This article reminds me of my mother's experience with
treatment for uterine cancer at the University of
Kentucky. After her surgery, it was recommended that
she begin a chemotherapy regimen. I immediately
wondered what scientific evidence there was to support
the therapy. I was eventually able to track down the
oncologist hired by my mother, and asked him what
evidence he had. He responded, "There is one study of
five people which is statistically insignificant." In
other words, he had nothing.

A physician (or other practitioner) who offers an
unproven remedy --such as laetrile-- will be
persecuted and possibly jailed. A respected university
physician who offers an unproven treatment will not
lose money, freedom, or even professional status.
Social position, cultural and political views
differentiate "quackery" from "experimentation."

The surgery almost certainly extended my mother's life
span, but the grueling (and expensive) chemo- and
radiation therapies probably had no effect and she
died from metastatic liver cancer 2 years later.

------------------------
New York Times
May 13, 2001

Study Suggests Overuse of Chemotherapy Near Life's End

By LAWRENCE K. ALTMAN

AN FRANCISCO, May 12 — Many cancer patients receive
chemotherapy at the end of life, even if their kind of
cancer is known to be unresponsive to the drugs,
according to a study reported here today.

The study, involving cancer patients who died in
Massachusetts in 1996, found that a third of them
received chemotherapy in the last six months of their
lives. That finding "strongly suggests overuse of
chemotherapy at the end of life," said Dr. Ezekiel J.
Emanuel, the senior author.

Dr. Emanuel, the chairman of the department of
clinical bioethics at the National Institutes of
Health, was one of several researchers to report
findings on cancer care at the opening of a meeting of
the American Society of Clinical Oncology, expected to
draw more than 24,000 cancer specialists.

His team's findings support the growing view that
oncologists continue to prescribe chemotherapy for too
many cancer patients when clinical evidence indicates
they are in the terminal stages of the disease. There
are no guidelines for the appropriate use of
chemotherapy at the end of life based on
scientifically controlled trials or consensus
statements, Dr. Emanuel said in an interview.

Dr. Emanuel's team from Boston University and Stanford
University linked information from death certificates
in Massachusetts and Medicare billing records. The
researchers used standard textbooks to classify
whether different cancers were generally responsive or
unresponsive to chemotherapy. Responsive cancers
included in the study were breast, colon and ovarian.
Unresponsive cancers included gallbladder, kidney,
liver and pancreatic cancer and melanoma.

The researchers then analyzed information about the
7,919 people in the study who died of cancer and
concluded that responsive and unresponsive cancers
were treated equally often with chemotherapy at the
end of life.

About one-third of patients with unresponsive cancers
received chemotherapy in the last six months of life;
the figures dropped below 10 percent in the last month
of life.

Additional studies are needed before such findings can
be confirmed nationally and to develop guidelines on
when chemotheraphy should be stopped in terminal
cases, Dr. Emanuel said. He also urged studies to
determine how much managed care and traditional
fee-for-service practices influenced the timing of
chemotherapy. In addition, he said, studies are needed
to better understand how the interaction among
doctors, patients and families influence the use of
chemotherapy in terminal stages of cancer.

Dr. Emanuel's study was one of many that researchers
have conducted in response to public criticism about
cancer care. Other studies reported today dealt with
how patients feel during chemotherapy, how families
respond to the stress the patients experience, and
issues surrounding care at the end of life.

A team led by Dr. Michael J. Glantz, then of Brown
University, found that married women with malignant
brain cancers had a much higher rate of separation and
divorce than men with the same condition.

Among 214 patients with brain tumors in the study,
women were eight times more likely to undergo
separation or divorce than men. Similar rates were
found among male and female patients with multiple
sclerosis and systemic cancer.

Because the people with brain cancers survived little
more than a year from the time of diagnosis, Dr.
Glantz said, the separation and divorce "occurred
rapidly and at a time when they were most in need of
support." His team did not examine the extent of
marital discord among the patients before the brain
tumor was diagnosed.

Dr. Glantz said he undertook the study because in
caring for patients with brain tumors, he developed a
sense that there was a high rate of divorce and "the
burden fell primarily on the woman when she was the
affected partner."

Dr. Glantz said that although he and other male
doctors were astonished by the findings, "none of the
nurses, colleagues and other women I work with was
surprised."

This summer, Dr. Glantz will start work at the Barrow
Institute in Phoenix and he said his team would begin
studies to determine if marriage counseling or other
types of counseling can help patients with brain
tumors and their spouses cope with the disease.

Depression and fatigue are frequent problems of
patients undergoing chemotherapy, and a common notion
among cancer doctors is that they are linked. But they
were found not to be linked in a study by Dr. Gary R.
Morrow's team from the University of Rochester Cancer
Center.

Dr. Morrow's team found that although a drug on the
market, Paxil, could relieve depression among cancer
patients receiving chemotherapy, it failed to relieve
symptoms of fatigue. "While the study does not totally
disprove the theory, it certainly casts doubt on it,"
Dr. Morrow said in an interview.

The findings suggest that fatigue in such patients is
more related to the cancer and its treatment rather
than depression, Dr. Morrow said.

Depression has been well recognized among cancer
patients but undertreated, Dr. Morrow said. He also
said that the study showed that a drug was as good for
depression among cancer patients as it was for
depressed patients without cancer.

Another major problem for cancer patients undergoing
chemotherapy is loss of appetite and weight. Many
people contend that marijuana lessens the problem.

But in another study involving 469 patients, a team
led by Dr. Aminah Jatoi of the Mayo Clinic in
Rochester, Minn., found that a marketed derivative of
marijuana, known as Marinol or dronabinol, was less
effective than a standard treatment, known as Megace
or megestrol acetate, in stimulating appetite among
cancer patients and increasing their weight.

The marijuana derivative was tested alone and in
combination with megestrol. Megestrol is a synthetic
female hormone that is widely prescribed to induce
weight gain.

Appetite improvement was reported more often by
patients receiving megestrol than dronabinol (73
percent compared with 47 percent). Weight gain was
also higher among the megestrol group (13 percent
compared with 5 percent).

Dr. Jatoi said her team was now studying other drugs,
but not marijuana or other components, for their
effect on appetite and weight loss.

Surgery is the standard therapy for cancer of the
esophagus. But in a large British study, Dr. Peter
Clark's team from the Medical Research Council in
London found that a short course of chemotherapy given
before surgery extended life for patients with cancer
of the esophagus.

And a combination of chemotherapy and radiation can
spare removal of the voice box among some patients
with cancer of the larynx, Dr. Arlene Forastiere of
Johns Hopkins reported. The study involved patients
who had spread of the cancer within the larynx but not
beyond it.

A study of an experimental drug, IMC-225 (cetuximab),
showed a benefit in some patients with colon cancer
that did not respond to standard drugs. Cetuximab is a
member of a new class of drugs that blocks a receptor
on the surface of cancer cells known as epidermal
growth factor. Colon cancers shrank by 50 percent or
more among 27, or 23 percent, of 121 patients who
received cetuximab in addition to standard
chemotherapy.


__________________________________________________
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A loud chorus attacks greedy HMO/insurers. So why are so many
of these "greedy" companies doing poorly?

New York Times
May 10, 2001

Aetna Posts Loss Amid Higher Costs
By REUTERS
Filed at 1:36 p.m. ET

CHICAGO (Reuters) - Aetna Inc. (AET.N), the largest U.S. health
insurer, on Thursday reported a first-quarter operating loss of
$36.6 million as higher-than-expected medical costs continued
to plague the company.

Hartford, Conn.-based Aetna said the loss amounted to 26 cents
per share and compared with a year-earlier profit of $86.2
million, or 61 cents per share.

The 148-year-old company, which in recent years has been
grappling with high medical costs, the integration of massive
acquisitions and contentious relations with physicians, is in the
midst of a vast restructuring that includes layoffs and changes in
business strategies.

``The quarter was evidence of the situation that Aetna is in, which
is a difficult one,'' said David Shove, an analyst at Prudential
Securities, who tracks managed-care firms.

Aetna's dismal first-quarter was even worse than analysts had
expected. Following a dire profit warning from the company last
month, analysts cut their earnings forecasts, to a consensus
estimate of 1 cent a share. Forecasts ranged from a loss of 15
cents a share to a profit of 10 cents.

Aetna's stock fell almost 7 percent to a new 52-week low of
$23.70 in morning trade on the New York Stock Exchange, but it
later recouped and was up 15 cents at $25.55 in afternoon
dealings. The stock has underperformed the Standard & Poor
Managed Care index by about 65 percent over the past year.

PROFITABILITY VS. MEMBERSHIP GROWTH

Investors had hoped Aetna would provide specific earnings
guidance for the remainder of the year, but company officials
said in a telephone conference call that they could not provide
quarterly or yearly earnings forecasts with any confidence.

Aetna said restructuring efforts and other changes would help
improve its financial performance through 2002 and make it
comparable to that of other national health insurers by the end of
2003.

Aetna officials also stressed during the call that the company
intends to renew its contracts with employers and other
customers and price its products with a focus on profitability,
even at the expense of a drop in membership.

``We will look at each market with a bias toward profitability, not
toward growth,'' Ronald Williams, Aetna's new chief of health
operations, said in the conference call.

In fact, the company said it expects a decline of up to 10 percent
in its overall health-care membership this year -- from 19.3
million members in 2000 -- and said additional reductions might
be necessary as its operations are analyzed.

Analysts said a reduction in membership is favorable for Aetna
because costs per member have been running high.

``Personally, (I think) this company needs to be significantly
smaller than it currently is,'' Shove said.

However, Dr. John Rowe, a physician and chairman and chief
executive of Aetna, told Reuters during a telephone interview that
the company hopes to get back to a growth mode next year.

``This is the first time we're getting smaller because we're
exercising more discipline with respect to markets,'' Rowe said.
''We are pruning the bush for future growth. After we cull the
membership of unprofitable cases, we'll grow the membership
going forward.''

COMPANY TO STICK TO KINDER, GENTLER STRATEGY

On a net basis, Aetna's first-quarter loss -- including $34.3
million in charges from prior-period medical costs related to
Medicare markets that the company exited -- was $48.2 million,
or 34 cents a share, compared with net income of $170 million,
or $1.20 a share, in last year's first quarter. Last year's net
income included a gain of $94.6 million, or 67 cents a share,
from discontinued operations.

Aetna's total revenues in the first quarter fell nearly 5 percent, to
$6.43 billion from $6.76 billion a year earlier. Revenues from
health-care premiums fell 7 percent, to $5.07 billion from $5.46
billion.

Aetna said it was disappointed with the first-quarter results and
blamed the higher-than-expected costs on increased patient use
of outpatient, pharmacy and other services for the second
straight quarter.

Analysts have said the higher costs are a result of Aetna's move
to become a ``kinder, gentler'' health-care manager by easing
restrictions on doctors, hospitals and its members. At one time
Aetna developed a reputation for being too stingy with its
payments to providers, but it has been working hard to repair
those relations.

Rowe said Aetna's strategy will help the company eventually
attain profitability.

``Is a kinder, gentler Aetna hurting us?'' he asked in the
conference call. ``We believe that for Aetna to be successful, we
need to improve relations with doctors and hospitals ... We are
confident that is the pathway to improved profitability. We have no
intention to retreat (from the strategy.)''

Aetna's medical loss ratio -- a key figure that looks at the portion
of premium revenues spent on medical costs such as payments
to doctors and hospitals -- increased sharply in the first quarter
in its private-sector commercial business and its Medicare
programs. Wall Street views a drop in the ratio as an
improvement.

InsightMag.com

A Prescription for Violence?

By Kelly Patricia O’Meara
komeara@...

The recent wave of school-shooting incidents has some
concerned parents demanding that the medical records
of students taking psychotropic drugs be made public.

In the last 10 shooting incidents at schools, a total
of 105 students, teachers and administrators were
killed or wounded. Beginning in March 1998 with the
shooting at Westside Middle School in Jonesboro, Ark.,
and ending with the March 22, 2001, shootings at
Granite Hills High School in El Cajon, Calif., six of
the 12 juvenile shooters are reported to have been on
prescribed mind-altering drugs.
       San Diego Deputy Public Defender William
Trainor announced last week that his client,
18-year-old Jason Hoffman, who is charged with the
shooting of five students and teachers at Granite
Hills High School, had been prescribed the
antidepressants Celexa and Effexor. Whether Trainor
intends to use this medical information as part of his
client’s defense is unclear, though he said that “the
drugs [Hoffman] was prescribed may help explain his
actions.” He adds that research “indicates that the
drugs that were prescribed are extremely powerful
antidepressants with the most dangerous side effects.”

