Last week, I wrote about the “cholesterol con,” the widespread belief that “bad Cholesterol” ( LDL cholesterol) is a major factor driving heart disease, and that cholesterol-lowering drugs like Lipitor and Crestor can protect us against fatal heart attacks. These drugs, which are called “statins,” are the most widely-prescribed pills in the history of human medicine. In 2007 world-wide sales totaled $33 billion. They are particularly popular in the U.S., where 18 million Americans take them.

We thought we knew how they worked. But last month, when Merck/Schering Plough finally released the dismal results of a clinical trial of Zetia, a cholesterol-lowering drug prescribed to about 1 million people, the medical world was stunned. Dr. Steven E. Nissen, chairman of cardiology at the Cleveland Clinic called the findings “shocking.”  It turns out that while Zetia does lower cholesterol levels, the study failed to show any measurable medical benefit.

This announcement caused both doctors and the mainstream media to take a second look at the received wisdom that “bad cholesterol” plays a major role in causing cardiac disease. A Business Week cover story asked the forbidden question, “Do Cholesterol Drugs Do Any Good?" 

The answer, says Dr. Jon Abramson, a clinical instructor at Harvard Medical School, and the author of  Overdosed America, is that “statins show a clear benefit for one group—people under 65 who have already had a heart attack or who have diabetes. But,” says Abramson,  “there are no studies to show that these drugs will protect  older patients  over 65—or younger patients who are not already suffering from diabetes or established heart disease –from  having a fatal heart attack. Nevertheless, 8 or 9 million patients who fall into this category continue to take the drugs, which means that they are exposed to the risks that come with taking statins –which can include severe muscle pain, memory loss, and sexual dysfunction.”

Finally—and here is the stunner—it turns out we don’t have any clear evidence that statins help the first group by lowering cholesterol levels.  It’s true that they do lower cholesterol, but many researchers are no longer convinced that this is what helps patients avoid a second heart attack. It now seems likely that they work by reducing inflammation. In other words, these very expensive drugs seem to do the same thing that aspirin does.  (Are they more effective than the humble aspirin? We’ll need head-to-head studies to find out.)

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Since 9/11, one Army division has spent more time in Iraq than any other group of soldiers: the 10th Mountain Division, based at Fort Drum, New York.

Over the past 6 years and and six months, their 2nd Brigade Combat Team (BCT) has been the most deployed brigade in the army. As of this month, the brigade had completed its fourth tour of Iraq. All in all, the soldiers of BCT have spent 40 months in Iraq.

At what cost?  According to a February 13 report issued by the Veterans for America Wounded Warrior Outreach Program, it is not just their bodies that have been maimed and, in some cases, destroyed. Many of these soldiers are suffering from severe mental health problems that have led to suicide attempts as well as spousal abuse and  alcoholism.

Meanwhile, the soldiers of the 2nd BCT have been given too little time off in between deployments:
In one case they had only six months to mentally “re-set”  following an eight-month tour in Afghanistan–-before beginning a 12- month tour in Iraq.

Then, in April 2007, Secretary of Defense Robert Gates decided to extend Army tours in Iraq from 12 to 15 months—shortly after the BCT had passed what it assumed was its halfway mark in Iraq.

As the VFA report points out:  “Mental health experts have explained that ‘shifting the goalposts’ on a soldier’s deployment period greatly contributes to an increase in mental health problems.”

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After the stock market bubble burst, the New York Times asked: “Where were the analysts? Why didn’t they warn us?”

To be perfectly honest, this was a somewhat disingenuous question. As experienced financial journalists understood all too well, the analysts plugging the high-flying issues of the 1990s were employed by Wall Street firms raking in billions as investors bet their nest eggs on one hot stock after another. It really wasn’t in their employers’ interest for analysts to tell us that their products were wildly over-priced.  When a small investor wades into the financial world, there are two words he needs to keep in mind: “caveat emptor.”

But physicians, I firmly believe, are different from the folks employed by Merrill Lynch. (I don’t mean to knock people who work at ML. I am simply saying that they have a very different job description.)  When consulting with your doctor, you should not have to be wary. You are not a customer; you are a patient. And your physician is a professional who has pledged to put your interests ahead of his or her own.

