Map of life expectancy at birth from Global Education Project.

Friday, December 31, 2004

The Greater Catastrophe?

The world will be sorting out the lessons, practical, ethical and metaphysical, from the tsunami catastrophe for years to come. The deeper philosophy is for other forums. (No pedants please: the Latin plural fora is not commonly used in English any more) But there is an important practical lesson appropriate to this blog.

I have read on Eschaton that some of our friends over at Free Republic, mired in their usual bigotry and ignorance, think there is not really any need for major infrastructure rebuilding because those places are primitive and backward and how much does it cost to replace a bunch of straw huts anyway? In fact, beyond the immediate loss of life, the terrible injuries, the bereavement and dispossession of millions of people, the possibility of an even greater disaster looms. The destruction of clean drinking water supplies could ultimately kill more people than the wave, if the world community cannot solve the problem in time.

The public health movement began with the problem of drinking water and the related problem of carrying away sewage so that it would not contaminate the clean water supply. In the late 19th Century, cities in the United States were horribly dangerous places, where many babies died and the average person didn't live much past 40. This all changed, however, long before antibiotics and other scientific advances enabled doctors to do more good than harm. The major causes of premature death were tuberculosis, and water-borne diseases. The American Public Health Association was formed to campaign for water and sewage systems. We take these for granted today, which is why we can take our lives for granted.

In the poorer countries, diarrheal diseases from contaminated drinking water remained the leading causes of death until well into the last century, and they still are in parts of Africa. But knowledge of sanitation, drilling of wells, and construction of sanitary systems have made a huge difference in major portions of what we used to call the Third World. The destruction of these facilities in the areas affected by the tsunami has created an unimaginable peril. Let us hope that the world can respond effectively, and in time to the emergency need; and effectively, over the long term, to the challenge of rebuilding. Meanwhile, send your cash.

Thursday, December 30, 2004

Take me out to the ballgame

This is a subject I promised to address on another blog, so here goes.

There's been a lot of attention lately to so-called Direct to Consumer Advertising of prescription drugs (DTCA). The term DTCA implies something interesting that a lot of people don't know about -- there is a whole lot of other drug advertising and marketing going on, not to consumers, but to doctors.

Every major drug manufacturer in the U.S. has assigned to essentially all physicians in specialties that prescribe their products a person called a Detailer. A friend of mine happens to have gone over to the dark side and is now practicing that noble profession. He has the use of a box at Yankee Stadium to which he takes doctors and their spouses (or other preferred companions); a country club membership so he can play golf with them; and an expense account for restaurants and catering, which he uses to set up nice meals for the M.D.s and their spouses or OPCs, which they pay for by hearing a brief lecture about the miraculous benefits of some drug or other that his company sells.

He also visits the doctors in their offices, where he gives them high quality office supplies printed with the brand names and advertising slogans for the latest potions his company is pushing, and lots of free samples they can give to their poor and needy patients. (Alas, some doctors have recently been caught selling their free samples. Tut tut.) I don't know what else goes on in those visits usually, but I have on tape one instance in which the doctor invited two drug company sales representatives to sit in on the visit while he interviewed a patient with HIV who was taking some of their pills. He didn't tell the patient who they were or why they were there. Come to think of it, I'm not exactly sure why he let them be there myself, but it's obvious why they wanted to: they got to hear the patient talk about the experience of taking the drugs, what he liked and didn't like about them, what he believed about them, etc. All useful information to a salesperson.

This relationship between the doctors and the drug companies begins in medical school, before the budding healers get their M.D. A recent survey (McCarthy et al, Academic Medicine, Nov. 2004) found that nearly 100% of medical students had been exposed to pharmaceutical industry marketing before they even got to their clinical experiences in the third year. They were given free meals, free textbooks, "pocket texts," and various baubles. This goes on right through the residency, where drug companies pay for lunch (and give a pep talk about their products), provide guest lectures, throw dinner parties, and keep handing out the trinkets.

Once they're in practice, doctors have to show they're staying up-to-date on the latest medical knowledge, and they have to get what are called Continuing Education Units to prove it. The drug companies are only too happy to fill the need, paying for doctors attend conferences in places that just happen to be tropical resorts, where the companies provide the content; paying for those dinners at nice restaurants I mentioned before; and sponsoring various more sober and serious workshops.

Medical journals are full of drug advertising. According to a recent study by some Finnnish researchers (Pharmacoepidemiology and Drug Safety, Nov. 2004), out of 883 marketing claims in medical journal advertisements, 68% included "vague or emotive statements," and not a single claim was supported by strong scientific evidence.

But wait, there's more. Drug companies write review articles for medical journals, which by some strange coincidence strongly support prescribing their products. Then they pay prominent physicians to pretend to have been the authors of the articles. I am shocked, shocked, that prominent physicians would participate in this dishonest practice! Of course, that's one way they get to be prominent -- by having their names on review articles in medical journals.

Now, as of this writing, there are various efforts underway to restrict or eliminate some of these practices, by regulation, institutional policy, promulgation of (unenforceable) standards, or shaming. The status, extent and effectiveness of these efforts is a complicated picture, but basically, not much has changed, at least not yet. We'll see where it all goes.


This seem slightly out of bounds, but the recent uproar over whether the response of the U.S. and other wealthy countries to the tsunami disaster has been sufficiently non-stingy reminds me that most people don't have a good intuitive grasp of the magnitude of large numbers. A good example of such a person is GW Bush, who at his appearance before the press corp in Crawford yesterday repeatedly said, with emphasis on the B, that the U.S. has pledged $35 billion for disaster relief.

Not so oh strong and resolute leader! The correct number is $35 million (much of that, as far as I can tell, in the form of loans).

One billion is one thousand times one million (here in the U.S. - the British have their own, strange ways of speaking). As a comparison, the war in Iraq -- you know, the one where we eliminated all of those Weapons of Mass Destruction (tm) -- has so far cost at least $200 billion. Compared to even $1 billion, $35 million is still pretty close to nothing -- specifically, it is 3.5 percent of $1 billion. It is .035% of $100 billion, and it is .00175% of $200 billion, or .0000175 X $200 billion.

Just to put it in context.

Tuesday, December 28, 2004

And another thing -- Medicaid

The Bush Administration's tax cuts for the wealthy and the huge federal budget deficits that resulted have often been described as irresponsible, but they aren't actually evidence of insanity. The deficits are completely intentional, and the hidden purpose is, in the words of neocon economic Svengali Grover Norquist, to "starve the beast." The beast is, of course, government social programs. The administration has been loudly screaming that Social Security is unaffordable and attempting to destroy it. Our friends elsewhere such as Atrios and Josh Marshall have covered that well.

Still largely under the radar is the Bush assault on Medicaid. Starting with Ronald Reagan, Republicans have wanted us to think of Medicaid as free health insurance for welfare queens in Cadillacs, who buy vodka with their food stamps, but in fact, Medicaid now finances health care for poor children whose parents are working, and most notably, for elderly and disabled people receiving long-term care in nursing homes. 42% of Medicaid expenditures are for people who are also Medicare eligible, and Medicaid pays for the care of 70% of the people in nursing homes, according to the National Governors Association.

