More Myths of the Healthcare System

Billy Rubin's Blog returns after a three-month hiatus (for professional reasons, largely), its slumber awakened by a link forwarded by a friend on Facebook. The link, entitled "You Are Not The Customer", is a nine-minute clip put out by The Cato Institute and featuring the commentary of Game Show Network CEO David Goldhill. It puts forth the argument that what has made American health care so bad is that there has not been enough free-market thinking guiding health insurance. That is, if we had even less government involvement and just let the system 'do its thing,' so to speak, we could eventually clean up this mess. Since the current system is mostly not overseen in any direct or even indirect way by the federal government, what could he be talking about? My best guess is that he's proposing that Medicare is what's screwing up all the pricing and keeping us in the dark ages, although he never explicitly says this. In a similar vein to Cato's free-market perspective, the libertarianish Gregg Easterbrook has been wondering why not simply apply standard pricing models to health care outside of catastrophic insurance—and doing this in football columns on ESPN! (Thus making it about the only football column worth reading.)

The tone of the whole clip is certainly an order of magnitude more intelligent than the more popular objections coming from that ideological end of the political spectrum, which as far as I have been able to tell has amounted to screaming "Socialism!" and "Death Panels!" and "Tyrrany!" and not much more. And while I don't share for the most part Goldhill's or Cato's perspective, I do agree, at least in theory, with some of the questions they raise. And (apparently) like them, I definitely believe that there are deep structural problems in American health care.

That said, Goldhill absolutely screws the pooch on one particular point, one that he appears to regard as the centerpiece of why anything other than a 'pure' laissez-faire capitalist model is doomed to failure. Here he tries to peddle a myth just as insidious as the Death Panel nonsense.

About two minutes in, he starts to complain about the shocking failure of hospitals to adopt computer technology. While his father was ill in the hospital, Goldhill says, "this hospital was less computerized than my dry cleaner...my dry cleaner is concerned enough about losing shirts that he's fully computerized, and the hospital's not as concerned about losing lives? Why is that? Why weren't those investments made? Why do they need to be made by the government?" Later (about 3 1/2 minutes in) he picks back up on the theme with his 'guy on the street knows more about this stuff than the healthcare pinheads' shtick:

"The reason my local sushi bar gave its waiters hand-held ordering devices was not because of the National Sashimi Act passed by Congress...its because they want to get the orders right and [do it] quickly. They capture some of that benefit--and by the way, the customer captures some of that benefit--from that fairly simple thing. The lack of information technology investment in health care is not the problem. It's a symptom."

I admire, from a rhetorical standpoint, his use of a well-grounded, easily visible example. And to a point, he's right: I work for a hospital on the weekends that uses a DOS program for its computerized order entry and electronic medical record. It's functional, I guess, but amazon.com would laugh a product like that out of its board room if someone came in and tried to sell it as the model for ordering books. Everything else at this hospital is state of the art: MRIs, CT scans, remodeled ICU & Surgical wings—all the stuff one can think of in a fine community hospital, but the information technology is from about two decades ago. And the good news (for the hospital) and the bad news (for you) is that they're no different from any other hospital—if anything, their system may be a little better because it's not prone to crash by being DOS based.

There's only one problem with his analysis, one little fact that makes this apparently sensible criticism look like the canard that it really is. The fact is this: there is one computerized system that would fulfill Goldhill's wildest dreams. It's user-friendly, it combines the electronic medical record with computerized order entry, physicians love it. Even IT nerdy-types love it. And it's been around for more than a decade. What is this amazing piece of technology and why hasn't it revolutionized health care the way the home computer revolutionized small business?

Well, it's called "VistA" (not to be confused with the Microsoft operating system), and it was not developed by someone trying to get shirts dry cleaned or a sushi order right—meaning it was designed without profit in mind. (I think that deserves an exclamation point: it was designed without profit in mind!) VistA is the computer system of the Veteran's Administration, was commissioned by the US Federal Government and began operating in 1997, and it was then and continues to be the Rolls Royce of healthcare information systems. Having worked at a VA during medical school, I can assure you that it was a joy to work with and I have yet to see its equal. As you can see here, VistA has a main page that has all the goodies a doc needs to retrieve the relevant info: a relevant medical history, a current medication list, links to scans, tests, notes, the whole shebang—just like having a chart in your hands only infinitely easier to deal with.