       According to Loren Mosher, professor of
psychiatry at the University of California at San
Diego, “Celexa and Effexor are selective serotonin
reuptake inhibitors [SSRIs] in a class with Prozac,
Paxil and Luvox” — the same drug prescribed to
Columbine shooter Eric Harris.
       It appears Trainor believes there is a
correlation between the drugs and the shootings.
Although he could not provide specific information
about his client, he tells Insight that this is a
hot-button issue and there are many people who don’t
want to look at the connection. “If you say those
drugs may be involved,” says Trainor, “you’ll be
labeled a kook.” But “with the history of these drugs
there is a huge unpredictability factor. When someone
goes off while on these drugs it should raise some
eyebrows in the community. I’m starting to wonder when
the public has the right to this information. What is
the balance of rights? It’s his medical rec-ords
versus the public right to be safe. Which one has the
trump card? It is a legitimate question.”
       Although Trainor is not the only public
official to consider the possibility that widely
prescribed mind-altering drugs may play a role in
much-publicized school violence, he is among the few
to make public the issue of medical records generally
being protected and put off-limits. The privacy of
medical records, including mental-health information,
is protected by law. The information about the
prescription-drug history of an accused perpetrator is
only made public when the information is released by
the family, school officials, friends and, sometimes,
law-enforcement officers and attorneys.
       And, of course, such information seems to be of
interest to the public only in the wave of concern
after a violent event, making it difficult even to
consider whether prescribed psychotropic drugs are a
chronic cause of otherwise senseless violence.
       In fact, so little information has been made
public about these mind-altering drugs and their
connection to shootings and other school violence that
the U.S. Department of Justice (DOJ) isn’t even
looking at the possibility. When asked about a
community’s right to know if an alleged shooter has
been prescribed a psychotropic drug, Reagan Dunn, a
spokesman for the DOJ, tells Insight: “There are two
issues that you’ve raised — medical-record privacy and
criminal records of juveniles. These records are
sealed by statute in all states. It [the connection
between psychotropic drugs and school shooters] isn’t
an issue we’re looking at — there are other priorities
we’re focusing on, such as school-resource officers
[safety officers] and other programs to reduce school
violence.”
       But two other federal law-enforcement agencies,
the FBI and the U.S. Secret Service, appear to be
concerned about the increasing number of school
shootings and have invested a great deal of time and
effort to look into the possible reasons for them. The
FBI published a report last year called The School
Shooter: A Threat Assessment Perspective. The 41-page
report was the result of a joint effort by the
National Center for the Analysis of Violent Crime
(NCAVC) and teachers, school administrators and
law-enforcement officers involved in investigating
each of the school shootings. They were assisted by
experts in adolescent violence, mental health,
suicidology and school dynamics. Eighteen
school-shooting cases were reviewed for the report.
       Although topics such as family relationships,
school dynamics, social problems, personality traits
and behavior, threat management in schools and the
role of law enforcement are discussed, there is no
mention in the report of increased prescription-drug
use by juveniles.
       Dewey Carroll of the Clinical and Forensic
Psychology Department at the University of Virginia
participated in a threat-assessment conference last
year during which he was asked if, based on the
correlation between psychotropic drugs and the school
shooters, this information should be made public.
Carroll argued that there was no correlation. “Six out
of 12 [school shooters] being on psychotropic drugs is
not a correlation, it is an observation,” he said.
       “A correlation,” explained Carroll, “would be
taking a sample of children on medication and those
not on medication and then making the comparison.
There are a lot of kids who take these medications who
do not commit violence. If you want to look at people
that have risk factors, you have to do scientific
studies.”
       Few professionals who are familiar with the
data would argue with that criticism, but one may
question how such a study can be conducted, as
suggested by Carroll, if the information about whether
a student is on prescribed mind-altering drugs is
regarded as a state secret. And, even when such
information is made available for study, it appears
that little use is made of it.
       Take, for instance, the Secret Service, which
in collaboration with the U.S. Department of Education
and the National Institute of Justice last year
produced a report on how to prevent school violence.
The Interim Report on the Prevention of Targeted
Violence in Schools was made public in October 2000,
involving “systematic analysis of investigative,
judicial, educational and other files and interviews
with 10 school shooters.”
       Although researchers reviewed primary-source
materials such as investigative, school, court and
mental-health records and conducted supplemental
interviews with 10 of the attackers, no mention was
made in the report about prescription medications of
the kind that Insight has collected. Nor did the
Secret Service respond to Insight’s questions about
why that issue was not addressed at the conference or
made part of the report.
       Despite the fact that two federal
law-enforcement agencies had the opportunity to view
the personal files of many of the school shooters,
important medical data gleaned from those files
apparently was ignored. This has caused many
interested in this issue to wonder, like San Diego’s
public defender, when the public has the right to know
such information.
       Not surprisingly, while every professional
interviewed for this article expressed concern about
the privacy rights of children, there also was concern
about the use of mind-altering prescription drugs.
Most are beginning to wonder at what point communities
into which disturbed children are sent while on
psychotropic drugs should be alerted to a potential
problem.
       JoAnne McDaniels, acting director for the
Center for the Prevention of School Violence, an
organization focusing on keeping schools safe and
secure, tells Insight, “There is concern on the part
of some in the education community that we are
overmedicating our youngsters — that it is easier to
drug them into appropriate behavior.
       “It is important to recognize that the schools
today have children that are being medicated in ways
that children were not years ago. We shouldn’t be too
quick to isolate psychotropic drugs as a causal
factor, but it is an important factor in trying to
understand what is taking place. In a general sense,
in a school population, parents should be able to see
this information,” McDaniels says. “If a parent moves
to a community and wants to know the numbers of
children who are on these drugs, making such numbers
available would not necessarily violate
confidentiality of children. I think as long as the
information is not individualized it should be
information a principal is comfortable providing. It
may force the principal to explain how the school
handles the entire violence issue and the use of
medication to control behavior in the school. It’s
reasonable for a school to share that information and
a parent to ask for it. It’s part of the school
community and part of the school’s fabric.”
       “The message,” concludes McDaniels, “is that we
need to develop youngsters without stimulants and
other foreign substances. Too often we are opting for
a way of treatment that is a lot easier to implement
than sitting down and working out the problems. This
is a public-health issue and it seems reasonable to
look at it.”
       James E. Copple is vice president of the
National Crime Prevention Council, a nonprofit
organization that focuses on creating safer
communities by addressing the causes of crime and
violence and reducing the opportunities for crime to
occur. He is a former principal and superintendent of
schools in Wichita, Kan., and sees the merits of both
sides of the issue. “I tend to lean on the side of
doing everything possible to protect the student’s
right to privacy,” he says, “but when they commit an
act of violence all the factors involved in the crime
— including medications — need to be known by that
community.”
       As Copple sees it, “Communities need to know if
large numbers of children are on psychotropic
medications. It is increasingly being talked about by
educators, and it has put schools in the position of
creating mini health clinics for drug management on
top of having to teach the children and all the other
responsibilities. Why all of a sudden do we have to be
a pharmacy? Principals are forced to choose between
hiring another much-needed teacher or another nurse to
dispense drugs.”
       The executive director of the National School
Safety Center, Ronald Stephens, isn’t convinced that
releasing information about the number of students
being prescribed mind-altering drugs necessarily is a
violation of a child’s rights. “It’s legal and it’s
become common practice to search lockers whenever the
student is involved in an incident, and there are some
states now mandating that teachers be given
information about the reasons behind a student who is
returned to school on probation. It’s the thought that
if you’re going to put Charlie Manson in my class I
have a right to know that.”
       According to Stephens, “We tend to get what we
measure. But if we don’t ask we’re not going to get
real answers. We have kids so medicated it’s
incredible. I don’t see parents asking the question
about the numbers of children on psychotropic drugs as
being all that invasive. The public would be shocked
at the number of file drawers of prescription drugs
that teachers are asked to dispense.” Stephens says he
thinks “it would be a great study for someone to go
back and see how many of the kids who committed these
violent acts were on these drugs. The community should
know who is taking them, and I think teachers will
want to know which kids are on these drugs. Knowing
what I know about school violence, I would support
having that information shared. Of course, there will
be a huge outcry that someone’s rights are being
violated, but at what point do they lose those
rights?”
       That is of course the question, and with 6
million to 8 million children already taking Ritalin,
and unknown millions being prescribed the much
stronger mind-altering SSRIs, many are starting to ask
it.
       

------------------------------------------------------------------------
This document was printed out from InsightMag.com.
You can find the original at
http://www.insightmag.com/archive/200105217.shtml

__________________________________________________
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Tuesday May 8 3:42 PM ET
95 Percent of U.S. Doctors Have Seen Medical Error

By Will Dunham

WASHINGTON (Reuters) - Some 95 percent of doctors say
they personally have witnessed a serious medical
error, according to a survey on quality in the U.S.
health care industry released on Tuesday.

Six hundred doctors, 400 registered nurses and 200
senior-level hospital executives were questioned in
the survey released by the Robert Wood Johnson
Foundation, which sponsors health care research.

Asked whether they had seen ``major quality of care or
medical mistakes,'' 4 percent of doctors said they had
witnessed them frequently, 27 percent said
occasionally and 64 percent said infrequently. The
survey did not define specifically what entailed a
major mistake.

Among the nurses asked the same question, 89 percent
said they had witnessed a mistake, with 71 percent
saying it was infrequent, 15 percent occasional and 3
percent frequent. Some 82 percent of hospital
executives also said they had seen a major medical
mistake (1 percent frequent, 13 percent occasional and
67 percent infrequent).

Experts said in a 1999 report that medical errors kill
between 44,000 and 98,000 people annually, with up to
7,000 of those deaths resulting from mistakes in
prescribing or dispensing drugs.

Those questioned in the survey generally gave high
marks to quality of the U.S. health care system in
terms of safety, effectiveness, timeliness and other
measures. Some 80 percent said it was either very good
or excellent (42 percent) or good (38 percent), while
18 percent rated it fair and 2 percent rated it poor.

``The quality-of-care problems in American medicine
are rooted in the culture of medicine, which has
emphasized individual performances over teams and
systems; in the structure and infrastructure of our
organizations and institutions; and in our payment
systems, which do not promote quality care,'' Lewis
Sandy, executive vice president of the Robert Wood
Johnson Foundation, said during a news conference.

``To many observers of the health care system, and to
many within it, these problems are so complicated that
they seem able to thwart every effort to significantly
improve the quality of care.''

The survey, conducted by polling firm Wirthlin
Worldwide, had a margin of error of plus or minus 4
percentage points.

In conjunction with the release of the survey, the
foundation announced the launch of a $20.9 million
initiativein which six hospitals and doctors'
organizations will be given grants of up to $3 million
to perform work aimed at improving the quality of
health care in America.

__________________________________________________
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Br J Sports Med 2001; 35:114-117
© 2001 the British Journal of Sports Medicine

Benefits from aerobic exercise in patients with major
depression: a pilot study

F Dimeo1, M Bauer2, I Varahram1, G Proest2 and U
Halter2

1 Department of Sports Medicine, Freie Universitaet,
Berlin, Germany
2 Department of Psychiatry


Correspondence to: Dr Dimeo, Freie Universitaet
Berlin, Benjamin Franklin Medical Center, Department
of Sports Medicine, Clayallee 229, 14195 Berlin,
Germany ferdimeo@...

Background—Several reports indicate that physical
activity can reduce the severity of symptoms in
depressed patients. Some data suggest that even a
single exercise bout may result in a substantial mood
improvement.

Objective—To evaluate the short term effects of a
training programme on patients with moderate to severe
major depression.

Methods—Twelve patients (mean (SD) age 49 (10) years;
five men, seven women) with a major depressive episode
according to the Diagnostic and Statistical Manual of
the American Society of Psychiatry (DSM IV) criteria
participated. The mean (SD) duration of the depressive
episode was 35 (21) weeks (range 12–96). Training
consisted of walking on a treadmill following an
interval training pattern and was carried out for 30
minutes a day for 10 days.

Results—At the end of the training programme, there
was a clinically relevant and statistically
significant reduction in depression scores (Hamilton
Rating Scale for Depression: before, 19.5 (3.3);
after, 13 (5.5); p = 0.002. Self assessed intensity of
symptoms: before, 23.2 (7); after, 17.7 (8.1); p =
0.006. Values are mean (SD)). Subjective and objective
changes in depression scores correlated strongly (r =
0.66, p = 0.01).

Conclusions—Aerobic exercise can produce substantial
improvement in mood in patients with major depressive
disorders in a short time.

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Depressed? Take a walk
Monday, 25 October  1999 

New research shows that a brisk 30-minute walk or jog
three times a week may be just as effective in
relieving major depression as anti-depressant
medications.

A Duke University Medical Center study, published in
the current edition of The Archives of Internal
Medicine, shows elderly subjects with major depression
had the same results from a mild exercise routine as
with standard anti-depressant treatment.

"Almost one-third of depressed patients in general do
not respond to medications, and for others, the
medications can cause unwanted side effects. Exercise
should be considered a viable option." said lead
researcher, psychologist James Blumenthal. "While we
don't know why exercise confers such a benefit, this
study shows that exercise should be considered as a
credible form of treatment for these patients,"

The researchers studied 156 elderly patients diagnosed
with major depressive disorder and assigned them to
three groups: exercise, medication, or a combination
of both. To the surprise of the researchers, after 16
weeks all three groups showed statistically
significant and similar improvement in measurements of
depression.

While the subjects in the study were middle-aged and
elderly people, Blumenthal said the results probably
hold true for the general population. "Because the
elderly tend to have additional medical problems that
might make regular exercise difficult, this is the
most difficult group to test the exercise hypothesis."


"Simply taking a pill is very passive," he said.
"Patients who exercised may have felt a greater sense
of mastery over their condition and gained a greater
sense of accomplishment."

The anti-depressant used in the study was sertraline
(trade name Zoloft), which is a member of a class of
commonly used anti-depressants known as selective
serotonin reuptake inhibitors.

---------------
Effects of Exercise Training on Older Patients With
Major Depression  
 
James A. Blumenthal, PhD; Michael A. Babyak, PhD;
Kathleen A. Moore, PhD; W. Edward Craighead, PhD;
Steve Herman, PhD; Parinda Khatri, PhD; Robert Waugh,
MD; Melissa A. Napolitano, MA; Leslie M. Forman, MD;
Mark Appelbaum, PhD; P. Murali Doraiswamy, MD; K.
Ranga Krishnan, MD

Background  Previous observational and interventional
studies have suggested that regular physical exercise
may be associated with reduced symptoms of depression.
However, the extent to which exercise training may
reduce depressive symptoms in older patients with
major depressive disorder (MDD) has not been
systematically evaluated.

Objective  To assess the effectiveness of an aerobic
exercise program compared with standard medication
(ie, antidepressants) for treatment of MDD in older
patients, we conducted a 16-week randomized controlled
trial.

Methods  One hundred fifty-six men and women with MDD
(age, 50 years) were assigned randomly to a program of
aerobic exercise, antidepressants (sertraline
hydrochloride), or combined exercise and medication.
Subjects underwent comprehensive evaluations of
depression, including the presence and severity of MDD
using Diagnostic and Statistical Manual of Mental
Disorders, FourthEdition criteria and Hamilton Rating
Scale for Depression (HAM-D) and Beck Depression
Inventory (BDI) scores before and after treatment.
Secondary outcome measures included aerobic capacity,
life satisfaction, self-esteem, anxiety, and
dysfunctional cognitions.

Results  After 16 weeks of treatment, the groups did
not differ statistically on HAM-D or BDI scores (P =
.67); adjustment for baseline levels of depression
yielded an essentially identical result. Growth curve
models revealed that all groups exhibited
statistically and clinically significant reductions on
HAM-D and BDI scores. However, patients receiving
medication alone exhibited the fastest initial
response; among patients receiving combination
therapy, those with less severe depressive symptoms
initially showed a more rapid response than those with
initially more severe depressive symptoms.

Conclusions  An exercise training program may be
considered an alternative to antidepressants for
treatment of depression in older persons. Although
antidepressants may facilitate a more rapid initial
therapeutic response than exercise, after 16 weeks of
treatment exercise was equally effective in reducing
depression among patients with MDD.

Arch Intern Med. 1999;159:2349-2356
 
Author/Article Information
From the Departments of Psychiatry and Behavioral
Sciences (Drs Blumenthal, Babyak, Moore, Herman,
Khatri, Forman, Doraiswamy, and Krishnan and Ms
Napolitano) and Medicine (Dr Waugh), Duke University
Medical Center, Durham, NC; the Department of
Psychology, University of Colorado, Boulder (Dr
Craighead); and the Department of Psychology,
University of California– San Diego (Dr Appelbaum).


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Tuesday May 8 5:55 PM ET
Sexual Problems Common with Antidepressant Use

By Paula Moyer

NEW ORLEANS (Reuters Health) - Sexual problems linked
with antidepressant use may be more common than widely
believed, according to research presented here at the
annual meeting of the American Psychiatric
Association.

In a study of nearly 6,300 patients on newer types of
antidepressants, almost 40% reported sexual
dysfunction--a rate nearly twice what the patients'
physicians predicted.

Dr. Anita L. H. Clayton of the University of Virginia
in Charlottesville and her colleagues used
questionnaires to gauge primary care doctors'
estimates of sexual problems related to
antidepressants, and their actual occurrence.

The physicians said that they expected 20% of patients
on antidepressants to have some type of sexual
problem. However, among the patients surveyed, 37% of
those on newer types of antidepressants such as
fluoxetine (Prozac) reported problems.

