Burning Down Our House

April 8, 2010

Rip Esselstyn, a former professional triathlete and currently a fireman, writes in his fine book The Engine 2 Diet:

Americans seem to feel it is their birthright to eat rich, fatty, meaty, and obesity-promoting foods. This mindset begs for a paradigm shift. Obesity is not caused by a fat gene passed down the family lines; its roots lie in bad eating habits and poor nutrition. These habits are colossal tragedy being passed from one generation to the next.

Rip’s dad, the famed cardiologist Dr. Caldwell Esselstyn, in clinical trials at the Cleveland Clinic, has shown that in almost all cases, heart-disease can be prevented and reversed through eating a plant-based diet of vegetables, whole grains, and beans. Esselstyn’s findings have been mirrored by other doctors such as Dr. Dean Ornish.

With that in mind, read this press release masquerading as a news story on MSNBC:  “KFC sandwich ditches the bread”:

KFC is thinking outside the bun.

The chicken chain rolls out its Double Down sandwich this weekend — although some might question whether it really is a sandwich. It consists of two white meat chicken breast fillets with a filling of bacon, Monterey Jack and pepper jack cheese with Colonel’s Sauce (a spicy mayonnaise).

Now read this story related by Dr. Dean Ornish in his book Love & Survival: 8 Pathways to Intimacy and Health:

Dr. Mimi Guarneri is an interventional cardiologist who directs a reversing-heart-disease program, based on my work, at the Scripps Clinic and Hospital in La Jolla, California. She spends part of her time performing angioplasties and part of her time teaching her patients how to change their lifestyle.

“I recently gave a lecture to a large group of cardiologists,” she told me. “At first, I talked with them about radioactive stents, a wire mesh designed to keep angioplastied arteries open by exposing them to high doses of localized radiation. Although it’s a new, totally unproven method with the possibility of highly toxic long-term side effects, the cardiologists just loved the idea of these radioactive stents. They couldn’t wait to try them. In the second half of my presentation I talked about our lifestyle program. Even though we have twenty years of randomized controlled trial data supporting your program, the cardiologists got so skeptical and even hostile to the ideas that patients could change their lifestyle and that emotions play a role in health and illness that many left the room.”

No wonder health care costs are unsustainable. This comedic, but tragic, situation in healthcare could not exist on a free market. In a free market, there would be few incentives for patients and doctors to unite in their desire to focus on curing symptoms through high-priced, dramatic interventions while ignoring both causes and lasting, low-cost solutions to health problems.

Homeowners insurance will not pay you to rebuild your house if it burns down after you bring your barbecue grill indoors and douse your briquettes with copious amounts of lighter fluid. Your insurance company would deny your claim on the grounds of gross negligence.

Most cases of type II diabetes and most cases of heart disease are preventable. Many cases of these diseases are caused by a steady consumption of high-fat animal foods and heavily processed foods laden with high-fructose corn syrup.

We are told that it is impractical to expect Americans to voluntarily make lifestyle changes. We are told that a largely plant-based diet is “draconian.”  Some patients might say, “I would rather die young than eat that way.” Of course, it is easy to make such flippant comments if others are paying the doctors’ bills. In his book Prevent and Reverse Heart Disease, Dr. Caldwell Esselstyn writes,

Some criticize this exclusively plant-based diet as extreme or draconian. Webster’s dictionary defines draconian as “inhumanly cruel.” A closer look reveals that “extreme” or “inhumanly cruel” describes not plant- based nutrition, but the consequences of our present Western diet. Having a sternum divided for bypass surgery or a stroke that renders one an aphasic invalid can be construed as extreme, and having a breast, prostate, colon, or rectum removed to treat cancer may seem inhumanly cruel. These diseases are rarely seen in populations consuming a plant-based diet.

We are told it will impact our basic freedoms if such lifestyle changes are required. This objection reflects a misunderstanding about how free markets work. On a free market, no one is entitled to anything that someone else is required to provide for them.  In a free society, we may voluntarily contribute to our neighbor who burns his house down after he barbecues indoors, but we are not required to help him rebuild his house.

Suppose health insurance companies could charge different premiums based on diet, exercise, and other habits that affect health risks. Now, some would object that this is impractical. Experts will be trotted out to tell us that the KFC Double Down sandwich can be enjoyed in moderation without adversely affecting our health. But the actuaries at the insurance companies are the single best of judges of risk, and they have every incentive to get it right.

Of course, there no guarantees; someone who eats a plant-based diet may well suffer a health crisis. Such is the nature of life. But insurance companies routinely discount automobile insurance to drivers who hold accident-free records and are free of speeding tickets. Such a driver may well have an accident next year, but the actuarial tables help health insurance companies profitably segregate by risk.

It is also true that a compassionate society may well seek the means to provide insurance for those with genetic conditions or those who do not engage in risky behavior but who do face what often seems to be inevitable health problems. Indeed, currently, because of wasteful spending in our healthcare system, those who through no fault of their own are truly in need go without care. But, as a sane society does not fund homeowners insurance for those who burn down their own house through their negligence, we shouldn’t subsidize health insurance for those who are negligent about their health and refuse to change. It is not compassionate to subsidize destructive behavior.

If health insurance premiums changed, behavior would change instantly. Voluntarily, fewer “double down” sandwiches would be sold, and more cookbooks on natural foods would be purchased. Parents would demand healthier choices in the school cafeteria. Patients would seek out doctors knowledgeable in preventive medicine.  The effects would cascade.

Now, I know that what I’m proposing is not going to happen in contemporary America. The issue would be endlessly litigated by a parade of lawyers and expert witnesses. It seems we are intent to go on spending billions of dollars for dubious, expensive, and often avoidable medical procedures—until we are bankrupt as a nation.


