History > 2009 > USA > Health (VII)
How Biology Influences Our Behavior
A Modest Public Plan
November 29, 2009
The New York Times
It is astonishing, but the question of whether a small slice
of Americans should be able to choose between a government-run health insurance
plan and private health insurance plans is threatening passage of much-needed
health care reform.
Senate Democrats barely mustered enough votes to start debating their reform
bill, and some senators who voted to allow debate have said flatly that they
will not support the final bill if it retains its public option clauses. If they
mean what they say, their defection could make it extremely hard to overcome a
We got to this juncture because, in an already overheated political debate, no
issue has drawn more demagoguery and less rational analysis than the public
option. And while both political parties exaggerate what a public plan could do,
Republican critics are particularly divorced from reality.
They say the public option would start a government takeover of all health care;
interpose government bureaucrats between patients and their doctors; sound the
death knell for private insurance; and lead many companies to dump insurance
benefits. They also say it could cost taxpayers a lot.
Democrats, meanwhile, claim that competition from a public plan would help drive
down insurance premiums and the overall cost of medical care.
We wish the proposed public plan could be powerful enough to demand low rates
from health care providers, charge much lower premiums than private plans and
attract large numbers of enrollees. But neither the House nor Senate versions
would have that kind of power.
Here is what a public option — as structured in the House and Senate bills —
would do and would not do:
HOW IT WOULD WORK Both bills would create new insurance exchanges, with an array
of plans to choose from, for a limited number of Americans — those who lack
group coverage and must buy policies directly from insurers and those who work
for small employers, about 30 million people within a few years. With millions
of potential new clients, all major insurers are expected to participate. And
Congress willing, a new public plan would also be available.
The government would run the public plan, but both the Senate and House versions
would require it to compete on a “level playing field.” It would have to follow
the same rules as the private plans, meet the same benefit standards, maintain
the same reserves, and support itself entirely with premium income, with no
federal help beyond start-up money that would have to be repaid.
The secretary of health and human services, as the head of the plan, would have
to negotiate rates with health care providers just as the private plans do.
WHAT IT COULDN’T DO Because of intense opposition from conservatives, both bills
shunned a more robust public plan that would have had the power to virtually
force doctors to serve its beneficiaries — at Medicare rates that are typically
less than private plans pay them.
As a result, the current weaker versions could find it difficult to compete with
well-entrenched private insurers. The Congressional Budget Office believes
public plan premiums would actually end up higher than the average private plan
premium. This is partly because the public plan would probably attract the
sickest patients, whose bills are highest, and who might fear that private plans
would find some way to jettison them.
All told, the C.B.O. estimates that the House bill’s public plan would attract
only six million enrollees. The Senate version, which would allow states to opt
out, might attract only three million to four million.
This is not going to destroy the private insurance market or start a government
takeover of the health care system, or put bureaucrats in control, any more than
private plans do. Nevertheless, in a recent Senate debate, Republicans insisted
that more than 100 million Americans might enroll in a public plan, the vast
majority of them dumped by employers from coverage that they were satisfied
That overblown claim is based on a study showing that a much more robust plan
could offer far lower premiums than private plans, and if available to virtually
everyone, it could attract huge numbers of enrollees.
In that no-longer-relevant scenario, private plans would indeed lose a lot of
their subscribers. But workers would still not lose their employer-sponsored
benefits. Their employer’s subsidy would follow them to the exchanges, where
they would have a much wider choice of plans than they now do. Even in a
nightmare scenario that lives only in Republicans’ fevered rhetoric, workers
would be better off than they now are.
Although the public plan is supposed to be self-sustaining, critics worry that
if it starts to fail, future Congresses will bail it out with taxpayer money. We
hope they are wrong. If the public plan gets into financial trouble, it should
simply raise its premiums or close.
SO IS IT STILL WORTH DOING? Even with the constraints, a public plan could be a
useful part of health care reform. Most important, it would compete in markets
dominated by one or two private insurers that can charge more and not worry
about losing customers.
The presence of a public plan could serve as a brake on unwarranted premium
increases by the private companies. The C.B.O. said a public plan with
negotiated rates would place “downward pressure on the premiums of private
plans.” A public plan would also provide a safe harbor for people who do not
trust the insurance industry and would prefer a government plan even if its
premiums were higher. And it would be a place to test innovative ideas for
controlling costs and improving quality.
The C.B.O., a notably cautious evaluator, could be wrong in its assessments. The
plan might turn out to be better at negotiating lower rates. And with no need to
turn a profit, it might be able to charge less than private plans and attract
millions more people than expected. That could force private plans to lower
their own rates.
We are not holding our breath. The public plan could face enormous practical
problems entering markets where private insurers already have well-established
networks of providers or where hospital groups already have the upper hand in
negotiating with insurers.
Even a weak public plan would be better than no public plan. It would expand the
choices available to millions of Americans and could help slow the relentless
increases in the cost of health insurance. Congress certainly owes Americans a
more rational and informed debate.
This editorial is a part of a continuing series by The New York Times that is
providing a comprehensive examination of the policy changes and politics behind
the debate over health care reform.
A Modest Public Plan,
The Cancer Lounge
November 29, 2009
The New York Times
By N. R. KLEINFIELD
The cancer patient racked them up and broke. Clackety-clack. Seven ball in
the corner pocket. Five ball in the side.
Light was seeping out of day. The long, brick-walled room was getting busy.
People hooked to IVs in whispered conversation. Others working a jigsaw puzzle.
Playing gin rummy. All of them caught in an unwelcome dance with mortality.
This is what passes for pleasure in a cancer hospital.
Paul Gugliotta always sought out the pool table. His game had sharpened beyond
expectations. Since a diagnosis of lymphoma in June, Mr. Gugliotta, a chemical
engineer from Long Island, had had two lengthy stays at Memorial Sloan-Kettering
Cancer Center on the Upper East Side. He chafed at being cooped up in his
antiseptic room. He even fled the grounds several times, in violation of the
rules, wandering down to the 59th Street Bridge and ordering a hot open-faced
turkey sandwich at a nearby diner. Then one day he stumbled upon the recreation
center, which can be reached from the hospital’s 15th floor, and it became his
It is something of a cancer patient’s corner bar, minus the booze. Mr. Gugliotta
hung around and talked cancer, talked life. He sampled just about everything the
center offered. Pottery, copper enameling, blackjack. He made a toolbox, a
stained-glass thermometer. His wife, Francine, said, “I never thought I’d see
him doing decoupage, but sure enough.”
Now, Mr. Gugliotta, 46, is a commuter, reporting every three weeks for
chemotherapy. While the chemicals are mixed, a process that can make patients
wait up to two hours, he repairs to the recreation center and begins
methodically rocketing balls into pockets. He knows the good cue is stashed in
the back. “It’s enjoyable here,” he said. “And it’s where you can talk about
what’s inside you, because it’s inside everyone here.”
Nothing about this big room will cure what brings its visitors to
Sloan-Kettering. Distraction from the truths and riddles of the vile disease
they have, though, is sometimes good enough, a counterpoint to the scientific
experiments that fill the rest of the hospital, and to the claustrophobia of
their thoughts. It’s a place to have some fun within a building where it’s hard
for many who enter to imagine fun.
Putting Fear in Its Place
Recreation centers are staples of nursing homes and pediatric wards, but are
unusual in general hospitals for adults. But since Sloan-Kettering is a cancer
hospital, patients typically stay a while — the average is six days, and many
are there for weeks or even months at a stretch — then return repeatedly as
“There is a lot of down time with nothing to do,” said Yolanda Toth, the adult
recreation center’s director. “After you’ve counted all the holes in the ceiling
of your room and all the blocks and watched enough television, you’re pretty
bored. And then you start thinking — what’s going to happen to me?”
Patients can avoid those crushing fears, or confront them, at the center, open
daily from 9 a.m. to 8 p.m. The sprawling room, its walls adorned with patient
art, contains a pool table, a foosball table, a movie screen, a sitting area and
tables for scheduled craft workshops; adjoining it is a terrace with commanding
views. Visiting performers appear — comedians, Juilliard students. The library
is braced with 12,000 volumes, including plenty of paperbacks; hardcover
editions are too heavy for some of the patients.
Doctors or nurses are not allowed in the recreation center. It’s the No White
Coats Rule. If they need to see a patient, they call and the person is sent back
to their room. “Sometimes doctors will wander in and we will very politely tell
them to wander out,” Ms. Toth said.
In a 434-bed hospital, the recreation center got roughly 35,000 visits last
year, including from outpatients and family members. At the start of a week,
when new patients tend to be admitted, only a few dribble in. Other times,
several dozen people populate the place.
Many patients are too weak or straitened by grief to come by, or don’t see the
point. Others glide into the center in wheelchairs, even on stretchers. Many pad
in rolling IV poles, the dangling drip bags working on their cancer even as they
make rag dolls or play cards.
All in the Cards
Texas Hold ’em was Monday evening. Just three patients showed, so the dealer,
another volunteer and a visitor joined in. No money changed hands. But there
would be prizes.
Douglas Meyers dealt the requisite two cards, accepted bets, turned over the
flop. He is 26, a technology project manager at Citibank, who volunteers to deal
poker hands. Cancer runs in his family — his mother died of melanoma — and that
connection got him engaged.
The weekly poker game commenced in June (before that Mr. Meyers presided over
the roulette wheel). Beginners are welcome. Not long ago, though, a former
participant in the World Series of Poker landed in the hospital. He sat down and
did quite well indeed.
On this Monday, Lee Piepho, 67, was fumbling his way through the hands. An
English professor at Sweet Briar College in Virginia, he was in the hospital to
address an infection after having had surgery for a soft-tissue sarcoma. And he
was rusty. Back in 1958, when he was 16, Mr. Piepho lost $25 in a Chicago poker
game, had to nervously explain the sour outcome to his father and abandoned
cards. But now this.
Unsure of his instincts, he folded successive hands, then raked in one big pot
with a straight, snatched another with two pairs. A young woman shuffled by with
her IV trolley, a scarf masking her baldness, and she smiled on his good
fortune. Besides cards, Mr. Piepho had been using the center’s library, caught
part of the Alfred Hitchcock film “Notorious” the other day, played Speed
He felt comfortable in the center. Among other things, it allowed his cancer to
be out front, because it was everywhere in the room. It is those without cancer
who felt strange here.
Outside of the hospital, Mr. Piepho rarely speaks of his condition, even to
close friends. “I think there’s a certain ethical responsibility about handling
cancer,” he said. “There’s a burden you place on people when you tell them you
have it. Here there’s no burden. This particular place is common ground.”
Nursing a decent stack of chips, Mr. Piepho played the remaining hands warily,
folding miserable cards early. He wound up the winner with a chip count of 19,
eclipsing a 68-year-old woman who had had surgery for uterine cancer and now
seemed to have a growth in her lungs.
Mr. Piepho collected his prize: a green Brooks Brothers tie.
Oil Painting Is Out
The recreation idea at Sloan-Kettering goes back to 1947, and in the early years
the department functioned out of two small second-floor rooms, ferrying
activities throughout the hospital. There were some art classes, sewing circles
and a little music. A spinet piano was wheeled clumsily from floor to floor.
Two years after Sloan-Kettering opened its new building in 1973, the recreation
department earned an entire floor of the old adjoining structure, where it
remains. The scope of activities broadened enormously. The place was renovated
with a gift from the estate of Abby Rockefeller Mauzé, and is paid for out of
the hospital’s operating budget.
Strong odors are avoided, since patients in chemotherapy can develop severe
headaches or nausea from potent smells. Therefore, no oil paints. Only stems
with mild scents are chosen for the flower-arranging sessions. Busy patterns can
make patients dizzy, so solid-colored carpeting and simple tile adorn the floor.
Ms. Toth has years of quirky episodes to recount. A man from Florida was
admitted for throat cancer surgery. His parents came up from Maryland to sit at
his bedside. Eventually, they began to gnaw at his nerves. He told Ms. Toth that
they were jigsaw puzzle nuts. Could she dig up the toughest puzzle she had and
get them going on it? She fished out a monster with 1,500 pieces and a fiendish
pattern. They spent days attacking it, affording their son the peace he craved.
Six years ago, the mother of a soon-to-be bride was a patient, not doing very
well, and the family feared she might not make the wedding. They moved up the
date and held the ceremony at the recreation center. A justice of the peace
presided. Ms. Toth made the wedding cake.
On New Year’s Eve, the center stays open until 1 a.m. Last year, there was
nonalcoholic Champagne and belly dancers. They’re coming again this year.
A Tough Crowd
Maury Fogel said, “Hi, did I wake you?”
He said, “Ever go to the eye doctor and get these magazines with small print? I
can’t see, Doc! You get new glasses — it costs you 500 bucks.”
The comedians come twice a month. The rules are: no vulgarity, no death jokes,
no cancer jokes, no edgy medical jokes. Mr. Fogel, a messenger who moonlights as
a stand-up comedian, puts the bill together. On this night, there was an
audience of 14.
Billy Bingo came on. He promotes himself as New York’s Bravest Comic, because he
used to be a firefighter. Mr. Bingo said: “People say I look like Sonny Bono.
What do you think? I usually get, ‘After the tree.’ ”
He said: “We had a fire in a massage parlor. You want to talk about a fast
response! I was already there.”
Some chuckles, an occasional deep-throated laugh. Tough crowd.
Earlier, the “Look Good ... Feel Better” program for women had 10 patients
clustered around a square table gazing into makeup mirrors. “We don’t talk about
doctors or appointments,” Penny Worth, a former Broadway performer and the
program’s coordinator, told them. “We get away from that. Be girls.”
The concept: Teach cancer patients to use makeup and wigs to improve their looks
and their spirits. Hence, sharpen eyebrow pencils every day when going through
treatment. Wash wigs after six to eight wearings in spring and summer, 12 to 15
in fall and winter.
Afterward, Ms. Worth and the volunteers broke into the old ragtime song “Oh, You
Josephine Walsh was circling the room. She’s a veteran. She is 84, and has been
coming to the recreation center for 22 years from her home in Queens. First she
had cancer in a kidney, then breast cancer, and now she is an outpatient. She
watched a daughter die of lung cancer at 40.
“My whole life is seeing doctors, trust me,” Ms. Walsh said. She shows up at
least once a week, likes to make jewelry, talk to whoever is around. “I ask them
where their boo-boo is,” she said. “It’s easy to talk with someone who lives in
the same shoes.”
She looked on as a woman from Florida with rectal and lung cancer pasted leaves
into a collage, something achieved. The woman inhaled deeply, feeling a little
Ms. Walsh told her: “You forget all your troubles when you’re in here.”
She told her: “You’ll be well. God bless you.”
The Would-Be Olympian
Stories take hold in the recreation center for moments in time, then relocate,
overtaken by new ones. Happy stories, sad stories.
For weeks, one of the odder sights had been the genial young man, usually
connected to the IV pole he had nicknamed Bertha, on the terrace doing the
regimen he devised: 1,000 jumping jacks, 250 push-ups, 500 situps, 400 lunges.
He was training to represent Nigeria in the Olympics in the skeleton, a sledding
He was aiming for the 2014 Olympic Winter Games in Sochi, Russia. Nigeria has
never sent anyone to the Winter Games in the skeleton. Nigeria has never sent
anyone to the Winter Games in anything. And he had never tried the skeleton.
The man’s name is Seun Adebiyi. He is 26. Born in Nigeria, he moved to Alabama
with his mother, a math professor, when he was 6. In May, he graduated from Yale
Law School. He is on leave from his job as an operations analyst with Goldman
Sachs in Salt Lake City. Salt Lake City happens to be one of two places in the
country with a facility to practice skeleton. You lie on your stomach and ride
the sled at absurd speeds down a twisting course.
Early next year, Mr. Adebiyi intends to take the New York bar exam. Eventually,
he hopes to return to Nigeria and try to make the country better. In addition to
his workouts, he has been studying for the bar in the center, in jeans and a
T-shirt. “I continue to think of me as I was before I came here,” he said.
“Wearing the hospital gown is like a form of surrender I’m not willing to do
Mr. Adebiyi said that he had felt since he was little that he ought to be in the
Olympics. For years, he swam competitively. He missed qualifying for the 2004
Summer Games by a tenth of a second in the 50-meter freestyle. The slim miss
sent him into a funk.
Last March, he researched alternate events that would be less competitive in
Nigeria. Well, winter sports aren’t big in a country without any actual winter.
Skeleton seemed the ticket. He had never been on a sled, but so what.
Then in June a swelling he had noticed in his groin led him to find out he had
lymphoblastic lymphoma and stem-cell leukemia, two rare and aggressive cancers.
As Mr. Adebiyi put it, “It completely reshuffled the deck.”
This was his seventh week at Sloan-Kettering. Chemotherapy had contained things
for now. Yet he urgently needed a bone marrow transplant. He has no full
siblings. Available donors are sparse for people of African descent. A good
donor has not yet been found.
Mr. Adebiyi dealt with the unknown through daily meditation. He began a blog,
nigeria2014.wordpress.com, in part to advocate for minority donors, to help
others if he can’t help himself.
He liked it at the recreation center. “When you talk about your cancer, you
don’t get the intake of breath, the sharp gasp,” he said. “No one is rushing to
The place provided him needed space from his hospital roommates, of which he’s
had 10. He had overheard one on the phone orchestrating his funeral, what sort
of urn for his ashes.
Mr. Adebiyi was discharged this month. The search for a donor continues. Those
who knew him at the center hope that he will return soon and that the hospital
will have something to put in him, give his story a good ending. Meanwhile, he
went looking for a used skeleton sled. He needed to practice.
The Cancer Lounge, NYT,
Fighting the Wrong Health Care Battle
November 29, 2009
The New York Times
By PAUL STARR
AS the health care debate enters its decisive stage, liberals in Congress should
be ready to trade the public option for provisions that will actually make the
Discussion of the public option — a government insurance plan that would be
offered to individuals and small businesses buying coverage through new
insurance exchanges — has been dominated by ideological politics. Conservatives
claim it would amount to a government takeover, while liberals imagine that it
would radically alter the insurance market by providing better protection at
As it now stands in Congress, however, the public option would do neither.
According to the Congressional Budget Office, it would enroll less than 2
percent of the population and probably have higher premiums than private plans.
For progressives to say they will block reform without a public option is not
just foolish, but potentially tragic if it results in legislative deadlock.
An earlier version of the public option, available to the entire public, might
have realized progressive hopes and conservative fears. By paying doctors and
hospitals at Medicare rates (which are 20 percent to 30 percent below those paid
by private insurers), the public option would have had a distinct price
advantage. But by severely cutting revenue to health-care providers, it would
also have set off such a political crisis that Congress would never have passed
Instead, the bills in Congress now call for the government plan to negotiate
rates with providers, as private insurers do. That limitation exposes a defect
in the idea. The government plan may well have to charge higher premiums because
it is likely to attract more than its share of the chronically ill and other
high-cost subscribers. It could go into a death spiral of mounting costs.
But giving the exchanges the necessary authority to regulate private insurers
could solve many of the problems that motivated the public option in the first
place. Strengthening that authority and accelerating the timetable for reform
are what liberals in Congress should be looking for in a deal.
The basic aim of reform is to create a more efficient and equitable system for
health insurance and health care and to provide subsidies so everyone can afford
coverage. Those who obtain insurance individually or through small businesses
now get a rotten deal in the market. Out of every dollar in premiums they pay,
nearly 30 cents goes for administrative overhead (as opposed to about 7 cents in
large-employer plans). And those in poor health may be denied coverage for
pre-existing conditions or be charged astronomical rates for insurance.
By creating a single, large “risk pool” for individuals and employees of small
businesses, the exchanges should give those vulnerable groups the advantages of
large-employer plans. The bill would also ban pre-existing condition exclusions
and require insurers to offer coverage to everyone in the exchange at the same
rate regardless of health (albeit with some adjustment according to age).
For these reforms to succeed, there needs to be effective regulatory authority
to prevent insurers from engaging in abusive practices and subverting the new
rules. The bill passed by the House would provide for that authority and lodges
it in the federal government, though states could take over the exchanges if
they met federal requirements. The Senate bill would leave most of the
enforcement as well as the running of the exchanges to the states.
Yet many states have a poor record of regulating health insurance, and some
would resist passing legislation to conform with the new federal law. Under the
Senate bill, the federal government can step in if a state failed to set up an
exchange. But it’s hard enough to get reform through Congress; to try to repeat
that process in 50 state legislatures would be asking for trouble and
Accelerating the timetable of reform ought to be a priority. Although the
legislation calls for some important interim measures, the Senate bill defers
opening the exchanges and extending coverage until 2014. By comparison, when
Medicare was enacted in 1965, it went into effect the next year.
For Congress to put off expanding coverage to 2014 would be asking for a lot of
patience from voters. It would also give the opponents of reform two elections
to undo it. President Obama would have to run for re-election in 2012 defending
a program from which people would have seen little benefit.
To speed the process, the legislation ought to give states financial incentives
to adopt the reforms on their own as early as mid-2011. A state like
Massachusetts, which already has a working exchange, could move expeditiously to
qualify for federal money. The final deadline for the federal government’s
expansion of coverage should be no later than Jan. 1, 2012.
Let the moderate Democrats who oppose the public option say they stopped a
government takeover. Liberals should be prepared to give up what is now a mere
symbol for changes in the bill that would deliver affordable insurance more
effectively and quickly to the millions of Americans who desperately need it.
Paul Starr, a professor of sociology and public affairs at Princeton, was a
senior health policy adviser in the Clinton administration.
Fighting the Wrong Health Care Battle, NYT,
Surgery for Mental Ills
Offers Hope and Risk
November 27, 2009
The New York Times
By BENEDICT CAREY
One was a middle-aged man who refused to get into the shower. The other was a
teenager who was afraid to get out.
The man, Leonard, a writer living outside Chicago, found himself completely
unable to wash himself or brush his teeth. The teenager, Ross, growing up in a
suburb of New York, had become so terrified of germs that he would regularly
shower for seven hours. Each received a diagnosis of severe obsessive-compulsive
disorder, or O.C.D., and for years neither felt comfortable enough to leave the
But leave they eventually did, traveling in desperation to a hospital in Rhode
Island for an experimental brain operation in which four raisin-sized holes were
burned deep in their brains.
Today, two years after surgery, Ross is 21 and in college. “It saved my life,”
he said. “I really believe that.”
The same cannot be said for Leonard, 67, who had surgery in 1995. “There was no
change at all,” he said. “I still don’t leave the house.”
Both men asked that their last names not be used to protect their privacy.
The great promise of neuroscience at the end of the last century was that it
would revolutionize the treatment of psychiatric problems. But the first real
application of advanced brain science is not novel at all. It is a precise,
sophisticated version of an old and controversial approach: psychosurgery, in
which doctors operate directly on the brain.
In the last decade or so, more than 500 people have undergone brain surgery for
problems like depression, anxiety, Tourette’s syndrome, even obesity, most as a
part of medical studies. The results have been encouraging, and this year, for
the first time since frontal lobotomy fell into disrepute in the 1950s, the Food
and Drug Administration approved one of the surgical techniques for some cases
While no more than a few thousand people are impaired enough to meet the strict
criteria for the surgery right now, millions more suffering from an array of
severe conditions, from depression to obesity, could seek such operations as the
techniques become less experimental.
But with that hope comes risk. For all the progress that has been made, some
psychiatrists and medical ethicists say, doctors still do not know much about
the circuits they are tampering with, and the results are unpredictable: some
people improve, others feel little or nothing, and an unlucky few actually get
worse. In this country, at least one patient was left unable to feed or care for
herself after botched surgery.
Moreover, demand for the operations is so high that it could tempt less
experienced surgeons to offer them, without the oversight or support of research
And if the operations are oversold as a kind of all-purpose cure for emotional
problems — which they are not, doctors say — then the great promise could
quickly feel like a betrayal.
“We have this idea — it’s almost a fetish — that progress is its own
justification, that if something is promising, then how can we not rush to
relieve suffering?” said Paul Root Wolpe, a medical ethicist at Emory
It was not so long ago, he noted, that doctors considered the frontal lobotomy a
major advance — only to learn that the operation left thousands of patients with
irreversible brain damage. Many promising medical ideas have run aground, Dr.
Wolpe added, “and that’s why we have to move very cautiously.”
Dr. Darin D. Dougherty, director of the division of neurotherapeutics at
Massachusetts General Hospital and an associate professor of psychiatry at
Harvard, put it more bluntly. Given the history of failed techniques, like
frontal lobotomy, he said, “If this effort somehow goes wrong, it’ll shut down
this approach for another hundred years.”
A Last Resort
Five percent to 15 percent of people given diagnoses of obsessive-compulsive
disorder are beyond the reach of any standard treatment. Ross said he was 12
when he noticed that he took longer to wash his hands than most people. Soon he
was changing into clean clothes several times a day. Eventually he would barely
come out of his room, and when he did, he was careful about what he touched.
“It got so bad, I didn’t want any contact with people,” he said. “I couldn’t hug
my own parents.”
Before turning to writing, Leonard was a healthy, successful businessman. Then
he was struck, out of nowhere, with a fear of insects and spiders. He overcame
the phobias, only to find himself with a strong aversion to bathing. He stopped
washing and could not brush his teeth or shave.
“I just looked horrible,” he said. “I had a big, ugly beard. My skin turned
black. I was afraid to be seen out in public. I looked like a street person. If
you were a policeman, you would have arrested me.”
Both tried antidepressants like Prozac, as well as a variety of other
medications. They spent many hours in standard psychotherapy for
obsessive-compulsive disorder, gradually becoming exposed to dreaded situations
— a moldy shower stall, for instance — and practicing cognitive and relaxation
techniques to defuse their anxiety.
To no avail.
“It worked for a while for me, but never lasted,” Ross said. “I mean, I just
thought my life was over.”
But there was one more option, their doctors told them, a last resort. At a
handful of medical centers here and abroad, including Harvard, the University of
Toronto and the Cleveland Clinic, doctors for years have performed a variety of
experimental procedures, most for O.C.D. or depression, each guided by
high-resolution imaging technology. The companies that make some of the devices
have supported the research, and paid some of the doctors to consult on
In one procedure, called a cingulotomy, doctors drill into the skull and thread
wires into an area called the anterior cingulate. There they pinpoint and
destroy pinches of tissue that lie along a circuit in each hemisphere that
connects deeper, emotional centers of the brain to areas of the frontal cortex,
where conscious planning is centered.
This circuit appears to be hyperactive in people with severe O.C.D., and imaging
studies suggest that the surgery quiets that activity. In another operation,
called a capsulotomy, surgeons go deeper, into an area called the internal
capsule, and burn out spots in a circuit also thought to be overactive.
An altogether different approach is called deep brain stimulation, or D.B.S., in
which surgeons sink wires into the brain but leave them in place. A
pacemaker-like device sends a current to the electrodes, apparently interfering
with circuits thought to be hyperactive in people with obsessive-compulsive
disorder (and also those with severe depression). The current can be turned up,
down or off, so deep brain stimulation is adjustable and, to some extent,
In yet another technique, doctors place the patient in an M.R.I.-like machine
that sends beams of radiation into the skull. The beams pass through the brain
without causing damage, except at the point where they converge. There they burn
out spots of tissue from O.C.D.-related circuits, with similar effects as the
other operations. This option, called gamma knife surgery, was the one Leonard
and Ross settled on.
The institutions all have strict ethical screening to select candidates. The
disorder must be severe and disabling, and all standard treatments exhausted.
The informed-consent documents make clear that the operation is experimental and
not guaranteed to succeed.
Nor is desperation by itself sufficient to qualify, said Richard Marsland, who
oversees the screening process at Butler Hospital in Providence, R.I., which
works with surgeons at Rhode Island Hospital, where Leonard and Ross had the
“We get hundreds of requests a year and do only one or two,” Mr. Marsland said.
“And some of the people we turn down are in bad shape. Still, we stick to the
For those who have successfully recovered from surgery, this intensive screening
seems excessive. “I know why it’s done, but this is an operation that could make
the difference between life and death for so many people,” said Gerry Radano,
whose book “Contaminated: My Journey Out of Obsessive-Compulsive Disorder”
(Bar-le-Duc Books, 2007), recounts her own suffering and long recovery from
surgery. She also has a Web site, freeofocd.com, where people from around the
world consult with her.
But for the doctors running the programs, this screening is crucial. “If
patients are poorly selected or not followed well, there’ll be an increasing
number of bad outcomes, and the promise of this field will wither away,” said
Dr. Ben Greenberg, the psychiatrist in charge of the program at Butler.
Dr. Greenberg said about 60 percent of patients who underwent either gamma knife
surgery or deep brain stimulation showed significant improvement, and the rest
showed little or no improvement. For this article, he agreed to put a reporter
in touch with one — Leonard — who did not have a good experience.
The Danger of Optimism
The true measure of an operation, medical ethicists say, is its overall effect
on a person’s life, not only on specific symptoms.
In the early days of psychosurgery, after World War II, doctors published scores
of papers detailing how lobotomy relieved symptoms of mental distress. In 1949,
the Portuguese neurologist Egas Moniz won the Nobel Prize in medicine for
inventing the procedure.
But careful follow-up painted a darker picture: of people who lost motivation,
who developed the helpless indifference dramatized by the post-op rebel McMurphy
in Ken Kesey’s novel “One Flew Over the Cuckoo’s Nest,” played by Jack Nicholson
in the 1975 movie.
The newer operations pinpoint targets on specific, precisely mapped circuits,
whereas the frontal lobotomy amounted to a crude slash into the brain behind the
eyes, blindly mangling whatever connections and circuits were in the way. Still,
there remain large gaps in doctors’ understanding of the circuits they are
In a paper published last year, researchers at the Karolinska Institute in
Sweden reported that half the people who had the most commonly offered
operations for obsessive-compulsive disorder showed symptoms of apathy and poor
self-control for years afterward, despite scoring lower on a measure of O.C.D.
“An inherent problem in most research is that innovation is driven by groups
that believe in their method, thus introducing bias that is almost impossible to
avoid,” Dr. Christian Ruck, the lead author of the paper, wrote in an e-mail
message. The institute’s doctors, who burned out significantly more tissue than
other centers did, no longer perform the operations, partly, Dr. Ruck said, as a
result of his findings.