Medicare is 100% paid for by the federal government, but the cost of Medicaid is shared with the states. The Republicans in Congress have been talking about cutting tens of billions of dollars from federal spending on Medicare and Medicaid -- we can't afford it, after all, just look at those horrific budget deficits. (Bonus question: what projects and programs, according to the Bush Administration, can we afford?) The governors, however, know what this really means: more of the cost of Medicaid will be shifted to the states. And, if Medicare benefits are cut, those costs will be shifted to Medicaid as well. Why is that? It's simple: the alternative is to throw Grandma out of the nursing home and onto the street. They have written to Congress, unanimously, with no Republican dissenters, asking the extremists who now chair the budget committees not to do this. We'll see if the Liberal Media cares to pay any attention.

Monday, December 27, 2004

Cross of Gold 3: Follow the Money

A Pfizer marketing executive defects! Peter Rost writes in the LA Times that drug companies are overcharging American consumers, particularly elderly people on Medicare, and people without insurance. Insurance companies and the VA negotiate lower prices with the drug companies, as do the government-financed or regulated health care systems in the other wealthy countries. That's why it's so much cheaper to re-import drugs from Canada or Europe. (Here's the link, registration required: Peter Rost

But there's more to the story. The drug manufacturers claim that they need to charge Americans those high prices because it's so expensive to develop new drugs, and they can't afford to come up with all those lifesaving medications if they don't take it out of grandma and grandpa. It is to laugh. They spend more on marketing than they do no developing new drugs -- and a lot of the drug development they do is just finding slight variations on old drugs, that they can market as improvements, in order to keep patented compounds on the market that they can charge monopoly prices for.

Even so, these new drugs aren't necessarily really improvements at all. Vioxx and Celebrex -- the so-called COX 2 inhibitors -- do the same job as aspirin. They were supposed to be an improvement because they have a lower risk of gastrointestinal bleeding, which can affect some people who take high doses of aspirin for a long time. But the companies marketed these drugs as miraculous new treatments for osteoarthritis, showing all those happy, health-looking old folks doing Tai Chi and dancing like Fred Astaire on TV, so that most people thought they work better than aspirin and its cousins. They don't, but they cost about 20 times as much. What is worse, they covered up evidence that Cox 2 inhibitors increase the risk of heart attacks and strokes.

Now, the truth is that these drugs probably are an appropriate choice for people who have debilitating arthritis, are at low risk for cardiovascular disease, and have experienced side effects from aspirin-like drugs. But they aren't the right choice for most people. If the drug companies told the truth, however, and didn't deceptively mass-market these compounds, they wouldn't have been major blockbusters that enabled them to make huge profits for their stockholders and executives.

More on marketing later . . .

Friday, December 24, 2004

Cross of Gold -- Cont.

So okay, so what's up with the Gold Standard?

By assigning people to the intervention and control groups at random, we don't assure that the two groups are the same, except for the intervention. In fact, we know they aren't. Just by chance, they will differ in innumerable ways. Biological systems such as human beings are inconceivably complicated, far too complicated for us to be able to describe more than a small fraction of them, so we won't even be able to measure, or for that matter, even imagine all the ways in which people differ that might affect how they respond to the drug, and all of those characteristics will just happen to be distributed a little bit differently between the intervention and control groups. What is more, the people's histories -- what happens to them, what they eat, what other diseases they get, whether they get hit by a bus, you name it -- will also be different through the trial, and these histories will just happen to be different in ways that matter between the two groups.

So what do we really gain by random assignment? We gain the ability to use certain mathematical tools that are well understood, based on probability theory, to assess the probability that the differences we observe at the end of the trial between the two groups are due to the drug, or just due to chance. And by chance, we don't actually mean God playing dice with the universe -- we really mean factors that we haven't measured, or at least haven't counted in our calculation. If the probability is below a certain arbitrary standard, we say that the difference between the two groups is statistically significant.

Statistically significant doesn't necessarily mean large. If the size of the two groups is large enough, a small difference between them can be statistically significant. Also, it doesn't mean that everybody in the intervention group benefited (or was harmed, if that's the way it turned out). It could be that a few benefited, and most got no benefit. It could even mean that some benefited, and some were harmed, but the average difference was in the desired direction.

As it turns out, this is apparently what happened in the trials of a relatively new class of anti-depressants called Selective Serotonin Reuptake Inhibitors (SSRIs). There is a very large placebo response to anti-depressants -- give a depressed person a pill, and tell them it might make them feel better, and around half the people will report feeling better. But a few more people in the intervention group said they felt better than did people in the control group. The estimates based on analysis of multiple trials are that about 15% of moderately depressed people get some benefit from taking SSRIs. That obviously goes far beyond the massive hype that accompanied the appearance of these drugs, with some people saying we ought to put them in the water supply to make the whole world happier.

Some later trials, it turns out, seemed to show no benefit at all -- placebo was actually better, in one study! And then it emerged that, at least for young people, a few were actually harmed. Giving SSRIs to depressed people may make a few of them feel better, but it will also make a few -- evidently a smaller number, but more than zero -- feel worse, even worse enough to try to kill themselves. This is a short-term effect -- it is possible that in the long run, these drugs actually reduce the risk of suicide, but we don't really know yet.

So how is it that we heard one story when the drugs were first approved and marketed, and we're hearing a somewhat different story now?

Thursday, December 23, 2004

Cross of Gold

Sorry for the wonky post which follows, but sometimes it's necessary. Some readers will know all about this; please bear with me or just skip it.

The so-called "Gold Standard" for determining the effectiveness of any medical intervention, including drugs, is the Randomized Controlled Trial -- the RCT. RCTs are the only way to get FDA approval.

To evaluate new drugs, researchers first feed them to a small number of people to see if anything obviously horrible happens, and to get some basic data on how they are metabolized, etc. If nobody has any parts fall off, they go to a Phase II trial, which is a relatively small-scale rehearsal for the big event in which they are looking for some evidence that the stuff actually works in some way -- not even necessarily by curing or preventing disease, possibly just by having some predicted biological effect thought to be beneficial in the longer term. And of course they're still presumably alert to any adverse effects, this time looking at more people for a little bit longer.

Then they go to the Big Show. You have to do the following:

* Specify, in advance, the results that you are predicting and wish to test.

* Recruit a bunch of people who meet some eligibility standards. That may include having a disease, not having certain other diseases or conditions, being within a certain age range, not taking certain other drugs, not having a problem such as addiction or mental illness which might interfere with "adherence to the protocol," etc.

* Randomly assign them to receive the new drug, or to some comparison treatment, which could be an approved treatment, or a fake treatment (placebo). It is essential that the assignment be purely by chance, and that neither the subject, nor the physicians and other researchers who work with the subject, know what the person is taking. Also, at this point, collect a bunch of information about the people, such as sex, height and weight, ethnicity, medical history -- whatever you think might matter somehow. Of course, you're only guessing about that.

* Over the course of the trial, keep careful track of the people: if they drop out, if blood tests show they aren't really taking the stuff right, if they have symptoms that might be side effects, and of course, at the end, if whatever you wanted to accomplish by giving them the drug has actually happened or not.

* Finally, open the secret envelope and find out who was taking the drug and who was in the control group. Do statistical analyses to see if there's a difference between the groups, specifically the kind of difference you predicted, such as they're more likely to have grown hair on their bald heads or to have been cured of cancer. Also, compare the reported negative symptoms of the intervention and control groups to see if there are adverse side effects that can be attributed to the drug.