Your Veterans benefit from this cost-effective, error-reducing system every single day—Lord knows they should—and they do it in a seamlessly linked nationwide system. If you're a Vet from the great town of Mansfield, Ohio and are on vacation in San Diego and you come down with appendicitis, the docs at the SD VA have your whole medical chart at their fingertips. Not bad considering how easy it is for patients to forget critical medications or allergies—assuming they are even conscious—where the lack of such information can lead to life-threatening complications. Meanwhile "private" medicine continues to struggle with thousands of different systems all over the country, few of them integrated (as an east coaster, I cannot comment on Kaiser Permanente's system with which I have no firsthand experience), and none that I have seen best the VA's Little Information Engine That Could.

Best part? Since this is your tax dollars at work, the software for VistA is in the public domain. Oh yes, it's a free program just waiting to be plucked out for eager hospitals who want happy physicians and greater productivity. So why hasn't this magnificent, almost revolutionary system been snatched up by every profit-oriented hospital in the country? A variety of reasons (and indeed some hospitals have adopted it), but the most important is that because the VA is a government-run health system, it never needed to trouble itself with translating medical codes for billing. Adequate billing obsesses every hospital CEO because insurance and medicare reimbursement is the lifeblood of the private health system, so while VistA may be marvelous for, you know, patients and their providers, it's useless for generating money under the current system. So I would say that Mr. Goldhill has this particular argument about as completely upside-down as possible: not only has the free enterprise model been unable to develop information technology nearly as well as a not-for-profit government-run system, it additionally can't even make use of the blue-ribbon technology that the government is willing to give away gratis! (And in the ultimate irony, other countries who see the value of the VistA technology are adopting it, as this article notes about Mexico's VistA use even surpassing that of the VA itself. Just think about this: we taxpayers have funded a system that we can only have access to as Veterans, but civilian Mexicans can benefit from this technology?! What would Lou Dobbs say?)

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PS--The blog is back! We took some time off, but are planning on weekly visits from now on. Please continue to drop in suggestions, questions, links and quibbles.

Of Hillary Clinton, the Media, and Women's Health

One would be forgiven if one had no idea what it was precisely that Secretary of State Hillary Clinton was doing in Africa this past week. After all, in addition to her husband's splashy, headline-grabbing quasi-diplomatic mission to North Korea, there has been this small matter of town hall meetings where people were theoretically learning about the health care reform proposal(s) wending their way through Congress that were dominating the headlines of the US media outlets.

But if one did hear about the Secretary's trip, it would likely have been about her testy response to one seemingly inappropriate question from a Congolese student asking about her "husband's" views on a loan made by the Chinese government to Congo. Seemingly because this appears to have been a mistranslation of the student's actual question (more anon). "What does Mr. Clinton think through the mouth of Mrs. Clinton on this situation?" was the question that the Secretary received, and--not altogether surprisingly--"Mrs. Clinton" bristled at the apparent implication.

"Wait--you want me to tell you what my husband thinks?" she replied. "My husband is not the Secretary of State, I am. So you ask my opinion, I will tell you my opinion; I'm not going to...be channeling my husband."

The flap may have been the result of a misunderstanding on part of the translator; the student claims he was trying to ask Secretary Clinton what President Obama's opinion was, and the translator, confusing the current president with a former one, made the slip between "President" and "husband." Mistranslation or no, Secretary Clinton's carefully-crafted trip to sub-Saharan Africa received virtually zero attention in the US...with the exception of this one, single, less than 20 second flare that she sent up while in Kinshasa. If you heard about her visit at all, odds are was that you heard about her tantrum. Video is below; a representative article from MSNBC is here.