In the United States, at least one patient has suffered disabling brain damage
from an operation for O.C.D. The case led to a $7.5 million judgment in 2002
against the Ohio hospital that performed the procedure. (It is no longer offered
Most outcomes, whether favorable or not, have had less remarkable immediate
results. The brain can take months or even years to fully adjust after the
operations. The revelations about the people treated at Karolinska “underscore
the importance of face-to-face assessments of adverse symptoms,” Dr. Ruck and
his co-authors concluded.
The Long Way Back
Ross said he felt no difference for months after surgery, until the day his
brother asked him to play a video game in the basement, and down the stairs he
“I just felt like doing it,” he said. “I would never have gone down there
He said the procedure seemed to give the psychotherapy sessions a chance to
work, and last summer he felt comfortable enough to stop them. He now spends his
days studying, going to class, playing the odd video game to relax. He has told
friends about the operation, he said, “and they’re O.K. with it — they know the
Leonard is still struggling, for reasons no one understands. He keeps odd hours,
working through most nights and sleeping much of the day. He is not unhappy, he
said, but he has the same aversion to washing and still lives like a hermit.
“I still don’t know why I’m like this, and I would still try anything that could
help,” he said. “But at this point, obviously, I’m skeptical of the efficacy of
surgery, at least for me.”
Ms. Radano, who wrote the book about her recovery, said the most important thing
about the surgery was that it gave people a chance. “That’s all people in this
situation want, and I know because I was there,” she said while getting into her
car on a recent afternoon.
On the passenger seat was a container of decontaminating hand wipes. She pointed
and laughed. “See? You’re never completely out.”
Surgery for Mental Ills
Offers Hope and Risk, NYT, 27.11.2009,
Trying to Explain a Drop
in Infant Mortality
November 27, 2009
The New York Times
By ERIK ECKHOLM
MADISON, Wis. — Seven and a half months into Ta-Shai Pendleton’s first
pregnancy, her child was stillborn. Then in early 2008, she bore a daughter
Soon after, Ms. Pendleton moved from a community in Racine that was thick with
poverty to a better neighborhood in Madison. Here, for the first time, she had a
As she cradled her 2-month-old daughter recently, she described the fear and
isolation she had experienced during her first two pregnancies, and the more
embracing help she found 100 miles away with her third. In Madison, county
nurses made frequent home visits, and she got more help from her new church.
The lives and pregnancies of black mothers like Ms. Pendleton, 21, are now the
subject of intense study as researchers confront one of the country’s most
intractable health problems: the large racial gap in infant deaths, primarily
due to a higher incidence among blacks of very premature births.
Here in Dane County, Wis., which includes Madison, the implausible has happened:
the rate of infant deaths among blacks plummeted between the 1990s and the
current decade, from an average of 19 deaths per thousand births to, in recent
years, fewer than 5.
The steep decline, reaching parity with whites, is particularly intriguing,
experts say, because obstetrical services for low-income women in the county
have not changed that much.
Finding out what went right in Dane County has become an urgent quest — one that
might guide similar progress in other cities. In other parts of the state,
including Milwaukee, Racine and two other counties, black infant death rates
remain among the nation’s highest, surpassing 20 deaths per thousand in some
Nationwide for 2007, according to the latest federal data, infant mortality was
6 per 1,000 for whites and 13 for blacks.
“This kind of dramatic elimination of the black-white gap in a short period has
never been seen,” Dr. Philip M. Farrell, professor of pediatrics and former dean
of the University of Wisconsin School of Medicine and Public Health, said of the
progress in Dane County.
“We don’t have a medical model to explain it,” Dr. Farrell added, explaining
that no significant changes had occurred in the extent of prenatal care or in
Without a simple medical explanation, health officials say, the decline appears
to support the theory that links infant mortality to the well-being of mothers
from the time they were in the womb themselves, including physical and mental
health; personal behaviors; exposure to stresses, like racism; and their social
Those factors could in turn affect how well young women take care of themselves
and their pregnancies.
Karen Timberlake, the Wisconsin secretary of health services, said that in Dane
County, the likely explanation lay in “the interaction among a variety of
“Our challenge is,” Ms. Timberlake said, “how can we distill this and take it to
Only about 5 percent of Dane County’s population is black, and the sharp drop in
the mortality rate also tracked larger declines in the numbers of very premature
and underweight births for blacks, said Dr. Thomas L. Schlenker, the county
director of public health.
A three-year study, led by Dr. Gloria E. Sarto of the University of Wisconsin,
is using tools including focus groups and research on pollution to compare the
experiences of black mothers here with those in Racine County, which has the
highest black infant mortality in the state.
It is not hard to imagine why death rates would be lower in Dane County than in
Racine, which is more segregated and violent, or in Milwaukee, a larger city.
Dane County has a greater array of public and private services, but pinpointing
how they may have changed over the decade in ways that made a difference is the
Dr. Schlenker, the county health director, credits heightened outreach to young
women by health workers and private groups. “I think it’s a community effect,”
he said. “Pregnant women need to feel safe, cared for and valued. I believe that
when they don’t, that contributes to premature birth and fetal loss in the sixth
or seventh month.”
He pointed to services that started in the mid-90s and have gathered steam. For
instance, a law center, ABC for Health, has increasingly connected poor women
with insurance and medical services. He said local health maintenance
organizations were now acting far more assertively to promote the health of
And a federally supported clinic, Access Community Health Center, which serves
the uninsured and others, has cared for a growing number of women using
nurse-midwives, who tend to bond with pregnant women, spending more time on
appointments and staying with them through childbirth.
County nurses visit low-income women at high risk of premature birth, providing
transportation to appointments and referrals to antismoking programs or
antidepression therapies. Another program sends social workers into some homes.
The programs exist statewide, but in Milwaukee, Racine and other areas they do
not appear to have achieved the same broad coverage, said Ms. Timberlake, the
state health leader.
And community leaders in Dane County, shocked by high mortality rates, started
keeping closer watch on young pregnant women.
“The African-American community in Madison is close-knit,” said Carola Gaines, a
black leader and coordinator of Medicaid services for a private insurance plan.
Similar community efforts are now being promoted in other struggling cities.
Brandice Hatcher, 26, who recently moved into a new, subsidized apartment in
Madison, spent her first 18 years in foster care in Chicago before moving two
When she learned last June that she was pregnant, Ms. Hatcher said, “I didn’t
know how to be a parent and I didn’t know what services could help me.”
Over the summer she started receiving monthly visits from Laura Berger, a county
nurse, who put her in touch with a dentist. That was not just a matter of
comfort; periodontal disease elevates the risk of premature birth, increasing
the levels of a labor-inducing chemical.
Ms. Hatcher had been living in a rooming house, but she was able to get help
from a program that provided a security deposit for her apartment. She attained
certification as a nursing assistant while awaiting childbirth.
Under a state program, a social worker visits weekly and helps her look for
jobs. And she receives her prenatal care from the community center’s
nurse-midwives. A church gave her baby clothes and a changing table.
Ms. Hatcher said she would not do anything to jeopardize her unborn baby’s
prospects. She has named her Zaria and is collecting coins and bills in a glass
jar, the start, she said, of Zaria’s personal savings account.
Trying to Explain a Drop
in Infant Mortality, NYT, 27.11.2009,
From the Hospital Room
to Bankruptcy Court
November 25, 2009
The New York Times
By KEVIN SACK
NASHVILLE — Some of the debtors sitting forlornly in this city’s old stone
bankruptcy court have lost a job or gotten divorced. Others have been summoned
to face their creditors because they spent mindlessly beyond their means. But
all too often these days, they are there merely because they, or their children,
Wes and Katie Covington, from Smyrna, Tenn., were already in debt from a round
of fertility treatments when complications with her pregnancy and surgery on his
knee left them with unmanageable bills. For Christine L. Phillips of Nashville,
it was a $10,000 trip to the emergency room after a car wreck, on the heels of
costly operations to remove a cyst and repair a damaged nerve.
Jodie and Charlie Mullins of Dickson, Tenn., were making ends meet on his
patrolman’s salary until she developed debilitating back pain that required
spinal surgery and forced her to quit nursing school. As with many medical
bankruptcies, they had health insurance but their policy had a $3,000 deductible
and, to their surprise, covered only 80 percent of their costs.
“I always promised myself that if I ever got in trouble, I’d work two jobs to
get out of it,” said Mr. Mullins, a 16-year veteran of the Dickson police force.
“But it gets to the point where two or three or four jobs wouldn’t take care of
it. The bills just were out of sight.”
Although statistics are elusive, there is a general sense among bankruptcy
lawyers and court officials, in Nashville as elsewhere, that the share of
personal bankruptcies caused by illness is growing.
In the campaign to broaden support for the overhaul of American health care, few
arguments have packed as much rhetorical punch as the
there-but-for-the-grace-of-God notion that average families, through no fault of
their own, are going bankrupt because of medical debt.
President Obama, in addressing a joint session of Congress in September, called
on lawmakers to protect those “who live every day just one accident or illness
away from bankruptcy.” He added: “These are not primarily people on welfare.
These are middle-class Americans.”
The Senate majority leader, Harry Reid of Nevada, made a similar case on
Saturday in a floor speech calling for passage of a measure to open debate on
his chamber’s health care bill.
The legislation moving through Congress would attack the problem in numerous
Bills in both houses would expand eligibility for Medicaid and provide health
insurance subsidies for those making up to four times the federal poverty level.
Insurers would be prohibited from denying coverage to those with pre-existing
health conditions. Out-of-pocket medical costs would be capped annually.
How many personal bankruptcies might be avoided is unpredictable, as it is not
clear how often medical debt plays a back-breaking role. There were 1.1 million
personal bankruptcy filings in 2008, including 12,500 in Nashville, and more are
expected this year.
Last summer, Harvard researchers published a headline-grabbing paper that
concluded that illness or medical bills contributed to 62 percent of
bankruptcies in 2007, up from about half in 2001. More than three-fourths of
those with medical debt had health insurance.
But the researchers’ methodology has been criticized as defining medical
bankruptcy too broadly and for the ideological leanings of its authors, some of
whom are outspoken advocates for nationalized health care.
At the bankruptcy court in Nashville, lawyers provided a spectrum of estimates
for the share of cases in Middle Tennessee where medical debt was decisive, from
15 percent to 50 percent. But many said they felt the number had been growing,
and might be higher than was obvious because medical bills are often disguised
as credit card debt.
“This has really become the insurance system for the country,” said Susan R.
Limor, a bankruptcy trustee who calculated that 13 of the 48 Chapter 7
liquidation cases on her docket one recent afternoon included medical debts of
more than $1,000.
Under Chapter 7, a debtor’s assets are liquidated and the proceeds are used to
pay creditors; any remaining debts are discharged, and filers are left with a
10-year stain on their credit ratings.
“You can’t believe how many people discharge medical debts,” Ms. Limor said.
“It’s a kind of trailing indicator of who’s suffering in this economy.”
Kyle D. Craddock, a bankruptcy lawyer here, said his medical cases were
heartbreaking because the financial devastation was so rapid and ill-timed.
“They’re sick, they’re bankrupt, and if they stay sick for too long, they end up
losing their jobs as well,” he said.
That was the case for Ms. Phillips, 45, who said she was fired in October from
her job in a shipping department because she had missed so much work while
recuperating from her car accident and operations. Her firing came only 11 days
after she filed for bankruptcy, listing about $7,000 in unpaid medical bills
among her $187,000 in liabilities.
“The medical bills put me over the edge,” said Ms. Phillips, who lost her health
insurance along with her job. “I had no money for food at this point. How was I
going to do it?”
It was the same for the Mullinses, who have two children. They had a mortgage
and owed money on credit cards and student loans. “But the medical problem is
what took us down,” said Ms. Mullins, who is packing to move from the
two-bedroom house they will soon surrender to Wells Fargo. “Everything was due,
they wanted their money now, now, now, and it just became overwhelming.”
For some, like Nathan W. Hale, 34, who had an attack of pancreatitis two months
after losing his job with a Nashville cable company, it is the absence of
insurance that pulls them under. Others, like Robin P. Herron, 35, of
Eagleville, Tenn., have insurance, but it is not enough. Her Blue Cross Blue
Shield policy covered only 80 percent of the cost when her daughter needed
surgery to remove a cyst from a fallopian tube, leaving her $6,000 in debt.
After cortisone injections failed to cure his gimpy knee, Mr. Covington, 31, had
surgery because the pain was forcing him to miss days of work as an emergency
medical technician. His recovery kept him off the job for five months.
Simultaneously, his wife, a 911 dispatcher, developed sciatica while pregnant
and had to take months off on reduced disability pay. Their insurance policy,
with an $850 monthly premium, has a $4,000 annual deductible per family.
As the bills rolled in, the Covingtons compounded their troubles by placing
medical charges on credit cards, simply to make the collection agencies stop
calling. They fell months behind on their mortgage, and by August had lost their
house and both cars.
Mr. Covington, who has taken a second job, said he found it ironic that it had
not been the recession that forced them into bankruptcy. “I tell my wife that we
beat the economy,” he said, “but health care beat us.”
From the Hospital Room
to Bankruptcy Court, NYT, 25.11.2009,
Scared and Silent, Runaway, 13,
Spent 11 Days in the Subways
November 24, 2009
The New York Times
By KIRK SEMPLE
Day after day, night after night, Francisco Hernandez Jr. rode the subway. He
had a MetroCard, $10 in his pocket and a book bag on his lap. As the human tide
flowed and ebbed around him, he sat impassively, a gangly 13-year-old boy in
glasses and a red hoodie, speaking to no one.
After getting in trouble in class in Bensonhurst, Brooklyn, and fearing another
scolding at home, he had sought refuge in the subway system. He removed the
battery from his cellphone. “I didn’t want anyone to scream at me,” he said.
All told, Francisco disappeared for 11 days last month — a stretch he spent
entirely in subway stations and on trains, he says, hurtling through four
boroughs. And somehow he went undetected, despite a round-the-clock search by
his panicked parents, relatives and family friends, the police and the Mexican
Since Oct. 26, when a transit police officer found him in a Coney Island subway
station, no one has been able to fully explain how a boy could vanish for so
long in a busy train system dotted with surveillance cameras and fliers bearing
But this was not a typical missing-person search. Francisco has Asperger’s
syndrome, a form of autism that often causes difficulty with social interaction,
and can lead to seemingly eccentric behavior and isolation. His parents are
Mexican immigrants, who say they felt the police were slow to make the case a
“Maybe because you might not understand how to manage the situation, because you
don’t speak English very well, because of your legal status, they don’t pay you
a lot of attention,” said Francisco’s mother, Marisela García, 38, a
housecleaner who immigrated in 1994 and has struggled to find ways to help her
The police, however, say they took the case seriously from the start,
interviewing school officials and classmates, canvassing neighborhoods and
leafleting all over the city.
Francisco says his odyssey wound through three subway lines: the D, F and No. 1.
He would ride a train until its last stop, then wait for the next one, wherever
it was headed. He says he subsisted on the little he could afford at subway
newsstands: potato chips, croissants, jelly rolls, neatly folding the wrappers
and saving them in the backpack. He drank bottled water. He used the bathroom in
the Stillwell Avenue station in Coney Island.
Otherwise, he says, he slipped into a kind of stupor, sleeping much of the time,
his head on his book bag. “At some point I just stopped feeling anything,” he
Though the boy’s recollections are incomplete, and neither the police nor his
family can retrace his movements in detail, the authorities say that he was
clearly missing for 11 days and that they have no evidence he was anywhere but
For his parents, the memories of those 11 frantic days — the dubious sightings,
the dashed hopes and no sleep — remain vivid. “It’s the most terrible thing,”
his mother said in Spanish.
Just what propelled Francisco to take flight on Oct. 15 is unclear.
Administrators at his school, Intermediate School 281, would not comment. But
Francisco said he had failed to complete an assignment for an eighth-grade
class, and was scolded for not concentrating.
After school, he phoned his mother to say he was heading home. She told him the
school had called and she wanted a serious talk with him.
His first impulse was to flee. He walked eight blocks to the Bay Parkway station
and boarded a D train. It seemed a safe place to hide, he said.
When he did not arrive home, his mother started to panic. In January, after
another problem at school, Francisco had left home and ridden the subway, but
returned after five hours. “We thought this time it would be the same,” Ms.
García said. “But unfortunately it wasn’t.”
Her husband, also named Francisco Hernandez, went to the nearest subway station
and waited for several hours while she stayed at home on Bay 25th Street with
their 9-year-old daughter, Jessica. After midnight, the couple called the
police, and two officers from the 62nd Precinct visited their apartment.
The next morning, Mr. Hernandez, 32, a construction laborer, borrowed a bicycle
and scoured Bensonhurst. He and his wife separately explored the subway from
Coney Island to Midtown Manhattan.
They had been trying to help their son for years. Born in Brooklyn, Francisco
grew up a normal child in many ways, his mother said, earning mostly passing
grades and enjoying drawing and video games. But he had no friends outside
school, and found it difficult to express emotions. A gentle, polite boy, he
spoke — when he did speak — in a soft monotone.
In 2006, his parents had him evaluated at a developmental disabilities research
clinic on Staten Island, where his Asperger’s was diagnosed. The clinic’s chief
neuropsychologist concluded that Francisco struggled in situations that demanded
a “verbal or social response.”
“His anxiety level can elevate, and he freezes in confusion because he does not
know what to do or say,” the doctor wrote.
After he disappeared, his parents printed more than 2,000 color leaflets with a
photo of Francisco wearing the same red hoodie; friends and relatives helped
post them in shops, on the street and throughout the subway in Brooklyn. The
family hand-lettered fluorescent-colored signs.
“Franky come home,” one pleaded in Spanish. “I’m your mother I beg you I love
you my little boy.”
Francisco said he never saw the signs. He lost sense of time. He was prepared,
he said, to remain in the subway system forever.
No one spoke to him. Asked if he saw any larger meaning in that, he said,
“Nobody really cares about the world and about people.”
Sightings were reported. An image of a boy resembling Francisco had been
captured by a video game store’s security camera, but he turned out to be
someone else, the police said. A stranger called Mr. Hernandez to say he had
spotted Francisco with some boys at a movie theater in Sheepshead Bay, Brooklyn.
A search turned up nothing.
Ms. García said one detective told her the boy was probably hiding out with a
friend. She replied that her son had no friends to hide out with. Frustrated,
the parents sought help from the Mexican Consulate. Officials there contacted
the Spanish-language news media, which ran brief newspaper and television
reports about Francisco, and called the police — “to use the weight that we have
to encourage them, to tell them that we have an emergency,” a consular spokesman
Six days after Francisco’s disappearance, on Oct. 21, the case shifted from the
police precinct to the Missing Persons Squad, and the search intensified. A
police spokeswoman explained that a precinct must complete its preliminary
investigation before the squad takes over.
The squad’s lead investigator on the case, Detective Michael Bonanno, said he
turned the focus to the subway. He and his colleagues blanketed the system with
their own signs, rode trains and briefed station attendants.
About 6 a.m. on Oct. 26, the police said, a transit officer stood on the D train
platform at the Stillwell Avenue station studying a sign with Francisco’s photo.
He turned and spotted a dirty, emaciated boy sitting in a stopped train. “He
asked me if I was Francisco,” the boy recalled. “I said yes.”
Asked later how it felt to hear about the work that had gone into finding him,
Francisco said he was not sure. “Sometimes I don’t know how I feel,” he said. “I
don’t know how I express myself sometimes.”
Apart from leg cramps, he was all right physically, and returned to school a
week later. But Ms. García said she was still trying to learn how to manage her
son’s condition. Though doctors had recommended that Francisco be placed in a
small school for children with learning disorders, she said, officials at his
school told her he was testing fine and did not need to be transferred.
“I tell him: ‘Talk to me. Tell me what you need. If I ever make a mistake, tell
me,’ ” she said. “I don’t know, as a mother, how to get to his heart, to find
out what hurts.”
One of the fluorescent signs hangs on the living room wall. The others are
stacked discreetly in a corner, and Ms. García said she was not ready to discard
“It’s not easy to say it’s over and it won’t happen again,” she said.
Scared and Silent,
Runaway, 13, Spent 11 Days in the Subways, NYT, 24.11.2009,
Shifting Vaccine for Flu to Elderly
November 24, 2009
The New York Times
By DONALD G. McNEIL Jr.
Federal health officials are trying to shift supplies of the seasonal flu
vaccine away from chain pharmacies and supermarkets to nursing homes, hoping to
counter a shortage that threatens to cause a wave of deaths this winter among
the nation’s most vulnerable population.
The extent of the shortage is still unclear, but Janice Zalen, director of
special programs for the American Health Care Association, which represents
11,000 nursing homes and assisted-living facilities, called it “a very big
Ms. Zalen said that of 1,000 nursing home managers who responded to a survey of
the association’s 11,000 members, 800 reported they could not get enough
Dr. Carol Friedman, head of adult immunization at the Centers for Disease
Control and Prevention, said she did not have a figure for the size of the
shortage, but added, “It’s a problem, and it’s all over the country.”
Mary Hahn, who manages six Ohio nursing homes with 800 beds, said she could not
get vaccine for any of her patients.
“It’s just so disheartening, because we’re having to leave people unprotected,”
she said. “You see people get flus and get sent to the hospital because they
really can’t fight it off.”
A nationwide shortage of the seasonal flu vaccine has been reported for several
weeks, but nursing homes and their suppliers have grown more alarmed in recent
days. Of the 36,000 Americans who die of seasonal flu in the average year, more
than 90 percent are 65 or older, and nursing home outbreaks are particularly
deadly. By contrast, the swine flu epidemic has been most deadly among younger
The nursing homes’ predicament has been caused by a confluence of factors.
Because of the swine flu pandemic, far more people than usual are seeking
vaccination, Dr. Friedman said — even though the seasonal vaccine does not
protect against swine flu.
The five companies licensed to make flu shots for the United States originally
planned to make only slightly more than the 118 million they made in 2008. Then,
production problems caused GlaxoSmithKline to cut its run by half; Novartis’s
shrank by 10 percent. Then all five companies had to switch over early to making
swine flu vaccine.
So the total supply of vaccine is about 114 million doses, of which about 95
million have been shipped.
At the same time, reports of price gouging have grown more frequent. That also
happened in 2004, when sterility problems at a British plant cut the American
flu vaccine supply in half; prices shot up as high as $90 a dose, from the
normal level of $8 to $9.
Gouging is illegal in about half the states, but each state varies in how big a
price increase constitutes gouging and as to whether an emergency must have been
declared for the law to kick in.
“To pursue a case, we need to show it’s not just a couple of dollars but is very
significant,” said Attorney General Richard Blumenthal of Connecticut, who has
opened an investigation.
Criminal charges are less likely than a civil suit, Mr. Blumenthal said. But he
added that if distributors were “masquerading or fraudulently claiming to have
vaccine,” that could end in a criminal charge. While he had suspicions, he said,
“we don’t have hard evidence yet.”
Dr. Friedman said that once the agency became aware of the shortage at nursing
homes, “we began working with the manufacturers to see if they could redirect
some of their vaccine.”
“Several big-box retailers and pharmacies volunteered to go into the
long-term-care facilities and set up flu clinics,” she said.
Dr. Friedman said she knew of one major supplier to nursing homes that received
100,000 fewer doses from the vaccine makers than it had ordered. Her agency
began acting as a broker among the homes, vaccine distributors and other
customers. Since then, she said, that supplier has found about 50,000 more
“That’s definitely not going to close the gap,” she said, “but it will help.”
Also, both she and Ms. Zalen said, pharmacy and supermarket chains like
Walgreen’s and Safeway that bought millions of doses to sell for $25 to $30 have
offered to give shots in nursing homes. They do not charge but get Medicare
reimbursements, which vary by state but run up to $25.
By contrast, Bob McKay, chief of sales for PharMerica, one of the two largest
wholesale pharmacies supplying nursing homes, said he had received 95 percent of
the 300,000 doses he ordered and “the voids are getting filled in” at the
nursing homes he supplies.
“We’re not hearing rage and craziness out there,” Mr. McKay said. “If a lot of
homes were still short, they’d be beating our doors down.”
But he said he had asked some not to buy shots for their staffs. Flu experts say
that in nursing homes, vaccination of staff members is just as important as
Prices offered to PharMerica for the extra doses they needed were “in the
$15-$16 range,” Mr. McKay said. “That’s more than we’d normally pay, but not
Jim Mathews, an executive at Hometown Pharmacy, a smaller wholesale
pharmaceutical company supplying Michigan nursing homes, said that late last
month he found himself 3,000 doses short; his usual supplier, which charges
$6.75 per dose, was out of stock. He called the C.D.C. for advice, was directed
to a Web page listing other suppliers and contacted all 10. Only one had
vaccine, and it sent him a fax in broken English asking for $57 to $59 per dose.
Mr. Mathews said he reported that to local law enforcement officials, but he is
more worried about the patients who will not get shots.
“When I first recognized the potential death toll from this shortage, there was
time to prioritize the remaining supply for the most vulnerable elderly,” he
said. “Now I’m afraid it’s too late. From what I see, the seasonal flu vaccine
shortage is going to cost more lives than the H1N1 shortage is.”
Dr. Friedman, of the C.D.C., said she had heard of “about 15” price-gouging
Dr. Lillian Overman, an internist in East Hartford, Conn., was one of the first
to alert Mr. Blumenthal, the state’s attorney general, about gouging
accusations. On Oct. 26, her office manager began looking for vaccine, for which
she normally pays $8.50 a dose. A saleswoman at ABO Pharmaceuticals in San Diego
wanted $60 per dose, she said.
“That’s just prohibitive,” a frustrated Dr. Overman said. “If I’d known there
would be a shortage, I would have called in my most vulnerable patients first.”
Mark Nemeth, an ABO sales manager, denied that anyone there had asked for $60.
“I can guarantee you without a shadow of a doubt, we would never have offered it
at that price,” he said; the company is asking “in the ballpark of $12 to $14”
for its remaining supplies.
Shifting Vaccine for Flu
to Elderly, NYT, 24.11.2009,
Health Care Debate
Revives Abortion Campaigners
November 24, 2009
The New York Times
By DAVID D. KIRKPATRICK
WASHINGTON — Lobbying over abortion was turning into a sleepy business. But
the health care debate has brought a new boom, and both sides are exploiting it
with fund-raising appeals.
“The reaction has been phenomenal, like a match dropped on dry kindling,” said
Cecile Richards, president of the Planned Parenthood Federation of America.
Abortion opponents have been blanketing their supporters with solicitations and
alarms since House Democrats laid out their health care proposals three months
ago. “The largest expansion of abortion since Roe vs. Wade,” warns the Web site
Stop the Abortion Mandate, which directs visitors to sign up with the
anti-abortion fund-raising group Susan B. Anthony List.
“It is far and away, in the history of our group, the biggest fulcrum of
activism we have ever had,” said Marjorie Dannenfelser, the group’s president,
adding that the 12-year-old organization has seen its contributions spike more
than 50 percent from 2007, the last year without a national election. Among
other things, her group is using the money for automated phone campaigns in
pivotal states and spending more than $130,000 on an advertising campaign aimed
at Senator Harry Reid, the Democratic leader, in his home state of Nevada. (The
National Right to Life Committee is soliciting donations at
Abortion-rights groups got into the act two weeks ago, when the House of
Representatives adopted an amendment sponsored by Representative Bart Stupak,
Democrat of Michigan, to block the use of federal subsidies for policies that
cover abortion. “Stop Abortion Coverage Ban!,” declares an online solicitation
from NARAL Pro-Choice America, warning that “Women could lose the right to use
their own personal, private funds to purchase an insurance plan with abortion
coverage in the new health system.”
“Stop Stupak!,” is the headline of a new online petition that doubles as a
fund-raiser for Emily’s List, which raises money for female candidates who
support abortion rights. The group’s president, Ellen Malcolm, said in an
interview that she had not seen such an outpouring of support since Webster vs.
Reproductive Health Services, the 1989 Supreme Court decision that appeared to
re-open the question of a right to the procedure.
“Women are up in arms,” Ms. Malcolm said, adding that her group had made an
exception to its no-lobbying policy to pressure the women it helped elect.
This week the Web site of Cosmopolitan Magazine carried a “Secrets and Advice”
column entitled “Are Your Rights in Jeopardy?” that directed readers to a
similar “Stop Stupak” Web site from the Planned Parenthood Federation of
America. A third “Stop Stupak” campaign, by a group called the Progressive
Change Campaign Committee, has raised more than $23,000 from more than 700
donors since it started Nov. 11, according to its host, the online fund-raising
“We have seen money coming in at every level,” said Ms. Richards of Planned
Parenthood, which is also patching calls into lawmakers’ offices in several
states. “Congressman Stupak managed to crystallize this movement in a way that
is hard to replicate.”
Veteran observers of the fight say that each side feels an honest threat from
the legislation. “It is not like burning your house down to collect the
insurance,” said Rachel Laser, of the moderate Democratic group Third Way.
But the practical stakes for abortion are in some ways quite narrow. No one in
the debate proposes adding or removing restrictions on the procedure itself. And
leaders of both parties say their goal is to avoid using federal tax money to
pay for abortion while subsidizing insurance coverage.
Democratic leaders favor requiring insurance companies to segregate any federal
subsidies they receive from private premiums that they could use to cover
abortion. Abortion opponents in Congress call that an accounting gimmick and
want to prevent women from using the subsidies to buy plans that cover abortion
no matter which dollars the insurer uses to pay for it. Women could still use
their own money to pay for the procedure. In any case the provisions would
directly affect roughly 15 percent of the population not currently receiving
health coverage from either employers or the government.
What’s more, polls shows that abortion ranks low among priorities in the health
care overhaul. In a poll conducted Nov. 12-15 by the nonpartisan Pew Research
Center, only 3 percent of respondents who opposed the health care proposal
volunteered abortion as their reason, and when offered a list of alternatives
just 8 percent chose abortion as a top concern.
Almost none of those who favor the overall proposals volunteered abortion as a
reason, and a plurality of them — 46 percent — agreed with abortion opponents
that coverage of the procedure should not be included in government benefits.
Thirty-five percent thought the plan should cover abortion. The poll was
conducted with 1,003 adults nationwide and has a margin of sampling error of
plus or minus four percentage points.