Now, this sounds like a pretty good way of doing a test, and there are indeed strong arguments in favor of it. But there are also lots of problems with it, both in principle, and even more so in the real world. I'll wait a bit to see if anyone cares to comment, before I do.

Wednesday, December 22, 2004

Pills, damn pills, and statistics

It's been a rough few months for the pharmaceutical industry, what with news about antidepressants increasing the risk of suicidal thoughts and behavior in children, so-called "hormone replacement therapy" and various nasty consequences, most recently news about Cox 2 inhibitors and cardiovascular disease, and now NSAIDs, plus some less publicized problems.

It's also been a rough patch for the people who were taking these drugs, obviously, and now a lot of folks out there are confused and don't know what the heck to do.

At the heart of these problems we have a tangled intersection of epistemology (the theory of knowledge - how we come to believe what we think we know [redundancy intended]), difficult value judgments, politics and yes, industry greed. The latter is to be expected, of course, but the epistemological thicket and the values fog make it difficult to properly contain.

Which thread to pull first in this skein? I pick the field called biostatistics. Medical practice and applied biomedical research depend very much on the language of probability, which is called risk when we care about what happens. But the so-called positivist epistemology which underlies the scientific approach to knowledge has a very hard time with probability. It is not clear in what sense statements about probabilities are verifiable. The blow dried guy comes on TV and tells us that there is a 50% chance of rain tomorrow. Tomorrow comes, and it rains or it doesn't rain. Guess what? He was right!

I tell you that you have a .5% (that's .005 out of 1) chance of having a heart attack in the next year, but if you start taking this pill your chance will be .75%. But that's not actually true any more if we learn more about you. For example, if we test your Low Density Lipoprotein ("bad" cholesterol) and find that it's below a certain number, your risk is less to begin with and is increased even less if you take the pill. Was I wrong when I gave you the figures of .5% and .75%? No, those are the odds when we don't know about the cholesterol, so I was right. And no matter what happens next year, whether you have a heart attack or not, I was still right. And what if I give this news to, say, 100 people? In order for me to be "right," does 1/2 of a person need to have a heart attack? No, I could still be right if nobody has a heart attack, or even if 10 people do, although I would then say that the outcome which ensued was an "unlikely" one. Well, it isn't unlikely any more, it happened! The probability of events which have actually occured is 1, 100%, no matter how unlikely they were before they occurrred.

What if I tell you that the pill increases your risk of attack by 50%. Does that sound scary? It probably isn't worth it. What if I tell you it increases your risk by only .25%, in other words that 2.5 people out of 1,000 will suffer a heart attack because of taking this pill. Maybe you'll take a chance now. But both of those statements are true -- in some sense, but neither of them may be true for you! In the end, you're either going to have a heart attack or you aren't, right?

Tuesday, December 21, 2004

Cultural competency -- a case study

Dramatis personae: Nurse=NP002
[Translation from Spanish, by Cervantes, is in italics ]

NP002: Okay. No allergies, no medications, very healthy. Has she ever been in the hospital overnight?
INTERPRETE: ¿Ella ha estado interna en el hospital por alguna razón? Has she been admitted to the hospital for any reason?
DELIA: No. Antes sí, pero ya ahora . . . No. Before, yes, but now...
INTERPRETE: ¿Cuándo? When.
DELIA: Hace mucho. Cuando ella estaba recién . . . más pequeñita. Como de tres años o dos años. It's been a long time. When she was recently ... much tinier. Like three years or two years.
INTERPRETE: Por qué? Why?
DELIA: Bueno, porque yo en el embarazo perdí el papá de ella . . . Well, because I lost her father during the pregnancy...
DELIA: Tenía tres meses de embarazo, y ya tú te puedes imaginar todo lo que yo pasé. Entonces de ahí, la niña me salió como con un problema en el estomaguito, que no digería bien, y todo. Y yo la llevé a un pediatra allá, y en la . . . me la . . . I was three months pregnant, and already you can imagine everything that I went through. From there, the girl came out of me with a stomach problem, so she couldn't digest well and everything. And I took her to a pediatrician there, and in the, to me she...
INTERPRETE: ¿Cuando tenía tres años la internaron? When she was three they admitted her?
DELIA: Sí, dos años. Yes, two years [old].
INTERPRETE: ¿Por ese mismo problema? For that same problem?
DELIA: Por ese mismo problema, pero ya ahora ella no tiene problemas. For that same problem, but now she doesn't have problems.
INTERPRETE: She says when she was either two or three years old, she had problems digesting food, and they admitted her. They admitted her. She says that she's okay now.
NP002: Okay.
INTERPRETE: She doesn't have any problems now.

As we can see, the interpreter doesn't bother to tell most of this story to the NP. But the interpreter didn't get most of it either. We did.

Delia is from the Dominican Republic, a very poor country. When she was two, the little girl, Susana, nearly died. Delia could not afford medical care for her. Desperate, she dressed Susana in a white robe and carried her barefoot around the church, lighting candles. Then she stood before the virgin and made a promise: if the virgin would allow the little girl to live, Delia would put her in school. (Poor children in the Dominican Republic, especially girls, usually get little education.)

The miracle was done. A cousin came up with the money, and Susana had her operation (probably for pyloric stenosis). That is why Delia was here in our city, to keep her promise to the virgin. She is lonely and homesick, with few friends and little family, but the promise must be kept. Susana is unhappy, she grinds her teeth at night and has made few friends. But maybe here she has a future.

How does this matter to primary pediatric care? How could this encounter have been more culturally competent? Would it have helped at all for the NP to have been taught in advance about promesas a la virgin? Or is the point really something else?

Cultural Competency

People who are considered about unequal treatment and disparate outcomes for people who are not of the dominant culture and ethnicity in our society -- what we usually call minorities -- worry about a lot of problems, including insurance coverage and discrimination. But a very hot issue is called cultural competency -- the idea that taking care of people who don't come from the dominant anglophone European settler culture here in the U.S.A requires some specific knowledge or set of skills.

Most of the literature about this subject, at least until recently, focused on "folk illnesses" and "folk healing." The idea was, these exotic people are hard to take care of because they all believe in the voodoo guy instead of you, the expert scientific doctor. Provider institutions figured the way to get culturally competent was to hire somebody to do Cultural Competency Training, which has become a very big business. So they'd have somebody come and tell the doctors and nurses that Puerto Ricans believe in mal de ojo, so you have to touch the kids on the head and say "Dios te bendiga." Or Mexicans believe in folk illnesses like empacho and they all go to curanderos. African-Americans, of course, go to root workers and get themselves a mojo hand.

Sadly, no. This is like saying that if you want to take care of Californians, you have to know that they believe in the healing power of crystals. All nations and cultures have various traditions, home remedies, beliefs and superstitions that aren't taught in medical school, and some people go for some of them and others don't. But except for a few immigrants from very remote places, immigrants and non-immigrant minorities in the U.S. are familiar with allopathic (that's the right word for so-called "Western" or "mainstream" medicine) medicine, know what doctors do, and don't get that mixed up with whatever else they may do about their health. As a matter of fact, the most common non-allopathic medical practice in the U.S., and throughout Latin America and much of Africa and Asia, happens to be Christian faith healing. But somehow that doesn't get included in the list of "folk beliefs."

Cultural competency is not principally, or even very much, about medical anthropology. It is about communication, which goes at least two ways. The next post will begin to address this most important idea.

Monday, December 20, 2004

News flash?