Billy is not here to defend the behavior of the Secretary, a politician for whom he has generally not held much enthusiasm, although he thinks that a mulligan should be allowed for this one, given that this would be about the worst, most condescending question to ask of a female politician accomplished in her own right...and the question being asked of her during a foreign tour and while adhering to what sounds like a fairly brutal schedule. For what it's worth, the Secretary did lose her composure, and in a perfect world she would have kept her cool. She didn't. I for one think that it's not much of a big deal, though the mainstream media would beg to differ. The link below is to an interview with Andrea Mitchell at NBC (the "Today" show), but one could just as easily pluck up clips from CNN and Fox as well.

What's most contemptible about this little episode of media coverage is that her twenty second screed got play, while essentially nothing of the actual substance of Clinton's reason for going in the first place got discussed. As it turns out, Clinton's visit was directly related to issues pertaining to health and medicine, although again one would be forgiven if one didn't recognize that these issues were viewed as "health" through the lens of the US. For in many parts of sub-Saharan Africa, often caught in the grips of war, "health" refers to the mere avoidance of being gang-raped. For women, that is. The UN notes that the Congo has the highest rate of sexual violence in the world, and Clinton's visit was in part designed to be the US government's attempt at stemming the tide of the violence.

Again--if you weren't following this closely, you would be forgiven for not being aware of this.

You would be forgiven because your media has done such an unbelievably poor job of explaining her mission to Africa--but what a wonderful job they did of explaining her twenty seconds of pique! The article above, which explains in detail the purpose of Clinton's visit, showed up on page A8 of the New York Times; that got virtually no play at the TV news networks. Her tete-a-tete with the student and his hapless translator did, however. That you just might have caught.

As long as our major media outlets are obsessed with this kind of lunch-room gossip, we're doomed. Not surprisingly, one could be forgiven if one had failed to learn anything about healthcare reform by watching mainstream TV news stories about the Town Halls this past week. Sure, one would understand that there are groups of angry people out there, but precisely why they are angry and what is actually being proposed would not be explained very much, because...well, it's just doesn't make for interesting viewing! (Or reading.) So lots of nonsense reigns. Billy had originally hoped to discuss the truly idiotic "death panels" a few days ago, but he felt that women's health in Africa superseded it for a day, and so you have this. Perhaps we will return to the topic of death panels, and try to make a (very, soft,) case for death in the coming days. But for now, we only humbly beg that you read the Times article that actually reports the point of why Secretary Clinton went to Africa in the first place.

(Also: it is late August, which is the time that Billy takes to get away and spend with his family on what is theoretically vacation. We just might find some time to write about the government's plans to pull the plug on Grandma...and how Chuck Grassley let us down as one of only two Republicans for whom Billy maintains any affection...but we make no promises. If we don't get it in, check back in September. If nothing else, we promise to talk about the Flu. Get those shots, team! A bad moon is rising, and God only knows what the hell is coming our way in the fall.)
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Visit msnbc.com for Breaking News, World News, and News about the Economy

Health Care Reform Debate & Mind-Numbing Stoopidity: A Match Made in Heaven (or, Quite the Laffer)

What happens when a prominent conservative economist takes to the airwaves to debate healthcare reform on national television?

Well, let's just say that George Orwell would have a chuckle.

You will recall that Orwell authored that polemical novel 1984 about how governments deceive their citizens. Most of us had the book assigned to us in high school because of the seemingly obvious anti-commie streak the book had, despite Orwell's open embrace of socialism and scathing criticism of western European democracies, all of which was politely swept under the rug. Billy took a pass on reading it at that time though he caught up in college during an Orwell Phase where he consumed not only '84 but also Homage To Catalonia, Down and Out in Paris and London and various essays including probably his greatest work, Politics and The English Language. Among the central preoccupations of 1984, as well as the entirety of Politics, are the rhetorical methods by which governments achieve duplicitous aims. Sometimes it involves subtle tricks such as euphemism, as the phrase "enhanced interrogation techniques" in place of torture makes abundantly clear (and is an example where our own allegedly "independent" media have completely and uncritically bought the government's line, for more see here). But sometimes it's fairly bald and just involves a flat-out lie, though done with the perfect straight face.