Just a few months ago, some pollsters were predicting an end to the culture wars
as younger generations grew more accustomed to same-sex unions and less
passionate about opposing abortion. The long-running abortion fight played
little role in the 2008 presidential race or even in last summer’s relatively
uneventful Supreme Court confirmation. But now the issue threatens to sidetrack
the broader debate over a health care overhaul. A group of Democratic abortion
opponents in the House said they will block the final legislation if it allows
subsidies for abortion coverage, and a group of abortion-rights supporters said
they will block the bill if it restricts the subsidies.
The interest groups that organized to do battle over the issue never decamped
from the sides of the Potomac, said Andrew Kohut, the president of the Pew
Research Center who oversaw its recent poll. And their determination to
reinvigorate their ground troops may be one reason abortion has become a flash
point in the health care debate.
“The advocates on both sides are very loud,” Mr. Kohut said, “and they are
making their case.”
Health Care Debate
Revives Abortion Campaigners, NYT, 24.11.2009,
Signs That Swine Flu Has Peaked
November 21, 2009
The New York Times
By DONALD G. McNEIL Jr.
Although federal health officials decline to use the word “peaked,” the
current wave of swine flu appears to have done so in the United States.
Flu activity is coming down in all regions of the country, the Centers for
Disease Control and Prevention said Friday, though it is still rising in Hawaii,
Maine and some isolated areas.
The World Health Organization said Friday that there were “early signs of a
peak” in much of the United States.
On Wednesday, the American College Health Association, which surveys over 250
colleges with more than three million students, said new cases of flu had
dropped in the week ending Nov. 13. It was the first drop since school resumed
in the fall, and it was significant — new cases were down 27 percent from the
And on Friday, Quest Diagnostics, the country’s largest laboratory, said its
tests of 142,000 suspected flu specimens since May showed that the flu peaked in
Nonetheless, Dr. Anne Schuchat, the director of immunization and respiratory
diseases at the C.D.C., chose her words carefully, saying: “I wish I knew if we
had hit the peak. Even if a peak has occurred, half the people who are going to
get sick haven’t gotten sick yet.”
Dr. Schuchat also noted that even when new infections topped out,
hospitalizations and deaths were still on the way up, because most took place
days or weeks later.
Privately, federal health officials say they fear that if they concede the flu
has peaked, Americans will become complacent and lose interest in being
vaccinated, increasing the chances of another wave.
In New York, where cases peaked last May, vaccine clinics have gone begging for
takers as long lines form in the rest of the country.
Epidemiologists expected a peak about now, because flu waves typically last six
to eight weeks.
The current fall wave of new infections began in late August in the Southeast,
where schools start earlier than on the East or West Coasts; it took several
weeks to spread across the country and began falling in the Southeast two weeks
The drop was clearly not caused by the swine flu vaccine drive, which has not
gone as fast as the authorities had hoped because the vaccine seed strain grew
Only about 54 million doses are available now, and Dr. Schuchat said she wanted
to “apologize for the frustration the public has been experiencing.”
Lone Simonsen, an epidemiologist at George Washington University, said she
expected a third wave in December or January, possibly beginning in the South
“If people think it’s going away, they can think again,” Dr. Simonsen said.
Based on death rates in New York City and in Scandinavia, she has argued that
both 1918 and 1957 had mild summer waves followed by two stronger waves, one in
fall and one in midwinter.
Only 43 states are now reporting “widespread” flu activity, down from 48 two
As Dr. Schuchat noted, that is still above peak activity in a typical flu
The winter flu season usually starts in December; it is expected to return this
Since last week, 21 children and teenagers died of confirmed or suspected cases
of the flu, Dr. Schuchat said. Based on her agency’s belief that three pediatric
deaths take place for each confirmed one, about 600 children and teenagers have
died since this epidemic began.
The World Health Organization said the flu appeared to be peaking in the United
States and some Western European countries, like Belgium, Britain and Ireland.
But it was moving rapidly east and north.
Canada’s outbreak is still intensifying, as is the one in Norway, and Eastern
Europe and Central Asia, including Afghanistan, are seeing a surge in cases.
Norway reported finding a mutated virus in three people who died or were
severely ill. The mutation, known as D222G on the receptor binding domain, allow
the virus to grow deeper in the lungs.
The mutation does not appear to be circulating and may have spontaneously arisen
in the three patients, said Geir Stene-Larsen, director of the Norwegian
Institute of Public Health. Only 3 of Norway’s 70 tested samples had it.
Asked about that, Dr. Schuchat said the same mutation had also been found in
mild cases in several countries and it did not make the virus resistant to
vaccine or to treatment with drugs like Tamiflu. She said that she did not want
to “underplay” it, but that “it’s too soon to say what this will mean long
The D222G mutation allows the virus to bind to receptors on cells lining the
lungs, which are slightly different from those in the nose and throat.
Henry L. Niman, a flu tracker in Pittsburgh, has been warning for a week that
the same mutation has repeatedly been found in Ukraine, which is in the grips of
a severe outbreak and where surprising numbers of people have died with lung
Separate reports of Tamiflu-resistant virus also surfaced Friday. Duke
University Medical Center said it had found four cases among its patients in six
weeks, and British health authorities reported five in one Welsh hospital.
Although Tamiflu resistance would be a serious worry for health officials, it
was not clear that the strains were circulating outside the hospitals. Many
isolated cases of resistant virus have been found.
Signs That Swine Flu Has
Peaked, NYT, 21.11.2009,
Culture Clash in Medicine
November 20, 2009
The New York Times
By KEVIN SACK
This week, the science of medicine bumped up against the foundations of
American medical consumerism: that more is better, that saving a life is worth
any sacrifice, that health care is a birthright.
Two new recommendations, calling for delaying the start and reducing the
frequency of screening for breast and cervical cancer, have been met with anger
and confusion from some corners, not to mention a measure of political
The backers of science-driven medicine, with its dual focus on risks and
benefits, have cheered the elevation of data in the setting of standards. But
many patients — and organizations of doctors and disease specialists — find
themselves unready to accept the counterintuitive notion that more testing can
be bad for your health.
“People are being asked to think differently about risk,” said Sheila M.
Rothman, a professor of public health at Columbia University. “The public state
of mind right now is that they’re frightened that evidence-based medicine is
going to be equated with rationing. They don’t see it in a scientific
For decades, the medical establishment, the government and the news media have
preached the mantra of early detection, spending untold millions of dollars to
spread the word. Now, the hypothesis that screening is vital to health and
longevity is being turned on its head, with researchers asserting that
mammograms and Pap smears can cause more harm than good for women of certain
On Monday, the United States Preventive Services Task Force, a federally
appointed advisory panel, recommended that most women delay the start of routine
mammograms until they are 50, rather than 40, as the group suggested in 2002. It
also recommended that women receive the test every two years rather than
annually, and that physicians not train women to perform breast
The task force, whose recommendations are not binding on insurers or physicians,
concluded after surveying the latest research that the risks caused by
over-diagnosis, anxiety, false-positive test results and excess biopsies
outweighed the benefits of screening for women in their 40s. It found that one
cancer death is prevented for every 1,904 women ages 40 to 49 who are screened
for 10 years, compared with one death for every 1,339 women from 50 to 74, and
one death for every 377 women from 60 to 69.
On Friday, the American College of Obstetricians and Gynecologists plans to
announce a similar revision to its screening guidelines for cervical cancer. It
will advise that women receive their first Pap test at age 21; the previous
standard had been three years after a woman’s first sexual intercourse or age
21, whichever came first. The group also is recommending that the test be
performed every two years instead of annually for women ages 21 to 30.
“A review of the evidence to date shows that screening at less frequent
intervals prevents cervical cancer just as well, has decreased costs and avoids
unnecessary interventions that could be harmful,” said Dr. Alan G. Waxman, a
professor at the University of New Mexico who directed the process.
The challenge of persuading patients and doctors to accept such standards
requires a transformational shift in thinking, particularly when the disease
involved is as prevalent, as deadly, and as potentially curable as cancer. How
do you convince them that it is in their best interest to play the odds when
they have been conditioned for so long to not gamble on health? After all, for
the one in 1,904 women in their 40s whose life would be saved by early detection
of breast cancer, taking the risk would in retrospect seem a bad choice.
“This represents a broader understanding that the efforts to detect cancer early
can be a two-edged sword,” said Dr. H. Gilbert Welch, a professor of medicine at
Dartmouth who is among the pioneers of research into the negative effects of
early detection. “Yes, it helps some people, but it harms others.”
Dr. Welch said this week’s recommendations could mark a turning point in public
acceptance of that notion. “Now we’re trying to negotiate that balance,” he
said. “There’s no right answer, but I can tell you that the right answer is not
always to start earlier, look harder and look more frequently.”
That concept is proving easier to swallow in the halls of Dartmouth Medical
School than in the halls of Congress. Coming as they did at the height of debate
over a sweeping health care overhaul, the recommendations have provided fresh
ammunition for those who warn that greater government involvement in medical
decision-making would lead to rationing of health care. It has not mattered that
the breast cancer screening recommendation is only advisory, and that the
federal government, the American Cancer Society, and numerous private insurers
have said they will not adopt it.
Senator Kay Bailey Hutchison, a Republican who is running for governor of Texas,
cited the task force’s screening statistics in a floor speech on Thursday. “One
life out of 1,904 to be saved,” Ms. Hutchison said, “but the choice is not going
to be yours. It’s going to be someone else that has never met you, that does not
know family history.” She added, “This is not the American way of looking at our
health care coverage.”
The health care bills in both the House and the Senate would establish
commissions to encourage research into the effectiveness of medical tests and
procedures, but would not require that the findings be translated into practice
or reimbursement policies.
As throughout history, it may take decades for medical culture to catch up to
medical science. Dr. Rothman pointed out that it took 20 years for the public to
accept the discovery in 1882 that tuberculosis was caused by a bacterium and not
by heredity or behavior. More than 160 years after the Hungarian-born physician
Ignaz Semmelweis posited that hand-washing could prevent the spread of
infectious disease, studies still show that half of all hospital workers do not
follow basic hygiene protocols.
“It’s going to take time, there’s no doubt about it,” said Louise B. Russell, a
research professor at the Rutgers University Institute of Health who has studied
whether prevention necessarily saves money (and found it does not always do so).
“It’s going to take time in part because too many people in this country have
had a health insurer say no, and it’s not for a good reason. So they’re not used
to having a group come out and say we ought to do less, and it’s because it’s
best for you.”
Culture Clash in
Medicine, NYT, 20.11.2009,
Guidelines Push Back Age
for Cervical Cancer Tests
November 20, 2009
The New York Times
By DENISE GRADY
New guidelines for cervical cancer screening say women should delay their
first Pap test until age 21, and be screened less often than recommended in the
The advice, from the American College of Obstetricians and Gynecologists, is
meant to decrease unnecessary testing and potentially harmful treatment,
particularly in teenagers and young women. The group’s previous guidelines had
recommended yearly testing for young women, starting within three years of their
first sexual intercourse, but no later than age 21.
Arriving on the heels of hotly disputed guidelines calling for less use of
mammography, the new recommendations might seem like part of a larger plan to
slash cancer screening for women. But the timing was coincidental, said Dr.
Cheryl B. Iglesia, the chairwoman of a panel in the obstetricians’ group that
developed the Pap smear guidelines. The group updates its advice regularly based
on new medical information, and Dr. Iglesia said the latest recommendations had
been in the works for several years, “long before the Obama health plan came
She called the timing crazy, uncanny and “an unfortunate perfect storm,” adding,
“There’s no political agenda with regard to these recommendations.”
Dr. Iglesia said the argument for changing Pap screening was more compelling
than that for cutting back on mammography — which the obstetricians’ group has
staunchly opposed — because there is more potential for harm from the overuse of
Pap tests. The reason is that young women are especially prone to develop
abnormalities in the cervix that appear to be precancerous, but that will go
away if left alone. But when Pap tests find the growths, doctors often remove
them, with procedures that can injure the cervix and lead to problems later when
a woman becomes pregnant, including premature birth and an increased risk of
needing a Caesarean.
Still, the new recommendations for Pap tests are likely to feed a political
debate in Washington over health care overhaul proposals. The mammogram advice
led some Republicans to predict that such recommendations would lead to
Senator Tom Coburn, a Republican from Oklahoma who is also a physician, said in
an interview that he would continue to offer Pap smears to sexually active young
women. Democratic proposals to involve the government more deeply in the
nation’s health care system, he said, would lead the new mammography, Pap smear
and other guidelines to be adopted without regard to patient differences,
hurting many people.
“These are going to be set in stone,” Mr. Coburn said.
Senator Arlen Specter, a Pennsylvania Democrat and longtime advocate for cancer
screening, said in an interview: “And this Pap smear guideline is yet another
cut back in screening? That is curious.” Mr. Specter, who was treated for
Hodgkin’s lymphoma in 2005 and 2008, said Congress was committed to increasing
cancer screenings, not limiting them.
Representative Rosa DeLauro, Democrat of Connecticut, said that the new
guidelines would have no effect on federal policy and that “Republicans are
using these new recommendations as a distraction.”
“Making such arguments, especially at this critical point in the debate, merely
clouds the very simple issue that our health reform bill would increase access
to care for millions of women across the country,” she said.
There are 11,270 new cases of cervical cancer and 4,070 deaths per year in the
United States. One to 2 cases occur per 1,000,000 girls ages 15 to 19 — a low
incidence that convinces many doctors that it is safe to wait until 21 to
The doctors’ group also felt it was safe to test women less often because
cervical cancer grows slowly, so there is time to catch precancerous growths.
Cervical cancer is caused by a sexually transmitted virus, human papillomavirus,
or HPV, that is practically ubiquitous. Only some people who are exposed to it
develop cancer; in most, the immune system fights off the virus. If cancer does
develop, it can take 10 to 20 years after exposure to the virus.
The new guidelines say women 30 and older who have three consecutive Pap tests
that were normal, and who have no history of seriously abnormal findings, can
stretch the interval between screenings to three years.
In addition, women who have a total hysterectomy (which removes the uterus and
cervix) for a noncancerous condition, and who had no severe abnormalities on
previous Pap tests, can quit having the tests entirely.
The guidelines also say that women can stop having Pap tests between 65 and 70
if they have three or more negative tests in a row and no abnormal test results
in the last 10 years.
The changes do not apply to women with certain health problems that could make
them more prone to aggressive cervical cancer, including H.I.V. infection or
having an organ transplant or other condition that would lead to a suppressed
It is by no means clear that doctors or patients will follow the new guidelines.
Medical groups, including the American Cancer Society, have been suggesting for
years that women with repeated normal Pap tests could begin to have the test
less frequently, but many have gone on to have them year after year anyway.
Debbie Saslow, director of breast and gynecologic cancer for the American Cancer
Society, said professional groups were particularly concerned because many
teenagers and young women were being tested and then needlessly subjected to
In addition, Dr. Saslow said, doctors in this country have been performing 15
million Pap tests a year to look for cervical cancer in women who have no
cervix, because they have had hysterectomies.
Dr. Carol L. Brown, a gynecologic oncologist and surgeon at Memorial
Sloan-Kettering Cancer Center, said the new guidelines should probably not be
applied to all women, because there are some girls who begin having sex at 12 or
13 and may be prone to develop cervical cancer at an early age.
“I’m concerned that whenever you send a message out to the public to do less,
the most vulnerable people at highest risk might take the message and not get
screened at all,” Dr. Brown said.
Dr. Kevin M. Holcomb, an associate professor of clinical obstetrics and
gynecology at NewYork-Presbyterian/Weill Cornell hospital, said that when he
heard the advice to delay Pap testing until 21, “My emotional response is ‘Wow,
that seems dangerous,’ and yet I know the chances of an adolescent getting
cervical cancer are really low.”
As with the new mammogram recommendations, women may not readily give up a
yearly cancer test.
“For people who’ve been having the testing regularly every year, it’s a big
emotional change to test less frequently and there’s this fear of ‘Oh my gosh, I
might be missing something,’ ” said Ivy Guetta, 49, of Westport, Conn., who
plans to continue with annual Pap tests. Ms. Guetta has three daughters, ages
17, 14 and 8, and at the moment, she would not encourage them to wait until they
Jen Jemison, 24, a legal assistant from Babylon, N.Y., said she thought she
began getting Pap smears when she was about 18, but said that if she had been
aware that the procedure for treating precancerous lesions could lead to
premature births, she would have waited until she turned 21.
On the other hand, Ms. Jemison said that now that she is over 21, “I would still
go every year” for the Pap test.
“One of my cousins had cervical cancer, so that’s in my head too,” she said.
“I’d rather get it checked out regularly than have to worry about that.”
Gardiner Harris contributed reporting from Washington, and Pam Belluck from
Guidelines Push Back Age
for Cervical Cancer Tests, NYT, 20.11.2009,
Rising Prices of Drugs
Lead to Call for Inquiry
November 19, 2009
The New York Times
By DUFF WILSON
Democrats in Congress asked for two separate investigations of drug industry
pricing Wednesday as they continue working on legislation to overhaul the
nation’s health care system.
Responding to news reports of unusually high wholesale price increases in
brand-name prescription drugs, four House leaders and one senator asked for
government reviews of the pricing practices.
Although drug makers challenge the theory, some experts say the run-up in
wholesale prices may be partly related to the industry’s concerns about future
cost containment under any health care legislation.
“Recent studies have indicated that the industry may be artificially raising
prices for certain pharmaceutical products in expectation of new reforms,” the
House Democrats wrote in a letter to the Government Accountability Office, a
nonpartisan investigative arm of Congress. “Any price gouging is unacceptable,
but anticipatory price gouging is especially offensive,” the letter added,
asking the G.A.O. to conduct an expedited review of the price increases.
The House letter was signed by four representatives who have been active in the
health care legislation: Charles B. Rangel of New York, chairman of the Ways and
Means Committee; Henry A. Waxman of California, chairman of the Energy and
Commerce Committee; and Pete Stark of California, and John Lewis of Georgia,
chairmen of two Ways and Means subcommittees.
Separately, Senator Bill Nelson of Florida, a Democrat who has led efforts in
the Senate to seek more concessions from drug makers, wrote to the inspector
general of the Department of Health and Human Services asking for “an immediate
and thorough investigation into drug industry pricing and recent increases, and
the extent to which these increases may affect the Medicare and Medicaid
Both letters cited a New York Times article on Monday reporting that wholesale
prices of brand-name drugs rose about 9 percent in the 12 months that ended
Sept. 30, the highest increase in years — even as the Consumer Price Index was
declining during the same 12-month period.
The Times article cited a Wall Street analyst’s calculations; a study sponsored
by the AARP, the advocacy group for older Americans; and a report by IMS Health,
a consulting firm to the drug industry.
The price increases could add more than $10 billion to the nation’s drug bill,
which is on track to exceed $300 billion this year.
At that rate, the increases would more than offset at least the first year of
savings that the drug industry has agreed to make under a provision of the
health care bill that was approved by the Senate Finance Committee and has been
incorporated into the full Senate bill introduced on Wednesday. That measure
calls for the industry to come up with discounts and rebates that would save
Medicare recipients and the government $8 billion a year for 10 years.
“I want to know if there’s a back-door move under way by the drug makers to
recover some of the concessions they’ve promised for health care reform,”
Senator Nelson said in a statement Wednesday.
Drug companies do not deny having raised wholesale prices at the highest rate in
years. But they say it has nothing to do with the impending health care
legislation. They say the price increases are necessary to maintain profits for
research and employment in the face of a difficult business environment, which
includes a slowdown in sales of many brand-name products, expiring patents and
increasing competition from generic drugs.
The wholesale prices of brand-name drugs most commonly used by Medicare
recipients rose in the latest 12-month period at the fastest rate since at least
1992, according to Stephen W. Schondelmeyer, a pricing expert working with AARP.
Separately, a study by the investment bank Credit Suisse found that prices for
all drugs from the eight largest United States pharmaceutical companies had
risen, on average, at the highest rate in at least five years.
And IMS Health said there were higher-than-expected price increases this year.
Mr. Schondelmeyer, professor of pharmaceutical economics at the University of
Minnesota, and Catherine J. Arnold, a senior drug industry analyst for Credit
Suisse, have said they believe that part of the reason for the price increases
was to get ahead of possible cost containment measures in health care reform.
Professor Schondelmeyer and Joseph P. Newhouse, a Harvard health economist, said
there were precedents for drug price increases before government actions
affecting the industry.
The House Democrats also said the G.A.O. had previously found unusual price
increases in some prescription drugs in the year before Congress added drug
benefits to Medicare.
The House letter on Wednesday said that the G.A.O. could build on that work.
The House members are also asking the G.A.O. to submit a proposal to
continuously monitor prescription drug prices. The House health care bill
already includes a provision authorizing Medicare to negotiate directly with
manufacturers — a proposal hotly opposed by the industry.
Ken Johnson, an official with the drug industry’s trade association, said in a
statement that calls for an investigation were “based on misleading use of
statistics and sensationalized media reports.”
Mr. Johnson, senior vice president for the Pharmaceutical Manufacturers and
Research Association, did not deny any of the specific findings of AARP, Credit
Suisse and IMS Health reports, which were based on data supplied by
manufacturers and wholesalers. But he said other measurements of drug price
increases show they have risen substantially less than 9 percent.
Mr. Johnson accused AARP of “trying to muddy the waters for its own political
gain as we enter the homestretch of the health care reform debate.”
An AARP executive vice president, John Rother, said in a statement: “This isn’t
about politics. It’s about affordable health care.”
Rising Prices of Drugs
Lead to Call for Inquiry, NYT, 19.11.2009,
Altering How We Use and Pay Doctors
November 19, 2009
The New York Times
To the Editor:
Re “Reform and Medical Costs” (editorial, Nov. 15):
I was disappointed that in your otherwise thoughtful analysis of health care
reform I couldn’t find the words “primary care” or “family physician” mentioned
Central to the problems of high cost, overtesting, overtreatment and poor
coordination endemic in our current system is the lack of value placed on
primary care medicine.
Which of the following do you think is more efficient and would lead to better
health outcomes: a patient who sees a cardiologist for his high blood pressure,
an endocrinologist for his uncomplicated diabetes and an orthopedic surgeon for
his osteoarthritis, or a patient who sees a single well-trained family physician
or general internist for all three — a doctor who can also assure that needed
screening and preventive care take place?
The answer is clear from a range of studies comparing counties, states and
countries: places where primary care and generalist physicians are valued have
the best health outcomes and lowest costs. We need to reform our system in such
a way that the best and brightest students are attracted to careers in primary
Athens, Ga., Nov. 16, 2009
The writer, a doctor, is deputy editor of American Family Physician and
associate professor in the department of epidemiology and biostatistics at the
University of Georgia.
To the Editor:
In your editorial you state, “Doctors mostly perform high-cost tests because
they want to help their patients and get paid handsomely for doing so.” In most
cases a physician’s income is unaffected by the costs of the outside diagnostic
studies that he orders.
As for handsome compensation, a physician’s income is not what it used to be.
Over the last two decades, physicians’ earnings have grown more slowly than
other workers’ earnings. Over the same period the portion of a typical doctor’s
day during which he works to cover his practice expenses has increased
High-achieving seniors in college must consider the duration and rigor of a
medical education, and the debt that they will probably owe at its conclusion.
They must also think about the income that they could earn over those seven or
eight years if they pursued a less demanding profession.
I believe that becoming a primary care physician or more recently even a general
surgeon is actually now a poor economic decision; if present trends persist it
will simply become an untenable one.
Wenatchee, Wash., Nov. 16, 2009
The writer is a doctor.
To the Editor:
Clinic-model hospitals where attending physicians are paid a straight salary
have the illusion of providing good care at a cheap cost because they are
bolstered by federal subsidies like research grants and large payments for
training resident physicians. But the truth is that without cheap
resident-physician labor (often at below-minimum wages if you do the math) and
those federal subsidies, these hospitals could not survive.
Now combine this illusion with the cynical view that most physicians are more
interested in a fast buck than taking good care of their patients and you arrive
at the misguided “expert” view that changing how physicians outside the clinic
system are paid will save money while improving patient care.
Some suggest that we change the fee-for-service method of physician payment to
one that pays a single fee per episode of illness regardless of the varying
amount of work necessary for each person.
The private insurance companies already tried this and called it “episodic
care.” It failed. And if the government were to force this method on the entire
health care system it would remove the pay incentive that drives every other
sector of our capitalist economy.
Physicians have families, too, and if they work harder and longer they simply
want to be paid for their time — which is very different from delivering
unnecessary care. But if you remove the incentive to work harder by forcing
episodic-care payments, what you’ll get is less effort and less talent.
Phoenixville, Pa., Nov. 15, 2009
The writer is an otolaryngologist.
To the Editor:
Discussing proposals to address the problem of rising medical costs, you write:
“Most agree that the solution is to push doctors to accept fixed payments to
care for a particular illness or for a patient’s needs over a year. No one knows
how to make that happen quickly.”
HealthAccessRI has known for several years how to make this happen immediately.
Our model of subscription or membership-based primary care (not concierge
medicine) gives people their own doctor with whom to develop a trusting
relationship at a cost nearly everyone can afford — just $25 to $30 per month.
Primary care provides the majority of people’s health care needs. Call up auto
insurance agents and ask for a policy that covers tune-ups and oil changes and
they’ll laugh at you. Diverting dollars that go to primary care through
insurance money handlers is equally absurd. Worse, it is the underlying reason
that there is a shortage of primary care physicians that will continue
While others tinker with insurance, we know that fixed payments to care for a
patient’s primary care needs over a year will make the majority of Americans’
health care needs affordable and accessible.
Barrington, R.I., Nov. 15, 2009
The writer is a doctor.
Altering How We Use and
Pay Doctors, NYT, 19.11.2009,
Breaching a Barrier to Fight Brain Cancer
November 17, 2009
The New York Times
By DENISE GRADY
Dr. Howard Riina threaded a slender tube through a maze of arteries in Dennis
Sugrue’s brain, watching X-ray images on a monitor to track his progress. At the
site where a previous operation had removed a malignant tumor, he infused a drug
called mannitol and unleashed a flood of the cancer drug Avastin.
Doctors and nurses watched intently, worried that the Avastin could cause brain
swelling, a hemorrhage or a seizure. But Mr. Sugrue emerged unscathed. A half
hour after the procedure, he woke up from anesthesia mumbling, “More is better,”
and wishing aloud that he could have had a bigger dose.
It was an experiment. Mr. Sugrue, 50, who works for a hedge fund and has two
teenage children, was in a study for people with glioblastoma — the same type of
brain tumor that killed Senator Edward M. Kennedy of Massachusetts in August —
and was only the second person ever to have Avastin sprayed directly into his
Getting drugs into the brain has always been a major challenge in treating
tumors and other neurological diseases, because the blood-brain barrier, a
natural defense system, keeps many drugs out. The study that Mr. Sugrue is in,
at NewYork-Presbyterian/Weill Cornell, combines old technologies in a new way to
open the barrier and deliver extraordinarily high doses of Avastin straight to
these deadly tumors — without soaking the rest of the brain in the drug and
exposing it to side effects.
The goal is to find better ways to treat glioblastomas. But the technique might
also be useful for brain metastases, meaning cancer that has spread from other
parts of the body, like the breasts or lungs — something that occurs in about
100,000 people a year in the United States. The same procedure could also
deliver other drugs and might eventually be used to treat neurological disorders
like multiple sclerosis or Parkinson’s disease, if suitable therapies are
The defense system that doctors are trying to breach evolved to keep out toxins
and microbes. It consists mainly of cells that line the walls of capillaries in
the brain and are so tightly packed that many molecules in the bloodstream
cannot slip out between cells to reach the brain tissue itself. But certain
drugs, like mannitol, will temporarily open the barrier and were first used more
than 20 years ago to help other medicines reach the brain.
The new technique refines the art of opening the barrier: it uses microcatheters
— fine, highly flexible tubes that are inserted into an artery in the groin and
then threaded up into tiny blood vessels nearly anywhere in the brain — to spray
chemotherapy directly onto tumors or areas from which they have been removed.
The catheters are normally used to deliver clot-dissolving drugs to the brain to
“This will substantially alter the way that chemotherapy is given in the
future,” said Dr. John Boockvar, the brain surgeon who devised the trial. “But
we have to prove that at certain doses, nobody gets hurt.”
Referring to glioblastoma patients, Dr. Riina said, “Everyone is looking for
something to do for these people.”
“Even if you buy someone just a year, that could be a wedding or a graduation,”
he continued. “You never know what might happen in the year they hold onto.”
The study, which began in August, is still in its earliest phase, meaning its
main goal is to measure safety, not efficacy — to find out if it is safe to
spray Avastin directly into brain arteries and at what dose. Nonetheless, the
doctors were pleased when M.R.I. scans of the first few patients showed that the
treatment seemed to erase any sign of recurring glioblastomas. But how long the
effect will last remains to be seen.
“A beautiful M.R.I. scan doesn’t mean it’s cured,” Dr. Boockvar said.
Despite a beautiful scan, the first patient who was treated died in October,
from pneumonia and the spread of glioblastoma to his brainstem.
Innovations are desperately needed to make headway against glioblastoma, which
is “one of the most deadly tumors that exist in humans,” said Dr. Russell
Lonser, chairman of surgical neurology at the National Institutes of Health.
“This is a very good start,” Dr. Lonser said. “The early data is very
interesting and exciting.”
The complexity of a study like this goes beyond the science. Clinical trials are
also a complicated pact, emotionally and ethically, between desperate patients
and doctors who must balance their ambition as researchers against their duty as
clinicians, and must walk a fine line between offering too much hope and not
“I tell patients, ‘I’m going to try to cure your disease, but so far
glioblastoma is an incurable disease,’ ” Dr. Boockvar said.
“I’m optimistic,” Mr. Sugrue said one morning in September, after scheduling a
second brain operation. But he had tears in his eyes.
There are about 10,000 new cases of glioblastoma a year in the United States,
mostly in people over 45. The tumors are notorious for growing back like weeds
even after being cut out and blasted with chemotherapy and radiation, and they
are nearly always fatal. With the best treatment, the median survival time is
about 15 months.
But in the last five years, the number of patients who survive 2 years has
increased to 25 percent, from 8 percent, largely because doctors began using a
chemotherapy pill called temozolomide, or Temodar, along with radiation (Temodar
is believed to seep through the blood-brain barrier).
Dr. Boockvar said he thought that if he could just keep patients alive for two
years, more advances might come along and give them time.
“The glioblastoma population is very studyable, unfortunately, because the
prognosis is so grim,” he said.