If nobody took the trouble to prove scientifically what we already know, then what we already know wouldn't be actual knowledge, right? Of course it still would have to be on TV before it was really real . . .

Anyway, the Commonwealth Fund (my favorite charity) has released a new report that tells us that the number of Americans without health insurance has gone up (again), 45 million at last count. Why? Because of "a decline in employer-sponsored health insurance coverage." And the consequences? The worst thing a poor person in this country can do is get a job. Now you're kicked off of Medicaid but your job doesn't come with health insurance and you sure as hell can't afford to buy it. 26% of the workforce makes less than $10/hr., and another 24% between $10 and $15. 46% of the people earning less than $10 and 20% earning $10-15 lacked health insurance at some point during the year. And of course, the low-paid workers are:

Less likely to have a regular doctor;
Less likely to have had their blood pressure checked;
Less likely to have had their cholesterol checked;
Less likely (for women) to have haed a pap test or a mammogram.

They're more likely to have had trouble paying for medical care and be behind on medical bills . . .

etc. etc.

Yeah, these are those lazy, shiftless good-for-nothing poor people George W. Bush complained to his business school professor about. You know, the ones who are working full time doing nasty jobs, like changing the bed pans in nursing homes and gutting the chickens for your cordon bleu . . .

Commonwealth Fund

And check out the rest of their publications here as well.

A radical proposal

Those of you outside the medical profession may not already know about the analysis by Wald and Law, published in the British Medical Journal last year, which proposed that the entire population be fed a "polypill" consisting of six chemicals, which they concluded would reduce cardiovascular disease rates by 80%. (Here's the link if you're interested: polypill

Now along come some wild-eyed radicals with a truly bizarre and disturbing proposal. If people would just drink a glass of red wine every day, eat fish four times a week and eat fruits and vegetables, dark chocolate, garlic and almonds every day, we could achieve a 76% percent reduction in cardiovascular risk. That is obviously preposterous, who would eat good food and drink wine when a pill was available? But if you want to see what these nutjobs have to say -- Franco, et al

Sunday, December 19, 2004

The Pill Era

We had the hunter-gather era, the agricultural era, the industrial era, the post-industrial era, and now we are entering the pill era.

I had the opportunity to spend some time with an elderly couple who don't know the Internet from a volleyball net and don't know Cervantes from Little Green Footballs. This gives me the freedom to use them as an example. Let's call them Betty and Ernie.

It is astonishing how much their lives revolve around pills. They each take about 8 to 10 different ones, a number which fluctuates a bit. Some pills come and go from their lives, others are always there. Ernie has some dementia, and one of Betty's greatest burdens in life is getting him to take all his pills. Although he has been officially told that he does not have Alzheimer's Disease, but rather vascular dementia, he has been prescibed two pills for Alzheimer's, called Nimenda and Aricept. He also takes Prazosin for high blood pressure, coumadin (which was originally rat poison), a statin, and an antidepressant. Betty took Dilantin all her life, as a result of which she has osteoporosis for which she takes pills, plus more pills for glaucoma and of course the requisite statin. Lately she's had an ear infection which made her dizzy. The doctors gave her valium for that, which she took for weeks until another doctor told her it was just making things worse. Recently Ernie woke up with an exacerbation of his osteoarthritis so the doctor called in codeine/tylenol and a muscle relaxer. Betty gets sinus infections and she frequently takes antibiotics for those, plus pain killers for bursitis and ..

Well, you get the idea. These folks spend half their lives trying to figure out which of their symptoms are side effects. In fact Betty's sister almost died from drug side effects because the doctor refused to believe her complaints and dismissed her as "hysterical," until she passed out in a restaurant. Sometimes the doctors decide they're suffering side effects and cancel or change a pill, sometimes they add one, either because they diagnose something new or they just figure the way to fight the side effects is with another pill.

Instead of doing crossword puzzles, crocheting, painting, going to the theater, building model boats, or going on a cruise, they sit around worrying and talking about pills, arguing about whether Ernie has taken his, whether he should use a pill boz, or whether Betty should stop taking something or start taking something, and much of the rest of the time trying to reach one of 8 different doctors on the telephone to get an explanation or an answer. Half of this stuff, they don't even know what it's for. They certainly don't know what side effects might happen from what pills, which is why they're always trying to guess. It's not their fault. Doctors usually don't tell patients about side effects because they're afraid if they do, the people won't take them.

Then of course there is the question of paying for this chemical soup. Fortunately Betty is a retired teacher and the union gives them Medigap insurance, which pays for most of the cost after a substantial annual deductible. As we know, many elderly people aren't so lucky, and it's don't take the pills or don't pay the heating pill.

So is this all worth it? Is it making their lives better? Is it making society healthier and happier? And why or why not?

Friday, December 17, 2004

Social Security crisis phony, Medicare crisis maybe not. . .

While the Bush administration is ginning up a largely fabricated imminent (or is it grave and gathering?) threat to Social Security, in order to panic the public and Congress into destroying the system, there are some real problems with Medicare. A reasonably good summary of the problem can be found at Health Affairs, by Mark Pauly .

Pauly writes: A key message, then, is that real Medicare benefits per beneficiary could be held constant, at approximately current tax rates, if overall economic growth is near the historical level; if it falls slightly below that level, tax rates would need to rise a little. However, it would be much more discouraging if real Medicare benefits continue to grow at their long-term real rates of 4.7 percent per year, or even at the more moderate rate of GDP growth plus 1 percent used in the trustees’ projections. Then revenues at constant tax rates would fall well behind spending, the Part A trust fund would be drawn down, and taxes would need to be raised or benefits would need to be limited. All of these projections exclude the MMA drug benefit; its estimates are very imprecise, but it will probably add at least 20 percent to Medicare taxes upon initiation and grow thereafter.

In short, while we wouldn't have a big problem if health care costs per capita were to hold steady, they don't. The cost of health care per capita, and as a share of GDP, has increased steadily over the decades, with some brief interruptions, and is still increasing. Bottom line? The looming crisis in Medicare is just a subset of the problem we have with health care overall. And the solution is also the same:

Universal, single payer national health care. That is the way to get control over costs and make sure we can take care of our seniors, our children, and our working age people. It will not, however, be good news for drug companies, which is one reason they are paying Billy Tauzin $2 million a year -- to make sure it never happens.

Wednesday, December 15, 2004

Revolving D(wh)oor

Billy Tauzin, former chairman of the House Energy and Commerce Committee, who was instrumental in crafting the legislation that forbade Medicare from negotiating with drug manufacturers for lower prices, has been named chief lobbyist for the drug industry. According to Bloomberg news, Tauzin, "A 61-year-old Louisiana Republican, Tauzin retired from his congressional role in overseeing Medicare and the Food and Drug Administration this year. He will replace Alan F. Holmer as chief executive on Jan. 3, the Pharmaceutical Research and Manufacturers of America said today in an e-mailed statement. The group has an annual budget of more than $150 million. Tauzin will represent an industry that generated more than $216 billion in U.S. sales last year. He will have to fight states' efforts to trim drug spending and navigate the expansion of drug coverage for 41 million elderly and disabled Americans, legislation that he helped push through Congress. Abbott Laboratories Chief Executive Officer Miles White led the yearlong search for a new president. "

A big payoff to the industry's agent in Congress. As for the people of Louisiana who continually reelected this guy, and the rest of the people, we're all nothin' but suckers.