Today, on CNN during a debate about healthcare reform, our subject, economist Arthur Laffer employed just this sort of rhetorical touch. As part of the Repbulican party mantra, or what I like to think of as the Reagan Credo ("Government is not the solution to our problem, government is the problem"), Laffer explained why the current "Public Option" proposal will lead to a complete disaster:

If you like the Post Office and the Department of Motor Vehicles and you think they're run well, just wait till you see Medicare, Medicaid and health care done by the government. [my emphasis]

Now, that right there is a gem, for Medicare and Medicaid is "health care done by the government"! And, moreover, they are popular programs--so popular, and apparently misunderstood, in fact, that at a recent town hall held by Congressman Bob Inglis (R-SC), a constituent demanded that the "government [keep its] hands off my Medicare." Former Senator John Breaux (D-LA) had a similar experience in 2005.

Such nitwits are merely given the right to vote; they are not, however, allowed onto national television and given substantial airtime to proclaim their nitwicity--and have their nitwittish assertions go unchallenged by anchors in the name of "fairness." But the same is not the case for Arthur Laffer, respected economist.

This, folks, is why health care reform is going down for the second time in less than two decades, and why we will continue to have the most expensive and least effective health care system in the developed world.

True that Laffer is not speaking for the government, while Orwell was describing a system in which the government is the group doing the lying. But since the debate centers around what government policy is going to be, it's a distinction without a difference, and I'm sure that Orwell would see Laffer as an ideological descendent of Le Big Brother.

The link is here (hat-tip to War Room and Media Matters):

Oh, and one other thing: I don't know about you but I like the Post Office!
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Senate Hearings on Continuing Medical Education

Today the Senate Special Committee on Aging (chaired by Herb Kohl, D-WI) held hearings on conflict of interest in medical education and research. Several speakers provided testimony, and if I have spare time in the coming days I will review their statements and maybe find some time for a separate entry on them. But one witness caught my eye, and his statement I read, and that is the subject of today's entry.

Thomas Stossel is a senior physician (Hematology) at the Brigham and Women's Hospital and a professor at Harvard Medical School. As I wrote last week, Stossel was the prime mover & shaker in arranging a conference for a group dedicated to the proposition that industry collaboration with physicians has been much more beneficial than harmful to patients over the past several decades. The goal of the group (Association of Clinical Researchers and Educators, or ACRE) is to organize a pushback against what they see as a movement comprised of anti-industry "zealots" who are out to "infect...medical school ethics instruction with guilt." (NB: this is more a paraphrase than an exact quote, although every word in quotations comes directly from his testimony.)

I noted after perusing their website that they were long on hot rhetoric but short on facts, and after reading Dr. Stossel's statement to the Senate Special Committee I remain not terribly impressed. His thinking seems to rely on a characterization of industry-funded CME critics as Luddites, who have a reflexive hatred of the profit motive: the "oft-repeated mantra that 'companies have a fiduciary responsibility to shareholders whereas physicians' fiduciary responsibility is to patients'...[is an] opaque platitude imply[ing] that business has no social responsibility and that physicians only behave in a venal manner when contaminated by business." In other words, Stossel believes his opponents think that industry (or profit, or both) is always equivalent to evil, and that physicians must remain pure from the evil profit motive.

Of course, that notion itself is so facile it can only induce a sigh. The issue, at least from my perspective, has always been one of bias. Physicians are a bit like little siblings of scientists in that scientists try to discover "truth" and in doing so are constantly vigilant against anything that could bias their view, while physicians have more practical concerns (their ultimate goal is generally to heal patients) but still are, and should be, deeply preoccupied with bias. Well, if lucrative financial deals don't constitute a profound source of bias, then pray tell what does?! It's not about the good or evil that comes of the profit motive, and indeed, the absolutely abominable behavior of some of the drug companies has given a bad name to the many good corporate citizens who do churn out useful products and deserve to profit from them. But to pretend that such bad behavior doesn't exist is to stick one's head in the sand. Moreover, regardless of the extent of bad behavior that has gone on in the past several years (of which there are an ample number of examples), ignoring the potential bias that can result in a physician's mind from financial perks doesn't merely ignore common sense, it ignores a great deal of psychology research that would suggest otherwise.