Patients often wind up on the frontlines of research, figuring they have little
to lose and hoping they will be lucky enough to test the big breakthrough. More
than 500 studies for people with glioblastoma are listed on the government Web
Mr. Sugrue, who lives in Stamford, Conn., with his wife, Donna, and their
children Molly and Tim, began having headaches in April. He thought he had a
sinus problem. But a scan found a brain tumor nearly the size of a golf ball. A
local doctor referred him to Dr. Boockvar. He had the standard treatment:
surgery, temozolomide pills and six weeks of radiation, which ended on June 25.
By July, an ominous bright spot on his M.R.I. scan suggested that the tumor
might already be growing back. He continued chemotherapy, but the spot kept
By mid-September, the Sugrues were back in Dr. Boockvar’s office to plan their
next step. Stubbly hair was growing in on Mr. Sugrue’s scalp, except for a bare
patch, around an arcing scar above his right ear. His eyes, bright blue with
thick, dark lashes that gave him a boyish look, searched the doctor’s face.
The headaches had returned. New scans, displayed on a computer screen, showed
signs of brain swelling and bright spots that should not have been there. Dr.
Boockvar recommended more surgery and then chemotherapy with Avastin, which had
recently been approved for recurring glioblastoma.
It was approved for intravenous use — to be dripped into a vein, usually in the
arm — but he said Mr. Sugrue would be an ideal candidate for his study, in which
the drug would be infused directly into an artery in the brain, producing levels
at least 50 times what the intravenous route could achieve. One other patient
had been treated that way, and M.R.I. scans showed that recurring tumors seemed
to have melted away.
Mr. Sugrue said he was all for it, even though Dr. Boockvar warned him that the
drug was no magic bullet. Then Dr. Boockvar ticked off the risks from a second
“I have to quote you a 5 percent risk you’ll be visibly weak,” he said. “A 1
percent chance of paralysis on the left side.”
Mr. Sugrue wiped his eyes and began to apologize for losing his composure, but
the surgeon cut him off and said, “In neurosurgery they say that if you don’t
make your patient cry, you haven’t gotten informed consent.”
The trial grew out of a conversation about a year ago between Dr. Boockvar and
Dr. Riina, an expert in using microcatheters to treat strokes.
“I said, ‘Why can’t you infuse chemotherapy for my brain tumor patients?’ ” Dr.
Boockvar recalled. “And he said: ‘I can. Just show me what you want to do.’ ”
Dr. Riina said, “Technically, I can go anywhere in your brain.”
He said microcatheter technology had advanced “light-years” in the last decade
and was just waiting for a new drug to come along for glioblastoma.
They wrote up a plan to test what they called “superselective intra-arterial
cerebral infusion” of Avastin in 30 patients with glioblastomas that had
recurred after standard treatment. Each patient would receive just one treatment
directed into the brain, followed weeks later by a series of intravenous
treatments with Avastin.
Their study involves a technique first developed about 30 years ago, which uses
mannitol to open the blood-brain barrier temporarily to get chemotherapy into
the brain. Mannitol pulls water out of the tightly packed cells lining the
capillaries so that they shrink and pull away from one another, opening up gaps
through which drug molecules can pass into the brain.
The technique was developed by Dr. Edward A. Neuwelt, a neurosurgeon at Oregon
Health Sciences University and the Veterans Affairs Hospital in Portland. Its
best results have been in people with a rare type of brain tumor called a
primary central nervous system lymphoma. But it has not been helpful with
glioblastoma, because until recently there was no chemotherapy to infuse that
would have much effect on those tumors.
Dr. Neuwelt said that Avastin had helped to renew interest in opening the
blood-brain barrier but that researchers disagreed about whether the drug would
lend itself to that use.
Avastin starves tumors by blocking the growth of new blood vessels, which they
need to survive. Dr. Boockvar said microcatheters should increase the odds of
success by delivering a high dose of the drug directly to where it was needed
most. Earlier research with other drugs used larger catheters inserted into the
carotid arteries, which feed the entire brain — meaning that the tumor did not
receive the most concentrated dose and that healthy brain tissue was exposed to
the toxic drugs.
By mid-November, the researchers had treated five patients, including Mr.
Sugrue; they first infused mannitol, waited five minutes and then sprayed in the
Avastin. In all the patients’ M.R.I. scans, the telltale bright spots that
marked tumor growth faded away after the treatment.
“I can’t tell you what it means,” Dr. Boockvar said. “Nobody knows.”
Indeed, the death of the first patient was a reminder that glioblastoma can
invade other parts of the brain and the spinal fluid and that the highly
localized spray of Avastin might miss deadly seeds of cancer.
But Dr. Boockvar remained hopeful for the remaining patients, describing the
scans as “astronomically far better than I had anticipated.”
Hope and Anxiety
Mr. Sugrue was still in the hospital in late September when Dr. Boockvar burst
into his room and got him out of bed to look at his own before-and-after scans.
“He took me to this room with all these computers and said, ‘I’ve got to show
you this,’ ” Mr. Sugrue recalled. “This M.R.I. was a thing of beauty. I’m
excited that he’s excited. That means a lot to me.”
Dr. Boockvar said: “Avastin may not be the best drug for this delivery
technique. What’s exciting about our results is that we’ve proven there is a
“Suppose someone said, ‘I have much better drug.’ Now I can say I at least have
a delivery system.”
With patients, Dr. Boockvar tries to walk a fine line, trying to level with them
and yet not rob them of all hope. He knows the emotional toll that a cancer
diagnosis can take: his own father had leukemia for about eight years and died
in September. Mrs. Sugrue said the doctor urged her and her husband to resist
doing an Internet search for glioblastoma because they would just read that it
was a death sentence.
They said they tried to follow his advice, but when the subject of prognosis
came up in an interview, both had tears in their eyes.
“You don’t ask the question if you don’t want the answer,” Mrs. Sugrue said.
“What will be, will be. You do what you can.”
Breaching a Barrier to
Fight Brain Cancer, NYT, 17.11.2009,
Panel Urges Mammograms
at 50, Not 40
November 17, 2009
The New York Times
By GINA KOLATA
Most women should start regular breast cancer screening at age 50, not 40,
according to new guidelines released Monday by an influential group that
provides guidance to doctors, insurance companies and policy makers.
The new recommendations, which do not apply to a small group of women with
unusual risk factors for breast cancer, reverse longstanding guidelines and are
aimed at reducing harm from overtreatment, the group says. It also says women
age 50 to 74 should have mammograms less frequently — every two years, rather
than every year. And it said doctors should stop teaching women to examine their
breasts on a regular basis.
Just seven years ago, the same group, the United States Preventive Services Task
Force, with different members, recommended that women have mammograms every one
to two years starting at age 40. It found too little evidence to take a stand on
The task force is an independent panel of experts in prevention and primary care
appointed by the federal Department of Health and Human Services.
Its new guidelines, which are different from those of some professional and
advocacy organizations, are published online in The Annals of Internal Medicine
They are likely to touch off yet another round of controversy over the benefits
of screening for breast cancer.
Dr. Diana Petitti, vice chairwoman of the task force and a professor of
biomedical informatics at Arizona State University, said the guidelines were
based on new data and analyses and were aimed at reducing the potential harm
While many women do not think a screening test can be harmful, medical experts
say the risks are real. A test can trigger unnecessary further tests, like
biopsies, that can create extreme anxiety. And mammograms can find cancers that
grow so slowly that they never would be noticed in a woman’s lifetime, resulting
in unnecessary treatment.
Over all, the report says, the modest benefit of mammograms — reducing the
breast cancer death rate by 15 percent — must be weighed against the harms. And
those harms loom larger for women in their 40s, who are 60 percent more likely
to experience them than women 50 and older but are less likely to have breast
cancer, skewing the risk-benefit equation. The task force concluded that one
cancer death is prevented for every 1,904 women age 40 to 49 who are screened
for 10 years, compared with one death for every 1,339 women age 50 to 74, and
one death for every 377 women age 60 to 69.
The guidelines are not meant for women at increased risk for breast cancer
because they have a gene mutation that makes the cancer more likely or because
they had extensive chest radiation. The task force said there was not enough
information to know whether those women would be helped by more frequent
mammograms or by having the test in their 40s. Other experts said women with
close relatives with breast cancer were also at high risk.
Dr. Petitti said she knew the new guidelines would be a shock for many women,
but, she said, “we have to say what we see based on the science and the data.”
The National Cancer Institute said Monday that it was re-evaluating its
guidelines in light of the task force’s report.
But the American Cancer Society and the American College of Radiology both said
they were staying with their guidelines advising annual mammograms starting at
The cancer society, in a statement by Dr. Otis W. Brawley, its chief medical
officer, agreed that mammography had risks as well as benefits but, he said, the
society’s experts had looked at “virtually all” the task force and additional
data and concluded that the benefits of annual mammograms starting at age 40
outweighed the risks.
Other advocacy groups, like the National Breast Cancer Coalition, Breast Cancer
Action, and the National Women’s Health Network, welcomed the new guidelines.
“This is our opportunity to look beyond emotions,” said Fran Visco, president of
the National Breast Cancer Coalition. The task force “is an independent body of
experts that took an objective look at the data,” Ms. Visco said. “These are the
people we should be listening to when it comes to public health messages.”
Some women, though, were not pleased. “I know so many people who had breast
cancer and survived, and what saved their lives was early detection,” Janet
Doughty, 44, of San Clemente, Calif., said in a telephone interview. She said
she had had an annual mammogram since her late 30s and would not stop now.
The guidelines are not expected to have an immediate effect on insurance
coverage but should make health plans less likely to aggressively prompt women
in their 40s to have mammograms and older women to have the test annually.
Congress requires Medicare to pay for annual mammograms. Medicare can change its
rules to pay for less frequent tests if federal officials direct it to.
Private insurers are required by law in every state except Utah to pay for
mammograms for women in their 40s.
But the new guidelines are expected to alter the grading system for health
plans, which are used as a marketing tool. Grades are issued by the National
Committee for Quality Assurance, a private nonprofit organization, and one
measure is the percentage of patients getting mammograms every one to two years
starting at age 40.
That will change, said Margaret E. O’Kane, the group’s president, who said it
would start grading plans on the number of women over 50 getting mammograms
every two years.
The message for most women, said Dr. Karla Kerlikowske, a professor in the
department of medicine, epidemiology and biostatistics at the University of
California, San Francisco, is to forgo routine mammograms if they are in their
Starting at age 50, Dr. Kerlikowske said, “the message is to get 10 mammograms
in a lifetime, one every two years.” That way they get the most benefit and the
least harm from the test. If women are healthy, she added, they might consider
having mammograms every two years until age 74.
Nearly two-thirds of all women in their 40s had mammograms within the last two
years, as did 72 percent of women age 50 to 65, according to an editorial by Dr.
Kerlikowske that accompanies the report.
In order to formulate its guidelines, the task force used new data from
mammography studies in England and Sweden and also commissioned six groups to
make statistical models to analyze the aggregate data. The models were the only
way to answer questions like how much extra benefit do women get if they are
screened every year, said Donald A. Berry, a statistician at the University of
Texas M. D. Anderson Cancer Center and head of one of the modeling groups.
“We said, essentially with one voice, very little,” Dr. Berry said. “So little
as to make the harms of additional screening come screaming to the top.”
The harms are nearly cut in half when women have mammograms every other year
instead of every year. But the benefits are almost unchanged.
The last time the task force issued guidelines for mammograms, in 2002, the
reportwas announced by Tommy G. Thompson, the secretary of health and human
services. When the group recommended mammograms for women in their 40s, some
charged the report was politically motivated. But Dr. Alfred Berg of the
University of Washington, who was the task force chairman at the time, said
“there was absolutely zero political influence on what the task force did.”
It was still a tough call to make, Dr. Berg said, adding that “we pointed out
that the benefit will be quite small.” In fact, he added, even though mammograms
are of greater benefit to older women, they still prevent only a small fraction
of breast cancer deaths.
Different women will weigh the harms and benefits differently, Dr. Berg noted,
but added that even for women 50 and older, “it would be perfectly rational for
a woman to decide she didn’t want to do it.”
Researchers worry the new report will be interpreted as a political effort by
the Obama administration to save money on health care costs.
Of course, Dr. Berry noted, if the new guidelines are followed, billions of
dollars will be saved.
“But the money was buying something of net negative value,” he said. “This
decision is a no-brainer. The economy benefits, but women are the major
Roni Caryn Rabin contributed reporting.
In Reversal, Panel Urges
Mammograms at 50, Not 40, NYT, 17.11.2009,
Reform and Medical Costs
November 15, 2009
The New York Times
Americans are deeply concerned about the relentless rise in health care costs
and health insurance premiums. They need to know if reform will help solve the
problem. The answer is that no one has an easy fix for rising medical costs. The
fundamental fix — reshaping how care is delivered and how doctors are paid in a
wasteful, dysfunctional system — is likely to be achieved only through trial and
error and incremental gains.
The good news is that the bill just approved by the House and a bill approved by
the Senate Finance Committee would implement or test many reforms that should
help slow the rise in medical costs over the long term. As a report in The New
England Journal of Medicine concluded, “Pretty much every proposed innovation
found in the health policy literature these days is encapsulated in these
Medical spending, which typically rises faster than wages and the overall
economy, is propelled by two things: the high prices charged for medical
services in this country and the volume of unnecessary care delivered by doctors
and hospitals, which often perform a lot more tests and treatments than a
patient really needs.
Here are some of the important proposals in the House and Senate bills to try to
address those problems, and why it is hard to know how well they will work:
FORCED PRODUCTIVITY GAINS Both bills would reduce the rate of growth in annual
Medicare payments to hospitals, nursing homes and other providers by amounts
comparable to the productivity savings routinely made in other industries with
the help of new technologies and new ways to organize work. This proposal could
save Medicare more than $100 billion over the next decade. If private plans
demanded similar productivity savings from providers, and refused to let
providers shift additional costs to them, the savings could be much larger.
Critics say Congress will give in to lobbyists and let inefficient providers off
the hook. That is far less likely to happen if Congress also adopts strong
“pay-go” rules requiring that any increase in payments to providers be offset by
new taxes or budget cuts.
CADILLAC COVERAGE The Senate Finance bill would impose an excise tax on health
insurance plans that cost more than $8,000 for an individual or $21,000 for a
family. It would most likely cause insurers to redesign plans to fall beneath
the threshold. Enrollees would have to pay more money for many services out of
their own pockets, and that would encourage them to think twice about whether an
expensive or redundant test was worth it. Economists project that most employers
would shift money from expensive health benefits into wages. The House bill has
no similar tax. The final legislation should.
SIMPLIFIED FORMS Any doctor who has wrestled with multiple forms from different
insurers, or patients who have tried to understand their own parade of
statements, know that simplification ought to save money. When the health
insurance industry was still cooperating in reform efforts, its trade group
offered to provide standardized forms for automated processing. It estimated
that step would save hundreds of billions of dollars over the next decade. The
bills would lock that pledge into law.
ELECTRONIC MEDICAL RECORDS The stimulus package provided money to convert the
inefficient, paper-driven medical system to electronic records that can be
easily viewed and transmitted. This requires upfront investments to help doctors
convert. In time it should help restrain costs by eliminating redundant tests,
preventing drug interactions, and helping doctors find the best treatments.
REFORM OF THE DELIVERY SYSTEM Virtually all experts agree that the
fee-for-service system — doctors are rewarded for the quantity of care rather
than its quality or effectiveness — is a primary reason that the cost of care is
so high. Most agree that the solution is to push doctors to accept fixed
payments to care for a particular illness or for a patient’s needs over a year.
No one knows how to make that happen quickly.
The bills in both houses would start pilot projects within Medicare. They
include such measures as accountable care organizations to take charge of a
patient’s needs with an eye on both cost and quality, and chronic disease
management to make sure the seriously ill, who are responsible for the bulk of
all health care costs, are treated properly. For the most part, these
experiments rely on incentive payments to get doctors to try them.
INDEPENDENT COMMISSION Testing innovations do no good unless the good
experiments are identified and expanded and the bad ones are dropped. The Senate
bill would create an independent commission to monitor the pilot programs and
recommend changes in Medicare’s payment policies to prod providers to adopt
reforms that work. The changes would have to be approved or rejected as a whole
by Congress, making it hard for narrow- interest lobbies to bend lawmakers to
MANAGED COMPETITION The bills in both chambers would create health insurance
exchanges on which small businesses and individuals could choose from an array
of private plans and possibly a public option. All the plans would have to
provide standard benefit packages that would be easy to compare. To get access
to millions of new customers, insurers would have a strong incentive to sell on
the exchange. And the head-to-head competition might give them a strong
incentive to lower their prices, perhaps by accepting slimmer profit margins or
demanding better deals from providers.
A PUBLIC PLAN The final legislation might throw a public plan into the
competition, but thanks to the fierce opposition of the insurance industry and
Republican critics, it might not save much money. The one in the House bill
would have to negotiate rates with providers, rather than using Medicare rates,
as many reformers wanted.
COMPARING TREATMENTS The president’s stimulus package is pumping money into
research to compare how well various treatments work. Is surgery, radiation or
careful monitoring best for prostate cancer? Is the latest and most expensive
cholesterol-lowering drug any better than its generic competitors? The pending
bills would spend additional money to accelerate this effort.
Critics have charged that this sensible idea would lead to rationing of care.
(That would be true only if you believed that patients should have an unbridled
right to treatments proven to be inferior.) As a result, the bills do not
require, as they should, that the results of these studies be used to set
payment rates in Medicare.
Congress needs to find the courage to allow Medicare to pay preferentially for
treatments proven to be superior. Sometimes the best treatment might be the most
expensive. But over all, we suspect that spending would come down through
elimination of a lot of unnecessary or even dangerous tests and treatments.
NEGOTIATING DRUG PRICES The House bill would authorize the secretary of health
and human services to negotiate drug prices in Medicare and Medicaid. Some
authoritative analysts doubt that the secretary would get better deals than
private insurers already get. We believe negotiation could work. It does in
MALPRACTICE REFORM Missing from these bills is any serious attempt to rein in
malpractice costs. (Trial lawyers, major supporters of the Democratic Party,
have seen to that.) Malpractice awards do drive up insurance premiums for
doctors in high-risk specialties, and there is some evidence that doctors engage
in “defensive medicine” by performing tests and treatments primarily to prove
they are not negligent should they get sued.
Patients who are injured because of a doctor’s or a hospital’s negligence must
have recourse. We favor reforms that would try to compensate injured people
fairly and promptly — perhaps through mediation or expert tribunals — but would
not prevent them from filing suit as a last resort or cap the awards they could
receive. Even then, the savings might be modest. Doctors mostly perform
high-cost tests because they want to help their patients and get paid handsomely
for doing so.
Republican critics say, correctly, that the health care bills would saddle the
government with large new costs to cover the uninsured by expanding Medicaid and
providing subsidies to help low- and middle-income people buy insurance. And
they say, incorrectly, that the effort should not move ahead until a sure-fire
way is found to rein in rising health care costs.
Their arguments overlook the fact that the government is already paying many of
these costs, through special payments to hospitals, each time a person without
insurance, and with no means to pay, goes to an expensive emergency room for
treatment. It also overlooks the fact that both bills are designed to keep
deficits from increasing over the next decade or two.
It would be unfair, and unnecessary, to leave tens of millions of people
uninsured while we wait to figure out ways to hold down the rise in health care
This editorial is a part of a continuing series by The Times that is providing a
comprehensive examination of the policy challenges and politics behind the
debate over health care reform.
Reform and Medical
Costs, NYT, 15.11.2009,
US adult smoking rate rises slightly
Friday November 13 2009
AP Medical Writer= ATLANTA (AP)
Cigarette smoking rose slightly for the first time in almost 15 years,
dashing health officials' hopes that the U.S. smoking rate had moved permanently
below 20 percent.
A little under 21 percent of U.S. adults said they smoked, according to a 2008
national survey by the U.S. Centers for Disease Control and Prevention. That's
up slightly from the year before, when just 19.8 percent said they were smokers.
It also is the first increase in adult smoking since 1994, experts noted.
The increase was so small, it could be just a blip, so health officials and
experts say smoking prevalence is flat, not rising. But they are unhappy.
"Clearly, we've hit a wall in reducing adult smoking," said Vince Willmore,
spokesman for the Campaign for Tobacco-Free Kids, a Washington, D.C.- based
research and advocacy organization.
There's a general perception that smoking is a fading public health danger.
Feeding that perception are indoor smoking laws, cigarette taxes and Congress'
recent decision to allow the Food and Drug Administration to regulate tobacco.
But health officials believe gains have been undermined by cuts in state tobacco
control campaigns. Some advocates believe tobacco companies are overcoming
Cigarette marketing has persisted and is effectively reaching kids and
minorities with messages about flavored or menthol products, said Dr. Clyde
Yancy, president of the American Heart Association.
The tobacco industry also has been discounting cigarettes to offset tax
increases and keep smokes affordable, Willmore said.
Between 1997 and 2004, the average retail price of a pack of cigarettes â?
adjusted for inflation â? jumped 63 percent, and adult smoking declined about 15
percent. Between 2004 and 2008, the price rose just 2 percent, while adult
smoking declined by just about 1 percent, he said, citing industry sales data.
"There's a clear correlation," Willmore said.
Cigarette smoking is the leading preventable cause of death and illness in the
United States, and is a cause of cancers, heart disease and other fatal
The adult smoking rate has been dropping, in starts and stops, since the
mid-1960s when roughly 2 out of 5 U.S. adults smoked. Now it's 1 in 5. However,
federal health goals for the year 2010 had hoped to bring the rate down to close
to 1 in 10.
Adult smoking hovered at about 21 percent from 2004 to 2006, then dropped a full
percentage point in 2007, said Dr. Matthew McKenna, director of the CDC's Office
on Smoking and Health.
The 2007 drop gave CDC officials hope that U.S. smoking was plummeting again.
"Now that appears to be a statistical aberration," McKenna said.
The new survey's results come from in-person interviews of nearly 22,000 U.S.
The study was released Thursday, published in the CDC publication, Morbidity and
Mortality Weekly Report.
Also on Thursday, the CDC released state-by-state results on smoking from a
different survey, conducted by telephone, of more than 400,000 adults. West
Virginia and Indiana had the highest smoking rates, at about 26 percent, but
four other states â? Kentucky, Missouri, Oklahoma and Tennessee â? had rates
about as high.
Utah had, by far, the lowest smoking rate, with only about 9 percent of Utah
residents describing themselves as current smokers.
Many of the states that have the lowest smoking rates are those that have been
the most aggressive about indoor smoking laws and about state taxes that drive
up the cost of cigarettes, said Dr. Thomas Frieden, the CDC's director.
Health officials are optimistic that more and more smokers will be discouraged
from lighting up by escalating cigarette taxes, including a 62-cent federal tax
that took effect in April. That may cause smoking to go down when the 2009
smoking data comes in, some advocates said.
Perhaps the recession will have an impact, too.
"In general, when people have less money, they smoke less," Frieden said. "Time
On the Net:
CDC report: http://www.cdc.gov/mmwr
US adult smoking rate
rises slightly, NYT, 13.11.2009,
Forty Years' War
Medicines to Deter Some Cancers
Are Not Taken
November 13, 2009
The New York Times
By GINA KOLATA
Many Americans do not think twice about taking medicines to prevent heart
disease and stroke. But cancer is different. Much of what Americans do in the
name of warding off cancer has not been shown to matter, and some things are
actually harmful. Yet the few medicines proved to deter cancer are widely
Take prostate cancer, the second-most commonly diagnosed cancer in the United
States, surpassed only by easily treated skin cancers. More than 192,000 cases
of it will be diagnosed this year, and more than 27,000 men will die from it.
And, it turns out, there is a way to prevent many cases of prostate cancer. A
large and rigorous study found that a generic drug, finasteride, costing about
$2 a day, could prevent as many as 50,000 cases each year. Another study found
that finasteride’s close cousin, dutasteride, about $3.50 a day, has the same
Nevertheless, researchers say, the drugs that work are largely ignored. And
supplements that have been shown to be not just ineffective but possibly harmful
are taken by men hoping to protect themselves from prostate cancer.
As the nation’s war on cancer continues, with little change in the overall
cancer mortality rate, many experts on cancer and public health say more
attention should be paid to prevention.
But prevention has proved more difficult than many imagined. It has been
devilishly difficult to show conclusively that something simple like eating more
fruits and vegetables or exercising regularly helps. And, as the response to the
prostate drugs shows, people are not enthusiastic about taking anticancer pills,
or are worried about side effects or not really convinced the drugs work. Others
are just unaware of them.
And prostate cancer is not unique. Scientists have what they consider definitive
evidence that two drugs can cut the risk of breast cancer in half. Women and
doctors have pretty much ignored the findings.
Companies have taken note, saying that it makes little economic sense to spend
decades developing drugs to prevent cancer. The better business plan seems to be
looking for drugs to treat cancer. That is a sobering lesson, said Dr. Ian M.
Thompson Jr., chairman of the urology department at the University of Texas
Health Science Center in San Antonio.
“A scientific discovery that is very clear cut and that is not implemented by
the public is a tragedy,” he said.
Few Sure Things
A few ways are known for sure to prevent cancer; the biggest is to avoid
cigarette smoking. That alone would drop the cancer death rate by a third. No
other measure comes close.
Another huge success, for breast cancer, is to avoid taking estrogen and
progestin at menopause. Sales of those drugs plummeted in 2002 after a federal
study, the Women’s Health Initiative, concluded that they did not prevent heart
disease and might increase breast cancer. The next year, the breast cancer rate
dropped by 15 percent after having steadily increased since 1945.
The vaccine for human papilloma virus, protects against most strains of the
virus, which causes cervical cancer.
But other measures that are often assumed — and marketed — as ways to prevent
cancer may not make much difference, researchers say.
For example, public health experts for years recommended eating five servings of
fruits and vegetables a day to prevent cancer, but the evidence is conflicting,
at best suggestive, and far from definitive.
Low-fat diets were long thought to prevent breast cancer. But a large federal
study randomizing women to a low-fat or normal diet and looking for an effect in
breast cancer found nothing, said its director, Ross L. Prentice of the Fred
Hutchinson Cancer Research Center in Seattle.
Fiber, found in fruits, vegetables and grains, is often thought to prevent colon
cancer, even though two large studies found no effect.
“We thought we would show relationships that were strong and true,” said Dr. Tim
Byers, professor of epidemiology at the Colorado School of Public Health,
“particularly for dietary choices and food and vegetable intake. Now we have
settled into thinking they are important but it’s not like saying you can cut
your risk in half or three-quarters.” Others wonder whether even such qualified
support is misplaced.
There has to be a reason the research disappointed, said Colin B. Begg, chairman
of the department of epidemiology and biostatistics at Memorial Sloan-Kettering
Cancer Center. Perhaps the crucial time to intervene is early in life.
“That’s one possibility,” Dr. Begg said. “The other is that it’s all sort of
nonsense to begin with.”
Many hold out hope for exercise or weight loss. Studies have associated
strenuous exercise with less cancer. But that is the same sort of evidence that
misled scientists about aspects of diet.
“I think it’s wishful thinking,” said Dr. Susan Love, a breast surgeon and
president of the Dr. Susan Love Research Foundation. “We would like things to be
more in our control. I think that’s part of it. And in the absence of anything
else, what do we tell women about how to prevent breast cancer? We tell them to
exercise and eat a good diet.”
As for obesity, researchers differ. Studies that observed large numbers of
people often found that fatter people have more cancer. But many of the
correlations are weak, and different studies have pointed to different cancers,
raising questions about whether some of the effects are real.
Dr. Otis W. Brawley, chief medical officer of the American Cancer Society, said
he was convinced. The strongest link, he and others say, is with obesity and
breast cancer. But there, Dr. Brawley says, the crucial period may occur early
in life — girls who gain weight when they are young, he said, tend to start
menstruating earlier, which increases their breast cancer risk because it adds
years of exposure to the body’s estrogen. It may be that weight loss in
adulthood does not help.
“We have very little evidence that losing weight or changing diet reduces risk
of cancer,” he said. “It is likely that it takes years to effect a change in
risk. We do have data that the change in diet decreases cardiovascular disease
risk, so it’s easier to advocate diet change.”
Others, like Donald A. Berry, head of the division of quantitative sciences at
the University of Texas M. D. Anderson Cancer Center, are dubious about blaming
obesity for cancer rates. If there is a risk, Dr. Berry said, he suspects it is
small. The studies are relying on correlations — they cannot assess cause and
effect. And studies that come up with such associations are likely to be
published, even though often the associations turn out to be spurious. That
means, Dr. Berry said, that “the false-positive rate skyrockets.”
Still, Dr. Prentice said, disheartening as the findings have been, it would be a
mistake to give up on lifestyle changes. Instead, he said, perhaps it is time to
rethink the way studies are done.
“This should be a stimulus to our research community to say, How can we conduct
observational studies in a way to reveal more reliable information?” Dr.
Diet and exercise, he added, “are likely quite important, but we just aren’t
getting the answers.”
Great Hopes Dashed
Dr. Peter Greenwald knows the dashed hopes of cancer prevention research
firsthand. As far back as 1981, when he arrived at the National Cancer Institute
to direct “cancer prevention and control,” Dr. Greenwald began thinking about
testing whether simple measures, like vitamin supplements, could prevent common
He focused on what looked like it could be a sure thing — beta carotene, found
in orange fruits and vegetables as well as in green leafy vegetables.
The body converts beta carotene to vitamin A, which can prevent cancer in rats.
People eating the most fruits and vegetables had less cancer. And the more beta
carotene in a person’s blood, the lower the cancer risk. Lung cancer seemed
particularly vulnerable to beta carotene’s effects, particularly in smokers and
What was needed was cause-and-effect evidence, studies showing that if people
bolstered their beta carotene and vitamin A levels, they would be protected from
cancer. The cancer institute decided to take it on with two large studies.
But not only did the supplements not work, but there was evidence that beta
carotene might actually increase cancer risk in smokers.
Dr. Greenwald and his colleagues still held out hope for vitamins and minerals
as cancer preventatives. So his group proposed the largest cancer prevention
clinical trial ever tried, involving 35,000 men 50 and older. This time, the
idea was that vitamin E and selenium might prevent prostate cancer.