``Doctors have been hesitant to discuss
antidepressant-related sexual dysfunction, often
because they are afraid that patients will not want to
talk about it,'' Clayton told Reuters Health.
''However, 70% of patients who were asked to
participate in the survey chose to do so.''

Because both patients and physicians are reluctant to
discuss sexual problems, the topic is often never
mentioned, she noted. However, the development of a
sexual problem, such as impotence, can be discouraging
enough to some patients that they stop their
medications.

Patients need to bring up sexual problems directly,
Clayton said. Most physicians will be willing to find
a solution to the problem, and often the doctor can
prescribe a different medication or adjust the dose.

If the physician seems uninterested or unwilling to
help, Clayton said, ``find a different doctor.''

In this study, she and colleagues found that several
circumstances added to a patient's risk of sexual
problems after starting antidepressant therapy. People
were more likely to have problems if they were age 50
or older, less educated, not fully employed, or smoked
6 to 20 cigarettes per day.

Surprisingly, married people were also more likely to
report problems, perhaps because married patients were
also likely to be older, said Clayton. Patients who
were simultaneously taking other medications also
stood a greater chance of experiencing sexual
dysfunction.

In addition, certain antidepressants were more likely
to be associated with sexual problems. All of the
drugs in a class of antidepressants known as selective
serotonin-reuptake inhibitors (SSRIs) were highly
associated with sexual dysfunction.

Fluoxetine (Prozac), paroxetine (Paxil) and sertraline
(Zoloft) are examples of SSRIs. Bupropion (Wellbutrin)
and nefazodone (Serzone), antidepressants that act
differently on the brain than do the SSRIs, were much
less likely to be associated with sexual dysfunction.

The study was funded by GlaxoSmithKline, which
manufactures several SSRIs as well as bupropion.

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8 May 2001

Adding Insult to Injury
By Jacob Sullum

In 1988, when he was the police chief of Snohomish,
Washington, Patrick Murphy came to the aid of a bus
driver who was being assaulted by a passenger. The man
smashed Murphy on the side of the head with the bus’s
radio, fracturing his jaw.

The broken joint still bothers him, despite two
operations. Worse, the injury, combined with several
others he suffered on and off the job during the next
seven years, put an end to his two-decade career in
law enforcement.

The problem wasn’t that Murphy’s injuries left him too
disabled to work. It was that they made him look like
a drug addict.

In October 1995, Murphy was charged with four counts
of fraudulently obtaining prescription drugs. The
felony charges were filed a week before voters decided
whether to elect him sheriff of Snohomish County, a
post to which he’d been appointed that year. He lost
the election by a landslide.

Six months later, a state judge ruled that the
prosecution had violated Murphy’s right to privacy by
obtaining his prescription records and medical
information without a court order. The evidence was
therefore inadmissible.

Although the judge also said that the state did not
have much of a case anyway, many people probably had
the impression that Murphy got off on a technicality.
Now a Snohomish County jury has vindicated him again,
concluding that he committed no crime and ordering the
state to pay him and his family $2.8 million in
damages.

Murphy believes local officials conspired against him
for political reasons--a charge they’ve always denied
and the jury rejected. Whether or not the prosecution
was malicious, the case illustrates how overzealous
enforcement of the drug laws can transform a patient
into a criminal.

After his jaw injury, Murphy was referred to a series
of doctors, culminating in an oral surgeon, a
specialist in head and facial injuries, who prescribed
the painkiller Percodan and the muscle relaxant Soma.
Murphy had to use a pharmacy that accepted the state’s
medical coverage for job-related injuries, and he says
he chose one outside his neighborhood to avoid gossip.

In November 1993, Murphy fell 22 feet from a ladder
onto the concrete floor of his two-story garage,
fracturing his skull, dislocating his shoulder, and
breaking a thumb, a cheek bone, three vertebrae, and
six ribs. An emergency room physician prescribed the
painkiller Vicodin ES, and two family doctors (both in
the same practice) later prescribed Percocet and M.S.
Contin, a time-release form of morphine.

With Murphy laid up for four months, his family got
his prescriptions filled at whatever pharmacy happened
to be convenient. When he went back to work, he
stopped taking Percocet and M.S. Contin but continued
taking Percodan and Soma for the persistent pain from
his jaw injury.

In April 1995, Murphy injured his knee while getting
out of a helicopter. His family doctor was in the
process of moving to new offices, and she told him to
go to a walk-in clinic, where a physician’s assistant
prescribed the painkiller Darvocet.

A few weeks later, Murphy aggravated his shoulder
injury while installing a sewer line, and his family
doctor prescribed Percocet. Because Murphy was going
away for the weekend, he filled the prescription at an
out-of-town pharmacy. A suspicious druggist called the
state Board of Pharmacy, triggering the investigation
that led to felony charges against Murphy.

From the regulators’ perspective, Murphy was clearly a
junkie looking to get high. After all, he had obtained
various narcotics at a bunch of different pharmacies
with prescriptions from several doctors.

Murphy, who says he always kept the jaw specialist
apprised of the additional drugs he was prescribed,
could have explained the pattern of behavior that
looked so sinister to the regulators. But he says they
never asked for his side of the story.

As a result of his ordeal, Murphy wants to become "an
advocate for intractable pain patients...who are
having problems getting their medication," people who
are "scrutinized, looked down upon, and mistreated"
because the drugs they need are the focus of so much
fear. C. Stratton Hill, a pain expert who testified
for Murphy at the civil trial, called the verdict "a
great victory" for such patients.

Bankrupted by legal expenses, Murphy and his wife can
certainly use whatever damages the state ultimately
pays them. But as he told the Seattle Times, "no
amount of money replaces your reputation."

© Copyright 2001 by Creators Syndicate Inc.

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May 9, 2001

Doubts Are Raised on Benefits of Reflux Surgery

By THE ASSOCIATED PRESS

CHICAGO, May 8 — Surgery for chronic severe heartburn
may not eliminate the need for medication or prevent
throat cancer, according to a study in Wednesday's
issue of The Journal of the American Medical
Association.

The study is a follow-up to research on 247 patients
published in 1992 suggesting that surgery was the best
treatment for severe, chronic heartburn, also called
gastroesophageal reflux disease, which is believed to
affect about 14 million Americans.

Dr. Stuart Jon Spechler, who led the study as chief of
gastroenterology at the Veterans Affairs Medical
Center in Dallas, said the 10-year follow-up
challenged the main arguments in favor of surgery:
that it offered permanent relief, that it prevented
cancer and that it eliminated the need for antireflux
medicine.

Dr. Spechler said surgery might still be advised for
patients who could not tolerate medication, offering
the possibility of at least a few years' relief.

The condition is caused by a faulty valve that allows
stomach contents to back up and cause heartburn.
Sufferers run an increased risk of esophageal cancer,
presumably because of the constant irritation.

Medication is the most common treatment. Each year,
about 35,000 Americans undergo surgery in which
doctors create a new valve by wrapping part of the
stomach around the end of the esophagus.

The new research involved 38 reflux patients operated
on in the late 1980's and 90 treated with drugs alone.
Ten years after their operations, 62 percent of the
surgery patients reported that they were using
antireflux medications regularly.

Four medicine patients and one surgery patient
developed esophageal cancer, but the difference was
not considered statistically significant.

Among the original 247 patients, 79 died: 40 percent
of the surgery patients but just 28 percent of the
medicine group. Nearly half the surgery patient deaths
were from heart disease.

Dr. Spechler said it was unknown whether surgery had
some unknown harmful effects on the heart or whether
reflux medications might somehow protect against heart
disease.



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New York Times
May 8, 2001

Drug Spending Grows Nearly 19%

By ROBERT PEAR

ASHINGTON, May 7 — As an aging population coped with
arthritis, diabetes and high cholesterol, spending on
prescription drugs shot up 18.8 percent last year, to
$131.9 billion, a new study shows.

Two dozen products accounted for half the increase,
which occurred not just because drugs are becoming
more expensive but because doctors are writing many
more prescriptions for higher-cost drugs, the study
said. The study was issued today by the National
Institute for Health Care Management Foundation, a
nonprofit, nonpartisan group that conducts research on
health care issues.

The trend will probably increase political pressure
for new government benefits to help elderly people buy
prescription drugs, but it also makes clear how costly
such benefits could be. President Bush has proposed
spending $153 billion on drug benefits and unspecified
"Medicare reforms" over the next 10 years, but
Democrats say that sum is grossly inadequate, and the
foundation's study may provide new ammunition to both
sides.

The $20.8 billion increase in spending "was
attributable, in large measure, to the rising volume
of prescriptions for the top-selling drugs," the study
said. Researchers said more aggressive marketing by
drug companies contributed to the growth.

The top sellers include Vioxx, an arthritis drug made
by Merck & Company; Lipitor, a cholesterol reducer
sold by Pfizer; Prevacid, an ulcer drug sold by Tap
Pharmaceuticals; Celebrex, an arthritis medicine
marketed by Pharmacia and Pfizer, and Glucophage, a
diabetes drug made by Bristol-Myers Squibb. The
increase in sales of these five drugs alone accounted
for one-fifth of the entire increase in sales of
prescription drugs last year, the study said.

The rate of increase in drug spending was about the
same last year as in 1999, so the foundation estimates
that drug spending rose 40 percent from 1998 to 2000.

That growth has pushed up health insurance premiums
for individuals and families. It has contributed to
increases in the cost of health benefits provided by
employers. And it has driven up the cost of Medicaid,
the federal-state program for the poor.

The report identified three factors contributing to
the increase in retail spending on prescription drugs
last year. It said that 42 percent was attributable to
an increase in the number of prescriptions written by
doctors and filled by pharmacies.

At the same time, it said, a shift toward the use of
more expensive drugs accounted for 36 percent of the
overall increase in spending, while price increases
accounted for the remaining 22 percent.

The 50 top-selling medicines accounted for 30 percent
of all prescriptions last year, and these medications
cost almost twice as much as other drugs, the report
said. The average price for a prescription for one of
the top 50 drugs was $67.15, while the average for
other drugs was $36, it said.

"Simply put," the study said, "Americans are
demanding, and physicians are prescribing, a higher
volume of medicines."

Alan F. Holmer, president of the Pharmaceutical
Research and Manufacturers of America, the main trade
association for drug companies, said, "This report
should be hailed as good news" because it means that
"more patients are getting more and better medicines."

Mr. Holmer said the report confirmed what many
patients had discovered for themselves, that
"prescription medicines are the best value in health
care today, allowing patients to stay out of the
hospital, off the surgery table, on the job and in the
home."

Retail pharmacies filled 2.9 billion prescriptions
last year, an increase of 7.5 percent over the 2.7
billion filled in 1999, the study said. But the 50
best-selling drugs posted a much sharper increase, as
the number of prescriptions rose 18.6 percent, to
866.6 million, from 730.6 million.

The government recently predicted that drug spending
would rise an average of 12 percent a year in the
coming decade, as scientists unlock secrets of the
human genome, the baby boom generation ages and the
nation pours huge sums into biomedical research,
filling the pipeline with potentially useful new
drugs.

Drug companies say they are developing more than 350
medicines to fight cancer and more than 120 to treat
or prevent heart disease and stroke.

Antidepressants were the best- selling category of
prescription medicines last year, as they were in
1999. Retail sales of antidepressants totaled $10.4
billion in 2000, up 20.9 percent from the previous
year.

The average price for a prescription of
antidepressants was $68.07 last year, up from $63.28
in 1999. The report said this change "reflects a rise
in the price of individual drugs, but also the fact
that pharmacies are dispensing more of the more
expensive antidepressants such as Paxil, Celexa and
Wellbutrin." These drugs, it said, are 50 percent to
75 percent more expensive than other antidepressants.

Comparing the number of prescriptions filled in each
of the last two years, the study found that retail
pharmacies dispensed 42 percent more Celebrex, 32
percent more Lipitor, 31 percent more Prevacid, 30
percent more Viagra (for impotence), 71 percent more
Enbrel (for rheumatoid arthritis) and 74 percent more
Singulair (for asthma).

Nancy Chockley, president of the National Institute
for Health Care Management Foundation, said: "The
recent rise in pharmaceutical spending is due, in
large measure, to the growth in sales of a relatively
small number of medicines. Most of these drugs are the
blockbusters many Americans have come to know by name
and see advertised more and more."

More aggressive marketing of prescription drugs to
consumers and doctors has stimulated a major increase
in sales, in part because consumers learn of new
remedies and ask their doctors for prescriptions,
researchers said. Better insurance coverage for drugs
has also contributed to the trend, by making consumers
somewhat less sensitive to drug prices.

Nineteen drugs had retail sales exceeding $1 billion
last year, up from 15 such drugs in 1999. Leading the
list of top sellers was Prilosec, the antiulcer drug
sold by AstraZeneca, with sales of $4.1 billion last
year, up from $3.6 billion in 1999.

While total sales of prescription drugs rose 18.8
percent last year, sales of the 50 best-selling drugs
rose 29.7 percent, to $58.2 billion, from $44.9
billion in 1999, the report said.

Drugs to treat ulcers, heartburn and other
gastrointestinal problems were second to
antidepressants in overall sales. Retail sales of
these medicines totaled $9.5 billion last year, up 20
percent from 1999. Sales of Prilosec rose 12.4
percent, to $4.1 billion last year, while sales of its
main competitor, Prevacid, increased 37.6 percent, to
$2.8 billion.

The study was based on data from Scott-Levin Inc., a
health care market research company in Newtown, Pa.
The figures do not include mail- order sales. But the
report said mail- order sales of prescription drugs
totaled $16 billion last year, up 26 percent from
$12.7 billion in 1999.

Copyright 2001 The New York Times Company | Privacy
Information

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The Georgetown Law Journal
March 1969

The Right to Health
by Thomas S. Szasz, M.D.

The State can protect and promote the interests of its
sick, or potentially sick, citizens in one of two ways
only: either by coercing physicians, and other medical
and paramedical personnel, to serve patients — as
State-owned slaves in the last analysis, or be
creating economic, moral, and political circumstances
favorable to a plentiful supply of competent
physicians and effective drugs.

The former solution corresponds to and reflects
efforts to solve human problems by recourse to the
all-powerful State. The rights promised by such a
State — exemplified by the right to treatment — are
not opportunities for uncoerced choices by
individuals, but rather are powers vested in the State
for the subjection of the interests of one group to
those of another.

The latter solution corresponds to and reflects
efforts to solve human problems by recourse to
individual initiative and voluntary association
without interference by the State. The rights exacted
from such a State-exemplified by the right to life,
liberty, and health — are limitations on its own
powers and sphere of action and provide the conditions
necessary for, but of course do not insure the proper
exercise of, free and responsible individual choices.

In these two solutions we recognize the fundamental
polarities of the great ideological conflict of our
age, perhaps of all ages and of the human condition
itself; namely, individualism and capitalism on the
one side, collectivism and communism on the other.

There is no other choice.

Dr. Szasz is a noted psychiatrist and the author of
The Myth of Mental Illness , Our Right to Drugs , and
many other works. This is an excerpt of an article
that originally appeared in the March 1969 issue of
The Georgetown Law Journal . Reprinted by permission
of the publisher, © 1969, The Georgetown Law Journal
and Georgetown University.