One can get a yuk or two in (should one be inclined to get yuks out of reading congressional testimony) by glancing at the beginning of Dr. Stossel's statement, in which he alleges that even the use of the phrase "conflict of interest" is a ploy (his exact word! see shortly) designed by that coterie of critics who wish to create an uneven playing field in the public relations war designed to win the hearts and minds of the public, and that nobody has any business even bringing the phrase to the discussion. I'm not kidding. Here is the paragraph (which, as a former English teacher, induces a cringe in me for being the polar opposite of lucid, with all of its subordinate clauses piled on top of one another, but you be the judge):

"'Conflict of interest' is only a meaningful term in terms of regulatory implications in the context of self-dealing by persons in positions of political or judicial power--and physicians and researchers do not even come close to having such influence. Therefore, the intent of the phrase in the context of medicine is a ploy, used since the beginning of recorded history, of adversaries to invoke allegedly evil motives of an opponent--such as greed--as a weapon in an argument they cannot win on substance."

Got that? Only someone in a position of political or judicial power can have a conflict of interest. Alas, this very, very narrow reading of the term is not what most people think when they utter the phrase "conflict of interest." Take this very simple, workman-like definition from Webster's New World College Dictionary: "a conflict between one's obligation to the public good and one's self-interest." That's how lots of people would define it, although even "public good" seems a touch narrow, since teachers or lawyers or the clergy have obligations to students, clients, and parishioners respectively rather than the public good. You can see how this contention that "conflict of interest" is a manufactured phrase doesn't hold up under even cursory scrutiny.

More damning to Stossel's contention, however, is the definition provided by the National Institutes of Health. That is, this is the principal body in the US that defines the ethical behavior of medical research: "a conflict of interest occurs when individuals involved with the conduct, reporting, oversight, or review of research also have financial or other interests, from which they can benefit, depending on the results of the research." Their definition doesn't even trouble itself with the characters that Stossel wants to reserve for exclusive use--judges and politicians.

Ignoring such obvious interpretations of the term might be viewed as, you know, maybe, um, a weapon in an argument one cannot win on substance.

(If the former English teacher can also get in a teaching point here, it is this: please read out loud your statement to a Senate committee before you go to Washington! The phrase the intent of the phrase in the context of medicine is a ploy really should have been written the phrase is a ploy--an "intent" can't be a ploy. Eliminate useless words, class! If there is evidence in this blog entry to the contrary, keep in mind that this blog is pretty much a first-version essay each time out with no time for revisions, and I'm not testifying before Congress.)

It's quite tedious to have to respond to the more fanciful accusations riddling Dr. Stossel's remarks: that nobody wants industry to fail, that physicians can have collegial relations (or even productive collaborations) with medical industry corporate employees, that...oh, you get the picture. The point that has to be made, again and again apparently, is that physicians can be biased by pharmaceutical companies, and that pharmaceutical companies have a responsibility to make money while physicians have a responsibility to treat patients. It's good that there's a profit incentive for corporations. It's bad when physicians are given financial incentives to try to influence the prescription patterns of their colleagues--precisely because those financial incentives allow bias not merely to creep in, but rather knock down the door, barge in, put up its feet on the coffee table, pop open a beer (or, since were talking about physicians, uncork a nice bottle of cabernet) and watch TV. That's bad for patients.

Dr. Stossel also implies that critics of my ilk are clamoring for governmental oversight into every nook and cranny of the industry-physician relationship. For my part I would prefer that government not have to legislate on such matters. Honestly. But here's the rub: I would likewise prefer that my professional brethren and sistren regard the baubles offered by the pharmaceutical industry with contempt, for after all, if the drugs the company makes are good, they will surely flourish under a peer-reviewed system in which no conflict of interest exists, right? I would hope that this would be the prevailing attitude among medical students, for instance. But--good God!--it's not even the majority position among the faculty! And if we can't get the house in order, and further and further evidence of abuses mounts, leading any sane person to conclude that there's a systemic problem out there, well...that's when you get Congress to take note. And as we have found in so many recent episodes in our country, it's not necessarily a good thing when Congress gets involved. But if it does, the fault will lie at the doorstep of the physicians who have abused the goodwill of their patients, as well as their apologists like Dr. Thomas Stossel.