Once again, there was presumptive evidence. But this time it was harder to
persuade scientists to go ahead. After the beta carotene and vitamin A studies,
several other studies had also failed to find evidence that food components or
special diets could prevent cancer.
“By this time, a lot of people were very concerned,” said Dr. Scott M. Lippman,
an oncologist at M. D. Anderson. He argued that the huge study had to be done.
The supplements were being promoted for “prostate health,” and the evidence that
they might actually work was tantalizing.
The selenium and vitamin E study ended early. Once again, there was no
protection from cancer, and there were hints the supplements might be causing
cancer. Once again, the great hope turned into a stunning disappointment.
Prevention researchers say they are left sadder but wiser.
“Over the years, I’ve grown more skeptical and more cautious,” said Dr. Meir J.
Stampfer, a professor of nutrition and epidemiology at the Harvard School of
Public Health. “Findings get reported in the literature, and the more extreme
findings tend to excite the imagination. Then, as evidence accumulates, those
findings are not confirmed.”
Dr. Stampfer remains optimistic, though, pointing to the story of heart disease,
where softer evidence eventually led to discoveries that measures like lowering
blood pressure and cholesterol could prevent disease. An amazing decline in
illness and death resulted. “Cancer is harder,” Dr. Stampfer said, but he added
that it is too soon to give up. Dr. Greenwald, too, has not given up. He still
hopes a diet with fruits and vegetables, along with exercise and weight control,
might help prevent cancer. But he knows the evidence is not definitive and
scientists have been fooled before. As for Dr. Lippman, he said the field had
suffered from an excess of premature enthusiasm, especially before the beta
“We were pulled into this,” he said. “People said, We’ve got it! There were
incredibly high expectations that were, in retrospect, unrealistic.”
Claims That Go Too Far
David G. Schardt, a senior nutritionist with the Center for Science in the
Public Interest, an advocacy group, likes to relax in front of his television
set at night. But what he was seeing last winter made his blood boil.
“I would sit there watching network news and the ads would come on,” Mr. Schardt
said. Bayer, advertising its One A Day vitamins, was saying the selenium in the
pills might improve “prostate health.” And as he drove to his office in
Washington, Mr. Schardt heard Bayer advertisements on the radio that actually
mentioned prostate cancer.
“I couldn’t believe it,” he said. After all, the federal study had already shown
that selenium was useless and might be harmful. Finally, on Oct. 1, Mr. Schardt
and the Center for Science in the Public Interest filed a lawsuit.
Tricia McKernan, a Bayer spokeswoman, says the advertisements relied on the Food
and Drug Administration’s “permitted qualified health claim that ‘selenium may
reduce the risk of certain cancers,’ ” especially prostate cancer. The F.D.A. no
longer permits that claim, Ms. McKernan noted. She said Bayer was revising its
packaging and promotional materials for its One A Day Men’s and One A Day Men’s
50+ vitamins, removing references to selenium reducing prostate cancer risk.
But a subtle promotion of selenium and vitamin E by supplement makers goes on,
with claims that the pills improve “prostate health” by increasing the body’s
Dr. Thompson said he sees the lure of supplements when he counsels patients. “I
can’t tell you how many times I talked to somebody about prostate cancer
prevention,” he said. He gives the high-risk men a prescription for one of the
drugs that work. But the men do not fill it.
Instead, he said, they are taking “prostate health” vitamins.
In 1990, Dr. Victor G. Vogel was at M. D. Anderson and had high hopes of
changing the world. It just may be possible, he thought, to prevent many cases
of breast cancer in women at high risk, a group that includes every woman over
age 60, the time when the risk takes a sharp turn upward.
Dr. Vogel was to be an investigator in a huge study of 13,000 women that seemed
to have everything going for it. It would test a drug, tamoxifen, an
estrogen-blocker widely used to treat women with breast cancer. The studies
showing the drug’s effects in breast cancer patients, though, had an unexpected
bonus. It looked as if tamoxifen was also preventing new cancers in the opposite
“By the time we got to 1990, there was just a huge amount of data,” Dr. Vogel
said. The drug’s risks were well established and seemed well worth taking if the
benefit was cutting cancer in half among women at high risk. Most side effects,
like hot flashes, were temporary. But there also was a risk of blood clots
similar to that conferred by birth control pills or estrogen used to relieve
symptoms of menopause. And there were about two additional cases of uterine
cancer per 1,000 women per year.
By 1998, the results were in. Tamoxifen cut the breast cancer rate in half.
Similar studies in Britain and Italy, also involving high-risk women who had not
had breast cancer, came to similar conclusions. And women did not have to take
the drug for a lifetime — they needed just five years of therapy.
Dr. Vogel was ecstatic.
“If I had told you in 1990 that in 10 years I would have a pill that would cut
the risk of breast cancer in half, you wouldn’t have believed me,” he said.
But, he said, to his shock, “The world said, So what?”
“We were met with shoulder shrugs and harrumphs,” Dr. Vogel said. Sales of
tamoxifen, worldwide, “didn’t budge.”
Maybe, Dr. Vogel thought, the problem was that internists and gynecologists were
not comfortable prescribing a drug used to treat cancer patients. Then, in 1999,
he had a chance to do another breast cancer prevention trial, this time of an
osteoporosis drug, raloxifene, or Evista, which did not have the cancer drug
taint. It was to be compared with tamoxifen.
The $110 million study, involving 19,000 women, ended in 2006. The two drugs
were found to be equally effective in preventing breast cancer, but with
raloxifene there was no excess uterine cancer and the clotting risk was 30
“It was a spectacular clinical trial,” Dr. Vogel said. But, he added, “Once
again, the world met the result with a shrug and a harrumph.”
“Those were your tax dollars and mine,” he added. “You can’t do too many $110
He cannot understand why no one cares, but some doctors say they see a number of
problems. It is usually not the cost; tamoxifen is about 30 cents a day and
raloxifene $3.30 a day. It is doctors’ practices and women’s concerns.
Most doctors, said Dr. Therese B. Bevers, medical director of the Cancer
Prevention Center at M. D. Anderson, do not take the first step — calculating a
woman’s lifetime risk of getting breast cancer — in part because that can lead
to the next step, spending an hour or so discussing cancer risk and drug risks
Dr. Bevers suggests the drugs for women whose lifetime odds exceeds 20 percent.
That could include, for example, a 55-year-old woman who began menstruating
early (increasing the risk), had her first child late (again increasing the
risk), and whose mother and sister got breast cancer. About half the time,
though, women with that kind of risk turn down the drugs, Dr. Bevers said. “The
No. 1 reason I hear is, ‘Oh, I just don’t like to take medications,’ ” she
Others, like Cecilia Anderson, who is 57 and lives in Houston, worry about side
effects. “I felt like my quality of life was in question,” she said. “I am busy,
I am out there. I totally love my life and don’t want it to be compromised.” Her
lifetime risk of breast cancer is 20.5 percent, compared with an average risk of
9.8 percent for a woman her age. Ms. Anderson declined the drugs. “I live a
different lifestyle,” she said. “I eat organic foods, I exercise. Through all of
that comes a spiritual element as well. Mind, body, and spirit are all
Then came the studies of finasteride and dutasteride for prostate cancer. The
drugs block the conversion of testosterone to dihydrotestosterone, a hormone
that prostate cancers need to grow. They are on the market to shrink the
prostate in older men, whose prostates often enlarge. (Finasteride is also sold
to grow hair — but the dose is one-fifth the dose that shrinks prostates and
that dose has not been tested for cancer prevention.) Doctors can prescribe the
drugs for cancer prevention but, at this point, that is not on their label.
The prostate cancer studies were complicated by other another factor; at first,
researchers thought, erroneously, that finasteride was actually spurring the
growth of aggressive prostate cancers. The drug’s side effects can include
impotence or decreased ejaculate. But the Food and Drug Administration concluded
that these effects, if they occur at all, are gone after a year.
Now, even though the F.D.A. deemed the drug’s adverse reactions to be “usually
mild and transient.” The American Urological Association and the American
Society for Clinical Oncology recommend that men 50 and older consider taking
it. But there appears to be little interest even among high-risk men.
Dr. Vogel wonders what message the indifference to the breast cancer and
prostate cancer drugs is sending. Why would a company want to develop drugs for
That is a lesson that hits home, said Dr. Gregory Curt, an oncologist who
directs emerging products at AstraZeneca, a drug company.
He hopes companies will take more interest when researchers find biomarkers —
cancer risk indicators that are the equivalent of blood pressure or cholesterol.
That way people taking the drugs can see that they are reducing their risk. And
studies can be smaller and quicker because companies can follow these markers
rather than waiting for people to develop cancer.
But risk assessment is not easy, and biomarkers are still more of a dream than a
reality. There are other problems, too. If each cancer requires a different drug
for prevention, how many drugs can a person take? For now, Dr. Curt said, the
very idea of cancer prevention is daunting. And since cancer can take decades to
develop, by the time a study concludes, a drug’s patent life may be over.
It is not a pretty picture, Dr. Vogel said.
“You have to think that in boardrooms they are saying, Man, did we learn a
lesson,” he said. “We will stay as far away as possible from cancer prevention.”
Medicines to Deter Some
Cancers Are Not Taken, NYT, 13.11.2009,
The Short Life of a Diagnosis
November 10, 2009
The New York Times
By SIMON BARON-COHEN
THE Diagnostic and Statistical Manual of Mental Disorders, published by the
American Psychiatric Association, is the bible of diagnosis in psychiatry, and
is used not just by doctors around the world but also by health insurers.
Changing any such central document is complicated. It should therefore come as
no surprise that a committee of experts charged with revising the manual has
caused consternation by considering removing Asperger syndrome from the next
edition, scheduled to appear in 2012. The committee argues that the syndrome
should be deleted because there is no clear separation between it and its close
The experts propose that both conditions should be subsumed under the term
“autism spectrum disorder,” with individuals differentiated by levels of
severity. It may be true that there is no hard and fast separation between
Asperger syndrome and classic autism, since they are currently differentiated
only by intelligence and onset of language. Both classic autism and Asperger
syndrome involve difficulties with social interaction and communication,
alongside unusually narrow interests and a strong desire for repetition, but in
Asperger syndrome, the person has good intelligence and language acquisition.
The question of whether Asperger syndrome should be included or excluded is the
latest example of dramatic changes in history of the diagnostic manual. The
first manual, published in 1952, listed 106 “mental disorders.” The second
(1968), listed 182, and famously removed homosexuality as a disorder in a later
printing. The third (1980) listed 265 disorders, taking out “neurosis.” The
revised third version (1987) listed 292 disorders, while the current fourth
version cut the list of disorders back to 283.
This history reminds us that psychiatric diagnoses are not set in stone. They
are “manmade,” and different generations of doctors sit around the committee
table and change how we think about “mental disorders.”
This in turn reminds us to set aside any assumption that the diagnostic manual
is a taxonomic system. Maybe one day it will achieve this scientific value, but
a classification system that can be changed so freely and so frequently can’t be
close to following Plato’s recommendation of “carving nature at its joints.”
Part of the reason the diagnostic manual can move the boundaries and add or
remove “mental disorders” so easily is that it focuses on surface appearances or
behavior (symptoms) and is silent about causes. Symptoms can be arranged into
groups in many ways, and there is no single right way to cluster them.
Psychiatry is not at the stage of other branches of medicine, where a diagnostic
category depends on a known biological mechanism. An example of where this does
occur is Down syndrome, where surface appearances are irrelevant. Instead the
cause — an extra copy of Chromosome 21 — is the sole determinant to obtain a
diagnosis. Psychiatry, in contrast, does not yet have any diagnostic blood tests
with which to reveal a biological mechanism.
So what should we do about Asperger syndrome? Although originally described in
German in 1944, the first article about it in English was published in 1981, and
Asperger syndrome made it only into the fourth version of the manual, in 1994.
That is, the international medical community took 50 years to acknowledge it. In
the last decade thousands of people have been given the diagnosis. Seen through
this historical lens, it seems a very short time frame to be considering
removing Asperger syndrome from the manual.
We also need to be aware of the consequences of removing it. First, what happens
to those people and their families who waited so long for a diagnostic label
that does a good job of describing their profile? Will they have to go back to
the clinics to get their diagnoses changed? The likelihood of causing them
confusion and upset seems high.
Second, science hasn’t had a proper chance to test if there is a biological
difference between Asperger syndrome and classic autism. My colleagues and I
recently published the first candidate gene study of Asperger syndrome, which
identified 14 genes associated with the condition.
We don’t yet know if Asperger syndrome is genetically identical or distinct from
classic autism, but surely it makes scientific sense to wait until these two
subgroups have been thoroughly tested before lumping them together in the
diagnostic manual. I am the first to agree with the concept of an autistic
spectrum, but there may be important differences between subgroups that the
psychiatric association should not blur too hastily.
Simon Baron-Cohen, the director of the Autism Research Center at Cambridge
University, is the author of “The Essential Difference.”
The Short Life of a
Diagnosis, NYT, 10.11.2009,
Obama Seeks Revision
of Plan’s Abortion Limits
November 10, 2009
The New York Times
By ROBERT PEAR
WASHINGTON — President Obama suggested Monday that he was not comfortable
with abortion restrictions inserted into the House version of major health care
legislation, and he prodded Congress to revise them.
“There needs to be some more work before we get to the point where we’re not
changing the status quo” on abortion, Mr. Obama said in an interview with ABC
News. “And that’s the goal.”
On the one hand, Mr. Obama said, “we’re not looking to change what is the
principle that has been in place for a very long time, which is federal dollars
are not used to subsidize abortions.”
On the other hand, he said, he wanted to make sure “we’re not restricting
women’s insurance choices,” because he had promised that “if you’re happy and
satisfied with the insurance that you have, it’s not going to change.”
Before passing its health bill on Saturday, the House adopted an amendment that
would block the use of federal money for “any health plan that includes coverage
of abortion,” except in the case of rape or incest or if the life of a pregnant
woman is in danger.
Some private insurance now covers abortion. Under the bill, most private
insurers would receive federal subsidies on behalf of low- and middle-income
The Senate is working on its own version of health legislation.
Senator Susan Collins, a Maine Republican and pivotal centrist courted by the
White House, delivered a blistering critique of the Senate bill on Monday,
saying she could not support it because it would increase insurance costs for
many middle-income families and small businesses.
“We should rewrite the whole bill,” Ms. Collins said. “There is considerable
unease on both sides of the aisle about the impact of this bill, and as more
analysis is done, I believe those concerns will only grow.”
Ms. Collins and the other Maine senator, Olympia J. Snowe, are among the few
Republicans who had been considered potential supporters of the bill, drafted
mainly by Senate Democrats with help from the White House.
Ms. Collins appeared to dash those hopes on Monday, even as she affirmed her
belief that Democrats and Republicans could still find significant areas of
Summarizing her study of the bill over the past 10 weeks, Ms. Collins said it
was “too timid” in revamping the health care system to reward high-quality care.
She said the bill included “billions of dollars in new taxes and fees that will
drive up the cost of health insurance premiums.”
And she noted that many of the taxes would take effect before the government
started providing subsidies to low- and middle-income people to help them buy
Thus, Ms. Collins said, “there will be a gap for even low-income people where
the effect of these fees will be passed on to consumers and increase premiums
before any subsidies are available to offset those costs.”
The bill sets standards for the value of insurance policies, stipulating that
they must cover at least 65 percent of medical costs, on average.
Most policies sold in the individual insurance market in Maine do not meet those
standards, Ms. Collins said, so many insurers would have to raise premiums to
comply with the requirements. As a result, she said, the premium for a
40-year-old buying the most popular individual insurance policy in Maine would
more than double, to $455 a month.
The chairman of the Senate Finance Committee, Max Baucus, Democrat of Montana,
has tried to answer such criticism, saying that many of the current policies
provided meager bare-bones coverage.
The Senate Democratic leader, Harry Reid of Nevada, has drafted a health bill
that he hopes to take to the Senate floor within weeks. He is waiting for a cost
analysis by the Congressional Budget Office.
Supporters of the Senate bill said they believed that their efforts would gain
momentum from the approval of a broadly similar bill in the House on Saturday by
a vote of 220 to 215. But Representative Robert E. Andrews, Democrat of New
Jersey and an architect of the House bill, said, “The hardest part is still
ahead of us.”
The House and Senate bills differ in at least five ways: how to configure a new
government insurance plan; whether to require employers to provide coverage to
employees; whether to finance the legislation with a tax on high-income people
or a tax on high-cost insurance plans; how strictly to limit coverage of
abortion; and whether illegal immigrants should have access to new insurance
marts, or exchanges.
The House bill imposes more stringent restrictions on the coverage of abortion.
Ms. Collins said the Senate Finance Committee “did a good job of putting up a
firewall that would prevent federal funds from being used to finance abortions.”
But she added, “If Congress makes the mistake of establishing a new
government-owned insurance company, it would need to extend the prohibition to
that company because it is using federal funds.”
Obama Seeks Revision of
Plan’s Abortion Limits, NYT, 10.11.2009,
The Ban on Abortion Coverage
November 10, 2009
The New York Times
When the House narrowly passed the health care reform bill on Saturday night,
it came with a steep price for women’s reproductive rights. Under pressure from
anti-abortion Democrats and the United States Conference of Catholic Bishops,
lawmakers added language that would prevent millions of Americans from buying
insurance that covers abortions — even if they use their own money.
The restrictions would fall on women eligible to buy coverage on new health
insurance exchanges. They are a sharp departure from current practice, an
infringement of a woman’s right to get a legal medical procedure and an
unjustified intrusion by Congress into decisions best made by patients and
The anti-abortion Democrats behind this coup insisted that they were simply
adhering to the so-called Hyde Amendment, which bans the use of federal dollars
to pay for almost all abortions in a number of government programs. In fact,
they reached far beyond Hyde and made it largely impossible to use a
policyholder’s own dollars to pay for abortion coverage.
The bill brought to the floor already included a careful compromise that should
have satisfied reasonable legislators on both sides of the abortion issue. The
vast majority of people expected to buy policies on the new exchanges would pay
part of the premium and receive government tax credits to pay for the rest. The
compromise would have prohibited the use of the tax subsidies to pay for almost
all abortions, but it would have allowed the segregation and use of premium
contributions and co-payments to pay for such coverage. A similar approach
allows 17 state Medicaid programs to cover abortions using only state funds, not
federal matching funds.
Yet neither the Roman Catholic bishops nor anti-abortion Democrats were willing
to accept this compromise. They insisted on language that would ban the use of
federal subsidies to pay for “any part” of a policy that includes abortion
If insurers want to attract subsidized customers, who will be the great majority
on the exchange, they will have to offer them plans that don’t cover abortions.
It is theoretically possible that insurers could offer plans aimed only at
nonsubsidized customers, but it is highly uncertain that they will find it
worthwhile to do so.
In that case, some women who have coverage for abortion services through
policies bought by small employers could actually lose that coverage if their
employer decides to transfer its workers to the exchange. Ultimately, if larger
employers are permitted to make use of the exchange, ever larger numbers of
women might lose abortion coverage that they now have.
The restrictive language allows people to buy “riders” that would cover
abortions. But nobody plans to have an unplanned pregnancy, so this concession
is meaningless. It is not clear that insurers would even offer the riders since
few people would buy them.
The highly restrictive language was easily approved by a 240-to-194 vote and
incorporated into the overall bill, which squeaked through by a tally of 220 to
215. It was depressing evidence of the power of anti-abortion forces to override
a reasonable compromise. They were willing to scuttle the bill if they didn’t
get their way. Outraged legislators who support abortion rights could also have
killed the bill but sensibly chose to keep the reform process moving ahead.
The fight will resume in the Senate, where the Finance Committee has approved a
bill that incorporates the compromise just rejected by the House. We urge the
Senate to stand strong behind a compromise that would preserve a woman’s right
to abortion services.
The Ban on Abortion
Coverage, NYT, 10.11.2009,
The Medical Industry Grumbles,
but It Stands to Gain
November 9, 2009
The New York Times
By DUFF WILSON
and REED ABELSON
For any industry, there has to be at least some good news any time Congress
votes to expand the market by tens of millions of customers.
But the business world found plenty to complain about Sunday, as it assessed the
House bill that would make sweeping changes in the health care system and extend
insurance coverage to millions more Americans.
Insurers do not like the provision to create a new government-run insurance
program. Drug makers oppose billions of dollars in rebates they would have to
give to the government over 10 years. Makers of artificial hips, heart
defibrillators and other medical devices are not particularly happy about the
proposed 2.5 percent tax on their products.
And employers large and small oppose rules that, for many of them, would make
health care coverage — long a job benefit — become a federally mandated
That is why, as attention now shifts to the Senate, where Democratic leaders are
trying to merge two bills into one, virtually every business group with a stake
in the outcome will be hoping to strike at least a slightly better deal than
they found in the House version.
And they may indeed get a break from the Senate, where the need for Democrats to
compromise to win 60 votes may ensure a more business-moderate outcome.
And yet, many analysts said on Sunday that even the House bill was not as bad
for business as many in the health care industry might have feared when the
overhaul effort began many months ago.
“All industries stand to gain from this legislation,” Steven D. Findlay, senior
health policy analyst with Consumers Union in Washington, said in an interview.
“They’re going to continue to fight their narrow issues and get the best that
they can get. But all of them are aware they stand to gain significant new
business and new revenue streams as more Americans get health coverage and money
flows into the system for them.”
Of course, new revenue streams apply only to companies in the business of
selling medical goods and services. To employers required to provide worker
health benefits or else, in many cases, pay some sort of financial penalty, the
House legislation offers little to cheer about.
Employer groups complained on Sunday that the House bill would impose insurance
obligations while doing little to rein in the medical costs that help drive
premiums higher year after year. In fact, those groups argue, the bill’s
creation of a government-run insurance program, which may pay doctors and
hospitals less than private insurers do, could end up shifting even more medical
costs to the private insurance system that employers use.
“This won’t just hurt business, it will hurt millions of workers who have
coverage through their employers,” said John J. Castellani, president the
Business Roundtable, a group of chief executives of some of the nation’s biggest
And the National Federation of Independent Business, representing many small
businesses, said it was furious with the legislation. Susan Eckerly, senior vice
president of the federation, attacked mandates, which she called punitive, and
“atrocious new taxes.” The legislation, she said, was “a failed opportunity to
help small-business owners with their No. 1 problem — skyrocketing health care
Another group, the Small Business Majority, praised the legislation but said the
Senate needed to take more steps to lower costs.
Employers hope the final Senate legislation ends up looking more like the bill
the Finance Committee passed, which does not require companies to insure their
Meanwhile, the health insurance industry has been increasingly vocal about the
emerging shape of the legislation, and it was sharply critical of the bill that
passed on Saturday night.
“The current House legislation fails to bend the health cost curve and breaks
the promise that those who like their current coverage can keep it,” Karen M.
Ignagni, the chief executive of America’s Health Insurance Plans, the industry
trade association, said.
The reference to a broken promise refers, in part, to people enrolled in
privately offered Medicare Advantage insurance plans, which would lose federal
subsidies under the House bill. Ms. Ignagni warned of cuts that would “force
millions of seniors out of the program entirely.”
But the promise reference also refers to the bill’s provision of a new
government-run insurance plan that would compete directly with the health plans
offered by private insurers. The insurance industry has long opposed such a move
and warns that it will eventually force many people with private insurance into
the government-run program.
That “public option,” as it is known, was also in the Senate health committee
bill approved in July. And the Senate majority leader, Harry Reid, Democrat of
Nevada, has also signaled that he intends to include some kind of public plan in
whatever Senate legislation is reached.
But some observers say the House legislation is much less of a threat than the
industry had feared. While insurers were worried that the government plan would
be able to piggyback on the Medicare program in being able to demand lower
prices than the private insurers get from doctors and hospitals, the House
legislation does not give the government plan the same bargaining power as
“The ability of that program to gain incredible market share and have the clout
to severely undermine the market is minimized,” Robert Laszewski, president of
Health Policy and Strategy Associates, a consulting firm in Alexandria, Va.,
said in an interview.
Erik Gordon, a business professor and industry analyst at the University of
Michigan, said insurers would find it difficult to price their new risks but
might not be hurt too much by the competition — considering how many new
customers they would have.
The drug industry expected harsh treatment from the House and got it. The bill
would require drug makers to pay much more in rebates and discounts than in the
$80 billion, 10-year deal that the industry struck in June with the White House
and the chairman of the Senate Finance Committee, Max Baucus. The House bill
tacked on $60 billion or so in rebates over 10 years, raising the total to
around $140 billion.
But the White House and Mr. Baucus have said they will stay with their deal. It
remains to be seen whether it survives the melding of Senate bills being
directed by Mr. Reid.
“A good critic doesn’t write his review at the end of the first act of a play,”
Ken Johnson, senior vice president of the pharmaceutical trade group the
Pharmaceutical Research and Manufacturers of America, said in an interview.
“We’re hoping the second act is a lot better.”
And while the House legislation allows direct government negotiation of Medicare
drug prices — something specifically precluded in the Senate Finance bill — it
does not allow Medicare to create a formulary, or list of limited drugs. Mr.
Findlay, of Consumers Union, said that largely neutered Medicare’s
price-negotiating power, although it would represent a first step down the
price-setting path that the industry is certain to fear.
In a victory for the biotechnology drug industry, the House bill would give
biotech drugs, which can cost tens of thousands of dollars a year, protection
from generic competition for 12 years.
Doctors were left holding a mixed bag. The American Medical Association
supported the House legislation. But the doctors’ group did not get its quid pro
quo — the restoration of $210 billion in cuts to physicians’ Medicare fees over
the next 10 years, which were already scheduled before the current effort.
Attempts in the House and Senate to restore those cuts have been set aside at
least temporarily because the issue has been seen as a political distraction
from the main health care overhaul effort.
Barry Meier and Andrew Pollack contributed reporting.
The Medical Industry
Grumbles, but It Stands to Gain, NYT, 9.11.2009,
For Opponents of Abortion,
a Victory in Health Care Vote
November 9, 2009
The New York Times
By DAVID D. KIRKPATRICK and ROBERT PEAR
WASHINGTON — A restriction on abortion coverage, added late Saturday to the
health care bill passed by the House, has energized abortion opponents with
their biggest victory in years — emboldening them for a pitched battle in the
The provision would block the use of federal subsidies for insurance that covers
elective abortions. Advocates on both sides are calling Saturday’s vote the
biggest turning point in the battle over the procedure since the ban on
so-called partial birth abortions six years ago.
Both sides credited a forceful lobbying effort by Roman Catholic bishops with
the success of the provision, inserted in the bill under pressure from
The provision would apply only to insurance policies purchased with the federal
subsidies that the health legislation would create to help low- and
middle-income people, and to policies sold by a government-run insurance plan
that would be created by the legislation.
Abortion rights advocates charged Sunday that the provision threatened to
deprive women of abortion coverage because insurers would drop the procedure
from their plans in order to sell them in the newly expanded market of people
receiving subsidies. The subsidized market would be large because anyone earning
less than $88,000 for a family of four — four times the poverty level — would be
eligible for a subsidy under the House bill. Women who received subsidies or
public insurance could still pay out of pocket for the procedure. Or they could
buy separate insurance riders to cover abortion, though some evidence suggests
few would, in part because few plan for unintended pregnancies.
Not many women who undergo abortions file private insurance claims, perhaps to
avoid leaving a record. A 2003 study by the Alan Guttmacher Institute found that
13 percent of abortions were billed directly to insurance companies. Only about
half of those who receive insurance coverage from their employers have coverage
of abortion in any event, according to a study by the Kaiser Family Foundation.
Abortion rights advocates, however, are grappling with a series of incremental
defeats in the courts and in Congress, and are now bracing for another struggle
as the health care legislation goes to the Senate.
“This is going to make it that much more challenging on the Senate side,” said
Nancy Keenan, president of Naral Pro-Choice America.
The president and Democratic leaders alike have long promised that their
proposed health care overhaul would not direct taxpayer money to pay for
elective abortions. But the president has never spelled out his answer to the
contentious question of how to apply that standard to the novel program of
offering insurance subsidies or a government-run plan to millions of poor and
House Democratic leaders had sought to resolve the issue by requiring insurers
to segregate their federal subsidies into separate accounts.
Insurance plans would have been permitted to use only consumer premiums or
co-payments to pay for abortions, even if individuals who received federal
subsidies used them to buy health plans that covered abortion. But the House
speaker, Nancy Pelosi, was unable to hold on to enough moderate and conservative
Democratic votes to pass the health bill using that approach, forcing her to
allow a vote Saturday night on the amendment containing the broader ban.
Five states go further than the amendment to the health care overhaul. The five
— Idaho, Kentucky, Missouri, North Dakota and Oklahoma — already bar private
insurance plans from covering elective abortions.
The federal employees’ health insurance plan and most state Medicaid programs
also ban coverage of abortion, complying with a three-decade old ban on federal
abortion financing. Seventeen state Medicaid programs, however, do cover the
procedure, by using only state money.
The bishops objected to the segregated funds proposal previously embraced by the
House and Senate Democratic leaders in part because they argued that it amounted
to nothing more than an accounting gimmick.
Advocates on both sides of the question weighed in, but the bishops’ role was
especially pivotal in part because many Democrats had expected them to be an
ally. They had pushed for decades for universal health insurance.
“We think that providing health care is itself a pro-life thing, and we think
that, by and large, providing better health coverage to women could reduce
abortions,” said Richard M. Doerflinger, a spokesman for the anti-abortion
division of the United States Conference of Catholic Bishops.
“But we don’t make these decisions statistically, and to get to that good we
cannot do something seriously evil.”
Beginning in late July, the bishops began issuing a series of increasingly stern
letters to lawmakers making clear that they saw the abortion-financing issue as
pre-eminent, a deal-breaker.
At the funeral of Senator Edward M. Kennedy in August, Cardinal Seán O’Malley,
the archbishop of Boston, stole a private moment with Mr. Obama to deliver the
same warning: The bishops very much wanted to support his health care overhaul
but not if it provided for abortions. The president “listened intently,” the
cardinal reported on his blog.
Bishops implored their priests and parishioners to call lawmakers. Conservative
Democrats negotiating over the issue with party leaders often expressed their
desire to meet the bishops’ criteria, according to many people involved in the
talks. On Oct. 8 three members of the bishops conference wrote on its behalf to
lawmakers, “If the final legislation does not meet our principles, we will have
no choice but to oppose the bill.”