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The dangers of socialized medicine
The Future of Freedom Foundation
copyright 1994

Chapter 8

Free...But the Patient Doesn’t Get Well
by Lawrence W. Reed

If government ever does to health care what it has
done to the Postal Service, we will be well down the
road to contracting the national illness known as
“socialized medicine.” With so many regulations
already, it’s arguable that we’re halfway there now.
We’ll know we’ve reached the end of the road when
doctors become federal employees and medical care is
“free.”
       What’s wrong with socialized medicine? A friend
of mine put it more concisely than I’ve ever heard it
put before. His name is Dr. Roberto Calderon—he is a
radiologist in Managua, Nicaragua.
       Dr. Calderon didn’t just answer the question
with exotic theories. His insight is derived from a
decade of experience, from a time when the Marxist
Sandinistas ran his country and tried to put the
state’s bureaucracy in charge of almost everything. He
saw socialized medicine from the inside and argues
forcefully that it doesn’t work for the following five
reasons:
       1. The patient can’t choose the doctor. The
bureaucratic process makes the important assignment of
which physician shall treat the patient. After all, he
who pays the piper calls the tune. There’s little room
for free choice—for shopping around—for switching from
one doctor to another—when medicine has “to go by the
book.” Too much freedom for the patient makes life
difficult for the bureaucrats—they already have more
than enough paperwork with which to deal.
       2. The doctor can’t choose the patient.
Assignments are assignments under socialized medicine.
Referring a patient to another doctor is an
unnecessary complication—an evasion of
responsibility—and it screws up the system. Because
medical services are made “free” by the state, demand
for them goes up, which means that every doctor
quickly becomes overbooked and overworked. So, doctors
receive their order: just get the job done whether you
like the patient or not and whether or not you are
suitable for him.
       3. The doctor gets paid at the end of the month
regardless of what or how well he did. Even an
eighth-grader understands why this is a prescription
for high cost and poor performance. What in the world
makes socialists think that people work harder and
better for some faceless bureaucracy than they work
for themselves?
       4. The patient doesn’t get consoled. Dr.
Calderon told me that it was common in Sandinista
Nicaragua for patients to complain that “the doctor
hardly speaks to me; he just says to sit there and be
quiet.” Ever since the Hippocratic oath was written,
it has been regarded as an important, even vital, role
of the healer to provide comfort, reassurance and a
positive mental attitude to the sick. This gets lost
when doctors, in effect, become short-order cooks in
an uncompetitive, state-run, medical soup-kitchen.
       5. The patient doesn’t get well. That’s exactly
the way Dr. Calderon put it, but he really meant that
far too many patients under socialized medicine are
“chronically sick” as a direct consequence of the
previous four points.
       Moreover, socialized medicine inevitably means
that the right equipment—and medicines—and
physicians—aren’t available at all or are simply not
at the right place at the right time. People go on
waiting lists to have operations performed, and many
of them die before they ever get to the head of the
line.
       The only consolation the patient gets from all
of this is that he won’t get a bill in the mail. His
taxes—and the taxes of everybody else—pick up the tab.
All of this misery and agony is for “free.”
       All things considered, I’d rather rely on
freedom, not government, to cure the ailments of
medical care.

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Medical Licensure
by Milton Friedman

The medical profession is one in which practice of the
profession has for a long time been restricted to
people with licenses. Offhand, the question, "Ought we
to let incompetent physicians practice?" seems to
admit of only a negative answer. But I want to urge
that second thought may give pause.

In the first place, licensure is the key to the
control that the medical profession can exercise over
the number of physicians. To understand why this is so
requires some discussion of the structure of the
medical profession. The American Medical Association
is perhaps the strongest trade union in the United
States. The essence of the power of a trade union is
its power to restrict the number who may engage in a
particular occupation. This restriction may be
exercised indirectly by being able to enforce a wage
rate higher than would otherwise prevail. If such a
wage rate can be enforced, it will reduce the number
of people who can get jobs and thus indirectly the
number of people pursuing the occupation. This
technique of restriction has disadvantages. There is
always a dissatisfied fringe of people who are trying
to get into the occupation. A trade union is much
better off it can limit directly the number of people
who enter the occupation-who ever try to get jobs in
it. The disgruntled and dissatisfied are excluded at
the outset, and the union does not have to worry about
them.

The American Medical Association is in this position.
It is a trade union that can limit the number of
people who can enter. How can it do this? The
essential control is at the stage of admission to
medical school. The Council on Medical Education and
Hospitals of the American Medical Association approves
medical schools. In order for a medical school to get
and stay on its list of approved schools it has to
meet the standards of the Council. The power of the
Council has been demonstrated at various times when
there has been pressure to reduce numbers. For
example, in the 1930's during the depression, the
Council on Medical Education and Hospitals wrote a
letter to the various medical schools saying the
medical schools were admitting more students than
could be given the proper kind of training. In the
next year or two, every school reduced the number it
was admitting, giving very strong presumptive evidence
that the recommendation had some effect. . . .

Control over admission to medical school and later
licensure enables the profession to limit entry in two
ways. The obvious one is simply by turning down many
applicants. The less obvious, but probably far more
important one, is by establishing standards for
admission and licensure that make entry so difficult
as to discourage young people from ever trying to get
admission. . . .

In the first place, does [licensure] really raise
standards of competence? It is by no means clear that
it does raise the standards of competence in the
actual practice of the profession for several reasons.
In the first place, whenever you establish a block to
entry into any field, you establish an incentive to
find ways of getting around it, and of course medicine
is no exception. The rise of the professions of
osteopathy and of chiropractic is not unrelated to the
restriction of entry into medicine. On the contrary,
each of these represented, to some extent, an attempt
to find a way around restriction of entry. Each of
these, in turn, is proceeding to get itself licensed,
and to impose restrictions. The effect is to create
different levels and kinds of practice, to distinguish
between what is called medical practice and
substitutes such as osteopathy, chiropractic, faith
healing and so on. These alternatives may well be of
lower quality than medical practice would have been
without the restrictions on entry into medicine.

More generally, if the number of physicians is less
than it otherwise would be, and if they are fully
occupied, as they generally are, this means that there
is a smaller total of medical practice by trained
physicians-fewer medical man-hours of practice, as it
were. The alternative is untrained practice by
somebody; it may and in part must be by people who
have no professional qualifications at all. Moreover,
the situation is much more extreme. If "medical
practice" is to be limited to licensed practitioners,
it is necessary to define what medical practice is,
and featherbedding is not something that is restricted
to the railroads. Under the interpretation of the
statutes forbidding unauthorized practice of medicine,
many things are restricted to licensed physicians that
could perfectly well be done by technicians, and other
skilled people who do not have a Cadillac medical
training. I am not enough of a technician to list the
examples at all fully. I only know that those who have
looked into the question say that the tendency is to
include in "medical practice" a wider and wider range
of activities that might well be done by others. The
result is to reduce drastically the amount of medical
care. The relevant average quality of medical care, if
one can at all conceive of the concept, cannot be
obtained by simply averaging the quality of care that
is given; that would be like judging the effectiveness
of a medical treatment by considering only the
survivors; one must also allow for the fact that the
restrictions reduce the amount of care. The result may
well be that the average level of competence in a
meaningful sense has been reduced by the restrictions.


Even these comments do not go far enough, because they
consider the situation at a point in time and do not
allow for changes over time. Advances in any science
or field often result from the work of one out of a
large number of crackpots and quacks and people who
have no standing in the profession. In the medical
profession, under present circumstances, it is very
difficult to engage in research or experimentation
unless you are a member of the profession. If you are
a member of the profession and want to stay in good
standing in the profession, you are seriously limited
in the kind of experimentation you can do. A "faith
healer" may be just a quack who is imposing himself on
credulous patients, but maybe one in a thousand or in
many thousands will produce an important improvement
in medicine. There are many different routes to
knowledge and learning and the effect to restricting
the practice of what is called medicine and defining
it as we tend to do to a particular group, who in the
main have to conform to the prevailing orthodoxy, is
certain to reduce the amount of experimentation that
goes on and hence to reduce the rate of growth of
knowledge in the area. What is true for the content of
medicine is true also for its organization, as has
already been suggested. I shall expand further on this
point below.

There is still another way in which licensure, and the
associated monopoly in the practice of medicine, tend
to render standards of practice low. I have already
suggested that it renders the average quality of
practice low by reducing the number of physicians, by
reducing the aggregate number of hours available from
trained physicians for more rather than less important
tasks, and by reducing the incentive for research and
development. It renders it low also by making it much
more difficult for private individuals to collect from
physicians for malpractice. One of the protections of
the individual citizen against incompetence is
protection against fraud and the ability to bring suit
in the court against malpractice. Some suits are
brought, and physicians complain a great deal about
how much they have to pay for malpractice insurance.
Yet suits for malpractice are fewer and less
successful than they would be were it not for the
watchful eye of the medical association. It is not
easy to get a physician to testify against a fellow
physician when he faces the sanction of being denied
the right to practice in an "approved" hospital. The
testimony generally has to come from members of panels
set up by medical associations themselves, always, of
course, in the alleged interest of the patients.

When these effects are taken into account, I am myself
persuaded that licensure has reduced both the quantity
and quality of medical practice; that is has reduced
the opportunities available to people who would like
to be physicians, forcing them to pursue occupations
they regard as less attractive; that it has forced the
public to pay more for less satisfactory medical
service, and that it has retarded technological
development both in medicine itself and in the
organization of medical practice. I conclude that
licensure should be eliminated as a requirement for
the practice of medicine.

When all this is said, many a reader, I suspect, like
many a person with whom I have discussed these issues,
will say, "But still, how else would I get any
evidence on the quality of a physician. Granted all
that you say about costs, is not licensure the only
way of providing the public with some assurance of at
least minimum quality?" The answer is partly that
people do not now choose physicians by picking names
at random from a list of licensed physicians; partly,
that a man's ability to pass an examination twenty or
thirty years earlier is hardly assurance of quality
now; hence, licensure is not now the main or even a
major source of assurance of at least minimum quality.
But the major answer is very different. It is that the
question itself reveals the tyranny of the status quo
and the poverty of our imagination in fields in which
we are laymen, and even in those in which we have some
competence, by comparison with the fertility of the
market. . . .

The impossibility of any individual or small group
conceiving of all the possibilities, let alone
evaluating their merits, is the great argument against
central governmental planning and against arrangements
such as professional monopolies that limit the
possibilities of experimentation. On the other side,
the great argument for the market is its tolerance of
diversity; its ability to utilize a wide range of
special knowledge and capacity. It renders special
groups impotent to prevent experimentation and permits
the customers and not the producers to decide what
will serve the customers best.

Professor Friedman, the winner of the 1976 Nobel Prize
in Economic Science, is Senior Research Fellow at the
Hoover Institution. This is an excerpt from his book
Capitalism and Freedom , published in 1962 by The
University of Chicago Press. © 1962 by The University
of Chicago Press. Reprinted by permission.



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The dangers of socialized medicine
The Future of Freedom Foundation
copyright 1994

Chapter 3

A Free Market for Health Care
by Sheldon L. Richman

Concerned about rising costs and the number of
Americans without medical insurance, nearly everyone
is worried these days about health care. Not a day
goes by without a presidential candidate or a magazine
calling for something drastic to be done. Each
advocate maintains that his plan will bring
skyrocketing costs under control, make health care
accessible to low-income people, and bring health
insurance within the reach of the 34 million Americans
who currently do without it.
       But the American people are being handed a
Hobson’s choice between a government takeover of the
medical insurance industry and mandatory provision of
insurance by the nation’s employers, with the
government as insurer of last resort.
       There is a real alternative—a solution that
relies on competition in the open marketplace. That
solution recognizes that the undesirable aspects of
the current system are not the result of the free
market, but rather are the outcome of decades of
governmental intervention in the health-care industry.
Elimination of that intervention would shift power and
responsibility from impersonal bureaucracies to
consumers. The resulting free market, characterized by
prudent consumers spending their own money, would
control costs and let the American people have the
kind of medical care they want.
       Those who call for greater governmental
involvement are fond of comparing how much Americans
spend on health care with how much is spent in other
countries. For example, in 1989 the average American
spent about 40 percent more on health care than his
Canadian counterpart: $2,354 versus $1,683. The West
Germans, French, Japanese, and Britons spent even
less. The 12 percent of gross domestic product that
the United States devoted to health care in 1991 ($650
billion) is double the portion so devoted in Great
Britain. By the year 2000, total spending is expected
to reach $1 trillion or 15 percent of gross domestic
product. Costs are increasing at 15 percent a year,
much more than the general rate of price increases.
The cost of employer-provided medical insurance
increased 21.6 percent from 1989 to 1990.
       But these comparisons are misleading for many
reasons. For example, the demographics of the
countries are different. A younger population, such as
Canada’s, would be expected to spend less on medical
care than an older population, such as that in the
United States. Moreover, the United States is the
richest country in the world, and more affluent
societies tend to spend more on health care than less
affluent ones. There are many other reasons why those
cost comparisons are deceptive.
       Nevertheless, we can say that Americans spend
too much on health care in this sense: identifiable
government interventions raise costs higher than they
would otherwise be. They do that by artificially
stimulating demand and artificially constricting
supply.
       On the demand side, the problem is simply this:
The government pays for about half the health care
purchased in this country, through the national health
insurance for the poor and elderly known as Medicaid
and Medicare. In 1990 the state and federal
governments spent $280 billion on health care. The
costs of these programs have exploded over the years.
Since Medicaid and Medicare patients pay little or
nothing for health care, they demand more of it than
they would otherwise. They have no need to shop for
the best value or to be prudent about elective
procedures.
       All of this puts tremendous upward pressure on
prices, harming everyone who pays for his own care.
Until 1983, Medicaid and Medicare reimbursed
health-care providers on a cost-plus basis, meaning
that neither patients nor providers had incentives to
keep costs down. This escalated prices, which, in
turn, pushed up premiums for health insurance. The
government-paperwork costs alone help raise the price
of medical care for everyone. As a result, many people
and small businesses are priced out of the insurance
market. Mandated coverage by the states for such
uninsurable things as hair pieces and in vitro
fertilization aggravates that process.
       On the supply side, various governmental
regulations enacted at the behest of the medical
profession have constricted the supply of doctors and
other health-care professionals. Medical licensing and
the power to accredit medical schools were explicitly
motivated by the medical profession’s wish to reduce
competition and to increase the remaining
practitioners’ incomes. Between 1910 and 1920, when
accreditation power was granted, the number of medical
schools in the United States dropped from 131 to 85.
The cut particularly harmed women and minorities; by
1944 the number of medical schools which predominantly
admitted blacks fell from seven to two. Thanks to
government, the medical industry is far less
competitive than it would be if left free of
interference.
       Most of the proposed solutions, however, ignore
the causes of the problem and would even aggravate the
situation. The most popular approach, the one taken by
many Democrats, as well as a coalition of Big Business
and Big Labor, is known as “play or pay.” Under this
plan, the federal government would require all
employers to provide health insurance to their workers
or to pay a new payroll tax (over 7 percent), the
revenue from which would provide insurance. The
supporters of “play or pay” also favor regulations on
insurance premiums and various methods of cost
containment. Notice that this proposal would only make
things worse. Government would insure even more people
than now, and its control of costs—price
controls—would bring all the distortions and
bureaucratic rationing we experienced in the 1970s.
Moreover, as the price of insurance continued to rise,
the system would create incentives for small
businesses to pay into the government fund, moving us
closer to national health insurance. And when “play or
pay” failed to improve the health-care system, the
statists would inevitably say, “Private enterprise was
given a chance and has failed; now it’s time for the
government to take over.”
       Some “reforms” go even further in the wrong
direction and call for a Canadian-type system, which
would make the government the sole health insurer in
the land. But the results of the Canadian system are
exactly what we would expect of government control.
Bureau- cratic planning has created shortages,
rationing, and long lines for service. For example,
Canada has 11 heart surgery facilities, one for every
2.3 million people. In the United States there are 793
facilities, one for every 300,000. The wait for a
coronary-bypass operation can last from four months to
a year in Canada. Bureaucratic strangulation has also
prompted a significant number of doctors to emigrate
or take early retirement. The system has failed to
even control health-care costs; the growth in spending
for Canada and the United States is almost the same.
       The Republicans offer no fundamental change in
the current system, merely some crumbs to low-income
people to buy insurance as well as a cap on
malpractice awards. Medicaid and Medicare will
continue to grow under President Bush’s
administration.
       It should be obvious that if governments at all
levels were not confiscating close to half of the
people’s wealth, medical care would be a manageable
necessity of life. Without the onerous tax burden
under which people now labor, they would be, able to
save for the medical expenses required during their
working and retirement years. True, some people would
not be able to provide for their own care—and they
would have to rely on private charity. But the medical
profession itself has always been generous in helping
the indigent.
       If the government did not dominate the
health-care industry through its humongous “insurance”
programs, costs would fall to the reasonable levels we
would expect of a free market. That would enable even
the lowest-income people to buy medical care and
health insurance. (To the extent governmental tax
policy distorts the private insurance industry, costs
would fall even further.)
       On the supply side, the repeal of medical
licensing, governmental accreditation of medical
schools, and restrictions on hospital construction
would increase the amount of care available, lowering
prices even more. This would expand individual liberty
and introduce real competition into the medical
marketplace. Quality assurance would be much better
handled in the free market through private
certification organizations, such as Underwriters
Laboratory and Consumer Reports.
       Governmental intervention is always dangerous.
But nowhere is it more so than in the health-care
industry. The sooner we get the government out, the
sooner we can all breathe easier—and perhaps even live
longer.
 
