to.

Taking these numbers, the “antis” make the following argument: While the relative reduction in “hard cardiac events” is 50% (1.8 to 0.9), the absolute reduction is only 0.9%, which, anyone would agree, is a pretty small number. So, they conclude, the actual benefit imparted by Crestor is actually quite small.

That’s a very interesting argument. Let’s look at it in a couple of ways.

So we’ve got a population of patients whose risk of heart attack, stroke, bypass surgery/stenting, or death is about 2% at about 2 years, and by giving them a pill we can reduce that risk to about 1%, and we’re arguing that the absolute drop of 1% is not very much to crow about. Well, OK. But what if we found a pill that reduced their risk to zero at 2 years? That is, it completely wiped out the risk of cardiovascular catastrophes altogether. Would that be a good thing? Or would we say, “It’s just a 2% drop, really not much greater than the 1% drop we had with Crestor, so it’s no big deal?” DrRich thinks not. DrRich supposes we would think that totally eliminating all cardiovascular risk would be a very big deal.

When you’re starting at a 2% risk, then any drop in risk is going to be an “absolutely” small number. And if we’re not going to pursue improvements in outcome of such a small magnitude, then why the heck are we worrying about preventative medicine in the first place? Once you get past the big things (drain the swamps, don’t drink the water downhill from the outhouse, etc.) then all preventative medicine tends to consist of small, incremental improvements in outcome. Popular pronouncements to the contrary notwithstanding, preventative medicine is largely the art of spending a lot of money for this kind of incremental improvement. If we decide we shouldn’t do this anymore, then DrRich would find it unfortunate but understandable. But it hardly seems reasonable to arbitrarily focus on this one, particular improvement in preventative cardiology, and (within a healthcare system that insists it is not rationing care) pronounce that this is the one we’re not paying for.

Another way of looking at this “the benefit is too small” argument is by considering that 7.4 million Americans fit the entrance criteria for JUPITER. By giving all these people a statin, we would be preventing about 66,600 major cardiovascular events over a 2 year period. If you’re going to say that 1% is a small number, DrRich will counter that 66,600 is a big number. So do statins offer a substantial benefit or not? It depends on whether you choose to focus arbitrarily on the 1% or the 66,600.

(DrRich understands that many of his readers are not focusing at this moment on the 66,600 cardiovascular catastrophes that could be prevented, but on the 7.4 million people who will be taking a drug that costs $120 per month. But we’re not talking about cost yet, we’re only talking about whether the drug does some good. If we decide it does, then we’ll need to link that “good” to a procedure that measures whether the “good” is worth the money we would need to spend to achieve it. The “antis” try to avoid talking about cost – since that would admit they’re rationing – by insisting that there’s just not enough “good” to bother with. DrRich is simply pointing out that such an argument – that preventing 66,600 very bad outcomes is not enough to bother with – is on its face absurd.)

Another argument invoked by the anti-alter-guidelinetarians is based on the “number needed to treat” (NNT) analysis. Again they rely on Hlatky’s unfortunate summary of the data: “120 participants were treated for 1.9 years to prevent one event.” This number – which the “antis” insist is just too high – is misleading for the reasons already discussed. The real NNT, based on more legitimate statistical analysis, is plainly laid out in the JUPITER paper itself. It turns out that the longer patients in this trial were treated with Crestor, the lower the NNT became. So: At 2 years, the NNT was 95; at 4 years, it was 31; and at 5 years, it was projected to be only 25. Whether you think it is reasonable to treat 25 people with a pill for 5 years to prevent one of them from having a heart attack, stroke, or death is, DrRich supposes, a matter of opinion. But based on NNT analyses for many widely-accepted therapies in medicine today, it looks pretty good.

All these arguments, of course, are merely distractions. The fact is that JUPITER showed a pretty striking reduction in nasty cardiovascular events over s pretty brief period of time, and the only real reason there’s any controversy at all is because of the cost of Crestor.

That cost is what makes us want to withhold Crestor, even though it is imparting at least some (and, DrRich, argues, quite a bit of) clinical benefit. In other words, the high cost makes us want to ration Crestor. The fact that we can only ration covertly, instead of openly, is what makes us want to bastardize the science and do a Kabuki dance with the statistics.