Many people may have seen last night's Frontline re-run about the U.S. Food and Drug Administration (FDA) approval process for new drugs. It is not unusual for regulatory agencies to be captured by the industries they regulate. Unfortunately, this has happened with the FDA. Under the present administration, it has happened throughout the federal government, but in fairness, the problems at the FDA began during the Clinton administration.

The Frontline piece focused on the Fen-Phen diet drug combination and some smaller scale debacles, but of course the big news lately, which came too late for that show, is the Vioxx catastrophe. Possibly the companies are starting to recognize that putting greed ahead of honesty may be a counterproductive policy in the long run.

In any case, this is a complicated problem to parse. In the days ahead, I hope to take up most of the pieces one at a time. They fit together, ultimately, but it's a complex diagram. Here's at least a partial list:

-- The value of drug patents and the specifics of the intellectual property laws;
-- The broader economics of drug development and manufacturing;
-- The randomized controlled trial and the broader theory of knowledge underlying medical practice;
-- The hard science of drug development and the current state of biomedical research;
-- Marketing of drugs to doctors;
-- Direct to consumer advertising and other marketing techniques directed at consumers;
-- How doctors talk to patients (or don't) about their prescriptions;
-- How patients talk to doctors (or don't) about their prescriptions;
-- What people expect from medicine, vs. what they are likely to get;
-- How doctors think about risks and benefits, vs. how people in general think about them.

Yeah it's a lot of territory. But it's important for us all to think about all of these issues as citizens, patients, and providers.


So how about it? Do the good people of Massachusetts owe Rosa a kidney? If not, should the family be hustled onto a plane and shipped back to El Salvador where Amado can watch his mother's painful death? If so, what about all those other poor people in El Salvador and around the world who have no hope of getting health care that is an entitlement of even the least worthy among us?

Please write legibly in your blue books. You have 20 minutes.

Tuesday, December 14, 2004

More on Rosa

Before I get back to the issue of doctors and patients (which is clearly the people's choice), let me take a moment to say a bit more about the case of Rosa, below. The physician's insensitivity is what stands out for most readers, but there is a lot more to this story.

First of all, its largest context. Rosa and Carlos fled El Salvador during a civil war. Actually I didn't even tell you that Carlos was originally from Guatemala. They were indigenas, Native American people, and their governments were waging war against them on behalf of the European settlers who dominate those countries economically and politically. In El Salvador, people who were suspected of revolutionary sympathies would disappear in the middle of the night.

The United States was supporting the government of El Salvador because the rebels were supposedly part of the international Communist conspiracy. (The President at the time they came here was George Bush the First, but the policy started under Saint Ronald Reagan.) So, people like Rosa and Carlos couldn't get political asylum in the United States. They were here illegally, to be sure. You can imagine what it meant to them to leave their infant son behind. At the same time Nicaraguans, whose government was on the "wrong side," could enter the U.S. with a claim of political asylum presumptively granted.

So they're here, working hard, doing jobs U.S. citizens won't do, and yes, paying taxes. But they don't have health care. In the United States, a vaccine for chicken pox was approved for adults in the early 1990s, and those adults who had not yet had the disease were immunized. Rosa was not. We don't know a whole lot about the etiology of lupus, but it is likely that had she been vaccinated against chicken pox, she would not have come down with the disease.

Although she could not have seen a doctor to receive basic preventive care, once she was seriously ill and needed hospitalization, she was taken care of, no questions asked. Who paid for it? In Massachusetts, it was paid for by the so-called "free care pool," which comes from a surcharge on insurance payments to hospitals. Ultimately, everyone who has insurance pays for it.

By the time of the events described below, the civil war in El Salvador had ended. Rosa and Carlos would have returned home, but now they could not, because without the high tech medical care available to them here, she would have died.

This is a morality tale that is too complex for me to parse. Who is responsible for what here? Who should pay? What should have happened differently? How far back does it go? Columbus and the Kings of Spain aren't taking my phone calls, however.

And by the way, this is not a fable. It is a 100% true story.

Monday, December 13, 2004

Doctors and Patients: Second Installment

Until the mid 20th Century, the generally accepted relationship between physicians and patients in the West was of a nature now characterized as "benevolent paternalism." The expertise and wisdom to choose the appropriate treatment of disease resided entirely with the physician. The patient's role was to trust the physician and to follow "doctor's orders" --a condition analogous to childish dependency.

Patients ordinarily could be said to have consented to treatment, if only because, as a practical matter, they had to physically submit to the surgeon's knife or swallow the doctor's potions. However, there was no expectation that the patient would be specifically informed about the physician's theory of the patient's disease state, the theoretical basis of the proposed remedy, possible adverse effects, or alternative treatments.

This paradigm came into serious question after 1950, in connection with broad changes in social attitudes about hierarchy and personal autonomy, and the growing technical complexity of medicine, which, along with more effective treatments, brought increasing uncertainty and tradeoffs among risks and benefits.

Some important critical examinations of the physician-patient relationship include work by Jonathan Katz (The Silent World of Doctors and Patients), Howard Waitzkin (The Second Sickness; The Politics of Medical Encounters), who viewed medical practice as, in part, an agent of social control, as did Alexandra Dundas Todd (Intimate Adversaries) who saw male ob/gyns as imposing patriarchal
morality on their female patients. A particularly fruitful and well-known analysis was by Elliott Mishler, in The Discourse of Medicine. Elliott saw patients speaking in "The Voice of the Lifeworld," trying to explain their conditions of health and illness and experience of symptoms in the context of their lives, and being thwarted by physicians, who controlled the discourse and channelled it into "The Voice of Medicine," focusing exclusively on the biomedical paradigm in which they were trained. Put another way: They just don't listen.

How to pay for it

I promised to open more discussion of the physician-patient relationship, but first, a visitor raises the important question of how to pay for universal health care, should the heavenly kingdom ever arise and that become possible here in the land of the radically individual. Due to some weird technical problem, her comment did not appear in Haloscan, so I append it here. (Yes, response first, comment later!)

I agree with many of the key points: universal health care, particularly within a system that emphasizes prevention, can be expected to save society money in the end. Economic transactions with substantial externalities should be taxed to reflect their real costs to society, e.g. sales of cigarettes, petroleum etc. However, I'm not sure that using such taxes to fund health care is quite right.

First, if government becomes dependent on taxing stuff we want to discourage, it develops a serious conflict of interest. Tobacco taxes are great if they discourage smoking, bad if they put state governments in a position where they don't want to discourage smoking because they're dependent on the revenue! Also, such sales taxes are generally not progressive, and fall hardest on the poor and moderate income people. The best method, in my view, is a sliding scale whereby affluent people pay full cost and progressive income taxes provide subsidies for the less well-to-do. We should still have sin taxes, but dedicate the revenue only to ameliorating the direct effects of the sins, e.g. petroleum tax to renewable energy research and development, and pollution abatement; cigarette taxes to tobacco control.

Finally, I would not give people a write off for being phyiscally fit, etc. That's a real can of worms, with a lot of counterproductive consequences. But we do want to promote fitness. Anybody else want to weigh in on all this?

Thursday, December 09, 2004

enough wonkery

I'm sorry for all the boring, discursive posts. Here's a true story.