 

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The dangers of socialized medicine
The Future of Freedom Foundation
copyright 1994

Chapter 1
The Real Free-Market Approach to Health care
by Jacob G. Hornberger


Part I
       In his book A Critique of Interventionism,
Ludwig von Mises wrote, “Authors of economics books,
essays, articles, and political platforms demand
interventionist measures before they are taken, but
once they have been imposed no one likes them. Then
everyone—usually even the authorities responsible for
them—call them insufficient and unsatisfactory.
Generally the demand then arises for the replacement
of unsatisfactory interventions by other, more
suitable measures. And once the new demands have been
met, the same scenario begins all over again.”
       No words could more accurately describe the
nature of America’s so-called health-care crisis.
After decades of governmental intervention into the
health-care arena, the failures are apparent for all
to see. But rather than root out the cause of the
problem, Americans are demanding that government do
something about it.
       What are the governmental interventions that
have caused America’s health-care crisis? Licensing,
Medicare, Medicaid, economic regulation, and income
taxation. What is the solution to America’s
health-care crisis? The repeal (not the reform) of
licensing, Medicare, Medicaid, economic regulation,
and income taxation.
       What is the response of the average American to
such a prescription? “That’s too radical. That’s too
extreme. The system needs to be reformed, not
abolished. Give us something we can work with.”
       And the same is true with many free-market
advocates. “You need to modify your views. No one is
going to take you seriously. Congress will never
invite you to testify. Newspapers won’t accept your
editorials. You need to be more practical.”

The denial of reality
       Most Americans, including many free-market
advocates, simply will not—perhaps cannot—face the
truth: that the welfare state (socialism) and the
managed economy (interventionism) have never worked
and can never work. No matter what is done—no matter
who is put in charge—no matter what plan is used—the
result will always be the same: failure. The sooner we
come to grips with this truth, the sooner we can begin
traveling the road to a healthy and prosperous
society.
       Why do Americans have such a difficult time
accepting the reality of their condition? Part of the
answer lies in the indoctrination they receive from
the time they are in the first grade and that
continues even after they graduate from college. The
indoctrination is so complete that no matter how
carefully you explain the reality of their
circumstances, Americans simply refuse to accept it.
       Let me give you an example. Ask any American if
the United States is a land of free enterprise. He
will proudly say, “Of course it is.” Ask him if it has
always been so. He will puff out his chest and
proclaim, “You bet it has. And free enterprise has
prevailed over socialism!”
       But then explain to him that during the first
150 years of American history, the American people
said “no” to the following: income taxation, welfare,
economic regulation, licensing, Medicare, Medicaid,
and Social Security. Then remind him that he, along
with his fellow Americans, say “yes” to the following:
income taxation, welfare, economic regulation,
licensing, Medicare, Medicaid, and Social Security.
Then ask him, “How can different principles be the
same? How can white be black? How can A be B? How can
opposites both be free enterprise?”
       He will stare at you with befuddlement. For he
cannot defend the way he has been taught to view the
world since he was six years old. As he tries to
reconcile reality with the way in which he has been
taught to see the world, ask him, “Do you favor the
Cuban way of life—a way of life which has income
taxation, welfare, economic regulation, licensing, and
free medical care for everyone?” He will not answer,
because he cannot answer.
       But the problem goes much deeper. Americans do
not want to face reality. For the reality is too
terrifying for them to consider. It means that
everything about America’s “free-enterprise system”
that they have learned in school—that they have taught
their children—that they have read in books,
newspapers, and magazines—is false. To accept reality
would constitute an admission that Americans have, for
decades, been living a life of the lie. It is much
less terrifying for them to continuing living a life
of deception.
       This is one reason that people resent so deeply
the true advocates of economic freedom—we expose their
lie. We make them confront the reality and pierce
through the deception that clouds their minds. We
provide the tough medicine that enables people to see
the world for what it is. We “cause” the pain
associated with their recovery process.
       Why is it so important that we do this? Because
we cannot begin solving societal woes until people
eliminate the psychological barriers to recognizing
the real nature of the problem. If people believe, for
example, that America’s health-care crisis is due to a
failure of the free market, then their natural
inclination is to accept what their public officials
say is the cure—governmental intervention. But if they
pierce through to the reality of what is happening by
recognizing that governmental intervention is the
cause of the health-care crisis, they are much more
apt to accept real free-market principles as the
solution.
       Would our fellow Americans be better off if we
simply let them continue living their lives of
deception? No. A life of a slave is not made better
simply because the slave thinks he’s free. Moreover, a
life of the lie ultimately manifests itself through
severe psychological disorders, which, in turn, often
result in an addiction to mind-altering drugs.
       Therefore, for us to validate the deception
would be morally wrong, for it would only worsen the
person’s condition and make it more difficult for him
to recover.

The “free-market” alternatives
       And that is the gravamen of some of the
so-called “free-market” solutions to America’s
health-care crisis—they mislead people into believing
that a reform of the welfare-state, managed-economy
way of life (as opposed to its elimination) is a
“free-market” approach to the problem.
       For example, consider two “free-market”
alternatives to the health-care plan proposed by
President Clinton—the plans proposed by two
conservative think tanks—the Heritage Foundation and
the National Center for Policy Analysis.
       The Heritage “free-market” plan would mandate,
by force of law, that people purchase health-care
coverage. In other words, under the principles of
“freedom” promoted by Heritage, people would be “free
to be forced” to buy health-care coverage.
       The NCPA plan is less oppressive. It calls for
“medical IRAs,” an income-tax device by which people
would be encouraged, by virtue of a tax deduction, to
donate money into a savings account that could only be
used to cover medical expenses.
       What is wrong with these two “free-market”
plans? They accept the legitimacy and inevitability of
the welfare-state, managed- economy way of life. Even
worse, they assume that their plan—the “free-market
altemative”—will save the welfare-state,
interventionist system and make it work more
efficiently. But worst of all, by making people
believe that these plans constitute a “free-market
alternative,” they validate the life of delusion and
unreality that afflict the American people.
       Mandated health care and income-tax deductions
do not constitute freedom. They may be less intrusive
and less oppressive alternatives to President
Clinton’s health-care plan, but they are not
free-market alternatives.
       Mandates and freedom are opposites. If a person
is free, then that means he is not mandated to buy
anything. If a person is mandated to buy something,
then he is not free. Mandates are not a free-market
alternative, because mandates violate free-market
principles.
       Moreover, to be free entails living your life
the way you choose (so long as it’s peaceful), to
accumulate unlimited amounts of wealth, and to decide
for yourself how to spend your own money. If
government controls the amount of income a person
keeps, then that is the essence of slavery, not
freedom. And to the extent that government is able to
use such devices as income-tax deductions to
manipulate people into buying things that they might
not otherwise purchase, to that extent a person cannot
be considered free. Consider the words of Friedrich A.
Hayek in his book The Constitution of Liberty:

The question of how many courses of action are open to
a person is, of course, very important. But it is a
different question from that of how far in acting he
can follow his own plans and intentions, to what
extent the pattern of his conduct is of his own
design, directed toward ends for which he has been
persistently striving rather than toward necessities
created by others in order to make him do what they
want. Whether he is free or not does not depend on the
range of choice but on whether he can expect to shape
his course of action in accordance with his present
intentions, or whether somebody else has power so to
manipulate the conditions as to make him act according
to that person’s will rather than his own. [Emphasis
added.]

In other words, an individual is considered free only
when he can decide for himself how to utilize his own
resources. He is not considered free when the state
either orders him to spend—or manipulates him into
spending—his resources in some state-approved fashion.

       Would people be better off under the Heritage
or NCPA plans, as compared to the President’s plan? Of
course, in the same manner that the slave on the
plantation is better off the more choices he is “free”
to make on the plantation. But the “freedom” of the
slave to make choices does not change the real nature
of his condition; it simply makes his slavery less
onerous.
       The welfare-state, managed-economy way of life
is doomed to fail, as central planning and economic
control have failed all over the world. Neither the
Heritage plan nor the NCPA plan will change this; at
best, they can delay the inevitable or make living
conditions less onerous in the meantime. But the major
drawback to their adoption is this: a few years from
now, when the health-care system is in even bigger
crisis (which it will be), public officials will make
their inevitable proclamation: “We have tried free
enterprise, and it has failed; now we must use
governmental intervention to fix the problem.”
       There is one and only one solution to America’s
health-care woes: a total separation of the economy
and the state. This involves, first, a recognition
that the welfare-state, managed-economy way of life is
a cancer that infects our body politic. And, second, a
cure that calls, not for Band-Aids but, instead, for
radical surgery by which such interventions as income
taxation, welfare, licensing, Medicare, Medicaid, and
Social Security are eliminated.

Part II
       For over one hundred years, the American people
said no to governmental intervention into health care.
Americans did not permit their respective states to
license physicians and other health-care providers.
They did not permit government to provide health care
to the poor and needy. No one was required to purchase
health insurance. The result of this unusual way of
life was the most advanced medical system in the
history of man.
       The real question is, “Why?” Why did five or
six generations of Americans say no to such
governmental schemes and controls as licensing,
Medicare, Medicaid, and compulsory health insurance?
       President Clinton and his wife Hillary would
have us believe that the reason is that Americans
simply had not yet invented or discovered these
devices. The Clintons claim that governmental control
over people’s health, and political redistribution of
their wealth, are brand-new, 21st-century concepts
whose time has come. And, unfortunately, most
Americans, having received their “education” in public
schools, don’t know any better.

The Declaration of Independence
       The reason for the American rejection of
socialized medicine for over one hundred years lies in
the principles of the Declaration of Independence. Our
ancestors had a radically different understanding of
the words in that document than their counterparts
living today.
       What did the words “. . .they [men] are endowed
by their Creator with certain unalienable rights; that
among these are life, liberty, and the pursuit of
happiness. . . .” mean to our ancestors? They meant
that you, as an individual, have the right to live
your life the way you choose, so long as you do not
interfere, in some direct way, with the rights of
others to do the same. You have a right to sustain
your life by producing goods and services through the
exercise of talents and abilities that God gave
you-and then trading these with others who are doing
the same. You have a right to accumulate unlimited
amounts of wealth (i.e., property) through this
process. And you have a right to choose what to do
with your own money.
       And while the political process was certainly
abused (i.e., slavery, tariffs, railroad grants), the
prevailing philosophy of our American ancestors was
that it was the height of evil and immorality to use
the political process to steal one person’s money in
order to give it to someone else. This is the
reason—not ignorance, but rather morality—that
Americans rejected such schemes as Medicare, Medicaid,
and Social Security. Unlike their modern-day American
counterparts, they believed in and practiced God’s
commandment, “Thou shalt not steal.”
       Here is an example of how radically different
our ancestors’ beliefs were compared to those of
Americans living today. In the 1880s, Texas farmers
suffered a long, devastating drought. Congress passed
a relief bill that appropriated $10,000 to the
farmers. The philosophy of our American ancestors was
expressed by President Grover Cleveland—a Democrat!—in
his veto message:

I find no warrant for such an appropriation in the
Constitution, and I do not believe that the power and
the duty of the General Government ought to be
extended to the relief of individual suffering which
is in no manner properly related to the public service
or benefit. A prevailing tendency to disregard the
limited mission of this power and duty should, I
think, be steadfastly resisted, to the end that the
lesson should be constantly enforced that though the
people support the Government the Government should
not support the people.
       The friendliness and charity of our countrymen
can always be relied upon to relieve their
fellow-citizens in misfortune. This has been
repeatedly and quite lately demonstrated. Federal aid
in such cases encourages the expectation of paternal
care on the part of the Government and weakens the
sturdiness of our national character, while it
prevents the indulgence among our people of that
kindly sentiment.and conduct which strengthens the
bonds of a common brotherhood.

       Thus, Americans believed that charity towards
others meant nothing unless it came from the willing
heart of the giver. They understood that “coerced
charity” was simply disguised thievery. And while they
would fight to protect the right of a person to say no
to his neighbor, they had faith that most people would
voluntarily help those in need.