If we were rationing healthcare openly, then we could do an objective, full-bore cost-benefit analysis on the use of Crestor in JUPITER patients, using legitimate and not ginned-up statistical analysis, and taking into account not only the cost of the drug, but also the cost that would be incurred by failing to stop preventable heart attacks, strokes, etc., and then determining where the overall cost-benefit result fell within our coverage criteria. If it met the criteria we would cover it, if not, not. This decision would not be arbitrary. It would be a fully transparent process, so that if the sponsor did not like the results, they would try diligently to find a way to reduce the cost of Crestor (DrRich thinks they would succeed) to a value that would be compatible with their staying in business. (And for the first time, the price of medical products would be determined by a Laffer-like curve, where a price that was too high – like taxes that are too high – would reduce revenue, instead of increase revenue. Companies, being fairly rational, would ratchet their prices down to the optimal price point.)

But since we insist on doing our rationing covertly, DrRich is sorry to say that we’re destined to keep making spurious arguments, and using dumbed-down statistical analysis to back them up. The JUPITER trial, while it is imperfect and while it does not answer every question, really is pretty straightforward. That we get so wrapped around the axle trying to fold such clinical trials into our covert rationing paradigm is simply another demonstration of the fact that covert rationing corrupts everything it touches.

________________________________

Now, read the whole story.

DrRich explains it all in, Fixing American Healthcare – Wonkonians, Gekkonians and the Grand Unification Theory of Healthcare.

Now on Kindle!

Podcast:

 

 Just Say No to Public Health [12:03m]: Play Now | Play in Popup | Download (316)

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.

Podcast:

 

 PCPs: Here's All You Need To Know About Our New Healthcare System [14:47m]: Play Now | Play in Popup | Download (3)

DrRich has decided it is time to begin studying the 2700-page healthcare reform bill that the Senate passed on December 24, as that is the bill which will actually become the law of the land. In the fall, DrRich had spent quite a bit of time with the House bill. This was such a painful and useless exercise that DrRich decided he would not waste any more of his time with proposed legislation, but instead (as Nancy Pelosi has wisely suggested) would wait until Congress passed a bill so he could find out what’s in it.

Now, DrRich does not have the stamina to study the new law all at once, as a whole. He must bite off little pieces. And the first thing he sought in embarking on his study of our new healthcare system was evidence of how the new law would rescue the Primary Care Physician.

This is important, since everyone acknowledges that we have a severe shortage of PCPs already, and when we add 32 million Americans to the rolls of the insured, that shortage will become extremely acute. Further, we know that very few medical school graduates are deciding to become PCPs, and further, that the PCPs who are in practice today are becoming older rapidly, and many may not be around in 10 years (or even in 10 months, once this reform bill passes).

As we all have heard, our President and his Congress have explicitly recognized the problem, and have frequently explicated on the need to build up and support our beleaguered primary care workforce. They have promised that their healthcare reforms will aggressively address this issue. And it is largely due to this promise that prominent physician organizations, like the AMA (which really represents a relatively small minority of the medical profession) and the American College of Physicians (which represents a large proportion of internists, of whom many are PCPs), have come out in support of the President’s reform efforts.

DrRich believes, of course, that for the Feds to suddenly make themselves the champions of PCPs, after spending nearly two decades systematically rendering primary care medicine a completely untenable proposition for American physicians, would be an unlikely outcome for any reform bill. Just to remind his readers, here’s what DrRich has previously observed about the carefully engineered plight of the American PCP:

“Their pay is determined arbitrarily by Acts of Congress, not by what they’re worth to their patients or to the market, and indeed in this way PCPs have a lot in common with workers in the old Soviet collectives.

They are directed to “practice medicine” by guidelines and directives which are handed down from on high; guidelines which, being forcibly based on what is called “evidence-based medicine,” necessarily address the average response of some large group of patients to the treatment being considered and do not allow much if any latitude for an individual patient’s needs; and which are often promulgated less to assure the excellent care of patients and more to further the agenda of various and competing interest groups, professional, governmental and otherwise.

They are limited to between 7.5 and 12.5 minutes per patient encounter (depending on the third party that controls a given patient’s medical care), and the content of what must occur during those 7.5 minutes is strictly determined by sundry Pay for Performance checklists, so as to strictly limit any interchanges between doctor and patient that do not meet the approved agenda for such encounters.

Their every move must be carefully documented according to incomprehensible rules, on innumerable forms and documents, that confound patient care but that greatly further the convenience of healthcare accountants and other stone-witted bureaucrats who are employed specifically to second-guess every clinical decision and every action the PCP takes.