This brings me to the question I ask in my headline: during the many years of the Cholesterol Con—where were the doctors?  When everyone from the makers of Mazola Corn Oil to the Popes of Cardiology assured us that virtually anyone could ward off heart disease by lowering their cholesterol, why didn’t  more of our doctors raise an eyebrow and warn us : “Actually, that’s not what the research shows” ?

No doubt, you’ve heard about the recent Business Week cover story, “Do Cholesterol Drugs Do Any Good?", which blew the lid off the theory that “statins”– drugs like Lipitor, Crestor, Mevacor, Zocor and Pravachol — can cut the odds that you will die of a heart attack by slowing the production of cholesterol in your  body and increasing the liver’s ability to remove L.D.L., or “bad cholesterol,” from your blood.   

It’s true that these drugs can help some people—but not nearly as many as we have been told. Moreover, and this is the kicker, we don’t have any clear evidence that they work by lowering cholesterol.

Although medical research suggests that statins can definitely benefit one group—men under 70 who already have had a heart attack–researchers are no longer convinced that the drugs stave off a second attack by lowering the patient’s cholesterol. The drugs do lower cholesterol, but that is not what helps the patient.

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In December I wrote about a government effort to block  the use of checklists in ICU’s.

Yesterday, I received an e-mail from Robert M. Wachter, MD, Professor and Chief of the Division of Hospital Medicine UCSF Medical Center, headlined: "a happy ending to the checklist story (thanks for your help)

Wachter sent this link to a story on his website which explains that "The Office for Human Research Protections (OHRP) – part of the U.S. Department of Health and Human Services – has concluded that Michigan hospitals can continue implementing a checklist to reduce the rate of catheter-related infections in intensive care unit settings (ICUs) without falling under regulations governing human subjects research."

Wachter commented "I must admit, I didn’t hold out high hopes that a ragtag band of committed clinicians and other quality improvers could change federal policy. But we’ve done just that. If the Feds are capable of rectifying this mistake, who knows what might be next!

Indeed.

Over at American Prospect, Ezra Klein offers a sharp, well-reasoned critique of our for-profit insurance system.

First, he points out that when insurers offer us many choices – catastrophic plans, high-deductible plans, consumer-driven plans with high co-pays –what they are really doing is “turning their attention to making deals with the most profitable among us, and avoiding deals, or finding ways to break contracts, with the least profitable. They are very innovative in their attempts to do this. But there’s nothing good about those attempts. Competition among drug dealers does not aid the neighborhood, and currently, competition among insurers does not aid the ill.”

In fact, Ezra stresses: “It is actually counterproductive for insurers to compete on giving us the best care. It’s not simply that they’re not doing it, but given the structure of the marketplace, they shouldn’t do it. Imagine insurer X creates the best damn diabetes protocols in the country. And they begin advertising this fact. What happens on Day Two? Well, they’re flooded with individuals suffering from diabetes, or individuals who fear they will one day be suffering from diabetes. These people, in the current system, are a bad deal. Not only is it near impossible to insure them at a profit, but pooling their costs (which is what insurers do, after all) raises premiums for all the insurer’s other customers . . .”

This explains why insurers so rarely compete on quality. Most often, they compete on price. And watch out when they do that. This is a market where you get what you pay for, and a less expensive policy is likely to be filled with holes that will open, like trap doors, when you become sick.

Is there any way that we could force private sector insurers to add value to our health care system?

Klein offers Tyler Cowen’s prescription for how, “in a more perfect world,” insurers might compete to offer better service, not just cheaper coverage.  But they would have to be tightly regulated.

Check out Klein’s full post here. It will also link you to Cowen’s argument.

On this blog, we have often debated these questions: “Why is U.S. healthcare so expensive? Why is it that states like Massachusetts and California just can’t seem to find a way to provide high quality, affordable medical care for all of their citizens?”

In the past, I have suggested that the answer can be found in the work done by Dr. Jack Wennberg and his colleagues at the Dartmouth Medical School. The story that I have posted below provides the narrative behind that assertion, tracing how, over a period of thirty years, Wennberg and his team uncovered the incredible, incontrovertible waste in our health care system.