Rosa and Carlos fled El Salvador in 1989, leaving their infant son in the care of Rosa's mother. For those of you who don't remember, there was a civil war going on in that country then, and people would disappear in the middle of the night. They found an apartment in East Boston with the help of an agency that assists Central American refugees. Carlos began to work three jobs in restaurant kitchens and cafeterias, and Rosa took a job as a housekeeper in a nursing home. They were just able to pay the rent and send a few dollars each month to Rosa's mother to support their child.

After a few years, Rosa had a bout with chicken pox. Shortly after she recovered, her hair started to fall out. Then one morning she awoke to find her face bloody. When she went to wash herself, blood streamed from her eyes, nose and mouth. She sat in her apartment for two weeks, terrified to go to a hospital for fear that they would demand money she didn't have, or turn her over to be deported. Finally, friends insisted that she go to a hospital, and practically dragged her into their car.

At the hospital, she discovered that they did not ask for a green card or concern themselves with her residency status. But there was bad news: she had lupus, and would soon need a kidney transplant. Realizing that Rosa could not get the medical care she needed in El Salvador, and that, although the civil war had ended, they could not return after all, Rosa and Carlos sent for their son Amado, now seven years old. Rosa went to enroll him in school, where she was happy to find people who spoke Spanish. They told her Amado needed to have his immunizations, and referred her to a hospital-based clinic where, they said, she could walk in and have it done easily, and for free.

Carlos took time off for work to accompany his ailing wife and child on the trip into town to get the shots. When they got to the clinic, they were again happy to discover that the receptionist spoke Spanish. "We used to just give the vaccinations," the receptionist told them, "but now we have a new policy. You have to talk to a doctor. You'll have to wait until we can get an interpreter."

Rosa and Carlos waited for five hours. All that time, Carlos was losing money – he doesn't get paid time off for sick days or doctor visits. Finally, just before closing time, the doctor came with an interpreter. This is what happened:

INTERPRETER: He says . . . mom says he grew up with his grandmother.


INTERPRETER: He was with his grandmother in El Salvador for six years . . .

DOCTOR: Okay, aha.

INTERPRETER: So he's only been here with her for one month.


INTERPRETER: ¿Un mes, nada mas, hace que lo tienes aquí?


INTERPRETER: He's only been here for one month.

DOCTOR: How long has his mom been here?

INTERPRETER: Y usted, ¿cuánto tiempo hace que está aquí?

ROSA: Siete años.

INTERPRETER: Seven years.

DOCTOR: Then you speak English. No?

INTERPRETER: No, ¿nada de inglés? ¿Nada? ¿Poquito?

DOCTOR: After seven years?

ROSA: Es que a veces si entiendo, pero el problema es que me vaya a confundir con una palabra, y entonces vaya a cometer algún error . . .

INTERPRETER: She says she understands some, but she's afraid she's confused when she, medical terminology. . .

DOCTOR: But you need to try.

INTERPRETER: She might give you the wrong information.

DOCTOR: Just keep trying. The more you try. . .

INTERPRETER: Que siga tratando, que entre más trate más rápido aprende.

DOCTOR: The more you try to talk, the quicker you'll learn, right? Don't run away yet. Don't run away.

INTERPRETER: Está haciéndote una prueba de si tú entiendes lo que ella te está diciendo. (Se ríe). [She's giving you a test to see if you understand what she's saying. (laughs)]

DOCTOR: But you need to practice. You understand me, don't you?
So today is the shot . . . and a shot, and a test for tuberculosis, and medicine in his mouth.

INTERPRETER: ¿Lo entendiste? [Did you understand it?]


And that was the extent of the doctoring they got that day, after five hours of waiting.

The Public Health Paradigm

A famous article appeared in the 1990s in the Journal of the American Medical Association, by Drs. McGinnis and Foege. They noted the famous "10 leading causes of death" in the U.S., from death certificates. As of 1990 (and it hasn't changed much) these were heart disease, cancer, strokes, accidents, chronic obstructive pumonary disease (AKA emphsyema), pneumonia and influenza, diabetes, suicide, chronic liver disease and cirrhosis, and HIV disease.

Now, the items on this list are not of an entirely consistent character. Some are quite specific -- emphysema, AIDS -- others are broad categories containing many different diseases, such as cancer. But most of them are actual diagnoses -- biomedically defined conditions of disease -- present at the time of death, though a couple of them are causes of injury -- accidents, suicide. The physiological condition resulting in death in those cases would presumably be some sort of trauma, or you might argue that "suicide" as a cause of death really means depression. But the list for the most part focuses on diseases, that is on conditions of the patient which physicians are trained to diagnose and treat.

McGinnis and Foege point out that these conditions can all be traced to root causes farther back in time, called the etiology of a disease. They went through the published literature to extract what is known about the etiology of the major death certificate causes of death. They came up with 9 leading causes of death that they estimate are responsible for at least half of all deaths. There are no diseases on this list. The number one killer of Americans, by a healthy margin (pardon my word choice) is tobacco. Number two is bad diet and lack of exercise -- basically eating too much saturated fat and being obese. Then we have "toxic agents," which doesn't mean drinking drano, but rather occupational or environmental exposures. Deaths from illicit drug use are principally because of HIV and other infections resulting from drug injection, not from the direct effects of the drugs themselves. Sexual behavior kills mostly because of AIDS as well, plus other sexually transmitted diseases and a few maternal deaths resulting from unintended pregnancies. The researchers avoid double counting. For example, motor vehicle deaths resulting from alcohol intoxication are counted under alcohol rather than motor vehicles.

These estimates are very conservative. They have excluded any etiology that is not generally considered well established. Furthermore, all of these numbers are based on the lowest bounds of available estimates.

McGinnis and Foege have introduced a paradigm shift, from the biomedical paradigm -- what diseases kill people -- to the public health paradigm -- why do people die? They don't quite make it all the way. For example, they refer to "accidents", which is neither a biomedical nor a public health concept. The biomedical cause of death in these cases would presumably be cerebral concussion, shock, ruptured aorta, or whatever. But the term "accident" is alien to the public health paradigm since it implies randomness, an act of God or the cosmos, which cannot be foreseen or prevented.

Similarly, McGinnis and Foege list "microbial agents", which belong to the biomedical paradigm. From a public health standpoint we would ask why people succumb to microbial agents. In the case of HIV, they have asked this question. Hence they do not list HIV, but rather sexual behavior and injection drug use, and deaths from HIV are not counted under "microbial agents". They also point out that most influenza and pneumonia deaths occur among people who are already sick and weak, often due to tobacco, diet and alcohol. Some of these they assign to those agents.

However, nosocomial infections -- that is, infections people get while in hospitals, which are very dangerous and disease ridden places -- as deaths due to microbial agents. From a public health standpoint, these deaths are caused by biomedical intervention in the form of hospitalization. And we could make public health arguments for many other deaths counted as due to microbial agents.

This paradigm shift has enormous implications. McGinnis and Foege point out that the U.S. spendt nearly $1 trillion per year on biomedical services (it's a lot more now!). That comes to more than $14,000 a year for a family of four, on average. Most of that sum will be spent to treat the physiopathological processes recorded on death certificates as the nation's leading causes of death. At the same time, the U.S. Centers for Disease control estimated total national spending to control etiologic factors as less than 5% of that trillion dollars, that is less than $700 per family -- and thanks to the Bush Administration, proportionately it is even less today. Furthermore, that trillion dollars in biomedical intervention obviously isn't doing much good in preventing the leading causes of death -- once people have cancer or heart disease, or AIDS, they are likely ultimately to die from those conditions regardless of the biomedical resources that are brought to bear.