On Sunday, some abortion rights advocates lashed out at the bishops. “It was an
unconscionable power play,” said Cecile Richards, president of Planned
Parenthood Federation of America, accusing the bishops of “interceding to put
their own ideology in the national health care plan.”
Now some Senate Democrats, including Bob Casey of Pennsylvania and Ben Nelson of
Nebraska, are pushing to incorporate the same restrictions in their own bill.
Senior Senate Democratic aides said the outcome was too close to call.
For Opponents of
Abortion, a Victory in Health Care Vote, NYT, 9.11.2009,
Obama-backed health care bill
7 November 2009
WASHINGTON (AP) — The Democratic-controlled House narrowly passed
far-reaching health care legislation, handing President Obama a hard-won victory
on his chief domestic priority though the road ahead in the Senate promises to
The 220-215 vote late Saturday cleared the way for the Senate to begin a
long-delayed debate on the issue that has come to overshadow all others in
"The House bill is dead on arrival in the Senate," Sen. Lindsey Graham, R-S.C.,
said Sunday. "It was a bill written by liberals for liberals." A Democratic
colleague, Sen. Jack Reed of Rhode Island, predicted an overhaul would pass the
Senate because "it's essential" to the country's economic success and people's
quality of life. "It will take time," he added.
House Republicans were nearly unanimous in opposing the plan that would expand
coverage to tens of millions of Americans and place tough new restrictions on
the insurance industry.
A triumphant Speaker Nancy Pelosi compared the legislation to the passage of
Social Security in 1935 and Medicare 30 years later.
Obama, who went to Capitol Hill on Saturday to lobby wavering Democrats, said in
a statement after the vote that he looked forward to signing a bill by year's
Republicans detailed their objections across hours of debate on the 1,990-page,
$1.2 trillion legislation.
"We are going to have a complete government takeover of our health care system
faster than you can say, 'this is making me sick,"' said Rep. Candice Miller,
In the run-up to a final vote, conservatives from the two political parties
joined forces to impose tough new restrictions on abortion coverage in insurance
policies to be sold to many individuals and small groups.
The legislation would require most Americans to carry insurance and provide
federal subsidies to those who otherwise could not afford it. Large companies
would have to offer coverage to their employees. Both consumers and companies
would be slapped with penalties if they defied the government's mandates.
Insurance industry practices such as denying coverage because of medical
conditions would be banned, and insurers would no longer be able to charge
higher premiums on the basis of gender or medical history. The industry would
also lose its exemption from federal antitrust restrictions on price fixing and
At its core, the measure would create a federally regulated marketplace where
consumers could shop for coverage. In the bill's most controversial provision,
the government would sell insurance, although the Congressional Budget Office
forecasts that premiums for it would be more expensive than for policies sold by
Graham said he thinks the government option "will destroy private health care.
Nobody in this country in the insurance business can compete with a
government-sponsored plan, where the government writes the benefits and
politicians will never raise the premiums."
Sen. Joe Lieberman, an independent from Connecticut, said that "if the public
option plan is in there, as a matter of conscience, I will not allow this bill
to come to a final vote because I believe the debt can break America and send us
into a recession that's worse than the one we're fighting our way out of today."
The House bill drew the votes of 219 Democrats and Rep. Joseph Cao, a first-term
Republican who holds an overwhelmingly Democratic seat in New Orleans. Opposed
were 176 Republicans and 39 Democrats.
From the Senate, Majority Leader Harry Reid of Nevada issued a statement saying,
"We realize the strong will for reform that exists, and we are energized that we
stand closer than ever to reforming our broken health insurance system."
To pay for the expansion of coverage, the bill cuts Medicare's projected
spending by more than $400 billion over a decade. It also imposes a tax
surcharge of 5.4% on income over $500,000 in the case of individuals and $1
million for families.
Graham and Reed were on CBS' "Face the Nation." Lieberman appeared on "Fox News
health care bill passes House, UT, 7.11.2009,
Behind Higher Infant Death Rates in U.S.,
November 4, 2009
The New York Times
By DENISE GRADY
High rates of premature birth are the main reason the United States has
higher infant mortality than do many other rich countries, government
researchers reported Tuesday in their first detailed analysis of a longstanding
In Sweden, for instance, only 6.3 percent of births were premature, compared
with 12.4 percent in the United States in 2005 — the latest year for which
international rankings are available.
Infant mortality also differed markedly: for every 1,000 births in the United
States, 6.9 infants died before they turned 1, compared with only 2.4 in Sweden.
Twenty-nine other countries also had lower rates.
If America could match Sweden’s prematurity rate, the new report said, “nearly
8,000 infant deaths would be averted each year, and the U.S. infant mortality
rate would be one-third lower.”
Dr. Alan R. Fleischman, medical director of the March of Dimes, said the new
report was “an indictment of the U.S. health care system” and the poor job it
had done in taking care of women and children.
Infant mortality is widely used as a way to gauge the health of a nation, and
the relatively high rates in the United States have long dismayed health
The high rates of prematurity in the United States have various causes. The
smallest, earliest and most fragile babies are often born to poor and minority
women who lack health care and social support. The highest rates of infant
mortality occur in non-Hispanic black, American Indian, Alaska Native and Puerto
When it comes to prematurity, fertility treatments — drugs that stimulate
ovulation, and procedures that implant more than one embryo in the uterus — also
play a role, by raising the odds of twins or higher multiples, which have an
increased risk of being born too soon.
Another factor is the increasing use of Caesarean sections and labor-inducing
drugs to deliver babies early, said Marian F. MacDorman, a statistician at the
National Center for Health Statistics and an author of the report.
“I don’t think there are doctors doing preterm Caesarean sections or inductions
without some indications, but there sort of has been this shift in the culture,”
Dr. MacDorman said. “Fifteen or 20 years ago, if a woman had high blood pressure
or diabetes, she would be put in the hospital and they would try to wait it out.
It was called expectant management. Now I think there’s more of a tendency to
take the baby out early if there’s any question at all.”
Premature Births Behind
Higher Infant Death Rates in U.S., Report Says., NYT, 4.11.2009,
in 46 States as Vaccines Lag
October 25, 2009
The New York Times
By JACKIE CALMES
and DONALD G. McNEIL Jr.
WASHINGTON — President Obama has declared the swine flu outbreak a national
emergency, allowing hospitals and local governments to speedily set up alternate
sites for treatment and triage procedures if needed to handle any surge of
patients, the White House said on Saturday.
The declaration came as thousands of people lined up in cities across the
country to receive vaccinations, and as federal officials acknowledged that
their ambitious vaccination program has gotten off to a slow start. Only 16
million doses of the vaccine were available now, and about 30 million were
expected by the end of the month. Some states have requested 10 times the amount
they have been allotted.
Flu activity — virtually all of it the swine flu — is now widespread in 46
states, a level that federal officials say equals the peak of a typical winter
flu season. Millions of people in the United States have had swine flu, known as
H1N1, either in the first wave in the spring or the current wave.
Although there has been no exact count, officials said the H1N1 virus has killed
more than 1,000 Americans and hospitalized over 20,000. The emergency
declaration, which Mr. Obama signed Friday night, has to do only with hospital
treatment, not with the vaccine. Government officials emphasized that Mr.
Obama’s declaration was largely an administrative move that did not signify any
unanticipated worsening of the outbreak of the H1N1 flu nationwide. Nor, they
said, did it have anything to do with the reports of vaccine shortages.
“This is not a response to any new developments,” said Reid Cherlin, a White
House spokesman. “It’s an important tool in our kit going forward.”
Mr. Obama’s declaration was necessary to empower Kathleen Sebelius, the
secretary of Health and Human Services, to issue waivers that allow hospitals in
danger of being overwhelmed with swine flu patients to execute disaster
operation plans that include transferring patients off-site to satellite
facilities or other hospitals.
The department first declared a public health emergency in April; Ms. Sebelius
renewed it on Tuesday. But the separate presidential declaration was required to
waive federal laws put in place to protect patients’ privacy and to ensure that
they are not discriminated against based on their source of payment for care,
including Medicare, Medicaid and the states’ Children’s Health Insurance
As a practical matter, officials said, the waiver could allow a hospital to set
up a make-shift satellite facility for swine flu patients in a local armory or
other suitably spacious location, or at another hospital, to segregate such
cases for treatment. Under federal law, if the patients are sent off site
without a waiver, the hospital could be refused reimbursement for care as a
A few hospitals, including some in Texas and Tennessee, have set up triage tents
in their parking lots to screen patients with fever or other flu symptoms. A
Health and Human Services official said no hospitals had requested a waiver.
David Daigle of the Centers for Disease Control and Prevention said he had not
heard of any hospital that has faced a surge of patients so large that it had to
set up a triage area or a treatment unit off site.
In Chicago on Saturday, health officials began giving free vaccinations at six
City College locations, and within hours hundreds of people were turned away
because supplies had been exhausted. The city distributed 1,200 vaccines to each
site, immunizing more than 7,000 people, said Tim Hadac, spokesman for the
Chicago Department of Public Health. All but two of the sites ran out of the
At Truman College on Chicago’s North Side, lines formed at 7 a.m., two hours
before the doors opened. Mary Kate Merna, 28, a teacher who is nine months
pregnant, arrived too late to get a vaccination. “I thought I’d be a priority
being nine months pregnant,” she said. “You hear it’s a national emergency and
it scares you.”
In Fairfax County, Va., officials had planned to have swine flu clinics at 10
different locations on Saturday. But the county did not receive the number of
doses it requested, and was forced to offer the vaccinations only at the
government building. People began lining up with camping gear the night before
to get vaccinations.
Merni Fitzgerald, Fairfax’s public affairs director, said officials were aiming
to administer 12,000 doses of the vaccine to those most at risk for serious
complications from the H1N1 virus, mainly pregnant women and children 6 to 36
But that did not stop some other high-risk patients. “I lied and told the
doctors I was pregnant,” said Theresa Caffey of Centreville, who has multiple
sclerosis and nurses her 11-week-old son, Joshua. “I’m religious. I don’t lie.
But it’s not about me. It’s for my son. It’s safer for him if I have the
In a briefing on Friday, Dr. Thomas Frieden, the C.D.C. director, acknowledged
problems with the vaccine production. “We share the frustration of people who
have waited on line or called a number or checked a Web site and haven’t been
able to find a place to get vaccinated,” he said.
Federal officials predicted last spring that as many as 120 million doses could
be available by now, with nearly 200 million by year’s end. But production
problems plagued some of the five companies contracted to make the vaccine. All
use a technology involving growing the vaccine in fertilized chicken eggs; at
most of them, the seed strain grew more slowly than expected.
The manufacturers are “working hard to get vaccine out as safely and rapidly as
possible,” Dr. Frieden said. But since it is grown in eggs, “even if you yell at
them, they don’t grow faster.”
Since last winter’s more isolated cases of swine flu, the expectation that the
virus would return with a vengeance in this flu season had posed a test of the
Obama administration’s preparedness. Officials are mindful that the previous
administration’s failure to better prepare for and respond to Hurricane Katrina
in 2005 left doubts that dogged President George W. Bush to the end of his term.
There is no overall shortage of seasonal flu vaccine — 85 million doses have
shipped, and the season has not started. But there are temporary local
shortages. The seasonal flu typically hospitalizes 200,000 and kills 36,000
nationwide each year. But over 90 percent of the deaths are among the elderly,
while the swine flu mostly affects the young.
Jackie Calmes reported from Washington, and Donald G. McNeil Jr. from New
York. Crystal Yednak in Chicago and Holli Chmela in Fairfax, Va. contributed
H1N1 Widespread in 46
States as Vaccines Lag, NYT, 25.10.2009,
In Shift, Cancer Society
Has Concerns on Screenings
October 21, 2009
The New York Times
By GINA KOLATA
The American Cancer Society, which has long been a staunch
defender of most cancer screening, is now saying that the benefits of detecting
many cancers, especially breast and prostate, have been overstated.
It is quietly working on a message, to put on its Web site early next year, to
emphasize that screening for breast and prostate cancer and certain other
cancers can come with a real risk of overtreating many small cancers while
missing cancers that are deadly.
“We don’t want people to panic,” said Dr. Otis Brawley, chief medical officer of
the cancer society. “But I’m admitting that American medicine has overpromised
when it comes to screening. The advantages to screening have been exaggerated.”
Prostate cancer screening has long been problematic. The cancer society, which
with more than two million volunteers is one of the nation’s largest voluntary
health agencies, does not advocate testing for all men. And many researchers
point out that the PSA prostate cancer screening test has not been shown to
prevent prostate cancer deaths.
There has been much less public debate about mammograms. Studies from the 1960s
to the 1980s found that they reduced the death rate from breast cancer by up to
The cancer society’s decision to reconsider its message about the risks as well
as potential benefits of screening was spurred in part by an analysis published
Wednesday in The Journal of the American Medical Association, Dr. Brawley said.
In it, researchers report a 40 percent increase in breast cancer diagnoses and a
near doubling of early stage cancers, but just a 10 percent decline in cancers
that have spread beyond the breast to the lymph nodes or elsewhere in the body.
With prostate cancer, the situation is similar, the researchers report.
If breast and prostate cancer screening really fulfilled their promise, the
researchers note, cancers that once were found late, when they were often
incurable, would now be found early, when they could be cured. A large increase
in early cancers would be balanced by a commensurate decline in late-stage
cancers. That is what happened with screening for colon and cervical cancers.
But not with breast and prostate cancer.
Still, the researchers and others say, they do not think all screening will — or
should — go away. Instead, they say that when people make a decision about being
screened, they should understand what is known about the risks and benefits.
For now, those risks are not emphasized in the cancer society’s mammogram
message which states that a mammogram is “one of the best things a woman can do
to protect her health.”
Dr. Brawley says mammograms can prevent some cancer deaths. However, he says,
“If a woman says, ‘I don’t want it,’ I would not think badly of her but I would
like her to get it.”
But some, like Colin Begg, a biostatistician at Memorial Sloan-Kettering Cancer
Center in New York, worry that the increased discussion of screening’s risks is
going to confuse the public and make people turn away from screening,
mammography in particular.
“I am concerned that the complex view of a changing landscape will be distilled
by the public into yet another ‘screening does not work’ headline,” Dr. Begg
said. “The fact that population screening is no panacea does not mean that it is
useless,” he added.
The new analysis — by Dr. Laura Esserman, a professor of surgery and radiology
at the University of California, San Francisco, and director of the Carol Frank
Buck Breast Care Center there, and Dr. Ian Thompson, professor and chairman of
the department of urology at The University of Texas Health Science Center, San
Antonio — finds that prostate cancer screening and breast cancer screening are
not so different.
Both have a problem that runs counter to everything people have been told about
cancer: They are finding cancers that do not need to be found because they would
never spread and kill or even be noticed if left alone. That has led to a huge
increase in cancer diagnoses because, without screening, those innocuous cancers
would go undetected.
At the same time, both screening tests are not making much of a dent in the
number of cancers that are deadly. That may be because many lethal breast
cancers grow so fast they spring up between mammograms. And the deadly prostate
ones have already spread at the time of cancer screening. The dilemma for breast
and prostate screening is that it is not usually clear which tumors need
aggressive treatment and which can be left alone. And one reason that is not
clear, some say, is that studying it has not been much of a priority.
“The issue here is, as we look at cancer medicine over the last 35 or 40 years,
we have always worked to treat cancer or to find cancer early,” Dr. Brawley
said. “And we never sat back and actually thought, ‘Are we treating the cancers
that need to be treated?’ ”
The very idea that some cancers are not dangerous and some might actually go
away on their own can be hard to swallow, researchers say.
“It is so counterintuitive that it raises debate every time it comes up and
every time it has been observed,” said Dr. Barnett Kramer, associate director
for disease prevention at the National Institutes of Health.
It was first raised as a theoretical possibility in the 1970s, Dr. Kramer said.
Then it was documented in a rare pediatric cancer, but was dismissed as
something peculiar to that cancer. Then it was discovered in common cancers as
well, but it is still not always accepted or appreciated, he said.
But finding those insignificant cancers is the reason the breast and prostate
cancer rates soared when screening was introduced, Dr. Kramer said. And those
cancers, he said, are the reason screening has the problem called overdiagnosis
— labeling innocuous tumors cancer and treating them as though they could be
lethal when in fact they are not dangerous.
“Overdiagnosis is pure, unadulterated harm,” he said.
Dr. Peter Albertsen, chief and program director of the urology division at the
University of Connecticut Health Center, said that had not been an easy message
to get across. “Politically, it’s almost unacceptable,” Dr. Albertsen said. “If
you question overdiagnosis in breast cancer, you are against women. If you
question overdiagnosis in prostate cancer, you are against men.”
Dr. Esserman hopes that as research continues on how to advance beyond
screening, distinguishing innocuous tumors from dangerous ones, people will be
more realistic about what screening can do.
“Someone may say, ‘I don’t want to be screened’ ” she said. “Another person may
say, ‘Of course I want to be screened.’ Just like everything in medicine, there
is no free lunch. For every intervention, there are complications and problems.”
In Shift, Cancer Society
Has Concerns on Screenings, NYT, 21.10.2009,
Have Faith in an AIDS Vaccine
October 19, 2009
The New York Times
By SETH BERKLEY
VACCINE researchers don’t often find themselves at the center of
public controversies. But a storm has erupted over the announcement last month
that an experimental AIDS vaccine tested in Thailand proved modestly effective.
It was billed as a major scientific advance — the long-awaited hard evidence
that it is possible to inoculate people against AIDS. But now the trial has been
called into question in a way that is overblown and possibly destructive.
At a biotech conference last week, I asked a major industry scientist what he
thought of the Thai trial announcement, and, although no additional data had
been presented, he replied simply, “I don’t believe it.” Unfortunately, such
pessimism may be hard to dispel and may ultimately thwart other efforts to
develop an AIDS vaccine.
Even before this controversy erupted, it had been an effort to maintain
sufficient support for AIDS vaccine research and development. In 2008, private
and public spending on this vital mission declined by 10 percent from the year
before. A few fanatical AIDS activists have even called for ending the American
government’s considerable support for AIDS vaccine research, and spending the
money instead on AIDS treatment. Patient care is vital, of course, but it alone
can only mitigate, not end, the pandemic.
This is why it is essential to clear things up.
The Thai study was the largest AIDS vaccine trial yet, following 16,402
volunteers for six years. It was a collaborative effort by, among others, the
United States military, the National Institutes of Health and the Thai Health
Ministry. (The organization I head, a nonprofit that conducts vaccine research
and development but was not involved and has no commercial interest in the
candidates tested.) The trial partners initially announced that the vaccine
combination reduced the risk of infection by 31.2 percent in a statistically
A few days later, the trial collaborators began to brief researchers privately
about additional data, including a second type of analysis that indicated the
vaccine regimen had been slightly less effective than the first analysis
suggested. This second analysis was not statistically significant, meaning that
chance, rather than the protective effect of the vaccine candidate, might
explain why fewer volunteers in the vaccinated group than in the placebo group
were infected with H.I.V.
Some researchers questioned why both analyses weren’t announced at the same time
— which certainly would have been preferable — and suggested to reporters that
the second analysis called the first one into doubt. The trial sponsors say they
thought the complexities of the second analysis and all additional data were
best explored in a peer-reviewed paper in a scientific journal and at a
presentation at the AIDS Vaccine Conference in Paris this week. But with news
outlets reporting that the trial results may be a fluke, there is a risk that
they will be forever tainted, whatever the final analyses show. What’s more, the
stain of dubiousness may remain on all AIDS vaccine research and development.
That would be a shame. Although the candidate duo tested in the Thai trial did
not prove to be a vaccine ready for the market, it may provide an unprecedented
opportunity to learn how an AIDS vaccine can work. A comparison of blood samples
from volunteers could indicate what specific immune responses the combination
may have activated to provide protection. If so, this knowledge could help
scientists improve upon the more promising candidates that have emerged since
the trial candidates were designed a decade ago, and determine which ones are
most likely to work.
This illustrates why the controversy over statistical significance is
exaggerated. Whether you consider the first or second analysis, the observed
effect of the Thai candidates was either just above or below the level of
statistical significance. Statisticians will tell you it is possible to observe
an effect and have reason to think it’s real even if it’s not statistically
significant. And if you think it’s real, you ought to examine it carefully.
Even if the Thai vaccine regimen turns out, on examination, to have had no real
benefit, researchers will still learn from the trial, as they do from every
study. Moreover, other noteworthy advances featured at the Paris conference this
week will offer fresh hope for an AIDS vaccine. Years of investment and dogged
science are providing leads for solving one of today’s most pressing research
challenges. Some 7,400 new H.I.V. infections occur daily throughout the world.
Clearly we need better methods of preventing the spread of H.I.V., and no public
health intervention is more powerful or cost-effective against infectious
disease than a vaccine.
Seth Berkley is the president and chief executive of the
International AIDS Vaccine Initiative.
Have Faith in an AIDS
Vaccine, NYT, 19.10.2009,
Who Should Treat Breast Cancer?
October 18, 2009
The New York Times
To the Editor:
In “Wanted: Mammologists” (Op-Ed, Oct. 10),
Ann V. Bell, Mark Pearlman and Raymond De Vries argue that women with breast
cancer need doctors “devoted to shepherding them through surgery, therapy and
healing.” But introducing a “mammologist” would create yet another specialist to
whom generalists would refer patients.
Mammologists would not necessarily reduce communication errors, which are often
institutional issues. Besides, many women use a family doctor, internist,
physician’s assistant or nurse practitioner as an initial care provider.
Coordination of care is a high priority, but why not turn to multidisciplinary
breast care centers that can, in a single visit, marshal the expertise of
subspecialists and ancillary services?
Wilsonville, Ore., Oct. 10, 2009
The writer is a radiologist.
To the Editor:
It is true that breast cancer treatment has become too complex for the current
models of care. The multiple specialties required make it impossible for a
single individual, no matter how well trained, to deliver that care.
The only solution is to put the patient at the center of the process. At many
leading institutions, a multidisciplinary approach allows all relevant
specialists to come together to see patients on the same day. Such an approach
leads to improved communication and better care for breast cancer, and should be
applied throughout medicine as care becomes more complex.
James P. Evans
Chapel Hill, N.C., Oct. 10, 2009
The writer, a doctor, is director of clinical cancer genetics at the Lineberger
Comprehensive Cancer Center, University of North Carolina at Chapel Hill.
To the Editor:
I am a nurse practitioner in internal medicine and have been practicing for 11
years, so I feel I have experience with breast-lump palpation and cancer
If a woman has not had a clinical breast exam in the past year or mentions a
lump, I do a breast exam. If we agree that there is a lump, she is immediately
sent to our breast imaging clinic, where a mammogram and an ultrasound are done
If the radiologist tells me the results are worrisome, the patient can
immediately see one of our breast surgeons.
A woman does not have to go to a gynecologist for this care. In fact, men or
women in our internal medicine clinic who mention a worrisome lump can be seen
that day, whether it is in the breast, neck or testicle. We have been doing it
this way for as long as I can remember.
Sayre, Pa., Oct. 10, 2009
To the Editor:
Your article describes the challenges for breast cancer patients who are
shuttled between specialists. As long as our system fixes us one piece at a
time, we will suffer the costs of miscommunication, and miss out on the benefits
of holistic care.
This à la carte health care surely helps explain why we spend more yet have a
shorter life expectancy than our European counterparts. As we consider health
care access for all, let’s make sure we treat all of each person.
Pittsburgh, Oct. 10, 2009
The writer is a student in the health law program at the University of
Pittsburgh School of Law.
To the Editor:
While the tone of “Wanted: Mammologists” seems conciliatory, the text is a
subtle rally to turf warfare, advocating that obstetrician-gynecologists learn
to do breast biopsies.
Collaborative efforts to help patients through breast cancer treatment are well
under way. In my hospital, these include a program that helps navigate patients
from radiology to surgery to radiation, as well as interdepartmental teaching
conferences and courses stressing comprehensive approaches.
Breast Cancer Awareness Month is as good a time as any to encourage better
Bronx, Oct. 10, 2009
The writer is a radiologist at Jacobi Hospital specializing in breast imaging.
To the Editor:
The decreasing mortality from breast cancer is due to earlier diagnosis because
of mammography and to multidisciplinary, innovative treatments.
Women should still have breast examinations by their primary-care doctors, and
be taught self-examination. But breast cancers are more frequently detected by
The diagnosis should then be established not by surgical biopsy, but by a less
invasive technique, like a needle biopsy by a radiologist or surgeon.
There is no reason to go back a century to when breast biopsies were performed
by gynecologists. The diagnosis and treatment of breast disease are taught
within the specialty of general surgery, and there are fellowships that train
specialists in all aspects of treating breast cancer.
We have too often seen the bad results of what the writers call “minimal”
surgery to diagnose breast disease. Surgery should be performed only by those
specifically trained to complete whatever additional procedures are deemed
necessary at the time — for example, the removal of lymph nodes. This is
state-of-the-art, optimal care.
Peter I. Pressman
Gordon F. Schwartz
New York, Oct. 10, 2009
The writers are, respectively, clinical professor of surgery at Weill Cornell
Medical College and a professor of surgery at Jefferson Medical College. Dr.
Pressman is co-author of “Breast Cancer: The Complete Guide.”
To the Editor:
It fell to general surgeons to treat breast cancer in the late 19th century when
William Stewart Halsted devised the first effective treatment for it.
As medicine has advanced, the skills of radiation oncologists and radiologists
have become far greater than those of practitioners who don’t do this work full
A team approach to most cancers, in which surgeons, oncologists, radiation
therapists and radiologists diagnose and treat cancer, should be universal. My
wife and I have both been cancer patients and, like others, we know that
treatment is often cumbersome and unpleasant, and need not be. But construction
of a new specialty won’t solve these problems.
Michael P. Kempster
Andover, Mass., Oct. 10, 2009
The writer is a retired general surgeon.
Who Should Treat Breast Cancer?, NYT,
Influences Our Behavior
October 15, 2009
The New York Times
To the Editor:
David Brooks’s terrific Oct. 13 column, “The
Young and the Neuro,” addresses the interdisciplinary nature of the research
being done today in cognitive neuroscience. Far from being merely the domain of
medicine or sociology, it is a new discipline being forged through the fusion of
biotechnology, psychology, physiology, and political and social science.
In the future, no single scholarly field will flourish without
interrelationships with others. That this truth is being recognized is apparent
in the Nobel committee’s decision to award the prize in economics to Elinor
Ostrom, a political scientist at Indiana University.
University administrators should be aware that other areas that are usually
relegated to “the arts” are also involved in cognitive science, including
theater and performance studies, which has been examining how mirror neurons are
engaged when audiences watch plays or view films.
Mr. Brooks is to be commended for recognizing the value of interdisciplinarity.
Let us not forget, especially at a time when university budgets are being
drastically cut, that those of us working in the humanities are contributing to
“neurohumanism” as well.
Bloomington, Ind., Oct. 13, 2009
The writer is a professor of English and West European studies at Indiana
To the Editor:
David Brooks heralds the new way that we will be analyzing our behavior, so that
we will more fully understand how we react to events and to others. But there is
one flaw in Mr. Brooks’s conclusion. He declares that the categories “emotion”
and “reason” will no longer be relevant.
On the contrary, this new “social cognitive neuroscience” will highlight the way
our reactions are determined by our emotions rather than our reason. We will
finally begin to understand scientifically what psychologists have understood
for decades: how most of our actions stem from our emotions rather than our
New York, Oct. 13, 2009
To the Editor:
For decades, the psychoanalytic community has been helping patients to lead more
productive, satisfying lives by searching for the conscious and unconscious
motivations behind their actions, attitudes and behaviors. Our work has lately
come under attack as being unscientific, but David Brooks describes just how our
clinical theories intersect with empirical research and wider social concerns.
With the benefit of new technology, young scientists can scan brain processes
and demonstrate how the unconscious brain affects behaviors and how human
attachments are developed or altered. As psychoanalysts, we struggle to retain
credibility in the health care debate, to get reimbursements from insurance
companies and to get a seat at the table of political and cultural discourse.
We need to rethink the way we define what we do and challenge the perception of
the analyst as insular and out of touch. An article like Mr. Brooks’s confirms
that we are relevant. I hope that the young scientists can help us find a better
way to engage. Mindy Utay
New York, Oct. 14, 2009
The writer is a social worker and psychoanalyst in private practice.
To the Editor:
David Brooks writes: “The anterior cingulate cortices in American and Chinese
brains activate when people see members of their own group endure pain, but they
do so at much lower levels when they see members of another group enduring it.
These effects may form the basis of prejudice.”
Aren’t these effects simply a result of prejudice? Is the biochemical process
the basis of prejudice or is prejudice the basis for a biochemical process
taking place? To simply assume that a biochemical correlate of a social activity
is its explanation is bad science, even if chemical reactions look less “fuzzy”
than the materials of social and cultural life. James Slotta
Portland, Ore., Oct. 13, 2009
To the Editor:
David Brooks seems to consider it delightful that the social cognitive
neuroscientists he saw at a recent academic conference were “young, hip and
attractive.” But as an un-hip 62-year-old professor in a different field, I
wonder whether the “geeks” and “graying professors” whose absence Mr. Brooks
seems to celebrate were not there because they would be unwelcome.
Such discrimination would be not only immoral but also foolish, since even the
old and un-hip just might have something to offer intellectually.
Felicia Nimue Ackerman
Providence, R.I., Oct. 13, 2009
The writer is a professor of philosophy at Brown University.
How Biology Influences Our Behavior, NYT,
The Young and the Neuro
October 13, 2009
The New York Times
By DAVID BROOKS
When you go to an academic conference you expect to see some geeks, gravitas
and graying professors giving lectures. But the people who showed up at the
Social and Affective Neuroscience Society’s conference in Lower Manhattan last
weekend were so damned young, hip and attractive. The leading figures at this
conference were in their 30s, and most of the work was done by people in their
20s. When you spoke with them, you felt yourself near the beginning of something
long and important.
In 2001, an Internet search of the phrase “social cognitive neuroscience”
yielded 53 hits. Now you get more than a million on Google. Young scholars have
been drawn to this field from psychology, economics, political science and
beyond in the hopes that by looking into the brain they can help settle some old
arguments about how people interact.
These people study the way biology, in the form of genes, influences behavior.