“Freedom” according to the Clintons
       How dramatically different things are today.
President and Mrs. Clinton tell us that Americans must
be forced to provide for everyone’s health care.
Private citizens are not able to take care of
themselves. And they certainly cannot be trusted to
help others voluntarily. People should be “free,” the
Clintons tell us, as long as they do what they are
told by their political masters. And worst of all, the
Clintons denigrate the memory of people like Thomas
Jefferson, George Washington, and Patrick Henry by
falsely claiming that the Declaration of Independence
entails “a right to health care,” that is, a right to
steal the fruits of someone else’s earnings through
the use of the political process.
       Whenever the Clintons extol the virtues of
socialized medicine, they point to the European model.
“France, Germany, and Great Britain all have
compulsory health care,” we are told, “and so how can
a major industrial power like the United States be
without it?”
       What the Clintons need to be reminded of,
however, is that two hundred years ago, our ancestors
fought a war in which they killed thousands of British
soldiers—and that the reason for these deaths was our
ancestors’ full and complete rejection of the European
model of omnipotent government that now holds the
Clintons and their statist supporters in its grip.
       The truth is that President and Mrs. Clinton
and their statist friends hate everything that the
American revolutionaries and their 18th-century
successors believed in. The idea that an individual
should be free to manage his own life is anathema to
the present-day American public official. Like his
European counterpart, he believes that private
citizens exist only to serve the public good-and to
obey the commands of public officials.
       The Clintons and their cohorts have one, and
only one, objective in mind—to maintain the
20th-century, statist empire over which they preside.
But they know that, in the final analysis, they need
the support of their subjects to continue and expand
their control. For this, they rely heavily on the
ignorance of those who received their “education” in
social-studies classes in public schools. And,
unfortunately, public-school teachers have done their
job well. For Americans honestly believe the claims of
the Clintons and their statist friends that the
so-called “health-care crisis” reflects the failure of
America’s “free-enterprise system.”

Free enterprise . . . or socialism?
       Free-enterprise system? How can licensing of
physicians and other health-care providers be “free
enterprise”? Free enterprise means to engage in
enterprise freely. If a person must receive the
permission of the political authorities to engage in
an enterprise, then the enterprise is not free. The
reason that 18th-century Americans had no licensing
was not because they were ignorant but because they
knew that people had the God-given right to engage in
any economic enterprise without seeking the permission
of their public officials.
       Licensing of physicians came into existence in
the U.S. at the beginning of the 20th century. It is a
device to limit the supply of doctors, to protect them
from competition, and to increase their income levels.
It is a throwback to the old European guild system
that Americans in 1776 found so revolting.
       Free enterprise? How can Medicare and Medicaid,
established in the 1960s, be free enterprise? Here,
the political process is used to steal money from some
individuals in order to give the loot to others. It is
a throwback to the old European, socialist notion of
“from each according to ability, to each according to
need.”
       Free enterprise? How can the taxing of incomes
be free enterprise? Either people have the right to
accumulate unlimited amounts of wealth by serving
others, or the political authorities decide how much a
person will be permitted to accumulate. The
progressive taxation of incomes is a throwback to the
old, European, socialist notion of public ownership of
the results of production.
       The truth is that it is not “free enterprise”
that has failed the American people. Rather, it is the
European, socialist experiment with which the Clintons
and their friends are so enamored that has failed the
American people. After several decades of the welfare
state and the managed economy, the chickens are coming
home to roost. The old, decrepit, bankrupt European
ideas of governmental licensing and medical care for
the poor and aged have failed, not only here, but in
Cuba, Russia, France, Great Britain, and everywhere
else they have been tried.
       And the results are clear for all to see. The
American revolutionaries and their 18th-century
successors have been proven right. And their
20th-century counterparts have been proven wrong—and
now they are panic-stricken at the thought of their
empire—and its omnipotent power over the lives of the
American people—coming crashing down.
       The struggle is not new—it has been going on
for centuries. On the one side are aligned the
supporters of empire—of control—of plunder. Aligned on
the other side are the small minority of those who
cherish individual freedom. As the empire continues to
crumble, the question is, will the solution be more
control, or will it be a dismantling of America’s
20th-century experiment with socialism?

Part III
       The only solution to America’s health-care
crisis is to end, not reform, governmental
intervention into economic activity. What would this
entail? A way of life in which people would be free:


* to do whatever they want, so long as their conduct
is peaceful and does not intrude, in some direct way,
on the rights of others to do the same;
* to engage in any economic activity without political
permission or restriction;
* to enter into mutually beneficial exchanges with
others;
* to accumulate unlimited amounts of wealth;
* to choose for themselves what to do with their own
money—save, spend, donate, invest, or whatever.


       Generally, the solution to America’s social
woes lies in ending, not reforming, its welfare-state,
regulated-economy way of life. Specifically, the
solution to America’s health-care crisis entails the
elimination of income taxation, licensing laws,
Medicare, and Medicaid.

Income taxation
       What is the relationship of income taxation to
the health-care crisis? A major part of the problem is
that people cannot afford the costs of health care.
But suppose income taxation had been abolished ten
years ago. Assume that a person has paid an average of
$15,000 a year in income taxes. If he had saved the
money, this would mean, of course, that he would have
$150,000 plus interest in his bank account—an amount
that would be very helpful in paying medical bills and
medical-insurance premiums today.
       Now, granted, that’s water under the bridge.
But the point is this: the more money that government
sucks out of the pockets of the people, the more
difficult it is for people to afford health care and
other things they wish to buy. Conversely, if people
were free to keep everything they earn, they would be
able to afford health-care costs, as well as a
multitude of other things.

Helping the poor
       What about the poor—those who still would be
unable to afford health care? Doesn’t government have
a duty to help them?
       No! First and foremost, it is important to
remember the fundamental immorality of governmental
assistance. Under Medicare, Medicaid, or any other
political subsidization, the money is taken by force
from one person (primarily through income taxation)
and given to another. When public officials engage in
this conduct, they celebrate the “goodness” of their
act. They say, “We are good because we are helping
others.” But the truth is that their conduct is highly
evil, for they are “being good” with the fruits of
earnings that have been taken by force from others. In
other words, while their conduct is legal, it ranks
with that of private thieves in terms of morality.
       What would happen to the poor if Medicare and
Medicaid (and all coercive transfer programs) were
eliminated (rather than reformed)? Would they starve
in the streets or die for lack of medical care?
       Governmental officials say, “Yes! The American
people cannot be trusted to care for others on a
voluntary basis. They must be forced to provide
assistance to others through the Internal Revenue
Service, Medicare, Medicaid, and other welfare
programs.”
       It is a lie. And it is the most important lie
underlying the entire welfare-state way of life. For
if the American people ever conclude that they can be
trusted to care for others on a purely voluntary
basis, that will be the day that the welfare state
will come to an end.
       How do we know that the American people would
help others if they were not forced to do so? Because
the evidence is all around us. The caring nature of
others can be found everywhere.
       I grew up on a farm on the U. S.-Mexican
border, near one of the poorest cities in the United
States. One day, one of our farm hands—a Mexican
illegal alien—discovered a lump on his neck. We took
him to our physician, who diagnosed the lump as
cancerous.
       What happened to him? Well, it’s a story that
will warm your heart. We had a friend who had been
poor for most of his life. His poverty had
dramatically ended with the discovery of huge
quantities of oil under lands on which he had a
sizable interest. Our friend learned about the plight
of our employee. The next day, our friend picked up
the employee, escorted him to the airport, put him on
his Learjet, and had him flown to Houston for
treatment at one of the world’s leading cancer
clinics. The man was admitted into the clinic, even
though he had no money (although we suspected that our
friend may have covered the bill). The cancer was
successfully treated—it never recurred.
       And the same beneficent attitude characterized
our family physician. Every time I visited him, his
waiting room was filled with people who could not
afford to pay for his services. I never saw him turn
away—or heard of him turning away—any patient for lack
of ability to pay. He just kept treating them even
though the chances of his getting paid were minuscule.

       Does this happen all over the country? You bet
it does! But it takes a willingness to see it happen.
The person who fails to see it is the person who does
not want to see it!
       It is useless to try to convince governmental
officials of the caring nature of the American people.
For public officials have a vested interest in the
continuation of the welfare state.
       Our battle must be for the hearts and minds of
those in the private sector. They must be persuaded
not only to have faith in themselves but, equally
important, to have faith in others as well. People’s
belief must go from, “I would help, but no one else
would,” to “I would help, and I know that others would
do the same.” Once this shift in mind-set takes place
among the American people, the foundation of the
welfare state will crumble.

Licensing
       Licensing is special-interest legislation for
the benefit of physicians and other medical personnel.
Its primary purpose and effect are to limit entry into
the medical profession in order to protect medical
people from competition.
       Does licensing ensure competent doctors and
nurses? If it does, then why do we continue to have so
many malpractice judgments against doctors and other
medical personnel? And one problem with licensing is
that it seduces the public into believing that because
a person has been licensed by the state, he must be
competent.
       What would happen if licensing were repealed?
Well, no one would run out into the street looking for
a quack to perform heart surgery on him. The current
stock of physicians would continue to exist. People
would probably continue using the doctor they are
using today. What if someone needed a new doctor? The
likelihood is the person would rely on the
recommendation of his current physician. Moreover,
well-established and well-known physicians in the
community would band together to publish a list of
recommended doctors in the area; private certifying
agencies (i.e., Consumer Reports or Good Housekeeping)
would do the same. The market would provide the
vehicles that people needed for selecting their
physicians and other health-care providers.
       What, then, is the difference between a system
of licensing and one without licensing? The latter
enables people to reject the official or approved
method of treatment! For example, suppose someone who
is not a licensed physician treats an AIDS patient in
some non-approved manner. Under current law, he is
thrown into jail for practicing medicine without a
license. And governmental officials tell the AIDS
patient that he cannot use the treatment because it
might kill or otherwise injure him.
       But what authority does the state have to
prevent a grown-up from seeking out the medical care
that he wishes to have? The decision as to what course
of action a person wishes to take with respect to the
treatment of his own illness properly lies with him,
not with governmental officials. And, while it may
appear unlikely to the established medical order,
there is always the possibility that the alternative,
non-approved treatment could prove to be effective.
       The idea behind medical licensure can be summed
up as follows: “We governmental officials will not
permit you to seek alternative medical care, because
you might hurt yourselves. No matter how old you are,
you will always be a child of the state. We will take
care of you, just as your daddy and mommy once did. We
will not permit you to make mistakes. We will not let
others take advantage of you.”
       But one fundamental problem is that the state
is not like daddy and mommy were. After all, very few
daddies and mommies inject their children with
malaria, hepatitis, and radiation, as the U.S.
government did to hundreds, possibly thousands, of
Americans, some of whom were innocently seeking
medical care when they unknowingly received their
injections. And most daddies and mommies would never
send their children to a place like the Veterans’
Administration Hospital for medical treatment; in
fact, if they did, they would surely be convicted of
child abuse by any jury in the land.

Conclusion
       Several decades ago, the American people were
seduced into abandoning the principles of our
ancestors. The state took control over our education.
It took control over our earnings. It took control
over our economic activity. It took control over our
social activity. It took control over our charitable
activity.
       And now the state wishes to take control over
our health care. If we permit this to happen, we will
reap the whirlwind, for the results will be as
disastrous as they have been in very other field of
governmental endeavor.

__________________________________________________
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The danger of socialized medicine
The Future of Freedom Foundation
copyright 1994

Chapter 6

The Case Against Medical Licensing

by Lawrence D. Wilson

For the first 120 years of our history, America had,
essentially, a free-market health-care system. There
were few licensing laws or other barriers to entry
into the healing arts. A variety of practitioners
offered services, including herbalists, nature-care
therapists, hydrotherapists, osteopaths, allopaths and
homeopaths. There was a variety of healing schools and
clinics. During this time, America was among the
healthiest nations, with the lowest infant mortality
rate in the world. (Now we are tied for 19th among 19
developed nations.) Costs were not a problem because
open competition kept prices down. Low costs made
health care widely accessible. Laws against fraud and
negligence protected the consumer.
       Efforts to change the situation began as early
as 1847. In this year, the American Medical
Association (AMA) was formed to protect the interests
of one group of doctors-the drug healers, or
allopaths. This group, by the way, at times did more
harm than good with their mercury, arsenic, leaches
and other crude methods. One of the AMA’s goals was to
improve the income of its members. The best way to do
this was to limit the supply of doctors.
       The AMA’s efforts culminated in 1910, when
Abraham Flexner, a former school director who was not
a physician, was commissioned by the Carnegie
Foundation for the Advancement of Teaching to evaluate
medical schools. He was the brother of Simon Flexner,
head of the Rockefeller Institute for Medical
Research. Working closely with the AMA, he completed a
survey of medical schools that was practically a
carbon copy of a report the AMA had done several years
before. The report found most schools to be
“substandard.”
       Mr. Flexner and his friends at the Carnegie
Foundation, Rockefeller Institute and the AMA
convinced Congress that to “improve” health care, most
healing schools should be closed. They also
recommended licensing of doctors and hospitals as well
as governmental subsidies to drug-medicine schools and
research. These measures were all adopted by Congress
between 1910 and 1920. The number of healing schools
fell from 131 in 1910 to 69 in 1944. The closings
meant many fewer physicians were trained. Not
surprisingly, only the drug-medicine schools survived.
The other healing schools were either shut down or
failed because their graduates could no longer get a
license. The situation remains the same today, except
that several alternative groups, including
chiropractors and naturopaths, have fought back by the
passage of their own licensing laws in many states.

       Problems with licensing can be divided into
several groups:

Philosophical and political objections
       Licensing changes the profession of healing
from a citizen’s sovereign right to contract with
another to a state privilege. This greatly expands the
power of the state and reduces the sovereignty of the
individual. Also, the state is permitted to intrude
deeply into one of the most intimate contracts-that
between the physician and patient.
       Medical-practice laws in most states make it a
criminal offense to “diagnose, prescribe, or treat
anything, mental or physical, real or imaginary”
(quoted from the Arizona medical practice act). These
laws needlessly criminalize thousands of
well-intentioned individuals who have done no harm to
anyone. Heavy-handed tactics, including daylight raids
by SWAT teams, have been used to enforce licensing
laws. Also, the laws are so vague that enforcement is
often arbitrary and based on personal antagonism,
vindictiveness, or envy rather than clear legal
guidelines.
       Licensing boards have police power, but are
made up only of members of the same profession.
Ordinary citizens have little or no representation,
but must abide by decisions of the licensing board.
       Licensing is inextricably involved with the
welfare state. For example, Medicare will only
reimburse licensed practitioners. In Arizona,
registered dietitians fought hard to become licensed,
not because of any public need, but so that they could
receive government insurance reimbursement. Medical
licenses also serve as “tickets of entry” for many
government research jobs, grants and fellowships.
Medical licensing is, in fact, an integral part of an
arbitrary system of forced wealth redistribution.

Economic objections
       Licensing places a barrier between the buyers
and sellers of health services. This restriction of
trade reduces the supply of services. Reducing the
supply of health services increases the cost of
services.
       Expensive schooling, internships, exam fees and
licensing fees raise the cost of entry into the
profession. These costs are passed on to the consumers
of health services, raising prices.
       Licensing reduces competition among
practitioners, resulting in higher prices and reduced
quality of care.
       Licensing reduces innovation by specifying what
is “approved” practice. Reduced innovation raises
costs and lowers the quality of services.

Medical objections
       Licensing reflects a fundamental
misunderstanding of the nature of the healing arts.
Healing is a gift and an art. Many gifted individuals
cannot afford, or for other reasons are not able to
enter and complete, the six to twelve years of
schooling necessary to obtain a medical license.
Licensing deprives the population of the skill and art
of these individuals.
       Licensing blocks innovation and the practice of
alternative methods of healing.
       A licensed physician is no longer responsible
only to the patient. His loyalty is divided between
satisfying the patient and satisfying his licensing
board.