Wennberg’s work reveals that roughly one out of three of our health care dollars is squandered on unnecessary tests, ineffective, unproven, sometimes unwanted procedures and over-priced bleeding-edge drugs and devices that are no better than the less expensive products that they have replaced.

Only a Luddite would fail to appreciate the wonders of 21st century medical technology. And Wennberg is no Luddite. He is quick to acknowledge that the most expensive, aggressive care that U.S. doctors and hospitals provide is often the most effective care.

But not always. This is what is less obvious. It would seem that by spending so much more than other countries, we would be buying the best care on earth. But the evidence shows that, often, we are not. And therein lies the conflict at the heart of our money-driven health-care system: while more health care equals more profits, it does not necessarily lead to better health.

The story below, which I wrote for the winter issue of Dartmouth Medicine, will, I think, give readers a much clearer understanding of the importance of the Dartmouth research. It begins in the early 1970s, when Wennberg realized that if his home were located just 100 yards farther north, his children would be in a school district where 70 percent of all children received tonsillectomies. Instead, they lived in a school district where there was only a 20 percent chance that they would undergo the operation.

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The Center for Public Integrity, a public interest investigative journalism organization, has obtained copies of a Centers for Disease Control and Prevention (CDC) study of environmental and health data in eight Great Lakes states that was scheduled for publication in July 2007. The report, which pointed to elevated rates of lung, colon, and breast cancer; low birth weight; and infant mortality in several of the geographical areas of concern has not yet been made public.

A few days before the report was slated to be released, it was pulled. Meanwhile, at precisely the same time, its lead author, Christopher De Rosa, has been removed from the position he held since 1992.  The Center for Public Integrity is asking why.

The study, “Public Health Implications of Hazardous Substances in Twenty-Six U.S. Great Lakes Areas of Concern” was developed by the CDC’s Agency for Toxic Substances and Disease Registry (ATSDR) at the request of the International Joint Commission, an independent U.S-Canadian organization that monitors and advises both governments on the use and quality of boundary waters.

The CDC report brings together two sets of data: environmental data on known "areas of concern" — including superfund sites and hazardous waste dumps — and separate health data collected by county or, in some cases, smaller geographical regions.

The study does not try to prove cause and effect. Instead, it outlines areas for further study and data collection on the link between pollution and health.

"Let’s say we have a superfund site and we also find elevated risk of leukemia in the county — is that related? We don’t know, but people living in the area can logically argue that we ought to find out," Dr. Peter Orris, a professor at the University of Illinois School of Public Health and one of the peer reviewers of the study told Oneworld.net.

Since 2004, dozens of experts have reviewed various drafts of the study, including senior scientists at the CDC, Environmental Protection Agency, and other federal agencies, as well as scientists from universities and state governments, according to consumeraffairs.com. Orris is just one of the several experts who reviewed the study and who, along with the International Joint Committee in a December letter to the CDC, have called for the report’s publication.

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A reader sent me this provocative piece on Canadian healthcare, written by someone who knows care on both sides of the border. It comes from the Campaign for America’s Future website. And it is, as advertised, a “myth-buster.” I look forward to Part II.

Mythbusting Canadian Health Care Part I                
By Sara Robinson                
February 4th, 2008

2008 is shaping up to be the election year that we finally get to have the Great American Healthcare Debate again. Harry and Louise are back with a vengeance. Conservatives are rumbling around the talk show circuit bellowing about the socialist threat to the (literal) American body politic. And, as usual, Canada is once again getting dragged into the fracas, shoved around by both sides as either an exemplar or a warning — and, along the way, getting coated with the obfuscating dust of so many willful misconceptions that the actual facts about How Canada Does It are completely lost in the melee.

I’m both a health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border. As such, I’m in a unique position to address the pros and cons of both systems first-hand. [my emphasis –mm] If we’re going to have this conversation, it would be great if we could start out (for once) with actual facts, instead of ideological posturing, wishful thinking, hearsay, and random guessing about how things get done up here.

To that end, here’s the first of a two-part series aimed at busting the common myths Americans routinely tell each other about Canadian health care. When the right-wing hysterics drag out these hoary old bogeymen, this time, we need to be armed and ready to blast them into straw. Because, mostly, straw is all they’re made of.