But they’re also trying to understand the complementary process of how social
behavior changes biology. Matthew Lieberman of U.C.L.A. is doing research into
what happens in the brain when people are persuaded by an argument.
Keely Muscatell, one of his doctoral students, and others presented a study in
which they showed people from various social strata some images of menacing
faces. People whose parents had low social status exhibited more activation in
the amygdala (the busy little part of the brain involved in fear and emotion)
than people from high-status families.
Reem Yahya and a team from the University of Haifa studied Arabs and Jews while
showing them images of hands and feet in painful situations. The two cultures
perceived pain differently. The Arabs perceived higher levels of pain over all
while the Jews were more sensitive to pain suffered by members of a group other
than their own.
Mina Cikara of Princeton and others scanned the brains of Yankee and Red Sox
fans as they watched baseball highlights. Neither reacted much to an
Orioles-Blue Jays game, but when they saw their own team doing well, brain
regions called the ventral striatum and nucleus accumbens were activated. This
is a look at how tribal dominance struggles get processed inside.
Jonathan B. Freeman of Tufts and others peered into the reward centers of the
brain such as the caudate nucleus. They found that among Americans, that region
was likely to be activated by dominant behavior, whereas among Japanese, it was
more likely to be activated by subordinate behavior — the same region rewarding
different patterns of behavior depending on culture.
All of these studies are baby steps in a long conversation, and young academics
are properly circumspect about drawing broad conclusions. But eventually their
work could give us a clearer picture of what we mean by fuzzy words like
‘culture.’ It could also fill a hole in our understanding of ourselves.
Economists, political scientists and policy makers treat humans as ultrarational
creatures because they can’t define and systematize the emotions. This work is
getting us closer to that.
The work demonstrates that we are awash in social signals, and any social
science that treats individuals as discrete decision-making creatures is
nonsense. But it also suggests that even though most of our reactions are fast
and automatic, we still have free will and control.
Many of the studies presented here concerned the way we divide people by
in-group and out-group categories in as little as 170 milliseconds. The anterior
cingulate cortices in American and Chinese brains activate when people see
members of their own group endure pain, but they do so at much lower levels when
they see members of another group enduring it. These effects may form the basis
But a study by Saaid A. Mendoza and David M. Amodio of New York University
showed that if you give people a strategy, such as reminding them to be racially
fair, it is possible to counteract those perceptions. People feel disgust toward
dehumanized groups, but a study by Claire Hoogendoorn, Elizabeth Phelps and
others at N.Y.U. suggests it is possible to lower disgust and the accompanying
insula activity through cognitive behavioral therapy.
In other words, consciousness is too slow to see what happens inside, but it is
possible to change the lenses through which we unconsciously construe the world.
Since I’m not an academic, I’m free to speculate that this work will someday
give us new categories, which will replace misleading categories like ‘emotion’
and ‘reason.’ I suspect that the work will take us beyond the obsession with
I.Q. and other conscious capacities and give us a firmer understanding of
motivation, equilibrium, sensitivity and other unconscious capacities.
The hard sciences are interpenetrating the social sciences. This isn’t
dehumanizing. It shines attention on the things poets have traditionally cared
about: the power of human attachments. It may even help policy wonks someday see
people as they really are.
The Young and the Neuro,
Congress Is Split
on Effort to Tax Costly Health Plans
October 13, 2009
The New York Times
By DAVID M. HERSZENHORN
and ROBERT PEAR
WASHINGTON — A proposed tax on high-cost, or “Cadillac,” health insurance
plans has touched off a fierce clash between the Senate and the House as they
wrestle over how to pay for legislation that would provide health benefits to
millions of uninsured Americans.
Supporters, including many senators, say that the tax is essential to tamping
down medical spending and that over 10 years it would generate more than $200
billion, nearly a fourth of what is needed to pay for the legislation.
Critics, including House members and labor unions, say the tax would quickly
spiral out of control and hit middle-class workers, people more closely
associated with minivans than Cadillacs.
The tax, a provision of the bill to be voted on Tuesday by the Senate Finance
Committee, is one of the few remaining proposals under consideration by Congress
that budget experts say could lead directly to a reduction in health care
spending over the long term, by prompting employers and employees to buy cheaper
insurance. Whether it remains in the bill is emerging as a test of the
commitment by President Obama and his party to slowing the steep rise of medical
It is also a prime example of the major differences still to be bridged by
Democrats as health care legislation advances to floor debate in both houses.
Under the Finance Committee bill, the tax would be imposed beginning in 2013 on
employer- sponsored health plans with total premiums exceeding $8,000 for
individuals and $21,000 for families, regardless of whether the coverage was
paid for by the employer, the individual or both. The tax would be paid by
insurers, who would be expected to pass along the cost to customers.
Critics say that would mean an increase in premiums or in out-of-pocket expenses
for employees, raising medical costs for individuals and families.
Supporters say the more likely prospect is that employers would bargain-hunt or
take other steps to avoid the tax, putting pressure on insurers to offer cheaper
coverage and slowing the rise in medical costs for everyone.
In a preliminary estimate, the Congressional Joint Committee on Taxation
calculated that absent any such employer efforts, 14 percent of family health
policies and 19 percent of individual policies would be hit by the tax in 2013.
By 2019, according to the estimate, 37 percent of family policies and 41 percent
of individual policies would be affected. Those numbers rise over time in these
calculations because although the initial tax threshold would increase with the
economy’s overall inflation, premiums would be expected to rise even faster.
Many Democratic senators, led by the Finance Committee chairman, Max Baucus of
Montana, like the idea of the tax, and Mr. Obama embraced it in his speech to
Congress on Sept. 9.
“This reform will charge insurance companies a fee for their most expensive
policies, which will encourage them to provide greater value for the money,” the
president said then. “This modest change could help hold down the cost of health
care for all of us in the long run.”
Congress has also heard from many economists, Republicans and Democrats alike,
who support the tax.
But House Democrats, led by Speaker Nancy Pelosi and Representative Charles B.
Rangel of New York, the chamber’s chief tax-writer, oppose the idea, as do labor
unions and businesses. Ms. Pelosi last week floated the idea of taxing insurers’
“windfall profits” as a possible alternative, to supplement the House’s main
revenue raiser, an income tax surcharge on the nation’s highest earners.
At least 173 House Democrats, two-thirds of the party caucus, have signed a
letter to Ms. Pelosi voicing opposition to the insurance tax .
“The tax, supposedly aimed at Cadillac health plans, would affect millions of
middle-class people,” said Representative Joe Courtney, Democrat of Connecticut.
“The American people soundly rejected the idea when it was proposed by
Republicans in elections last year.”
Under current law, employer-paid premiums for health insurance are not taxable.
Experts say this provides a big government subsidy for such coverage, and an
incentive for businesses to provide better benefits in lieu of higher wages.
In an unusual alliance reflecting the shared interest of some unions and
businesses on the issue, the A.F.L.-C.I.O. and the United States Chamber of
Commerce are mobilizing opposition to the tax.
James P. Gelfand, senior manager of health policy at the Chamber of Commerce,
said that if the tax is imposed, “employers will have to reduce wages or
benefits or increase cost-sharing.” And, he said, “employees will blame
employers, not the government.”
Leaders of organized labor, which in recent years has often negotiated for
benefits in place of raises, descended on Capitol Hill last week to lobby
against the tax, which could hit many health plans covering unionized workers.
Larry Cohen, president of the Communications Workers of America, said at least
half his members would be in health plans subject to the tax in 2013.
John P. Yrchik, executive director of the Connecticut Education Association, has
lobbied Mr. Courtney and other members of the state’s Congressional delegation,
noting that the tax would affect teachers in 30 percent of Connecticut towns. In
some towns, Mr. Yrchik said, health insurance premiums for teachers’ family
policies already exceed $25,000.
Aides to Mr. Baucus, the Finance Committee chairman, said the tax had numerous
benefits, and predicted that employers and employees would shop for health plans
to avoid it, forcing insurers to rein in costs.
They also cited projections by the Joint Committee on Taxation that about $142
billion of the 10-year total of $201 billion to be raised by the proposal would
come from increased income and payroll taxes — evidence, they said, that workers
would receive increased wages if employers spent less on health benefits.
But the same expectation that employers would adjust their health plans to avoid
the tax was cited by some critics as a potential harm for workers.
“Employers and insurers will reduce their benefits to avoid paying the proposed
tax,” said Representative Pete Stark, the California Democrat who heads the Ways
and Means Subcommittee on Health. “As a result, middle-class families will be
forced to pay more for health care.”
Some experts said that the tax was a complicated, backdoor way to tax
employer-provided health benefits, and a number of them maintained that simply
ending the tax exemption for such benefits would be a better approach.
Others said the tax would have an uneven impact, falling harder on businesses
that, for instance, have older employees or are situated in high-cost regions.
Robert H. Dobson, an actuary at Milliman, an employee benefits consulting firm,
said, “The high cost of so-called Cadillac plans has as much to do with the
characteristics of the covered population as it does with the richness of the
Congress Is Split on
Effort to Tax Costly Health Plans, NYT, 13.10.2009,
Assails Health Care Legislation
October 12, 2009
The New York Times
By ROBERT PEAR
WASHINGTON — In a blistering new attack, the health insurance industry said
Sunday that health care legislation drafted by Senate Democrats would drive up
premiums, rather than making coverage more affordable, as the White House
A lobby for the industry, America’s Health Insurance Plans, focused its
criticism on a bill likely to be approved Tuesday by the Senate Finance
“The overall impact will be to increase the cost of private insurance coverage
for individuals, families and businesses above what these costs would be in the
absence of reform,” said Karen M. Ignagni, president of the trade association.
Democratic aides on the Finance Committee disputed the conclusion. They said the
bill would provide tax credits to millions of people to help them afford
coverage. Moreover, they said, people could keep the coverage they now have if
they wanted. In addition, they said, some provisions of the bill would reduce
the administrative costs of insurance.
Ms. Ignagni cited a report done last week for her organization by
PricewaterhouseCoopers, the accounting firm.
The report says that the cost of the average family coverage, now $12,300, will
rise to $18,400 in 2016 under current law and to $21,300 if the Senate bill is
adopted. Likewise, it said, the cost of individual coverage, now $4,600, will
average $6,900 in 2016 under current law and $7,900 under the bill.
The study provides ammunition to Republicans attacking the legislation and might
intensify the concerns of some Democrats who worry that the bill does not
provide enough help to low- and middle-income people to enable them to buy
Scott Mulhauser, a spokesman for Democrats on the Finance Committee, said: “This
report is untrue, disingenuous and bought and paid for by the same health
insurance companies that have been gouging consumers for too long. Now that
health care reform grows ever closer, these health insurers are breaking out the
same tired playbook of deception. It’s a health insurance company hatchet job.”
Ms. Ignagni and PricewaterhouseCoopers said several provisions of the Senate
bill would drive up insurance premiums.
First, they said, the bill would require insurance companies to sell coverage to
all applicants and would prohibit them from considering health status in setting
rates. But, they said, the penalties for going without coverage are modest, so
the “individual mandate” is weak.
This creates “a powerful incentive for people to wait until they are sick to
purchase coverage,” Ms. Ignagni said. Sick people with high medical expenses are
likely to join the insurance pool, while healthier people may defer buying
insurance, secure in the knowledge they can get it when they need it, the study
In addition, the study says, the bill would impose a new excise tax on high-cost
insurance policies and new fees on insurance companies. The study, like the
Congressional Budget Office, predicts that insurers will pass these costs on to
their customers, in the form of higher premiums.
Finally, the study says, the bill would cut hundreds of billions of dollars from
the projected growth of Medicare. To make up for these cutbacks, it says,
hospitals and other health care providers are likely to increase charges to
private insurers, which in turn would increase premiums charged to businesses,
families and individuals.
Assails Health Care Legislation, NYT, 12.10.2009,
October 10, 2009
The New York Times
By ANN V. BELL,
and RAYMOND DE VRIES
Ann Arbor, Mich.
OCTOBER is Breast Cancer Awareness Month, but what is it we need to be aware of?
We know that for women, breast cancer is the most common cancer and, after lung
cancer, the leading cause of cancer death. This month, pink ribbons and yogurt
containers will remind us of the need to find a cure. But equally important is
improving access to life-saving therapy for women already living with breast
cancer — many of whom don’t even know it.
Delayed diagnosis of breast cancer — measured from the first health care
consultation for a breast complaint to a diagnosis of cancer — is the most
common and the second most costly medical claim against American doctors.
Moreover, the length of delays in breast cancer diagnosis in cases that lead to
malpractice litigation has been increasing in recent years. According to a study
by the Physician Insurers Association of America, in 1990 the average delay was
12.7 months; in 1995 it was 14 months. The most recent data, from 2002, showed
the average delay had risen to 16.3 months.
Why are there such long delays, even for women who get regular examinations? The
insurers association identifies five causes: a misreading of the mammogram, a
false negative mammogram, findings that fail to impress the doctor, the doctor’s
failure to refer the patient to a specialist and poor communication between
providers. Four of these five are preventable human errors (a false negative
mammogram is a machine failure) and two — failure to make a referral and poor
communication — are products of the way we organize health care.
The breast is something of an orphan in our health care system. We have
cardiologists, nephrologists, hepatologists, proctologists and neurologists —
but we have no “mammologists.” How did the breast get lost?
To answer this question we need to look at the division of labor in medicine and
the history of specialization. In 1940, 24 percent of doctors were specialists;
by the late 1960s, nearly 90 percent of medical graduates were entering
specialty residencies. In the 1930s, obstetrician-gynecologists attempted to
define themselves as surgeons specializing in women’s reproductive organs. But
general surgeons had long considered all things surgical their exclusive turf,
so obstetrician-gynecologists instead created a niche for themselves as “women’s
doctors,” a kind of primary care specialty. They became the point of entry to
health care for most women. Some were able to diagnose breast problems, but
treatment of the breast remained for the most part with general surgeons.
When radiologists — specialists who can also diagnose breast cancer — appeared
on the scene, another caregiver became involved in treatment. And radiologists
were followed by radiation oncologists, medical oncologists, reconstructive
surgeons and medical geneticists.
Women with breast cancer get lost in the mix, forced to make several different
appointments, sit in various waiting rooms and see multiple doctors. In most
cases, a woman with a breast problem will start with her
obstetrician-gynecologist, who will then refer her to a surgeon (for a biopsy)
or a radiologist (for a mammogram). The referring obstetrician-gynecologist may
never see or hear from the patient again, and may not know if she kept her
appointment or got adequate care.
Contrast this with the care given to women with gynecologic cancer. Because
there is a subspecialty of gynecologic oncology, women see the same doctor from
diagnosis to post-surgery follow-up. Breast malignancies outnumber gynecologic
cancers 10 to one, and yet we have no subspecialty for breast care.
Why don’t more obstetrician-gynecologists perform the initial, minimal surgery
required to diagnose breast cancer? The answer lies in the training of medical
residents. Three organizations oversee the education of future
obstetrician-gynecologists: the Accreditation Council for Graduate Medical
Education, the American College of Obstetricians and Gynecologists and the
American Board of Obstetrics and Gynecology. All three have different
requirements regarding training in breast care. At the end of their years as
residents, some obstetrician-gynecologists have a great deal of experience with
the minimally invasive diagnostic procedures needed to respond to breast
complaints and others do not.
Women with breast cancer need obstetrician-gynecologists who have learned how to
diagnose breast cancers and breast care specialists devoted to shepherding them
through surgery, therapy and healing. Given the haphazard growth in medical
specialties and varied training programs for obstetrician-gynecologists, it is
no surprise that there is a mismatch between patient needs and caregiver skills.
Campaigns to raise awareness of breast cancer must do more than push for a cure.
They must also seek to improve the way we organize care for those who suffer
from this illness.
Ann V. Bell is a graduate student in sociology at the University of Michigan.
Mark Pearlman is a professor of obstetrics and gynecology and the director of
the Breast Fellowship Program at the University of Michigan Medical School.
Raymond De Vries is a professor of obstetrics and gynecology and bioethics
Tell of Their Journey to the Streets
October 10, 2009
The New York Times
By DAMIEN CAVE
OWOSSO, Mich. — Action means many things to abortion opponents. Lobbyists and
fund-raisers fight for the cause in marble hallways; volunteers at crisis
pregnancy centers try to dissuade the pregnant on cozy sofas.
Then there are the protesters like James Pouillon, who was shot dead here last
month while holding an anti-abortion sign outside a high school. A martyr to
some, an irritant to others, Mr. Pouillon in death has become a blessing of
sorts for the loosely acquainted activists who knew him as a friend: proof that
abortion doctors are not the only ones under duress, proof that protests matter,
and a spark for more action.
“Jim suffered the persecution for us,” said Dan Brewer, who recalls swearing at
Mr. Pouillon during one of his one-man protests in the ’90s, only to join him
later after becoming a born-again Christian. “Now we just have to go out and do
A national tribute is already planned. Anti-abortion groups are calling on
protesters to stand outside schools with signs that depict abortion on Nov. 24
in 40 to 50 cities nationwide.
Some who plan to take part, like Chet Gallagher, a former Las Vegas police
officer, have been answering such calls for decades; he first got involved in
the ’80s, when every month seemed to bring a new “rescue,” another chance to
lock arms with fellow Christians and block access to an abortion clinic.
Others have arrived at the cause after experiencing personal traumas — in the
case of Deborah Anderson, an abusive childhood and then an unwanted pregnancy —
while still more fell into it through personal connections.
Together, these street activists make up an assertive minority of a few thousand
people within the larger anti-abortion movement. Neither the best financed nor
largest element in the mix, they are nonetheless the only face of anti-abortion
that many Americans see. Indeed, persistent provocation is their defining
attribute: day after day on street corners from California to Massachusetts,
they stand like town criers, calling to women walking into abortion clinics, or
waving graphic signs as disturbing as they are impossible to ignore.
Their ranks are more infused with emotion — they would say commitment — than
Ziad Munson, a sociologist at Lehigh University who has interviewed hundreds of
abortion opponents, said street protesters rarely moved into other areas of the
movement and tended to work alone or in smaller groups. Even in cases when they
form large and influential organizations, it is sometimes difficult to get
beyond the culture of passionate dispute.
To critics, like Nancy Keenan, president of Naral Pro-Choice America, these
protesters look like bullies bent on harassment. Among those who share their
views but not their tactics, street activists have been marginalized as
attention hogs who prefer to attract outrage rather than inspiring compassion.
In the case of Mr. Pouillon, that outrage may have led to death. The police said
the man charged in the killing, Harlan J. Drake, a local truck driver, was
bothered by the signs Mr. Pouillon showed children as they came to school. The
day he was shot, Mr. Pouillon was showing a mangled fetus, part of an almost
daily effort to put abortion into the minds of his neighbors. “It’s all about
the eyes,” he used to say to fellow demonstrators. “It’s all about the eyes.”
But as the personal stories of Mr. Gallagher, Mr. Brewer and Ms. Anderson
suggest, the motivations of many protesters are more complicated. They see
themselves as righteous curbside critics, prophets warning the world with what
they describe as the horrific truth no one wants to see. They have endured
insults, threats and even estrangement from their families because they have
found what nearly every activist craves: conviction, camaraderie and conflict.
The Police Officer: From Civil Law to Biblical
Chet Gallagher did not plan to join the blockade at the abortion clinic in
Atlanta when he traveled there 21 years ago. But when he saw the passion of so
many Christians outside the clinic, he said, he could not resist: he ended up in
jail for 11 days, with James Pouillon and 700 others.
Three months later, Operation Rescue, the umbrella anti-abortion group, arrived
in Las Vegas, where Mr. Gallagher was a police officer. He refused to arrest
protesters, and when his sergeant suspended him, he joined the “rescuers.”
“I learned something that changed my life,” Mr. Gallagher said. “It wasn’t civil
disobedience; it was biblical obedience.”
Christian fervor nourishes anti-abortion activism like little else. Church
groups nationwide regularly ask Mr. Gallagher to speak because he chose his
spiritual beliefs over the law. Bible quotations appear on posters and on motor
homes that have become traveling billboards, and in conversation they serve as
evidentiary support, like statistics.
This is a particularly American brand of faith: confrontational and action
oriented. The most cited verses come not from the Gospels detailing the life of
Jesus Christ but from the Old Testament prophets. Mr. Gallagher said he was
inspired by Jeremiah 7, where the Lord says Israel’s “people, animals, trees,
and crops will be consumed by the unquenchable fire of my anger.”
Nancy Keenan, president of Naral Pro-Choice America, said she worried that the
emphasis on judgment provides tacit approval for violence, like the recent
killing of Dr. George R. Tiller, an abortion provider in Kansas.
But Mr. Gallagher, 60, a white-bearded father of six, disagreed. He said
Christianity must be emphasized because churches are the only institutions with
the power to put abortion clinics out of business. Like Mr. Pouillon, who often
protested outside congregations on Sunday mornings, Mr. Gallagher said far too
many Christians nodded, but did not act.
“It really can end,” he said of abortion, “if all the Christians just went out
there for seven days in a row to tell the truth peacefully.”
As for the more aggressive tactics he employs, like bringing protests to the
neighborhoods where abortion doctors live, he said they were a product of faith,
economics and politics.
Faith, because he said he believed abortion doctors deserve to be shamed;
economics because that shame might motivate them to do other work; and politics
because the era of rescues ended in 1994, after President Bill Clinton signed
the Freedom of Access to Clinic Entrances Act.
The law made it a felony to use “force, threat of force or physical obstruction”
to prevent someone from providing or receiving reproductive health services.
“That required us to use some other strategies,” said Mr. Gallagher, who left
the police force shortly after and is now director of operations for Operation
Save America in Las Vegas.
Among other things, the clinic law led to the proliferation of large
anti-abortion signs with graphic pictures of mutilated fetuses. Mr. Gallagher
said he believed that everyone, including children, should see them. “I know I
offend a lot of people,” he said. “But I’ve talked to mothers who said, ‘Because
you were there with those signs I decided to have that baby.’ “
Even in protesters’ families, not everyone agrees with the approach. Mr.
Gallagher said his wife divorced him in 1989 after revealing she had three
abortions before they met. They remarried in 1991, but Mr. Gallagher said some
of their six children had gone years without speaking to him.
“We know this is a real war and we have to fight it,” he said. “Some of our
families suffered as a result. I wish I could say it was different but it’s
The Survivor: An Early Gusto for a Fight
Deborah Anderson, 62, a professional test-driver for Ford with the style of a
no-nonsense grandmother, introduced herself as “someone who should have been
“I’m an unwanted child,” she said, standing at a vigil for James Pouillon with
an anti-abortion poster peeling from overuse. “My mother couldn’t find a
back-alley abortionist, so she gave me up for adoption.”
She was 18 months old. Her sister was 4, and their adoptive mother, Ms. Anderson
and her sister said in interviews, turned out to be abusive.
Childhood in their suburb of Detroit was defined by broken bones beneath frilly
dresses, she said. The girls ran away when they could, but when friends or the
local priest visited, Ms. Anderson said, their mother chained them to poles in
“I learned to bite and kick and scream,” she said.
That gusto for the fight is a highly valued trait in protester circles. Mr.
Pouillon earned kudos for standing with anti-abortion signs even while attached
to an oxygen tank. Ms. Anderson also told stories of long, cold protests,
insults and jail (after being arrested at Notre Dame in May when President Obama
Her son, Jason Anderson, 35, an automobile engineer, said that as a teenager, he
learned to take pride in his mother’s passion when he saw her enduring abuse for
holding a graphic sign. “She’s really trying to open up people’s minds to the
horrific nature of this,” he said.
The most repeated anecdotes involve abortions averted. Ms. Anderson recalled
what she said was her first triumph. It was the early ’80s. After becoming
pregnant with a boyfriend while separated from her husband — and deciding to
have the baby despite friends’ advice to abort, she said — she was a single
mother with a bumper sticker on her Chrysler Fifth Avenue that said “the heart
beats at 24 days for an unborn child.”
One day in a parking lot near her home, Ms. Anderson said, a woman came up to
her and said she had been on her way to get an abortion when she saw that simple
statement and changed her mind. “There was a 2-year-old in the back seat,” Ms.
At her home in Memphis, Mich., other examples followed: of two girls from Ohio
who left an abortion clinic and, she said, told Ms. Anderson that her presence
had persuaded them had not gone through with it; of a young man who knocked on
her door in the dead of night, after seeing anti-abortion signs in her window.
Then Ms. Anderson pulled out a black cassette recorder. Sitting on a red couch a
few feet from two abortion posters, she replayed what she said was a voicemail
message from several years ago. An older woman, sounding unsure and emotional,
said she wanted to thank her because “you was at the clinic, and really helped
Ms. Anderson smiled. “I can’t tell you how many babies have been saved because
of abortion protesters outside the abortion mills,” she said. “That’s what it’s
The Friend: Drawn to the Cause
Within months of becoming a born-again Christian, Dan Brewer says, he knew he
had to make things right. When he saw James Pouillon on a corner in Owosso one
day, he stopped his car, walked over and asked forgiveness for having accosted
“I put my head on his shoulder and cried,” he said.
It was the beginning of what would become an alliance. Ziad Munson interviewed
abortion opponents for a book, “The Making of Pro-Life Activists,” and said most
people entered the movement through social connections and only later developed
an ideological commitment.
Mr. Brewer exemplifies the process. He did not have much passion for the cause
early on, he said, but the resistance and support he experienced alongside Mr.
Pouillon led him to more research and activism.
He said there was something rebellious, something American, about standing up
against abortion. In the past, he had occasionally held signs with bible verses
emphasizing love, but they did not lead to as many conversations.
Or conflicts — like the time a man drove up on the sidewalk, running over Mr.
Brewer’s sign and forcing him to jump out of the way, he said.
“I don’t want to say the conflict is fun, because it isn’t,” said Mr. Brewer,
40, an easygoing state pool champion with an earring high in his left ear. “But
the interaction is fun, to be able to talk to people who take the time to listen
to what you have to say.”
A layoff last year from his job at a boat factory pushed him further. He joined
Mr. Pouillon about three times a week, he said, partly for the camaraderie and
partly — like other anti-abortion protesters — because he had come to see
attention and opposition as proof of impact.
He just never thought it could turn deadly. Nor did his son Cameron.
Now 16, the second oldest of Mr. Brewer’s five children, including a foster
child, Cameron was at school when the shooting happened at a nearby corner. He
ran there, fearing for his father, instead finding a bloodied friend. “I got
down next to him,” Cameron said. “I counted four bullet holes.”
The Brewers said they did not expect more violence. And like hundreds of others,
they said they planned to keep Mr. Pouillon’s efforts alive. Mr. Brewer may not
be there as often, because he is taking nursing classes, but Cameron said he was
eager to fill the void.
“I thought it was cool that he did what he did,” he said. “Now that he’s dead,
it makes you want to do it more.”
Abortion Foes Tell of
Their Journey to the Streets, NYT, 10.10.2009,
John Wild, 95,
a Developer of Ultrasound
in Cancer Diagnoses, Dies
October 7, 2009
The New York Times
By VICKI GLASER
Dr. John J. Wild, who collaborated on some of the first equipment to use
high-frequency sound waves, or ultrasound, to obtain images of human tissue,
especially for cancer diagnosis, died Sept. 18 in Edina, Minn. He was 95.
His death, at the N. C. Little Hospice, was confirmed by his daughter, Ellen
The ultrasound scans commonly used in medicine today for cancer diagnosis and
for monitoring fetal development derived from the discoveries of Dr. Wild and
his contemporaries, who demonstrated that ultrasonic echoes could produce images
of soft tissues inside the body.
While working as a surgeon in London during World War II, Dr. Wild treated
patients suffering bowel failure due to impact trauma from bomb blasts during
the Blitz. He sought a noninvasive method of evaluating the bowel and drew on
his familiarity with an echo-testing technique that used sound waves to detect
cracks in the armor plating of tanks. The sound of the returning echoes would
vary with the thickness of the tissue and its ability to contract and relax,
providing information about the condition of the bowel wall.
Dr. Wild did not yet use the technique on people, but developed the idea after
immigrating to the United States in 1946 and going to work in the surgery
department at the University of Minnesota.
At a nearby air base, the Navy was studying the use of ultrasonic echo signals
to simulate enemy terrain for pilot radar training. Dr. Wild applied this
concept to tissues, first in animals, demonstrating that sound energy would echo
off soft tissue. He collaborated with William Reid, an electrical engineer, and
together they built an instrument that could translate the ultrasonic signals
into visual images, providing a window into the human body.
Using the device to obtain images of breast tissue, Dr. Wild showed that
ultrasonic pictures made it possible to distinguish between cancerous and
noncancerous tissue, providing a noninvasive method for detecting and evaluating
breast tumors. Drs. Wild and Reid expanded the technology to other tissues and
later developed a hand-held rectal scanner for studying the large bowel and a
“Wild and Reid were the first to develop equipment specifically designed for
breast scanning and attempted to differentiate benign from malignant disease,”
Dr. Richard Gold, professor of radiological sciences emeritus at U.C.L.A.
Medical Center, wrote in “Diagnosis of Diseases of the Breast” (W.B. Saunders,
2nd ed., 2005). “Furthermore, they were the first to differentiate between
cystic and solid masses in the breast by means of ultrasonography.” (Other early
work on ultrasound breast tissue imaging had been done independently by the
Japanese researcher Toshio Wagai and his colleagues.)
Drs. Wild and Reid first published their work in the journal Science in 1952.
“Theoretically it was thought possible to record soft tissue structure by
tracing the information obtained from a sound beam sweeping through the tissues
onto a fluorescent television screen,” they wrote. They concluded, “The
immediate application of echography to the detection of tumors in accessible
sites in the living intact human organism is envisaged.”
The cover of the March 1955 issue of Electronics magazine depicts the two
researchers using their “cancer detector,” with the caption “Ultrasonic ranging
speeds cancer diagnosis.”
Dr. Wild was awarded a Japan Prize from the Science and Technology Foundation of
Japan, valued at $370,000, in 1991 for his work in ultrasonic imaging.
John Julian Wild was born Aug. 11, 1914, in Kent, England. He attended Cambridge
University and received a B.A. in natural science in 1936, an M.A. in 1940, and
a medical degree in 1942. In 1950, Dr. Wild moved his laboratory from the
surgical department to the electrical engineering department at the university.
He left Cambridge in 1953 and continued his research with support from local
sponsors and grants from the Public Health Service.