Social objections
       Licensing gives the consumer of health care a
false sense of security in his physician that can lead
to false and unfulfilled expectations. This impairs
the doctor-patient relationship and contributes to
dependency and, later, anger and resentment. The
present malpractice crisis is in part due to
excessively high expectations of the public, generated
in part by licensing of physicians.
       Licensing discriminates against the poor, who
have more difficulty meeting educational and other
requirements for licensure. Licensing has also been
used to keep minorities and women out of the healing
professions.
       Without licensing, private certifying agencies
would spring up to replace state licensure. Many such
groups already exist. One could still choose an
AMA-approved, board-certified physician. But one could
also choose among a variety of alternative
practitioners who are not permitted to practice at
present. The public would be better protected from
fraud and malpractice because no physician would be
shielded by his license. Physicians would be directly
accountable to their patients. Health care would
operate in a manner similar to car care. There would
be many levels and types of care available. Not
everyone enjoys the same level of car care, but most
people receive care, innovations are permitted, and
competition keeps prices in check.
       The negative effects of licensing include
higher prices, reduced innovation, reduced access to
care, restriction of the right to contract, and much
poorer health of our population. Licensing also is an
integral part of the welfare state whose principles
are alien to our American way of life. America once
did very well in the area of health care without
medical licensing. It is time to move toward our
previously successful experiment with a free-market
system of health care.

__________________________________________________
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HMOs vs. Patents
National Review Online
May 3, 2001

HMOs want to discourage new biotech drugs that they
are worried about paying for.

By Robert Goldberg, senior fellow at the National
Center for Policy Analysis.

What do South Africa and U.S. health plans have in
common? They both want to destroy patents as a way to
reduce the price of drugs. Recently, biotech and drug
companies withdrew a suit in South African court
against a law that would give that country's health
ministry uncontested power to import or copy any drug
it wanted, irrespective of any patent protection. In
doing so it ignored not only patent rights, but also
the availability of other ways to bring HIV drugs into
South Africa at little or no cost. It also skipped
over the impact of weakening intellectual-property
protection on the ability of innovator companies to
attract capital to invest in the next generation of
new medicines.

You would think such knee-jerk assaults on profits
would be the exclusive domain of Third World
socialists or graduate students in International
Development. But slashing the intellectual-property
protection generally afforded to biotech and
pharmaceuticals is now the main legislative goal of
companies such as Wellpoint Health, Oxford, Kaiser,
Aetna, General Motors health plan, and Blue Cross Blue
Shield. Their gripe is that over the years medicines
have received so many patent advantages that generic
drugs will never have a chance to enter the market.
Drug prices are kept "artificially high" because of
the lack of competition, marketing, etc. They say that
if we cut patent protection back, there would be more
generics and still plenty of room for innovation. The
only thing we would lose as consumers are all the
"copy cat" drugs that come out at high prices to treat
exactly the same illness that the first two or three
drugs to have arrived on the market handled in exactly
the same way. The plans will lobby Congress to enact
this proposal and further fuel anti-drug company ire.

In fact, the last thing we want to do is discourage
brand competition. Such competition reduces drug
prices. Further, no one drug works well for everyone.
Despite the several drugs available to treat such
chronic illnesses as depression, schizophrenia,
diabetes, high cholesterol, and high blood pressure,
many people still find that no medicine helps, or they
find the need to switch drugs as they add medicines,
get older, or confront other illnesses. Further, as
genomics allows us to understand how diseases and
drugs work at the molecular level, companies will
begin to tailor medicines to specific groups and
individuals, a move that will eliminate deadly side
effects and improve response to treatment. Why would
HMOs want to undermine patent incentives for
individualizing medicines? More individual medicines
mean more people taking drugs as they should.

Then there is the case of discovering new uses for
existing drugs. The longer a drug stays on patent and
on the market, the more applications are found beyond
its existing indication. Treating PMS with Prozac is a
classic case. Using Taxol for a whole host of cancers
is another. Using anti-convulsives for pain management
is another burgeoning area. Guess how much of this
research is paid for by generic companies? Close your
eyes and tell yourself what you see. The fewer new
uses, the fewer things HMOs and insurance companies
have to pay for. Less patent life, lower prices, less
spending.

In other cases the HMOs are just being overtly cheap
and selfish. They want to roll back patent protection
for rare diseases, the ones hardly anyone makes any
money on. No generic company will ever make orphan
drugs because the market is too small. So why cut
patent life and incentives for research? The HMOs and
insurance companies want to discourage the "tidal
wave" (their words) of new biotech drugs that they are
worried about paying for.

The irony is that in the long run, overall medical
innovation meshes with the message of managed care:
Investing in the prevention of disease leads to longer
and more productive lives and more efficient health
care. In the short run, biomedical innovation, in the
form of new drug consumption, drives down health-care
costs and makes people more vital and productive.
Managed care expert J. D. Kleinke points out that even
after 20 percent spending increases over the past
three years, drugs as a percentage of HMO health
budgets rose only a point from 8 to 9 percent of total
managed-care spending. Meanwhile, hospital spending
has remained flat. HMOs claim that the Hatch-Waxman
act, which created the generic drug industry, needs to
be changed so that more patent life is cut from brand
drugs. Given the benefits of new drug consumption, is
that really the wisest course?

So why the Third World response to medical progress?
Because HMOs and insurers are largely creatures of the
regulatory state. They fear the market as much as AIDS
activists hate capitalism. And ultimately these
powerful emotions have brought them into common cause
to strip the most potent source of medical innovation
of their patent life for one reason only: to
redistribute wealth now being invested in new drug
development. One can forgive AIDS activists for being
misguided in the belief that socialism will save
lives. What can American health plans offer up as an
excuse for their like-minded efforts?


__________________________________________________
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New York Times
May 5, 2001

License of Prominent Doctor Suspended During Inquiry

By JENNIFER STEINHAUER

The New York State Commissioner of Health has
suspended the license of the president of the medical
board of New York Methodist Hospital in Brooklyn,
calling the doctor, who has a large surgery practice
there, a danger to patients.

The doctor, Mohammad Oloumi, is under investigation by
the Health Department on numerous negligence and
incompetence charges stemming from his surgical
practice at the hospital, where he has worked for
roughly 30 years and is among the top administrators
and moneymakers. Colleagues at the hospital, including
the head of surgery, have complained to administrators
about Dr. Oloumi's care of patients for at least four
years, according to doctors there, including those who
support Dr. Oloumi.

Dr. Oloumi is the latest, and most prominent, doctor
to be brought up on charges of negligence at Methodist
by the Health Department in recent years. The hospital
has more doctors who have been disciplined or
investigated in negligence cases than any other major
hospital in the city, according to the State Health
Department.

The health commissioner, Dr. Antonia C. Novello,
opted, with a power she uses infrequently, to suspend
Dr. Oloumi's license while his hearings continued. Dr.
Oloumi "constitutes an imminent danger to the health
of the people of this state," said the order issued by
Dr. Novello. A final conclusion to the hearings could
range from a total restoration of his license to its
final revocation.

The state began its investigation last year after
complaints from hospital staff members regarding
numerous surgical cases. In suspending Dr. Oloumi, Dr.
Novello cited two of the cases. In one, the state
accused the doctor of attempting dangerous and
unneeded stomach surgery on an 89-year-old patient who
was being treated at the hospital for congestive heart
failure.

In the other, the doctor was accused of inappropriate
treatment of a patient who came to the hospital for
weight reduction surgery. According to a sonogram
taken before the operation, the patient had a mass
near her abdominal wall, but the doctor proceeded with
the elective surgery anyway. The patient, who was
later found to have cancer, should never have had the
elective operation, according to the state.

Dr. Oloumi's lawyer, Robert A Barrer, said in a
written statement: "We are surprised and dismayed at
this unwarranted decision by Commissioner Novello and
are considering all options, including a court
challenge. Dr. Oloumi has never been the subject of
any charges of any kind. Dr. Oloumi has denied all of
the allegations against him and looks forward to the
opportunity to clear his name and his reputation."

Administrators at the hospital did not answer e-mailed
questions regarding Dr. Oloumi yesterday and did not
return repeated calls.

Through the years, a variety of doctors have
complained to hospital administrators about Dr.
Oloumi's surgical practice, but he has never been
sanctioned by the hospital, said nearly a dozen people
who work within the department and who spoke only on
the condition of anonymity, for fear of being fired.

One doctor, Moshe Schein, had complained repeatedly to
the chairman of surgery at the hospital, Dr. Leslie
Wise, and was fired last March. Dr. Schein was
inexplicably rehired less than two weeks later,
letters between the doctor and administrators show.
Dr. Schein would not comment, citing a legal agreement
with the hospital not to discuss his situation.

Tensions between Dr. Oloumi and those who have
expressed concern over his care have erupted over the
years in a variety of ways. At conferences that are
held for the medical staff to objectively and
privately evaluate cases with poor outcomes, tempers
flared and arguments ensued, which is unusual in that
type of setting, according to several participants.

In a meeting involving a case in which Dr. Oloumi
operated on the healthy breast of a 9-year-old girl,
several doctors contended that the surgery was
unneeded and wrong- headed, according to minutes from
the meeting and several people who attended it, and
Dr. Oloumi became furious and defensive. "What you did
is dangerous," said a doctor who was brought in as a
guest from Babies and Children's Hospital of New York
Presbyterian Hospital, minutes from the meeting show.
That case is one of those being investigated by the
state.

"The whole atmosphere in this department is hard to
deal with," said one medical resident. "It is very
unpleasant."

Supporters of Dr. Oloumi agreed that the atmosphere
had been increasingly toxic in the department, but
blamed his detractors. Dr. Hossein Hedayati, a surgeon
in the department, called Dr. Oloumi "an excellent
surgeon." Dr. Wise, the chairman of surgery who was
brought in to save the residency program, which was
close to closing in the mid- 1990's because of poor
quality, denied that his department was in turmoil.
"The department is in good condition," he said
yesterday. "There is nothing to defend. We have high
standards." He declined to comment further.

By all accounts, even among his adversaries, Dr.
Oloumi is a respected and even revered member of the
hospital. Several members of the board of directors
and hospital administrators have sent their family
members to him for surgery. As the president of the
medical board, Dr. Oloumi oversaw the hiring of all
doctors at the hospital and the quality of care being
given. He also was among the top 10 percent of
moneymakers at the hospital in 1999, according to
state data.

Many concur that his technical skills are unrivaled at
the center, but contend that he makes errors deciding
which patients require surgery and who should be left
untreated. "Technically he is excellent, just
unbelievable," said one surgeon, who echoed four
others. All five agreed that Dr. Oloumi's choices of
when to operate were poor.

According to numerous accounts, the tensions between
Dr. Oloumi and others in the surgical department
intensified four years ago, after Dr. Wise recruited
Dr. Schein, a respected academic surgeon from Israel,
who had published hundreds of articles on surgery. The
hospital is trying to grow and compete with large
academic hospitals in Manhattan.

"He was brought in as an academic moderator," said one
surgeon, who approved of the increased academic tenor.
In many ways the hospital has grown: pediatric
surgical cases have increased dramatically in recent
years, and the hospital has attracted strong residents
to the program.

But the elevated atmosphere of questioning and
critical scientific evaluation of cases did not sit
well with Dr. Oloumi and others who have controlled
the medical staff over the last few decades and who
prefer to view surgery more as an art form in which
sucesses cannot be quantified by scientific measures,
said several people in the hospital.

"The goals of the department have to do with
education, developing good quality of care, working to
get better," said one doctor. "Things here would be a
lot better, insofar as that goes, without this
controversy."

Some doctors at Methodist said they believed that Dr.
Oloumi had been undone by jealous rivals. "I have
known Dr. Oloumi for 30 years,' said Dr. Faraj
Motahedeh, an obstetrician. "If any loved one in my
family gets sick, I would trust him with my heart. He
is a good physician and a caring physician. Obviously
there is a lot of anomosity and jealousy, and I
believe the major reason for the state's case is
that."

In recent years, several doctors practicing at
Methodist have been sanctioned by the state but
retained by the hospital. In the obstetrics and
gynecology department, two doctors have been
disciplined for botching cases. Another doctor at the
hospital was sanctioned for sexually harrassing a
patient. Another prominant surgeon has been under
investigation by the Health Department and recently
retired quietly.

"Community hospitals are a little less than optimally
vigilent about these things," said one surgeon who has
been critical of Dr. Oloumi. "And it is really too bad
because Methodist has a great spirit. It is full of
great people who put patients first. But the hospital
also has a tremendous responsibility because when
people show up off the street, they believe they are
always getting physicians of quality."


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A Prescription for Violence?

By Kelly Patricia O’Meara
Insight magazine

The recent wave of school-shooting incidents has some
concerned parents demanding that the medical records
of students taking psychotropic drugs be made public.
. . .

See full article here:
http://www.insightmag.com/archive/200105217.shtml

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As if on schedule to prove my point about people with
pain being undermedicated, here comes more proof.
Americans are so obsessed with controlling the
personal behavior of people who might "abuse drugs"
(by which we actually mean abuse themselves) that we
are willing to effectively deprive, torture, and even
drive to suicide, others who might benefit from pain
medications.

If people want to self-medicate without permission of
doctors, the government or their neighbors, that is
their own business. Must we torment the chronically
ill to satisfy our desires to prevent habits we don't
approve of?

What Americans have called "abuse" since just 1914 was
the inalienable right of Americans and virtually all
other people since the beginning of human life on
earth. Thomas Jefferson self-medicated with opium for
his digestive problems. Then it was perfectly legal,
now he would spend most of his adult life in prison if
caught, and his doctor wouldn't "trust" him.

This is unmitigated cruelty. It is the basis for what
follows: "physician-assisted suicide." People would
rather die than suffer, or kill some people so others
won't "abuse drugs."

Contrary to what this report suggests, the "abusers"
aren't "determining" that doctors underuse OxyContin,
it is American attitudes about drugs, medicine, and
self-control that make such a determination and
enforce it. The doctors are literally the drug police.

We give physicians more control over our lives, and
they trust us less. We are increasingly the enemy of
those who are hired to heal. It is our own fault.

______________________.

Thursday May 03 06:26 PM EDT

OxyContin Abuse Hurting Real Patients
By Jennifer Mitol ABCNEWS.com

Many people in chronic pain can benefit from the
painkiller OxyContin. But its widespread abuse by
those snorting it for a quick high are making some
doctors suspicious of prescribing it. Federal
officials are trying to stop the abuse.

It was early on a Sunday morning, about 3½ years ago,
a beautiful sunny day, when Brett fell from the roof
of his suburban Chicago house and landed on concrete,
18 feet below, and broke his back.

After years of rehabilitation, the pain was still so
intense it would make him sick. He tried everything to
dull it: narcotic painkillers, acupuncture,
homeopathics. Nothing worked.

Then he tried a relatively new drug, a
sustained-release form of synthetic morphine called
OxyContin. "My quality of life has improved
immensely," Brett says, holding his daughter. "It's
given me a whole bunch of life back."