They are expected to operate flawlessly under a system of federal rules, regulations and guidelines that cover hundreds of thousands of pages in immeasurable volumes that are never available in any readily accessible form. If they do not operate flawlessly according to those rules, regulations and guidelines, they are guilty of the federal crime of healthcare fraud. Furthermore, the specific meanings of these rules, regulations and guidelines are not merely opaque and difficult to ascertain, but indeed they are fundamentally indeterminate – that is, no individual or group of individuals in existence can say what they mean. So, PCPs operate under a massive quantum cloud of rules as best they can, but their actual status (regarding healthcare fraud) is, like Schrodinger’s cat, fundamentally unknowable – until the “box is opened” (typically through criminal prosecution), whereupon the meaning of the rules is finally crystallized in a court of law, and doctors who had been practicing in good faith find that they have at least a 50- 50 chance (like the cat) of learning that they are actually professionally dead.

Worst of all, PCPs have been charged with the duty of covertly rationing their patients’ healthcare at the bedside, and they have been pressed to nullify the classic doctor-patient relationship, by the healthcare bureaucracy that determines their professional viability, by the United States Supreme Court, and by the bankrupt, new-age ethical precepts of their own profession.”

How does our new healthcare law propose to “fix” these problems? DrRich can find two proposed solutions in the Senate bill.

First, the new law promises to address some of the pay discrepancy which punishes doctors for going into primary care specialties. It is unclear to DrRich how much this new pay fix will bring to PCPs. He will merely observe that, until now, the Feds have intentionally rendered primary care medicine such a soul-wrenching, personally and professionally demeaning endeavor that it has pushed most PCPs beyond mere anger, frustration, or resignation. Many of them are desperately looking for any practicable exit strategy. And to DrRich’s thinking, since it is not primarily their relatively low income that has caused all this anguish, a mere boost in income cannot overcome it.

But, of course, that’s for the PCPs themselves to decide.

Second, the new law proposes to fund new training opportunities for PCPs. This also sounds nice. But DrRich wonders what effect these new training programs will have, when the training programs that already exist cannot come close to filling their slots.

DrRich contends that these two stated “fixes” for manufacturing more PCPs cannot possibly provide an actual solution to the PCP shortage, and further, that the authors of the Senate bill cannot possibly believe they will. And so, DrRich decided to look a little deeper.

The answer to the PCP shortage – at least, the answer our political leaders are actually relying upon – is revealed deep in the Senate bill, in Section 5501, where the definition of “Primary Care Practitioner” is actually provided. Note, first of all, that once this bill becomes the law of the land, “PCP” will no longer mean “primary care physician,” but rather, will mean “primary care practitioner.”

And here’s how the new law defines Primary Care Practioners:

The term ‘primary care practitioner’ means an individual who —

(I) is a physician (as described in section 1861(r)(1)) who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or

(II) is a nurse practitioner, clinical nurse specialist, or physician assistant (as those terms are defined in 9 section 1861(aa)(5))

And so, to his readers who are primary care physicians, DrRich must report that the real “fix” your political leaders have envisioned for the PCP shortage has been to declare you and nurse practitioners to be functionally (and legally) equivalent. This, DrRich submits, is all you need to know.

Having painstakingly reduced you unfortunate practitioners of primary care medicine to tools of the state – whose job is to follow the guidelines and place chits on the checklists which are handed down from on high, and to fill out the electronic forms which are designed not to advance patient care but to convenience the healthcare accountants who will thereby judge your “quality” – it is only natural for the central authority to eventually notice that you really don’t need all that training to do the kind of job they have invented for you. Nurses – who can be “trained up” much more rapidly than you, who will work for much less money than you, and who (they think) will be much less recalcitrant about following handed-down directives than you – will fill the gap. And you, doctor, can go pound salt.

DrRich must hasten to add, by the way, that, regarding the nurse practitioners, he believes the Feds have miscalculated. DrRich knows a lot of nurse practitioners and greatly admires their professionalism. He believes that “PCP” has been so successfully demeaned that many fewer nurse practitioners than our political leaders think will actually jump at the opportunity to become one (especially when you take into account the liability you assume when you become a PCP in a non-tort-reform paradigm like the one our leaders have made for us). Trusting in their common sense, DrRich will leave the nurse practitioners to their own wise counsel.

To his primary care physician friends, who have bravely held on, clinging to the promises made by our political leaders that their noble efforts will not go unrewarded, and to the assurances made by their own professional organizations that all will be well once the system is reformed, DrRich is forced to say: Told you so.

He also reminds you that it is still not illegal to opt out, and urges you to consider that it soon might be.