Dr. Stossel's statement can be found here. It takes some time to get through but for those interested in the CME issue it's worth the time investment. In the coming days I hope to have more to offer on some of the other witnesses (or even some of the Senators!).

Hat-tip to the Carlat Blog for the link as well as his attendance. I wanted to make it to the conference as it's down the road from my house, but pressing research issues (including a meeting with the boss) took precedence.
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Fresh Air on Health Care Reform

Although I try to make my blog entries more than just a link to a "read/watch/hear this," today I just heard a discussion so lucid and crisp that I feel like extensive commentary would not add greatly to it. On NPR's Fresh Air, host Terri Gross invited two economists involved in health care reform to discuss the basics of the economics of health insurance, and for those who have found the news about the legislation working its way through Congress a bit confusing, this is the show for you. It only costs about forty minutes of your time, and is well worth the listen.

The economists are rather philosophical adversaries: Stuart Butler serves as the vice president for domestic and economic policy studies for the conservative think tank The Heritage Foundation, and Paul Krugman (a favorite of Billy's) recently won the Nobel Prize in Economics, writes a column for the NY Times and is a champion of political liberalism. As always, such terms as "conservative" and "liberal" get a little slippery and often aren't helpful, although in this case I use the labels since they indicate their general attitude toward their faith in "free markets" and whether they believe government involvement can improve or worsen a more laissez-faire system. Both men are highly articulate and offer a much more in-depth discussion than that found on cable network news. Moreover, given their divergent perspectives, it is astonishing listening to how much they agree about in terms of how ridiculous, wasteful, expensive and ultimately ruinous the current system is.


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ACRE: Physicians Who Wish To Maintain Status Quo Fight Back

This Thursday, at Harvard Medical School, there will be a one-day conference that amounts to a new front in an ongoing war within the medical community. Probably no more than one or two hundred people will attend. I doubt it will get much play in large media outlets, but its agenda, and whether or not it wins the hearts and minds of the next generation of physicians, could have a major impact on determining the quality of care for patients for the next several decades, possibly just as important as the health-insurance reform bill working its way through Congress.

So what's the conference and why such a big deal?

First, some background and a little explanation of the "war." Over the past decade or so, an increasingly vocal but small minority of physicians have begun to publicly question the relationship that physicians have with for-profit companies involved in medicine, primarily pharmaceutical companies. They have noted that many physicians have become wealthy, for instance, by serving as "professional experts" earning honoraria speaking to audiences of physicians who are fed free dinners (compliments of the company sponsoring the event) and who receive credit for "continuing medical education." They have questioned the structure of postgraduate medical education, which can be heavily influenced by the pharmaceutical industry in the form of Medical Education and Communication Companies, or "MECCs," allowing pharm companies to sidestep sticky conflict-of-interest issues by paying physicians directly for teaching, instead using the MECC as a third-party payer. Indeed, they have highlighted the problems of medical school education as well, since many of these doctors who serve as paid speakers for drug companies also teach medical students without ever revealing that they do so.

Many docs have become involved in this critique of the current relationship between physicians and industry--and I count myself among these people--but probably none is more important than Marcia Angell, whose book The Truth About Drug Companies: How They Deceive Us and What to Do About It lays out in just over 300 pages, and in fairly lurid detail, the tactics used by the pharmaceutical industry to deceive physicians and patients alike in order to boost sales and profits. It is an excellent and highly readable book, and remains the best overview of the critical problems in this often overlooked area of medicine.