Basic Assumptions

March 17, 2010

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.

Great Strides Forward

March 17, 2010

There was an old joke told in the former Soviet Union: “During Stalin’s time our economy stood at the precipice of disaster. Since then we have made great strides forward.”  No matter what side of the health care debate you are on, a fair assessment is that we have taken great strides forward to relinquishing our basic freedoms in America.

First, consider the role of the media. Rather than report on the contents of the health-care bill, daily we read multiple headlines and stories handicapping whether or not there are enough votes to pass the bill.  This should not be too surprising since few know exactly what is in the bill. But no matter, over and over we hear the inane squawk: “We have to get the job done now.” As though we don’t have to know what job is being done. Consider this admission by Speaker of the House Nancy Pelosi: “We have to pass the bill so that you can find out what is in it.”

Next, listen to President Obama as he flunks elementary school mathematics by mindlessly reading from his teleprompter to adoring crowds. Obama promises the crowd that they “will see premiums fall by as much as 3000% which means that they can give you a raise.”

Perhaps I’m making a big deal over a simple flub? (A price cannot fall by more than 100%.) But, this flub passed through multiple layers—the speechwriters, the president, and the crowd.  And notice the smug assuredness as Obama reads the line.

A nation without the will or the education to enter into a genuine conversation about the important issues of the day cannot remain free. Indeed, we have the leaders we deserve—leaders who apparently are guided by no higher value than to exercise power over us. No doubt things will change. “What I see in America today,” Hilmar von Campe has observed, “is people painting their cabins while the ship goes down.” Some are looking forward to the day when a deeper crisis forces us to stop painting our cabins. I do not. The social disruption and suffering from a deeper crisis is likely to be enormous. Much better to change now, and avoid the worst.

Miles to Go, Promises to Break

October 28, 2009

We are assured that whatever version of healthcare reform is passed, it will save us money and provide more access to healthcare. Promises can be made, but the laws of economics trump words.

There are indeed ways to reduce health care costs. Increasing competition and/or increasing innovation can reduce costs by increasing supply. Demand can be reduced; demand for health care falls when consumers take more responsibility through self-care, diet, and exercise. Demand can also be reduced by lowering the quality of the product or by rationing care. With a process controlled by politicians who are ignorant of economics and by lobbyists from the medical and pharmaceutical industry, which door do you think will be chosen? If you answered “ration care or reduce quality” you are correct. Fundamental reforms that increase competition will not be accepted by doctors; increasing consumer responsibility is against the interests of the pharmaceutical industry who depends upon millions of Americans taking drugs for conditions that could be treated in safer and less invasive ways.

I am sure of one thing—any healthcare reforms passed by government will take us more towards top-down, centralized healthcare and move us further away from a free-market. This will in turn create the need for even more “reform” that moves us further from a free-market. There are indeed many problems with our current healthcare system, but unlike our cousins in Canada and the United Kingdom, a dire shortage of healthcare is not one of them.

Allow me to share a tale. Last week, I began to experience light flashes in the corner of my eye; a few days later I began to experience what appeared to be black filaments floating in front of my field of vision. From that starting point, I will contrast my experience with the experience of a United Kingdom (UK) citizen who had similar symptoms.

My experience: My wife calls a Blue Cross hotline and speaks to a registered nurse. The nurse advises my wife to get me to an emergency room immediately as I was at risk of suffering from a detached retina.

UK citizen: “I went to see my GP (I’m from the UK). He didn’t seem to know much about it so he had to resort to looking in his pocket book of family health (which really gave me a lot of confidence). Despite his clear lack of knowledge, he suddenly decided he was an expert and told me that I was just worrying about nothing, everyone gets them etc. But I told him that this had just suddenly come on over a week, but he just said I was a worrier and that there was really nothing wrong.”

My experience: We consider our options. There is a local rural hospital close by or there is Dartmouth-Hitchcock Medical Center which is about an hour and half drive away. We decide that should I need surgery, Dartmouth-Hitchcock is the place to be. I pack an overnight bag and off we go.

UK citizen : “I wasn’t satisfied with that so I went to the opticians who were surprisingly well equipped with digital retina cameras etc. The optician was very nice and took great interest in finding out was wrong. He could clearly see that something was wrong (and unofficially made the correct diagnosis) and referred me to a specialist.” [Brownstein’s note—the only place that our UK cousin got good care was from the optician who is not part of the NHS (National Health Service.)]

My experience: I arrive at Dartmouth-Hitchcock where, in the emergency room, I am triaged into a high priority category. An ophthalmological surgeon is immediately called in who does a very thorough and caring exam. Fortunately, mine is a benign condition called vitreous separation, there is absolutely no retinal damage. I am referred to a local ophthalmologist for follow-up checkups. My wife and I go out to lunch, feeling greatly relieved.

UK citizen: “When I eventually got to see the specialist (this is the NHS I’m talking about, so it took a while), he said I had a detached vitreous in both eyes. He then shooed me away like I was wasting his time.”

Now a fair criticism of my account would be something like this: “You have insurance that allowed you to seek the best possible care. What about someone who has no insurance? A fair enough question indeed; I would not want to go through my experience having either no money to pay for care or to be told that it would be weeks or months until I could see a specialist.

Now, I realize that the current proposals do not call for socialized healthcare as in the Canada or the United Kingdom. But this is a slippery slope—more regulations cause more problems, which breed more regulations, which create lower quality care and less access. The answers lie in true market-based reforms that remove barriers to competition and give more access at lower costs to more Americans. Access to a waiting list, like the UK citizen experienced, is not access at all.

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