DrRich wishes to congratulate Bob Doherty of the ACP Advocate Blog for his victory over the Covert Rationing Blog in the 2009 Weblog Award Competition, in the category of Best Health Policy/Ethics Blog. As DrRich has said before, Doherty is a gentleman and a fine writer, and anyone who has read his blog will see right away that he is a worthy victor.

And now DrRich must turn to his loyal readers, to try to assuage what must be their bitter disappointment. We are, many of us, surprised, if not stunned, by the outcome of this vote. After all, the Covert Rationing Blog led the voting by a reasonably substantial margin throughout most of the two-and-a-half-week voting period, and indeed remained with a comfortable lead when most of us retired last night (Sunday, Feb. 14). Then upon awakening this morning, we find that our worthy competitor had received a truly impressive onslaught of last-minute votes, in the few hours before the polls closed at midnight, to secure the win.

DrRich cannot, of course, completely wipe out the disappointment for most of you. The pain, understandably, must be far too deep for mere words to vanquish. But allow DrRich to leave you with some thoughts to ponder as you work to resolve your frustration.

1) This election result merely reflects modern American political reality. While it is commonly said that, in elections, the winning strategy is to “Vote early and vote often,” the more assured path to victory is, “He who tabulates his votes last votes best.” That is, don’t let the opposition know how many votes you have until you yourself know how many votes you need. This rule was established by Mayor Daley (the original one) in the presidential election of 1960, and it has held up very nicely for 50 years. The ACP, which is largely a political organization, may be aware of this axiom.

2) For those who believe that the last-minute, stroke-of-midnight outpouring of support for the ACP (on a Sunday! on Valentine’s Day!) seems suspicious, remember who you are dealing with here. This may be difficult for readers of the Covert Rationing Blog – who tend to be salt-of-the-earth, red-blooded, lusty folks, who (no doubt) spent the last few hours of Valentine’s Day with their loved ones doing, well, Valentine-y things – to understand. But you’re dealing with doctors here, and not with the let’s-just-go-cut-the-damned-thing-out surgery types, either. You’re dealing with internal medicine specialists. These are the guys (and girls) you knew in college who looked forward to football Saturdays because the library would always be so much quieter. It is not so unreasonable to visualize the ACP membership entering into their Blackberries a few weeks ago a notice to vote for the ACP at 11:59 PM on February 14. They knew they would probably be logged on to their computers at that moment anyway, reading the latest research on the complement cascade.

3) It would have been greatly embarrassing for the ACP to lose in this vote, while it was not at all embarrassing for the Covert Rationing Blog to lose. DrRich took great pains to make it so, what with his loud, persistent (and, if you’re the ACP, annoying) challenge to the New Ethics promulgated by the ACP. Especially when the ACP made a fairly ineffective and dismissive early effort to respond to DrRich, and then assiduously ignored him thereafter, DrRich did not think for a moment that this large and influential organization would allow this embarrassment to happen. Anyway, by virtue of the ACP’s victory, there is much less embarrassment in the universe today than otherwise would have been the case. And that’s a good thing.

4) DrRich never really believed he would be able to beat the mighty ACP in this competition. Their resources are simply too great. His only chance of victory, he understood from the beginning, would have been to remain entirely silent about the Weblog award, and hope the ACP did not take much notice of it. But instead, DrRich decided to use the fortuitous occasion of being named a co-finalist with the ACP in a medical ethics competition to call them out on medical ethics. By relentlessly poking away at what might otherwise have remained a sleeping giant, DrRich assured his own loss. But, dear readers, getting the ACP to respond publicly to this challenge was far more rewarding, and far more important, than winning a Weblog award. DrRich, for one, feels more firmly now than ever (based on that anemic response) about the ethical bankruptcy of the New Ethics.

In this process, DrRich hopes he was able to call the dangers of the New Ethics to the attention of at least a few of his readers – especially some of the patients who have become entirely marginalized by the New Ethics, and some of the doctors who are considering extricating themselves from the quagmire, and re-establishing the doctor-patient relationship outside the traditional system. If so, the experience will have been very worthwhile and very satisfying.

DrRich would like to thank the people at medGadget for selecting him as a finalist, and especially for selecting the ACP as a co-finalist; and he would particularly like to thank all the hundreds of people who went out of their way to vote for the Covert Rationing Blog. The magnitude of your support – which (judging from the evidence) may have required an extraordinary last-minute effort on the part of the mighty ACP to eke out a face-saving victory – is truly humbling.