There is a lot of pushback by the industry and those physicians already co-opted by them. One small, precious example can be found here, where one Jonathan Leo, professor of Neuroanatomy at Lincoln Memorial University in Tennessee, tried to point out to the Journal of the American Medical Association, one of the premier medical journals in the US, that one of the lead authors of a paper had not properly disclosed a serious conflict-of-interest to the journal. The study involved giving antidepressants to stroke victims prior to developing depression in an attempt to prevent it (depression being a common condition following stroke); the lead author had been a paid consultant by the very company whose drug was being studied. When Dr. Leo questioned the conflict, he never received a reply from the JAMA editors, so nearly six months later he had his letter published in the British Medical Journal, which was met with howling outrage by the JAMA editors who not only verbally threatened Dr. Leo, but also told reporters at the Wall Street Journal that Leo was a "nobody and a nothing," and that "he is trying to make a name for himself." (Question: isn't that what you're supposed to do in academics? And he sure did! And for the right reasons!) Best part: while the study showed that treatment with the study drug (Lexapro, generic name escitalopram) was significantly better than placebo, it failed to show that it was significantly better than psychotherapy. The mainstream media who picked up the piece, however, quoted the study authors as saying that they believed all stroke patients should be given antidepressants--no quotes could be found about the fact that the drug was no better than therapy.

Anyway, Thursday's get-together at Harvard is the inaugural meeting of a group called the Association of Clinical Researchers and Educators. They state that "ACRE seeks to define and promote balanced policies at academic medical centers and within government that will enhance rather than interfere with our highly valued collaboration." Seems entirely innocuous, no? After all, who isn't for "balanced policies," whatever that is?

More specifics can be found elsewhere in the website, where they state that "ACRE is to be a forum for what we believe is a hitherto silent majority of individuals engaged in clinical service, medical education and medical innovation ready to oppose (but not debate) a small but well organized and well-funded coterie responsible for an anti-industry movement. This movement has inverted reality by extrapolating from an astonishingly small number of adverse events related to industry compared to the incontrovertible evidence of social good that has eventuated from thousands of industry actions over my lifetime in medicine. The movement particularly demonizes industry marketing, despite the lack of any evidence that, on balance, such marketing impacts anything but positively on patient care."

What the writer--who appears to be Dr. Thomas Stossel of Harvard, but not fully clear--means by "oppose but not debate" is unclear to me although it sounds vaguely undemocratic, but the idea that there is a "well organized and well-funded coterie responsible for an anti-industry movement" is so remarkably laughable that it must rank as one of the great overestimations in recent American history. (I particularly like the use of the word "coterie," as if somehow I've been sitting around in a parlor sipping tea with Doc Angell snarling about the bad guys of big pharma.) If critics like Dr. Angell, or the bloggers Dr. Dan Carlat, Dr. Doug Bremner or Allison Bass are so well-funded yet so anti-industry, who has the money to fund them? The local chapter of the American Communist Party?

More disturbing is a complete lack of data on the website; as far as I can tell ACRE does not marshal one fact to support their hypothesis. There are no references on the website, although there is a "link" page which includes several articles complaining about the critics, nearly half of those articles written by Dr. Stossel. Given that this is a website whose leadership consists of academic medical researchers, one would figure there would be at least a modicum of references and facts marshaled in order to make a convincing argument. But from what I can see, there's a lot of hemming and hawwing but no argument based in evidence. Ironically, the statement above notes that "the movement demonizes industry marketing despite the lack of any evidence that...such marketing impacts anything but positively on patient care" [my emphasis], which makes one wonder whether or not the authors have taken the time to even glance at the first page of The Truth About Drug Companies. Or Jerome Kassirer's book On The Take: How Medicine's Complicity With Big Business Can Endanger Your Health. Or Jerry Avorn's book Powerful Medicines: The Benefits, Risks and Costs of Prescription Drugs. Might ACRE disagree with their conclusions? Perhaps. But to me it seems fairly ludicrous to suggest that this whole critique has been generated of whole cloth. Meanwhile, ACRE has not generated one shred of evidence to support their claim on the website.