1. Canada’s health care system is "socialized medicine."

False. In socialized medical systems, the doctors work directly for the state. In Canada (and many other countries with universal care), doctors run their own private practices, just like they do in the US. The only difference is that every doctor deals with one insurer, instead of 150. And that insurer is the provincial government, which is accountable to the legislature and the voters if the quality of coverage is allowed to slide.

The proper term for this is "single-payer insurance." In talking to Americans about it, the better phrase is "Medicare for all."

2. Doctors are hurt financially by single-payer health care.

True and False. Doctors in Canada do make less than their US counterparts. But they also have lower overhead, and usually much better working conditions. A few reasons for this:

First, as noted, they don’t have to charge higher fees to cover the salary of a full-time staffer to deal with over a hundred different insurers, all of whom are bent on denying care whenever possible. In fact, most Canadian doctors get by quite nicely with just one assistant, who cheerfully handles the phones, mail, scheduling, patient reception, stocking, filing, and billing all by herself in the course of a standard workday.

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Today, the New York Times reported on a “troubling new report from the Agency for Healthcare Research and Quality (AHRQ), which analyzed hundreds of studies in an effort to advise men about the best treatments for prostate cancer. The report compared the effectiveness and risks of eight prostate cancer treatments, ranging from prostate removal to radioactive implants to no treatment at all. None of the studies provided definitive answers. Surprisingly, no treatment emerged as superior to doing nothing at all. [my emphasis]

“When it comes to prostate cancer, we have much to learn about which treatments work best,” said agency director Carolyn M. Clancy. “Patients should be informed about the benefits and harms of treatment options.”

The Times went on to quote the agency saying “Considerable over-detection and over-treatment may exist.” 

I have written about this issue here  and here; Niko has written about it here.

I am not going to repeat what we have said in the past. But let me emphasize that the AHRQ looked at practically every treatment now being used:

“The agency review is based on analysis of 592 published articles of various treatment strategies. The studies looked at treatments that use rapid freezing and thawing (cryotherapy); minimally invasive surgery (laparoscopic or robotic-assisted radical prostatectomy); testicle removal or hormone therapy (androgen deprivation therapy); and high-intensity ultrasound or radiation therapy. The study also evaluated research on ‘watchful waiting,’’ which means monitoring the cancer and initiating treatment only if it appears the disease is progressing.”

The agency goes on to warn that “all active treatments cause health problems, primarily urinary incontinence, bowel problems and erectile dysfunction.”

Finally, the Times points out that while “one study has shown that men who choose surgery over watchful waiting are less likely to die or have their cancer spread, another study found  no difference in survival between surgery and watchful waiting.” Moreover—and this is important—“few patients in the study had cancer detected through P.S.A. tests. As a result, it’s not clear if the results are applicable to the majority of men diagnosed with the disease.”

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The worst thing that a journalist can do is to present opinion as fact—especially when talking about something important. To do it on Super Tuesday is particularly irresponsible.

Yet that is exactly what conservative columnist David Brooks has done in today’s New York Times.

Responding to what Paul Krugman wrote yesterday (see my post below, “But There Is A Difference Between Obama and Clinton on Healthcare”), Brooks attacks Hillary Clinton for insisting that if we want universal healthcare, we are going to have to ask everyone to get into the pool. Rich and poor, young and old, healthy and sick—everyone will need to contribute to the national healthcare fund by signing up for insurance. Otherwise, we won’t be able to afford the subsidies that low-income and working class families will need to enroll in the plan.  Hillary’s mandate is much like the mandate that we all contribute to Social Security or Medicare.

As Brooks sees it, the issue “is over whether to use government to coerce people into getting coverage. The Clintonites argue that without coercion, there will be free-riders on the system.”

In other words, the Clintonites are concerned that young, healthy people who earn too much to qualify for subsidies may not sign up—especially since, under healthcare reform, they will know that once they do get sick, insurers will be required to cover them and will not be allowed to charge them more than they charge everyone else. Thus, while older, sicker people pay into the pool, younger healthier people will get a “free ride”—until they need insurance.   

“They’ve got a point,” Brooks admits briefly, referring to Clinton’s position.  It’s really rather hard to argue with common sense. “But,” he adds, “there are serious health care economists on both sides of the issue.”

Who exactly does he have in mind?  Brooks doesn’t say.

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