Timed-Release Painkiller

Called a "breakthrough" for patients, OxyContin has
found its way to stardom. In just six years on the
market, it topped $1 billion in sales last year,
becoming the No. 1 selling brand-name prescription
painkiller. The reason: its sustained-release coating
was a significant advance in keeping people out of
pain for longer periods of time without taking another
tablet.

But it didn't take long for abusers to figure out that
by crushing the tablet, then snorting or injecting it,
they could get the full effect of the drug, meant to
last 12 hours, in one hit.

Because the drug is so valuable on the street and so
easily obtained, it's a financial windfall for people
tempted to sell their prescription.

Who Can You Trust?

"You take a 75-year-old man," said Dan Smoot, a
detective with the Kentucky State Police. "He wouldn't
have access to the cocaine, nor could he climb the
mountain to plant marijuana. But he can sure go to the
doctor."

A one-month supply from the pharmacy can go for as
much as $4,000 on the street.

That put doctors in the uncomfortable position of
questioning their patients. "There was a time when you
would trust the patient, the patient was always
right," lamented Dr. Joe Florence, who runs a health
clinic in Hazard, Ky. "In this day and time we are not
doing that."

That effort to stop the flow to abusers has in effect
stopped the flow to legitimate patients as well.

Purdue-Pharma, of Stamford, Conn., which manufactures
OxyContin, says that's going too far. "Every strong
medication that is on the market legally in this
country has an abuse potential, said David Haddox,
Purdue-Pharma's medical director. "That's why they're
called controlled substances."

But OxyContin seems to be different. Federal officials
say no prescription drug in the last 20 years has been
so widely abused so soon after its release, wreaking
havoc on many communities, especially Hazard, where
more than half the inmates at a local county jail are
in for OxyContin-related crimes.

Kentucky state police already count 31
OxyContin-related fatalities this year, and that's
just one state.

Feds Hoping to Stem Tide

The Drug Enforcement Administration says the problem
is quickly spreading beyond the rural strongholds of
Appalachia and into places like south Florida and New
England. They have asked the company to limit the
drug's distribution to doctors who specialize in pain,
hoping to choke off the supply.

The agency, along with the Food and Drug
Administration, only has authority to make
recommendations. It cannot force the company to change
its policy. New Federal Initiative.

That leaves patients like Donna Jetter, of
Shepherdsville, Ky., who was hit by a car four years
ago, with sparse access to an FDA (news - web
sites)-approved medication.

"Once I say 'long-acting pain medication such as
OxyContin,' it's like you immediately hit a brick
wall," says Jetter. "They don't want to talk to you
anymore."

She says one doctor told her he couldn't give her the
medication because she would become an addict and end
up on skid row.

"I'm in pursuit of anything that will help me live a
normal life again."

Even Haddox is frustrated. "When drug abusers
determine the medical care for the rest of us, that is
a travesty."

So far, Johnson is lucky. OxyContin abuse has yet to
hit his community. "I know there's other people like
me," says Johnson. "This might be the only thing that
could help them, because it's been the only thing that
could help me."

ABCNEWS' Geoff Morrell of NewsOne Chicago contributed
to this report.

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One tries to be generous, but this does suggest that
there are a lot of people practicing medicine who are
lacking in even elementary smarts.

Thursday May 3 5:39 PM ET
Study: Doctors Mismeasuring Kids

By JENNIFER BROWN, Associated Press Writer

PHILADELPHIA (AP) - Pediatricians and family doctors
inaccurately measure children's height most of the
time, often because the youngsters are wearing hats or
shoes or the equipment is faulty, researchers say.

Researchers said the mistakes could make it harder to
recognize serious growth disorders or other health
problems.

Measuring height during a doctor's visit is "really
the best, quick indication of the health of
children,'' said study co-author Terri Lipman, a nurse
practitioner in endocrinology and diabetes at The
Children's Hospital of Philadelphia. "If you say to a
parent, `Your child is growing normally,' they
understand that and it doesn't take a lot of medical
knowledge to know that's healthy.''

The study of 660 children showed that pediatricians
and family doctors took incorrect height measurements
for two-thirds of the youngsters. Babies, older
children and teen-agers were mismeasured by an average
of about 3/4 inch and as much as 41/2 inches.

Among the reasons given: Doctors use floppy measuring
arms, or the youngsters wear hats or shoes, or have
high hairdos, or just squirm a lot.

The study, conducted by the Pediatric Endocrinology
Nursing Society, did not distinguish between children
whose height measurements were too high and those
whose measurements were too low.

The three-year study was funded by the Genentech
Foundation for Growth and Development, a nonprofit
organization that gets funding from Genentech Inc.,
which makes growth hormone.

Even a slightly inaccurate measurement that is
compounded over several visits can delay the diagnosis
of growth problems, said Dr. Robert Rapaport, director
of pediatric endocrinology and diabetes at Mount Sinai
Hospital in New York.

"Sometimes growth failure may be the only clue to an
underlying problem,'' said Rapaport, who attended the
study's presentation this week at the Society of
Pediatric Nurses in Baltimore. "Height measurements
are the single most important tool that we have to
diagnose a child's health.''

The study involved pediatric and family-care practices
around the country. Researchers reviewed the
measurements taken by doctors, then measured the
children again using accurate equipment and
techniques.

Healthy children grow about 21/2 inches a year on
average. More or less growth could be an early
indication of kidney problems, malnutrition, hormonal
problems or chronic illnesses.

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"Mental health" providers are lobbying successfully to
get legislatures to force insurance companies to cover
psychiatric services. The result of this will be
higher insurance premiums, fewer people insured, and
reduced medical care.

Mackinac Center for Public Policy
Posted: Monday, April 30, 2001

Mental Health Parity Could Decrease Access to Affordable
Insurance
http://www.mackinac.org/print.asp?ID=3442

Article from DRCNet site:

Chronic pain treatment

One of the most serious problems in modern medicine is
the undertreatment of patients in chronic pain.  More
than 30 million patients suffer from chronic pain, and
seven million of them cannot relieve their pain
without opioids (narcotics), but only 4,000 doctors in
the country are willing to prescribe them, according
to the National Chronic Pain Outreach Association.  A
New England Journal of Medicine editorial stated that
56 percent of cancer outpatients and 82 percent of
AIDS outpatients were undertreated for pain, as were
50 percent of hospitalized patients with a range of
conditions. . . .

See full article here:
http://www.drcnet.org/gateway/pain.html

Be sure to visit the links on that page.

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Pharmaceutical giant Eli Lilly is promoting Sarafem as
a miracle pill for women suffering from ‘mental
disorder’ not yet proved to exist. What’s
more, Eli Lilly admits that Sarafem has the same
active ingredient as Prozac, complete with the same
dangerous side effects.

http://www.insightmag.com/archive/200104301.shtml

Insight magazine

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Mandatory Vaccination Programs and Medical Ethics

Physicians, upholding the Oath and individual-based
ethics of Hippocrates, actually benefit not only their
individual patients but also society . . . secondarily

by Miguel A. Faria Jr., M.D.

http://www.heartland.org/health/apr01/vaccine.htm

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Why We Need
Market-based Health Care Reform

by The Health Policy Consensus Group

Part 1
http://www.heartland.org/health/mar01/why.htm

Part 2
http://www.heartland.org/health/apr01/market2.htm

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The author argues that the real problem is not a
deficiency of laws and lawsuits, but the inability of
consumers to free choice in insurance.

"Bill of Rights" a Boon to Lawyers, Not Patients
by Grace-Marie Arnett

http://www.heartland.org/health/apr01/rights.htm

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More victims of the "war on drugs"

------------------------------
Tuesday April 10 5:34 PM ET

Survey: Multiple Sclerosis Pain Undertreated

NEW HAVEN, Conn. (Reuters Health) - A large-scale
survey of more than 7,000 multiple sclerosis (MS)
patients shows that most MS patients are undertreated
and often unrecognized for pain management.

Yale University neurologist Dr. Marco Rizzo presented
these findings last week here at the 15th Yale
Neuroimmunology Symposium.

"MS patients experience migraine headaches, eye, leg,
facial, bladder and skin pain. Muscular spasms and
prickling or tingling sensations of the skin are
common, and the pain is chronic,'' Rizzo explained.

MS is a central nervous system disorder in which the
thin protective coating called myelin that insulates
nerve fibers in the brain and spine becomes damaged.
Eventually, lesions develop in the brain and spinal
cord that can lead to a loss of vision, weakness,
numbness and tingling.

MS occurs when white blood cells known as T cells
attack the proteins that make up myelin. Currently,
there is no cure for the disease.

Chronic pain causes ``miswiring,'' leading to abnormal
pain pathways, Rizzo noted. Typical pain medications
do not work in chronic pain and so MS patients need to
be treated with medications such as a class of
antidepressants known as tricyclic antidepressants,
and anticonvulsants. Typically, more than one
medication or combination needs to be given in order
to effectively tackle the pain, Rizzo pointed out.

Some of the medications Rizzo finds to be effective
are gabapentin (Neurontin), lamotrigine (Lamictal),
amitriptyline, the broad-spectrum anticonvulsant
(divalproex) Depakote, topirimate (Topamax) and
baclofen. OxyContin, a new opiate, has shown no
results in managing chronic MS pain, according to
Rizzo.

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This is a strange story. How is it that records can be
so sloppy that "experts" overstimate heart attacks by
a huge number? It could be quite good news for overall
health, but horrible news for those who expect good
medical statistics.

----------------------------
26 April 2001
Rocky Mountain News

U.S. may have 200,000 fewer heart attacks than
believed

By Jim Erickson, News Science Writer

University of Colorado researchers say there are
100,000 to 200,000 fewer heart attacks in the United
States each year than experts had believed, an
overestimate caused by double-counting patients
transferred between hospitals.

The American Heart Association says more than 1
million Americans are hospitalized for heart attacks
every year, and nearly half die. Heart disease is the
leading cause of death in the United States.

But in an eight-state study of hospital discharge
data, Dr. John W. Westfall and a colleague at the CU
Health Sciences Center found that 10 percent to 15
percent of heart attack incidents might have been
counted twice because of the increasingly common
practice of transferring patients between hospitals.

If that rate of overcounting is the same nationwide,
then the true number of U.S. heart attacks each year
is 800,000 or 900,000, Westfall said. The
double-counting is especially a problem in rural
areas, where heart attack patients are often
transferred to large urban hospitals for specialized
care.

"People have said, `Yeah, we know that people get
transferred,' but no one realized that it generated
the number of double-counted records that it does,"
Westfall said Wednesday. Results of the CU study are
published in the May edition of the journal Medical
Care.

Double-counting, which has increased over the past 10
to 15 years as more and more patients are transferred,
might also account for part of the reported drop in
in-hospital heart-attack deaths during that same
period, Westfall said.

If double-counting drives the heart-attack numbers up
while the number of heart-attack deaths remains
roughly constant, then the mortality rate appears to
drop, he said.

"There are about 100,000 or 200,000 fewer heart
attacks per year. That's the good news," he said. "The
bad news is that you're more likely to die from your
heart attack than we previously thought."

Not so, said Dr. Wayne Rosamond of the University of
North Carolina at Chapel Hill, who led a seven-year
study of more than 352,000 heart patients in four U.S.
communities. Rosamond said his study, published three
years ago in the New England Journal of Medicine, took
double-counting into account.

"We investigated each case, tracking down information
regarding transfers to avoid the very problem he
describes," Rosamond said Wednesday. The North
Carolina researchers found that in-hospital mortality
from heart disease fell 5.1 percent in each year of
the study.

Dr. Ira Nash of Mount Sinai Hospital in New York City
said the CU researchers "are highlighting in a fairly
dramatic way" the over-counting problem. But the
Colorado researchers "may have overstated it a little
bit," Nash said.

He and his colleagues analyzed more than 30,000 U.S.
hospital admissions for heart attacks and published
their results two years ago in the American Journal of
Cardiology.


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Monday April 23 2:43 PM EST

U.S. Aims to Improve Data on Medical Errors

By Will Dunham

WASHINGTON (Reuters) - Aiming to prevent potentially
deadly medical errors, the Bush administration on
Monday launched an effort to establish a confidential
database on the Internet of mistakes made by doctors
and hospitals.

The database would draw on information already being
given to states or the federal government and would
not be available to the general public to check up on
blunders committed by any specific doctor or hospital,
according to officials from the U.S. Department of
Health and Human Services (news - web sites).

The project is intended to help government regulators
and medical professionals spot trends in mistakes in
an effort to avoid repeating them, while cutting
through the red tape that hinders reporting on such
errors, officials said.

The HHS agencies spearheading the effort are the
Agency for Healthcare Research and Quality, the
Centers for Disease Control and Prevention (news - web
sites), the Food and Drug Administration (news - web
sites), and the Health Care Financing Administration.

``What the public will gain from this system is
improved health care because this is going to make
available to (health care) providers at all levels
information that's going to allow them to learn from
errors and to enhance safety,'' Dr. Gregg Meyer,
director of AHRQ's Center for Quality Improvement and
Patient Safety, told Reuters.

Experts said in a 1999 report that medical errors kill
between 44,000 and 98,000 people annually, with up to
7,000 of those deaths resulting from mistakes in
prescribing or dispensing drugs.

HHS Secretary Tommy Thompson on Monday announced the
formation of a task force to seek ways to improve the
collection of data on patient safety. Thompson asked
the task force to devise a user-friendly
Internet-based patient safety reporting system that
would enable faster cross-matching and electronic
analysis of reports on medical errors.

Concern Over A ``Data Graveyard''

A number of states require health care providers to
report on mistakes, while federal agencies collect
such information provided on a voluntary basis. But
whether this data is being put to good use is
questionable.

Meyer said he was concerned that reports on medical
mistakes currently may reside in a ``data graveyard.''
For example, he said experts examining dialysis
centers were forced to sift by hand through reports to
three government agencies that, once considered
together, showed that certain cleaning techniques used
on dialysis machines caused deadly infections.

``Someone had to sit down and hand match data that the
government was already collecting,'' Meyer said. ``We
think that just simply doesn't make sense, and is not
a situation that can be carried forward.''

Thompson announced the initiative during a meeting of
officials from medical professional organizations,
state health departments, state licensure boards,
accrediting bodies and patient advocacy groups.

``Working with our state and private-sector partners,
we can make much better use of the information we
already collect, and we can translate that information
into quality gains for patients,'' Thompson said in a
statement. ``At the same time, we will streamline the
reporting burdens that providers face today, and we
will make important findings more accessible, more
quickly to the providers who need to know.''

Meyer said the initiative is not aimed at producing a
database naming individual doctors involved in medical
mistakes.

``In terms of having this be a data bank of
provider-level error rates, that's not the direction
that we're going,'' he said. ``The reason we're not
going there is that what we have learned from research
is that the way to approach patient safety is to take
a systems-based approach to get away from that old
system of name, blame and shame.''

Meyer said it may take a year or two to put in place
the task force recommendations. Officials said the
department's budget request for the next fiscal year
seeks $72 million for efforts to improve patient
safety and reduce errors.