So we have a major misallocation of society's resources. This is a political issue which is gravely underappreciated.

Wednesday, December 08, 2004


We now have haloscan commenting! You no longer have to be anonymous if you aren't registered with blogspot. It will be faster and easier to comment, and more flexible. So please keep those comments coming.

"Race" and ethnicity

A major problem with the way people nowadays talk about health disparities -- and many other areas of inequality -- is confusion about the biological and social meanings of race and ethnicity. The U.S. is still a racist society, by which I mean that people believe in the reality of "race" both as a biological phenomenon and an organizing principle for social advocacy -- whether they are white supremacists or, unfortunately in too many cases, Black academics.

Ethnicity refers to group identity within a larger society, often connected with cultural differences and sometimes reinforced by socially accepted beliefs about the significance of certain physical traits. Such prejudices about physical differences underlie the construction of social “races.” The scientific consensus does not doubt that certain variant genes differed in frequency in different places in ancient times. However, it rejects the socially constructed concepts of race that pervade society. African Americans are a very real ethnic group, but very few African Americans are of exclusively African ancestry, and many people who are not ethnically African American have a higher proportion of African ancestry than many African Americans. Pakistanis, Chinese, and Filipinos are all aggregated into a putative “Asian” race, but this is as nonsensical biologically as it is socially. Examples are endless.

It must also be said that the notion that humanity was once divided into five reproductively isolated, independently evolving groups is obviously false. Native Americans came from Asia in evolutionarily very recent times. Africans, Europeans, and Southwest Asians were never reproductively isolated, rather their genes and populations flowed and intermingled along gradients. The genes of Africans flowed into Europe throughout history, and vice versa. (Remember Antony and Cleopatra, Othello and Desdemona, or Solomon and the Queen of Sheba?) The construction of five races from gene frequencies, physical traits, or anything else, is largely arbitrary. Pick a different set of characteristics as dispositive, and you get a different set of races.

The differences in health status that correlate with ethnicity – or “race,” if one bases analysis on racial categories – have much to do with social phenomena and little to do with genes. These include socio-economic status and access to opportunities, prejudice and discrimination, differing physical environments, cultural differences in diet and other behaviors that affect health, and many other factors including some as yet unknown. Whatever the importance of sickle cell anemia, Black people in the United States do not have shorter life expectancies than white people because of their genes.

Ethnicity, culture, group identity -- these are socially constructed but are real social phenomena. Race, as a biological concept, is also socially constructed but entirely false. Never forget this.

Tuesday, December 07, 2004

Health Disparities

I couldn't blog yesterday because I was attending a conference, sponsored by the New England Coalition for Health Equity, on state policy to eliminate health disparities. "Health disparities" is a term which refers specifically to the substantial differences in life expectancy and health status among segments of the population. Most people know that rich people live longer than poor people, and are healthier, but it is also true that after you control for wealth, income and education, Black people in the U.S. are substantially less healthy, and don't live as long, as White non-Hispanic people. ("Black" is actually a heterogeneous category that includes African Americans and other ethnic groups such as Haitian and Cape Verdean people, but African Americans constitute most of the group and drive the statistics. If we could disagreggate, which we usually can't, we would probably see differences within the group as well.)

For Latinos, the picture is more complex. Immigrants from Mexico tend to be healthier than their low average socio-economic status would predict, but they lose that advantage in the second and third generations. Puerto Ricans tend to be less healthy than the average in the U.S. We don't know very much about other immigrant groups from Latin America, many of which are growing fast such as Colombians and Central Americans. We don't even count Brazilians or recognize their existence in our standard system of racial and ethnic classification.

The reasons for these disparities are only partly understood. Health care probably doesn't explain most of it, but it has been shown by a lot of good research that minority group members, even when they have insurance and can get in the door of the clinic, often receive inferior care. This could have to do with racism or other kinds of prejudices on the part of providers, poor provider-patient communication, non-financial barriers to receiving good care -- we don't completely know. But methods of raising quality overall tend to reduce disparities, because they make medical decision making less arbitrary and better based in evidence.

So, this is another major topic for this blog. More on this later. Soon, I want to respond to some of the interesting comments I've recieved in a top-level post. And I will also talk about citizen organizing and activism for public health and better health care, which I believe are a very promising approach to democratizing social policy in the U.S. Thanks to everyone who has visited and contributed!

Friday, December 03, 2004

Reality bites

So we have a Chairman of the Dept. of Economics somewhere writing a letter to the Boston Globe (Wednesday, Dec. 1) explaining that the reason the U.S. spends so much on health care is that people have insurance, so that consumers are insulated from the costs. If we can just get rid of that ugly violation of free market principles, we'll see health care spending much better controlled.

The gentleman just proves what has always been obvious: economics is a branch of theology, not science. Out there in that godless place called Reality, one observes that the U.S. spends 2 to 3 times as much per capita on health care as do any of the other affluent countries. Yet in all those other countries, everybody has health insurance. In the U.S., something like 15% of the people don't! Not only that, but in most of those countries that just refuse to obey the laws of economics and of God, consumers make little or nothing in the way of copayments, whereas here, most people pay something like $10 and up for an office visit and $5 to $20 for a prescription. Medicare recipients generally have paid 100% of the cost of their drugs. But for some reason, health insurance isn't causing even half as much spending in other countries as it does here.

The scientific process consists of observing reality, and trying to explain what one observes. Theology consists of starting with received wisdom and building fanciful arguments on that foundation. If reality doesn't happen to correspond to one's conclusions, the fault lies with reality. Hence our newly faith-based National Park Service tells visitors that the Grand Canyon was created by Noah's flood, and the Department of Economics tells students, and newspaper readers, that our excessive health care costs are created by health insurance.

As Mr. Bush's Lower Father once said, Facts are stupid things.

Thursday, December 02, 2004

Medical Savings Accounts

We've talked about some of the ways in which free market fundamentalism makes no sense whatever as applied to medical services. (Not that it makes sense in any other context either, but that's for others to discuss.)

Now Mr. Bush, as part of his so-called "ownership society," wants to let us set up tax-advantaged savings accounts to pay for medical costs, keeping only catastrophic insurance. Supposedly, this will give us "control" over our own health care, while restraining spending on medical services by making consumers pay more of the cost out of pocket. The theory is, of course, that since most people's costs are paid by insurance, they don't are about the cost and so they tend to overconsume, ergo that is the explanation for the steadily rising share of GDP represented by health care.

I think my recent postings give readers enough tools to discover the problems with this proposal. I'll weigh in later, but for now, does anyone care to comment?

Wednesday, December 01, 2004

The Ideology of Privilege

Sorry for the long post, some ideas are just complicated.

