Lost in the health-care debate is an examination of basic assumptions. Consider two basic assumptions. One is that there is currently a free market in health care and that the free market has created our health care problems. The other basic assumption is that more health care leads to improved health. What, if these assumptions are wrong?
In a provocative essay in the Atlantic Monthly Myth Diagnosis Megan McArdle asks, “Everyone knows that people without health insurance are more likely to die. But are they?” McArdle’s writes:
The possibility that no one risks death by going without health insurance may be startling, but some research supports it. Richard Kronick of the University of California at San Diego’s Department of Family and Preventive Medicine, an adviser to the Clinton administration, recently published the results of what may be the largest and most comprehensive analysis yet done of the effect of insurance on mortality. He used a sample of more than 600,000, and controlled not only for the standard factors, but for how long the subjects went without insurance, whether their disease was particularly amenable to early intervention, and even whether they lived in a mobile home. In test after test, he found no significantly elevated risk of death among the uninsured.
How can this be? Simple, there are drugs and surgeries that harm and there are alternatives to both, including no treatment at all.
Consider the drug Fosamax. Almost everyone believes that there is an epidemic of osteoporosis and osteopenia (thinning of bone mass) and that effective therapy is to treat the disease with drugs such as Fosamax. But, a belief is not a fact.
For most individuals, bones continue to mineralize even after we have stopped growing, sometime after puberty ends. Usually, by the age of 50 our bones start to lose mineralization. Often this process is more pronounced in women, but this demineralization is normal and not pathological. The risk of a pathological condition can be reduced by both exercise and diet. What if we have medicalized a normal condition (osteopenia) and harmed millions of Americans in the process?
In 2008, bisphosphonate sales such as Fosomax exceeded $8 billion and over 37 million prescriptions were written for these osteoporosis medications. Fosomax has important side effects:
1. During the time a patient is on the drug, their body’s own ability to remineralize their bones is completely suspended and perhaps lost forever.
2. According to Kathleen Daniels:
One study concluded that women using Fosomax are almost twice as likely to develop irregular heartbeat, or atrial fibrillation. Another team found an increased incidence of a jaw tissue infection, and in a large seven year study, Canadian researchers found that this class of drugs nearly triples the risk of developing bone necrosis, that can result in “incapacitating pain.” A fairly strongly worded FDA alert suggests that use of bisphosphonates can lead to “the possibility of severe and sometimes incapacitating bone, joint and/or muscle pain” and that health professionals should consider temporary or permanent discontinuation of the drug.
3. The Fosamax drug insert admits that “taking this drug increases your risk of fracturing your femur, or thigh bone, even during low impact activities.”
It is a safe bet that many of the millions of Americans (mostly women) have no idea of the side effects of these drugs. How could they? They go to a doctor for a routine check-up. Their doctor recommends a bone density screening. The screening comes back that they are at risk; the doctor tells them with assurance that these drugs will help reduce their risk of a hip fracture. Their doctor’s visit was probably insured, the drug is covered by insurance, and the whole sequence of events takes place with minimum interaction with the doctor. And sadly, there is a vague satisfaction among the patient that they have a medically recognized condition. If you doubt the latter, visit Florida, and observe seniors engaged in conversation about their latest doctor visits.
But what about hip fractures? For an elderly woman such an event can be life threatening. Pharmacist Jennifer Montgomery has dissected the statistics and found that among “100 women taking Fosamax for 3 years, the drug will prevent one woman from getting a fracture.” Others will experience the devastating negative side effects previously described.
Alix Spiegel’s ”How A Bone Disease Grew To Fit The Prescription” explains how Merck helped to convince millions of Americans that a normal condition of aging needed to be treated by a dangerous drug. The story begins in Rome in 1992 where:
A group of osteoporosis experts gathered under the auspices of the World Health Organization. The meeting had been organized because professional opinion about how to diagnose and measure osteoporosis was all over the map. Doctors and researchers didn’t even have a shared view of how osteoporosis should be defined.
For a long time doctors and researchers were only able to diagnose osteoporosis after a woman experienced a bone fracture. But by the early ’90s technology had evolved, and bone scanners made it possible to determine whether the bones were weak before any fractures occurred.
The question before the experts in Rome then was this: Since after the age of 30 all bones lose density, how much bone loss was normal? And, how much put women at risk and therefore should be considered a disease?
Anna Tosteson is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and Dartmouth Medical School who attended the meeting. She says that over a two- or three-day period the experts in the room went back and forth and back and forth, looking at research and trying to decide precisely where on a graph of diminishing bone density to draw a line.
“Ultimately it was just a matter of, ‘Well … it has to be drawn somewhere,’ ” Tosteson says. “And as I recall, it was very hot in the meeting room, and people were in shirt sleeves and, you know, it was time to kind of move on, if you will. And, I can’t quite frankly remember who it was who stood up and drew the picture and said, ‘Well, let’s just do this.’ ”
So there in the hotel room someone literally stood up, drew a line through a graph depicting diminishing bone density and decreed: Every woman on one side of this line has a disease.
Then a new question arose: How do you categorize the women who are just on the other side of that line?
To address this issue, Tosteson says, the experts — more or less off the cuff — decided to use the term osteopenia. Tosteson says they created the category mostly because they thought it might be useful for public health researchers who like clear categories for their studies. They never imagined, she says, that people would come to think of osteopenia as a disease in itself to be treated. The chairman of the meeting, John Kanis, of the WHO Collaborating Centre for Metabolic Bone Diseases, says the same thing.
Nevertheless, 17 years later (Katie) Banghauser, of Richmond, Va., a woman whose bone density is just a hair away from that of the average healthy 30-year old, is not only medicated for osteopenia but literally spends her days worried about breaking a bone.
“I used to run marathons, and I would fall and trip on broken sidewalks,” she told me. “And you know initially before I had this diagnosis I didn’t think anything of it. But now every time I fall I get up and think, ‘Oh, good, I haven’t broken anything.’ ”
“I’m much more aware of making sure I lift my feet up and I don’t trip on the sidewalks, but you know, if I didn’t know that I had osteopenia, maybe I wouldn’t be so cautious.”
In other words, by definition, anyone who does not meet the bone density of a thirty-year old woman is defined as diseased. No wonder the pharmaceutical companies are on board with health-care reform. More health care means more doctors visits and an expanded market for their often useless and dangerous snakeoil.
Will our health improve with a policy that assures us of all the Fosamax we don’t need to take? If this is an example of “health care,” do Americans really need more of it? This basic question is not being addressed. And until it is, this unaddressed question threatens not only our health but the solvency of the nation.