My suspicion is that they can't rely on evidence because it's not on their side, and they require strawmen to knock down so that they can look reasonable. I myself cannot speak for the other critics, but my main objection is that some doctors are allowed to generate large sums of money in the service of pharmaceutical companies in a variety of ways, and do not consider this inappropriate. Well, I consider this inappropriate, and I believe the overwhelming majority of patients consider it equally so. And I consider it inappropriate because drug companies exist primarily to make money while doctors exist primarily to serve their patients. Anyone who refuses to see that a physician cannot serve both ends hasn't been reading about what's been happening in medicine for the past two decades.

One last link: don't say docs don't have a sense of humor! Here is a link to a satirical twin of the ACRE website: "Academics Craving Reimbursement for Everything." One juicy quote: "ACRE is to be a forum for a hitherto silent majority of doctors which believes that a small but well organized coterie of do-gooders are conspiring to prevent them from buying that third home on the lake." They even get that coterie word in. Love that.

As a quick post-script, I note that one of the featured speakers at the event will be Dr. Jeffrey Flier, who is the current Dean of Harvard Medical School. A few months ago I had written about the Harvard medical students who launched a protest about the conflict-of-interest issues in the pharmacology course, and noted that Dr. Flier had made noises that he wanted to change the policies at HMS. While those changes have partially taken place (following the lead of Johns Hopkins, although this new policy is through the hospitals affiliated with HMS, not the medical school itself), I can't say I am especially encouraged by Dr. Flier's acceptance to speak at this gathering, though we will have to see what he will say.
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Effects of the Anti-Vaccine Campaign

Anyone out there thinking about going to merry old England for a summer excursion? Well, think carefully before you go--especially if you head to the northeast of that storied country, where they are experiencing the largest measles outbreak in nearly 20 years. A local public health official noted that "the majority of these cases could have been prevented as most were in children who were not fully protected with MMR." MMR is the acronym for the measles, mumps, and rubella vaccine, which has been around for decades and is one of the safest vaccines known to man.

The vaccine rate for MMR was quite high in England until 1998, when a gastroenterologist named Andrew Wakefield held a press conference where he presented research that indicated the MMR vaccine was linked with autism. The "findings" were trumpeted by the British press, and the vaccination rate fell over the next several years from 92 percent to below 80 percent. Alas, Dr. Wakefield's research was later found to have massive financial conflicts of interest; by March 2004 a dozen of Wakefield's co-authors, including some of the preeminent names in medical research in the UK, withdrew their names from the paper. But by that time the horses were out of that particular barn, and the effects are still being felt there today. And the problem has spread to our shores as well, with any number of otherwise educated people spouting about the vaccines-autism connection as if it were fact. Newsweek magazine provides the whole story in all its sordid details here. They did a commendable job of providing crucial context and essential details; would that mainstream journalism produce this kind of work more often.

Since most Americans--or for that matter most anyone who lives in a relatively developed country--hardly give it a thought, a couple of facts about the measles might be worth sharing. It is one of the most highly contagious viruses known to humans; consequences of infection can range from mild (a few days of generalized illness and the famous facial rash) to serious (among other things, a slowly progressive brain disorder called subacute sclerosing panencephalitis, which is as ugly as it sounds), to death. In fact, in countries where the MMR vaccine is not available due to adequate funds, refrigeration, or trained personnel to administer the vaccine, it is an all-out killer: in 1999 it had killed 873,000 children (and a smaller number of adults) in just one year. As part of a massive vaccination campaign in the areas where the children are not immunized or given boosters (mostly India, Indonesia, Pakistan, Somalia, Sudan and the distant rural provinces of China), the World Health Organization has been trying to get the number under control, with the annual mortality down to under 250,000 children in recent years. To give you some sense of perspective, in any given year just a bit over 10,000 children younger than age 14 die in the US each year. So this is by no means a trivial problem.

For further reading, you can peruse the information here (a guide to the studies about vaccines and autism) and here (stuff about vaccine ingredients), among other places. Also, Dr. Paul Offit, one of vaccine's greatest and most lucid proponents has written a book about the whole controversy entitled Autism's False Prophets, which I have not read but it is on my reading list. I am, however, working my way through journalist Arthur Allen's tome Vaccine: The Controversial Story of Medicine's Greatest Lifesaver, and it's been a very good read thus far.
--br