Economists have provided capitalists with a comforting concept called the "free market." This is essentially a religious idea. It does not describe any part of reality, at any place or time. It's a mantra conveniently invoked when it is proposed that government do something the faithful don't like, and just as conveniently ignored whenever they want government to do something for them.
The "free" market is supposed to insure that society's resources are allocated "efficiently". We are all taught to pursue efficiency, but it is definable only in terms of desired outcomes, that is to say value judgments.
Markets are not a force of nature. They are human social constructions, and cannot exist independent of social conventions. In complex societies, such as nation-states, they cannot exist apart from systems of law and politics. No market is "free," all markets are regulated. The question is how they will be regulated, for whose benefit, not whether they are "free". Furthermore, the characteristics of the "free" market which are supposed to maximize allocative efficiency, while they can never be attained in practice, can only be approached through sustained and elaborate political and legal intervention.
The economists' method is to make a number of fundamental assumptions which are contrary to fact, not sometimes, but all the time. They then spin out an elaborate theory of efficient "free" markets based on these counterfactual assumptions. Thereafter, their project is to somehow reconcile the real world with their fantasy. This is not science, but theology. Just as theologians must depend on mysticism to reconcile the existence of evil with a benevolent, omnipotent creator, so free market ideologues are practitioners of faith-based sophistry.
Although all markets violate the requirements of the so-called free market, the market for medical services is one in which this is particularly easy to see. For example, ideal market transactions are supposed to be based on "perfect information." Consumers are supposed to know everything of importance to them about products offered for sale, and alternative products. That condition is impossible to satisfy in principle, but sometimes we can come reasonably close. We can try several brands of cheese until we find one we like. Of course, if we don't know what's in it, in particular its nutritional content, we lack critical information. That's why the ideologues could not resist food labeling requirements.
Medical services are not like cheese. We might know that we have a good personal rapport with our family doctor, but few consumers have any basis for comparing the quality of available services on most dimensions of importance. How good are your surgeon's hand skills? You won't know until it's too late. That is the rationale for requiring physicians to go through prescribed training regimens, to pass licensing examinations, and to retain their licenses at the will of a government authority – in other words, government intervention in the market. (The particular way this happens in the real world is a more complex story. Licensing gives a monopoly of prestige, eligibility for reimbursement and the most lucrative employment, to a politically influential priest-like caste of healers who adhere to an exclusive ideology. )
Another way in which all markets depart from the theoretical ideal is called "externalities." The theology of the market assumes that all of the costs and benefits of a transaction are felt by the parties to the transaction – that no-one else is affected. This is never true. The most commonly recognized example is pollution. Buyers and sellers make markets for cars and gasoline, but bicycle riders and pedestrians have to breathe the fumes. So we regulate the design of motor vehicles to reduce pollution, though not enough.
An obvious example of an externality in medicine is communicable disease. If we count on people to seek out and pay for treatment on their own, we leave others at risk when they don't. A slightly more subtle example is that people whose economic productivity is constrained because they are ill or disabled can't contribute to the support of their families or the total wealth of society. Because society chooses not to provide adequate services to people with mental illness or substance abuse problems, many of them end up living on the street, as a visible social problem which interferes with other people's use of public spaces.
As another example, ideal market transactions are supposed to take place between "willing sellers and willing buyers." Sellers of medical services are no doubt willing, but buyers? You might well go into the emergency room unconscious, in such pain or distress, or so demented, that you can't make any choices.
I was admitted to a hospital a few years ago with a diagnosis of acute appendicitis. They told me they were going to remove my appendix, and anaesthetized me. When I woke up seven hours later, I found they had removed half my colon, in the mistaken belief they had discovered cancer. Thanks to the surgery and ensuing complications, I spent 11 days in the hospital. They sent me a bill for $25,000. Was I a willing buyer?
Even when consumers are lucid, the notion of "willingness" on the part of buyers is often elusive. If we believe the alternative to buying a service is death or disability, are we willing? Economists will say yes, we are extremely willing, in fact. But philosophically, the idea of need enters the market for medical services, although economists would prefer to speak of "preferences" or "tastes". Well, most of us prefer life to death.
Notice I've left out the ethical implications. The dirty little secret of the free-market ideologues is that, no matter how they stretch and torture their theory, nobody has been able to make an intellectually respectable case that the free market in any way insures distributive justice. This is true generally, but in the case of health care, it's immediately obvious. Notwithstanding that there is much we can do as individuals, families and communities to protect and improve our health, sickness and injury are often the product of just plain bad luck. If a child develops leukemia, we don't consider that a just product of the invisible hand.
Yet people may be impoverished by large medical bills, or completely unable to pay for needed medical services. Hence we feel it is right and proper that medical services be paid for by insurance. That's a major reason why those 40 million-plus uninsured, and 60 million underinsured people, are a serious social problem.
That's also why most people are in fact covered by insurance. However, that wholly or partially insulates the individual consumer from considerations of cost. Our physicians know this also, so under the old indemnity insurance system, they would have no compunctions about ordering up all the tests, procedures, consultations, nursing services and other interventions they could think of.
Medical services are expert services: we depend on our physicians to tell us what we need. This basic fact, which is related to the above issues of imperfect information and unwilling buyers, constitutes provider induced demand. In the (non-existent and fantastic) free market, consumers create demand. Suppose that every time Bill Gates said you needed a new word processor, you went out and bought one. What would happen to the price of software? To the volume of software sold? (To some extent, of course, this does happen – but that's another discussion.)
Medical services, historically, have been exactly like that. Some argue that physicians have a "target income" – that they will do enough procedures to make their boat payments and send their daughters to Bennington. It is a fact, for example, that the number of coronary bypass operations per capita varies enormously by geographic region, not related to the incidence of heart disease, but only to the concentration of cardiac surgeons.
Now we can begin to see why we pay so much more in the U.S. for medical services than in other countries, and why costs have increased so much in past decades. The first reason for the trend of dramatically increasing costs has to do with the development of expensive new technologies. New technologies don't have to increase costs. For example, arthroscopic surgery saves money compared with old-fashioned knife surgery. But our system has had no good way of selecting for technologies that are more efficient. If it's possible to do a PET scan, everybody has to have one.
This is a difficult issue for many Americans to confront, but it's profoundly important. At what point does it make sense to forego vastly expensive measures that have little prospect of prolonging or restoring a decent quality of life? People seem to have an instinctive aversion to the idea of "rationing" health care. It seems morally compelling, when confronted by a specific, desperately sick individual, to do whatever is possible that may offer a chance of saving that person. Yet these costs are ultimately born by society, paid through taxes or other people's insurance premiums – a society which is unwilling to spend enough to properly educate, feed and house all its children. And all too often, high technology intervention with desperately ill people merely inflicts needless suffering. Other wealthy societies have in fact made different choices about these issues; their medical systems do not have the same presumption of unrestrained interventionism.
The second reason for the upward trend in medical costs is simple: the price of goods and services used in medicine has tended to increase faster than general inflation. Drug companies' profits are greater than the average rate of profit, physicians' salaries increased steadily after World War II, as did the salaries of hospital executives and administrators. These prices are much higher than in other countries, as anyone knows who has purchased pharmaceuticals abroad.
Two other reasons why costs are so much higher in the U.S. than elsewhere are unnecessary "care" and administrative costs. When someone is subjected to a medical procedure which does not benefit them, and probably harms them, I'm not sure how you can call it "care", but that's what they call it. This is related, obviously, to provider induced demand. Administrative costs in the U.S. are high principally because of the system of private insurance. Insurance companies have marketing and claim processing costs, and make large profits; providers have costs associated with the complexities of billing many different payers. The systems in other countries avoid many of these costs.
Finally, many people assume that the aging of the population is an important reason for rising medical costs. Elderly people do consume more medical services, but the "graying of America" is a gradual process which explains little of the cost trend so far.