In 1953, Dr. Wild founded a research unit at St. Barnabas Hospital in
Minneapolis, where he worked until becoming director of research at the
Minnesota Foundation in St. Paul in 1960. Disagreements between Dr. Wild and the
foundation, which administered his grant from the National Cancer Institute, led
the foundation to discontinue support for his work in 1963. Dr. Wild sued the
Minnesota Foundation and in 1972 was awarded more than $16 million in defamation
damages. An appeals court later overturned the award, and the suit was settled
out of court in 1981. Dr. Wild was director of the Medico-Technological
Institute of Minneapolis from 1966 to 1999 and also maintained a private medical
In addition to his daughter, Ellen, of Bethesda, Md., his survivors include
Valerie Wild, his wife of 41 years; two sons from a previous marriage, John and
Douglas, both of Minneapolis; and three granddaughters.
“Universal recognition of his achievements and vision was slow to materialize,”
Ms. Wild said. He was often at odds with those overseeing the direction of his
Dr. Wild wrote, “I think I must have come into this world with a propensity for
making chaos out of order, since I always seem to be upsetting those concerned
with maintaining conventional levels of orderliness and humbleness.” He
continued, “in my ultrasonic work I have met many people who did not believe the
evidence of their own eyes.”
He patented his first invention at the age of 14, a valve to control the flow of
cold and hot water into the bathtub.
John Wild, 95, a
Developer of Ultrasound in Cancer Diagnoses, Dies, NYT, 7.10.2009,
Share Nobel Prize for Medicine
October 6, 2009
The New York Times
By NICHOLAS WADE
The Nobel Prize in Physiology or Medicine was awarded this year to three
American scientists who solved a problem of cell biology with deep relevance to
cancer and aging. The three will receive equal shares of a prize worth around
The recipients solved a longstanding puzzle involving the ends of chromosomes,
the giant molecules of DNA that embody the genetic information. These ends,
called telomeres, get shorter each time a cell divides and so serve as a kind of
clock that counts off the cell’s allotted span of life.
The three winners are Elizabeth H. Blackburn of the University of California,
San Francisco, Carol W. Greider of Johns Hopkins University School of Medicine
and Jack W. Szostak of Massachusetts General Hospital. Only eight women have
previously won the Nobel prize in Medicine or Physiology, and it is the first
time any science Nobel has been awarded to more than one woman.
The discoveries were made some 20 years ago in pursuit of a purely scientific
problem that seemingly had no practical relevance. But telomeres have turned out
to play a role in two medical areas of vast importance, those of aging and
cancer, because of their role in limiting the number of times a cell can divide.
Dr. Greider said in an interview Monday that she saw the prize as a celebration
of the value of basic research.
Though Americans have once again made a clean sweep of the Nobel medicine prize,
two of the three winners are immigrants. Dr. Blackburn was born in Tasmania,
Australia, and has dual citizenship; Dr. Szostak was born in London. Dr.
Blackburn came to the United States in the 1970s because it was “notably
attractive” as a place to do science.
Despite ups and downs in recent years, America is still a magnet for foreign
scientists, she said, “but one shouldn’t take that for granted.”
Dr. Szostak said the world was now more competitive in terms of scientific
research. “So maybe we have to work a little harder to attract people from
around the world and make sure they stay here,” he said.
All three of the prize-winners seem to have had science in their genes, and
certainly in their home environment. Dr. Greider is the daughter of two
scientists with doctorates from the University of California, Berkeley, and she,
too, has a Ph.D. from that school. Dr. Szostak’s father was an engineer, which
had some influence on his choice of career, he said. Both of Dr. Blackburn’s
parents were family physicians, and her grandfather and great-grandfather were
geologists in Australia.
The study of telomeres is notable as a field of research in which female
scientists are particularly prominent. Dr. Greider said she ascribed this to a
“founder effect,” the founder being Dr. Joseph Gall of Yale University. Dr. Gall
was very supportive of women in science, Dr. Greider said. He trained Dr.
Blackburn and other women, and they recruited others to the field “because there
is a slight tendency for women to work with other women,” Dr. Greider said. She
herself trained with Dr. Blackburn.
The field of telomere research grew out of a puzzle in the mechanics of copying
DNA. The copying enzyme works in such a way that one of the two strands of the
double helix is left a little shorter after each division. Work by the three
winners and others led to the discovery of telomerase, a special enzyme that can
prevent the shortening by adding extra pieces of DNA.
Dr. Blackburn addressed this problem by working with a single-celled organism
found in pond water known as Tetrahymena. It was particularly suitable because
its genome is divided into many small chromosomes so each cell has a large
number of telomeres.
While she and Dr. Greider were working with Tetrahymena, Dr. Szostak was
studying the same problem in yeast. The two groups in collaboration worked out
the basic mechanism of how telomerase works and the special piece of RNA it
carries to help elongate the chromosomes. RNA is a close chemical cousin of DNA.
This piece of basic biology soon turned out to have important implications for
aging and cancer. Telomerase is usually active only at the beginning of life;
thereafter the telomeres get shorter each time a cell divides. When they get too
short, a cell is thrown into senescence, meaning that it is prevented from
Short telomeres are known to play a role in certain diseases of aging, and may
be of more general importance. Telomeres are also important in cancer, a disease
in which control of cell proliferation is lost. Cancer cells need to reactivate
the telomerase gene, or their telomeres will get steadily shorter, forcing them
into senescence. In some 80 to 90 percent of human cancer cells, the telomerase
gene has been switched back on, Dr. Blackburn said. Clinical trials are under
way to see if cancers can be treated by inhibiting telomerase.
Three Americans Share
Nobel Prize for Medicine, NYT, 6.10.2009,
Trail of E. Coli
in Inspection of Ground Beef
October 4, 2009
The New York Times
By MICHAEL MOSS
Stephanie Smith, a children’s dance instructor, thought she had a stomach virus.
The aches and cramping were tolerable that first day, and she finished her
Then her diarrhea turned bloody. Her kidneys shut down. Seizures knocked her
unconscious. The convulsions grew so relentless that doctors had to put her in a
coma for nine weeks. When she emerged, she could no longer walk. The affliction
had ravaged her nervous system and left her paralyzed.
Ms. Smith, 22, was found to have a severe form of food-borne illness caused by
E. coli, which Minnesota officials traced to the hamburger that her mother had
grilled for their Sunday dinner in early fall 2007.
“I ask myself every day, ‘Why me?’ and ‘Why from a hamburger?’ ”Ms. Smith said.
In the simplest terms, she ran out of luck in a food-safety game of chance whose
rules and risks are not widely known.
Meat companies and grocers have been barred from selling ground beef tainted by
the virulent strain of E. coli known as O157:H7 since 1994, after an outbreak at
Jack in the Box restaurants left four children dead. Yet tens of thousands of
people are still sickened annually by this pathogen, federal health officials
estimate, with hamburger being the biggest culprit. Ground beef has been blamed
for 16 outbreaks in the last three years alone, including the one that left Ms.
Smith paralyzed from the waist down. This summer, contamination led to the
recall of beef from nearly 3,000 grocers in 41 states.
Ms. Smith’s reaction to the virulent strain of E. coli was extreme, but tracing
the story of her burger, through interviews and government and corporate records
obtained by The New York Times, shows why eating ground beef is still a gamble.
Neither the system meant to make the meat safe, nor the meat itself, is what
consumers have been led to believe.
Ground beef is usually not simply a chunk of meat run through a grinder.
Instead, records and interviews show, a single portion of hamburger meat is
often an amalgam of various grades of meat from different parts of cows and even
from different slaughterhouses. These cuts of meat are particularly vulnerable
to E. coli contamination, food experts and officials say. Despite this, there is
no federal requirement for grinders to test their ingredients for the pathogen.
The frozen hamburgers that the Smiths ate, which were made by the food giant
Cargill, were labeled “American Chef’s Selection Angus Beef Patties.” Yet
confidential grinding logs and other Cargill records show that the hamburgers
were made from a mix of slaughterhouse trimmings and a mash-like product derived
from scraps that were ground together at a plant in Wisconsin. The ingredients
came from slaughterhouses in Nebraska, Texas and Uruguay, and from a South
Dakota company that processes fatty trimmings and treats them with ammonia to
Using a combination of sources — a practice followed by most large producers of
fresh and packaged hamburger — allowed Cargill to spend about 25 percent less
than it would have for cuts of whole meat.
Those low-grade ingredients are cut from areas of the cow that are more likely
to have had contact with feces, which carries E. coli, industry research shows.
Yet Cargill, like most meat companies, relies on its suppliers to check for the
bacteria and does its own testing only after the ingredients are ground
together. The United States Department of Agriculture, which allows grinders to
devise their own safety plans, has encouraged them to test ingredients first as
a way of increasing the chance of finding contamination.
Unwritten agreements between some companies appear to stand in the way of
ingredient testing. Many big slaughterhouses will sell only to grinders who
agree not to test their shipments for E. coli, according to officials at two
large grinding companies. Slaughterhouses fear that one grinder’s discovery of
E. coli will set off a recall of ingredients they sold to others.
“Ground beef is not a completely safe product,” said Dr. Jeffrey Bender, a food
safety expert at the University of Minnesota who helped develop systems for
tracing E. coli contamination. He said that while outbreaks had been on the
decline, “unfortunately it looks like we are going a bit in the opposite
Food scientists have registered increasing concern about the virulence of this
pathogen since only a few stray cells can make someone sick, and they warn that
federal guidance to cook meat thoroughly and to wash up afterward is not
sufficient. A test by The Times found that the safe handling instructions are
not enough to prevent the bacteria from spreading in the kitchen.
Cargill, whose $116.6 billion in revenues last year made it the country’s
largest private company, declined requests to interview company officials or
visit its facilities. “Cargill is not in a position to answer your specific
questions, other than to state that we are committed to continuous improvement
in the area of food safety,” the company said, citing continuing litigation.
The meat industry treats much of its practices and the ingredients in ground
beef as trade secrets. While the Department of Agriculture has inspectors posted
in plants and has access to production records, it also guards those secrets.
Federal records released by the department through the Freedom of Information
Act blacked out details of Cargill’s grinding operation that could be learned
only through copies of the documents obtained from other sources. Those
documents illustrate the restrained approach to enforcement by a department
whose missions include ensuring meat safety and promoting agriculture markets.
Within weeks of the Cargill outbreak in 2007, U.S.D.A. officials swept across
the country, conducting spot checks at 224 meat plants to assess their efforts
to combat E. coli. Although inspectors had been monitoring these plants all
along, officials found serious problems at 55 that were failing to follow their
own safety plans.
“Every time we look, we find out that things are not what we hoped they would
be,” said Loren D. Lange, an executive associate in the Agriculture Department’s
food safety division.
In the weeks before Ms. Smith’s patty was made, federal inspectors had
repeatedly found that Cargill was violating its own safety procedures in
handling ground beef, but they imposed no fines or sanctions, records show.
After the outbreak, the department threatened to withhold the seal of approval
that declares “U.S. Inspected and Passed by the Department of Agriculture.”
In the end, though, the agency accepted Cargill’s proposal to increase its
scrutiny of suppliers. That agreement came early last year after contentious
negotiations, records show. When Cargill defended its safety system and
initially resisted making some changes, an agency official wrote back: “How is
food safety not the ultimate issue?”
On Aug. 16, 2007, the day Ms. Smith’s hamburger was made, the No.3 grinder at
the Cargill plant in Butler, Wis., started up at 6:50 a.m. The largest
ingredient was beef trimmings known as “50/50” — half fat, half meat — that cost
about 60 cents a pound, making them the cheapest component.
Cargill bought these trimmings — fatty edges sliced from better cuts of meat —
from Greater Omaha Packing, where some 2,600 cattle are slaughtered daily and
processed in a plant the size of four football fields.
As with other slaughterhouses, the potential for contamination is present every
step of the way, according to workers and federal inspectors. The cattle often
arrive with smears of feedlot feces that harbor the E. coli pathogen, and the
hide must be removed carefully to keep it off the meat. This is especially
critical for trimmings sliced from the outer surface of the carcass.
Federal inspectors based at the plant are supposed to monitor the hide removal,
but much can go wrong. Workers slicing away the hide can inadvertently spread
feces to the meat, and large clamps that hold the hide during processing
sometimes slip and smear the meat with feces, the workers and inspectors say.
Greater Omaha vacuums and washes carcasses with hot water and lactic acid before
sending them to the cutting floor. But these safeguards are not foolproof.
“As the trimmings are going down the processing line into combos or boxes, no
one is inspecting every single piece,” said one federal inspector who monitored
Greater Omaha and requested anonymity because he was not authorized to speak
The E. coli risk is also present at the gutting station, where intestines are
removed, the inspector said
Every five seconds or so, half of a carcass moves into the meat-cutting side of
the slaughterhouse, where trimmers said they could keep up with the flow unless
they spot any remaining feces.
“We would step in and stop the line, and do whatever you do to take it off,”
said Esley Adams, a former supervisor who said he was fired this summer after 16
years following a dispute over sick leave. “But that doesn’t mean everything was
Two current employees said the flow of carcasses keeps up its torrid pace even
when trimmers get reassigned, which increases pressure on workers. To protest
one such episode, the employees said, dozens of workers walked off the job for a
few hours earlier this year. Last year, workers sued Greater Omaha, alleging
that they were not paid for the time they need to clean contaminants off their
knives and other gear before and after their shifts. The company is contesting
Greater Omaha did not respond to repeated requests to interview company
officials. In a statement, a company official said Greater Omaha had a
“reputation for embracing new food safety technology and utilizing science to
make the safest product possible.”
In making hamburger meat, grinders aim for a specific fat content — 26.6 percent
in the lot that Ms. Smith’s patty came from, company records show. To offset
Greater Omaha’s 50/50 trimmings, Cargill added leaner material from three other
Records show that some came from a Texas slaughterhouse, Lone Star Beef
Processors, which specializes in dairy cows and bulls too old to be fattened in
feedlots. In a form letter dated two days before Ms. Smith’s patty was made,
Lone Star recounted for Cargill its various safety measures but warned “to this
date there is no guarantee for pathogen-free raw material and we would like to
stress the importance of proper handling of all raw products.”
Ms. Smith’s burger also contained trimmings from a slaughterhouse in Uruguay,
where government officials insist that they have never found E. coli O157:H7 in
meat. Yet audits of Uruguay’s meat operations conducted by the U.S.D.A. have
found sanitation problems, including improper testing for the pathogen. Dr.
Hector J. Lazaneo, a meat safety official in Uruguay, said the problems were
corrected immediately. “Everything is fine, finally,” he said. “That is the
reason we are exporting.”
Cargill’s final source was a supplier that turns fatty trimmings into what it
calls “fine lean textured beef.” The company, Beef Products Inc., said it bought
meat that averages between 50 percent and 70 percent fat, including “any small
pieces of fat derived from the normal breakdown of the beef carcass.” It warms
the trimmings, removes the fat in a centrifuge and treats the remaining product
with ammonia to kill E. coli.
With seven million pounds produced each week, the company’s product is widely
used in hamburger meat sold by grocers and fast-food restaurants and served in
the federal school lunch program. Ten percent of Ms. Smith’s burger came from
Beef Products, which charged Cargill about $1.20 per pound, or 20 cents less
than the lean trimmings in the burger, billing records show.
An Iowa State University study financed by Beef Products found that ammonia
reduces E. coli to levels that cannot be detected. The Department of Agriculture
accepted the research as proof that the treatment was effective and safe. And
Cargill told the agency after the outbreak that it had ruled out Beef Products
as the possible source of contamination.
But federal school lunch officials found E. coli in Beef Products material in
2006 and 2008 and again in August, and stopped it from going to schools,
according to Agriculture Department records and interviews. A Beef Products
official, Richard Jochum, said that last year’s contamination stemmed from a
“minor change in our process,” which the company adjusted. The company did not
respond to questions about the latest finding.
In combining the ingredients, Cargill was following a common industry practice
of mixing trim from various suppliers to hit the desired fat content for the
least money, industry officials said.
In all, the ingredients for Ms. Smith’s burger cost Cargill about $1 a pound,
company records show, or about 30 cents less than industry experts say it would
cost for ground beef made from whole cuts of meat.
Ground beef sold by most grocers is made from a blend of ingredients, industry
officials said. Agriculture Department regulations also allow hamburger meat
labeled ground chuck or sirloin to contain trimmings from those parts of the
cow. At a chain like Publix Super Markets, customers who want hamburger made
from whole cuts of meat have to buy a steak and have it specially ground, said a
Publix spokeswoman, Maria Brous, or buy a product like Bubba Burgers, which
boasts on its labeling, “100% whole muscle means no trimmings.”
To finish off the Smiths’ ground beef, Cargill added bread crumbs and spices,
fashioned it into patties, froze them and packed them 18 to a carton.
The listed ingredients revealed little of how the meat was made. There was just
one meat product listed: “Beef.”
Tension Over Testing
As it fed ingredients into its grinders, Cargill watched for some unwanted
elements. Using metal detectors, workers snagged stray nails and metal hooks
that could damage the grinders, then warned suppliers to make sure it did not
But when it came to E. coli O157:H7, Cargill did not screen the ingredients and
only tested once the grinding was done. The potential pitfall of this practice
surfaced just weeks before Ms. Smith’s patty was made. A company spot check in
May 2007 found E. coli in finished hamburger, which Cargill disclosed to
investigators in the wake of the October outbreak. But Cargill told them it
could not determine which supplier had shipped the tainted meat since the
ingredients had already been mixed together.
“Our finished ground products typically contain raw materials from numerous
suppliers,” Dr. Angela Siemens, the technical services vice president for
Cargill’s meat division, wrote to the U.S.D.A. “Consequently, it is not possible
to implicate a specific supplier without first observing a pattern of potential
Testing has been a point of contention since the 1994 ban on selling ground beef
contaminated with E. coli O157:H7 was imposed. The department moved to require
some bacterial testing of ground beef, but the industry argued that the cost
would unfairly burden small producers, industry officials said. The Agriculture
Department opted to carry out its own tests for E. coli, but it acknowledges
that its 15,000 spot checks a year at thousands of meat plants and groceries
nationwide is not meant to be comprehensive. Many slaughterhouses and processors
have voluntarily adopted testing regimes, yet they vary greatly in scope from
plant to plant.
The retail giant Costco is one of the few big producers that tests trimmings for
E. coli before grinding, a practice it adopted after a New York woman was
sickened in 1998 by its hamburger meat, prompting a recall.
Craig Wilson, Costco’s food safety director, said the company decided it could
not rely on its suppliers alone. “It’s incumbent upon us,” he said. “If you say,
‘Craig, this is what we’ve done,’ I should be able to go, ‘Cool, I believe you.’
But I’m going to check.”
Costco said it had found E. coli in foreign and domestic beef trimmings and
pressured suppliers to fix the problem. But even Costco, with its huge buying
power, said it had met resistance from some big slaughterhouses. “Tyson will not
supply us,” Mr. Wilson said. “They don’t want us to test.”
A Tyson spokesman, Gary Mickelson, would not respond to Costco’s accusation, but
said, “We do not and cannot” prohibit grinders from testing ingredients. He
added that since Tyson tests samples of its trimmings, “we don’t believe
secondary testing by grinders is a necessity.”
The food safety officer at American Foodservice, which grinds 365 million pounds
of hamburger a year, said it stopped testing trimmings a decade ago because of
resistance from slaughterhouses. “They would not sell to us,” said Timothy P.
Biela, the officer. “If I test and it’s positive, I put them in a regulatory
situation. One, I have to tell the government, and two, the government will
trace it back to them. So we don’t do that.”
The surge in outbreaks since 2007 has led to finger-pointing within the
Dennis R. Johnson, a lobbyist for the largest meat processors, has said that not
all slaughterhouses are looking hard enough for contamination. He told U.S.D.A.
officials last fall that those with aggressive testing programs typically find
E. coli in as much as 1 percent to 2 percent of their trimmings, yet some
slaughterhouses implicated in outbreaks had failed to find any.
At the same time, the meat processing industry has resisted taking the onus on
itself. An Agriculture Department survey of more than 2,000 plants taken after
the Cargill outbreak showed that half of the grinders did not test their
finished ground beef for E. coli; only 6 percent said they tested incoming
ingredients at least four times a year.
In October 2007, the agency issued a notice recommending that processors conduct
at least a few tests a year to verify the testing done by slaughterhouses. But
after resistance from the industry, the department allowed suppliers to run the
verification checks on their own operations.
In August 2008, the U.S.D.A. issued a draft guideline again urging, but not
ordering, processors to test ingredients before grinding. “Optimally, every
production lot should be sampled and tested before leaving the supplier and
again before use at the receiver,” the draft guideline said.
But the department received critical comments on the guideline, which has not
been made official. Industry officials said that the cost of testing could
unfairly burden small processors and that slaughterhouses already test. In an
October 2008 letter to the department, the American Association of Meat
Processors said the proposed guideline departed from U.S.D.A.’s strategy of
allowing companies to devise their own safety programs, “thus returning to more
of the agency’s ‘command and control’ mind-set.”
Dr. Kenneth Petersen, an assistant administrator with the department’s Food
Safety and Inspection Service, said that the department could mandate testing,
but that it needed to consider the impact on companies as well as consumers. “I
have to look at the entire industry, not just what is best for public health,”
Dr. Petersen said.
Tracing the Illness
The Smiths were slow to suspect the hamburger. Ms. Smith ate a mostly vegetarian
diet, and when she grew increasingly ill, her mother, Sharon, thought the cause
might be spinach, which had been tied to a recent E. coli outbreak.
Five days after the family’s Sunday dinner, Ms. Smith was admitted to St. Cloud
Hospital in excruciating pain. “I’ve had women tell me that E. coli is more
painful than childbirth,” said Dr. Phillip I. Tarr, a pathogen expert at
Washington University in St. Louis.
The vast majority of E. coli illnesses resolve themselves without complications,
according to the Centers for Disease Control and Prevention. Five percent to 10
percent develop into a condition called hemolytic uremic syndrome, which can
affect kidney function. While most patients recover, in the worst cases, like
Ms. Smith’s, the toxin in E. coli O157:H7 penetrates the colon wall, damaging
blood vessels and causing clots that can lead to seizures.
To control Ms. Smith’s seizures, doctors put her in a coma and flew her to the
Mayo Clinic, where doctors worked to save her.
“They didn’t even think her brain would work because of the seizuring,” her
mother said. “Thanksgiving Day, I was sitting there holding her hand when a
group of doctors came in, and one looked at me and just walked away, with
nothing good to say. And I said, ‘Oh my God, maybe this is my last Thanksgiving
with her,’ and I stayed and prayed.”
Ms. Smith’s illness was linked to the hamburger only by chance. Her aunt still
had some of the frozen patties, and state health officials found that they were
contaminated with a powerful strain of E. coli that was genetically identical to
the pathogen that had sickened other Minnesotans.
Dr. Kirk Smith, who runs the state’s food-borne illness outbreak group and is
not related to Ms. Smith, was quick to finger the source. A 4-year-old had
fallen ill three weeks earlier, followed by her year-old brother and two more
children, state records show. Like Ms. Smith, the others had eaten Cargill
patties bought at Sam’s Club, a division of Wal-Mart.
Moreover, the state officials discovered that the hamburgers were made on the
same day, Aug. 16, 2007, shortly before noon. The time stamp on the Smiths’ box
of patties was 11:58.
On Friday, Oct. 5, 2007, a Minnesota Health Department warning led local news
broadcasts. “We didn’t want people grilling these things over the weekend,” Dr.
Smith said. “I’m positive we prevented illnesses. People sent us dozens of
cartons with patties left. It was pretty contaminated stuff.”
Eventually, health officials tied 11 cases of illness in Minnesota to the
Cargill outbreak, and altogether, federal health officials estimate that the
outbreak sickened 940 people. Four of the 11 Minnesota victims developed
hemolytic uremic syndrome — an usually high rate of serious complications.
In the wake of the outbreak, the U.S.D.A. reminded consumers on its Web site
that hamburgers had to be cooked to 160 degrees to be sure any E. coli is killed
and urged them to use a thermometer to check the temperature. This reinforced
Sharon Smith’s concern that she had sickened her daughter by not cooking the
But the pathogen is so powerful that her illness could have started with just a
few cells left on a counter. “In a warm kitchen, E. coli cells will double every
45 minutes,” said Dr. Mansour Samadpour, a microbiologist who runs IEH
Laboratories in Seattle, one of the meat industry’s largest testing firms.
With help from his laboratories, The Times prepared three pounds of ground beef
dosed with a strain of E. coli that is nonharmful but acts in many ways like
O157:H7. Although the safety instructions on the package were followed, E. coli
remained on the cutting board even after it was washed with soap. A towel picked
up large amounts of bacteria from the meat.
Dr. James Marsden, a meat safety expert at Kansas State University and senior
science adviser for the North American Meat Processors Association, said the
Department of Agriculture needed to issue better guidance on avoiding
cross-contamination, like urging people to use bleach to sterilize cutting
boards. “Even if you are a scientist, much less a housewife with a child, it’s
very difficult,” Dr. Marsden said.
Told of The Times’s test, Jerold R. Mande, the deputy under secretary for food
safety at the U.S.D.A., said he planned to “look very carefully at the labels
that we oversee.”
“They need to provide the right information to people,” Mr. Mande said, “in a
way that is readable and actionable.”
With Ms. Smith lying comatose in the hospital and others ill around the country,
Cargill announced on Oct. 6, 2007, that it was recalling 844,812 pounds of
patties. The mix of ingredients in the burgers made it almost impossible for
either federal officials or Cargill to trace the contamination to a specific
slaughterhouse. Yet after the outbreak, Cargill had new incentives to find out
which supplier had sent the tainted meat.
Cargill got hit by multimillion-dollar claims from people who got sick.
Shawn K. Stevens, a lawyer in Milwaukee working for Cargill, began
investigating. Sifting through state health department records from around the
nation, Mr. Stevens found the case of a young girl in Hawaii stricken with the
same E. coli found in the Cargill patties. But instead of a Cargill burger, she
had eaten raw minced beef at a Japanese restaurant that Mr. Stevens said he
traced through a distributor to Greater Omaha.
“Potentially, it could let Cargill shift all the responsibility,” Mr. Stevens
said. In March, he sent his findings to William Marler, a lawyer in Seattle who
specializes in food-borne disease cases and is handling the claims against
“Most of the time, in these outbreaks, it’s not unusual when I point the finger
at somebody, they try to point the finger at somebody else,” Mr. Marler said.
But he said Mr. Stevens’s finding “doesn’t rise to the level of proof that I
need” to sue Greater Omaha.
It is unclear whether Cargill presented the Hawaii findings to Greater Omaha,
since neither company would comment on the matter. In December 2007, in a move
that Greater Omaha said was unrelated to the outbreak, the slaughterhouse
informed Cargill that it had taken 16 “corrective actions” to better protect
consumers from E. coli “as we strive to live up to the performance standards
required in the continuation of supplier relationship with Cargill.”
Those changes included better monitoring of the production line, more robust
testing for E. coli, intensified plant sanitation and added employee training.
The U.S.D.A. efforts to find the ultimate source of the contamination went
nowhere. Officials examined production records of Cargill’s three domestic
suppliers, but they yielded no clues. The Agriculture Department contacted
Uruguayan officials, who said they found nothing amiss in the slaughterhouse
In examining Cargill, investigators discovered that their own inspectors had
lodged complaints about unsanitary conditions at the plant in the weeks before
the outbreak, but that they had failed to set off any alarms within the
department. Inspectors had found “large amounts of patties on the floor,”
grinders that were gnarly with old bits of meat, and a worker who routinely
dumped inedible meat on the floor close to a production line, records show.
Although none were likely to have caused the contamination, federal officials
said the conditions could have exacerbated the spread of bacteria. Cargill vowed
to correct the problems. Dr. Petersen, the federal food safety official, said
the department was working to make sure violations are tracked so they can be
used “in real time to take action.”
The U.S.D.A. found that Cargill had not followed its own safety program for
controlling E. coli. For example, Cargill was supposed to obtain a certificate
from each supplier showing that their tests had found no E. coli. But Cargill
did not have a certificate for the Uruguayan trimmings used on the day it made
the burgers that sickened Ms. Smith and others.
After four months of negotiations, Cargill agreed to increase its scrutiny of
suppliers and their testing, including audits and periodic checks to determine
the accuracy of their laboratories.
A recent industry test in which spiked samples of meat were sent to independent
laboratories used by food companies found that some missed the E. coli in as
many as 80 percent of the samples.
Cargill also said it would notify suppliers whenever it found E. coli in
finished ground beef, so they could check their facilities. It also agreed to
increase testing of finished ground beef, according to a U.S.D.A. official
familiar with the company’s operations, but would not test incoming ingredients.
Looking to the Future
The spate of outbreaks in the last three years has increased pressure on the
Agriculture Department and the industry.
James H. Hodges, executive vice president of the American Meat Institute, a
trade association, said that while the outbreaks were disconcerting, they
followed several years during which there were fewer incidents. “Are we
perfect?” he said. “No. But what we have done is to show some continual
Dr. Petersen, the U.S.D.A. official, said the department had adopted additional
procedures, including enhanced testing at slaughterhouses implicated in
outbreaks and better training for investigators.
“We are not standing still when it comes to E. coli,” Dr. Petersen said.
The department has held a series of meetings since the recent outbreaks,
soliciting ideas from all quarters. Dr. Samadpour, the laboratory owner, has
said that “we can make hamburger safe,” but that in addition to enhanced
testing, it will take an aggressive use of measures like meat rinses and safety
audits by qualified experts.
At these sessions, Felicia Nestor, a senior policy analyst with the consumer
group Food and Water Watch, has urged the government to redouble its effort to
track outbreaks back to slaughterhouses. “They are the source of the problem,”
Ms. Nestor said.
For Ms. Smith, the road ahead is challenging. She is living at her mother’s home
in Cold Spring, Minn. She spends a lot of her time in physical therapy, which is
being paid for by Cargill in anticipation of a legal claim, according to Mr.
Marler. Her kidneys are at high risk of failure. She is struggling to regain
some basic life skills and deal with the anger that sometimes envelops her.
Despite her determination, doctors say, she will most likely never walk again.
Gabe Johnson contributed reporting.
Trail of E. Coli Shows Flaws in
Inspection of Ground Beef,