Direct Contracting Entities: Scamming Medicare and you and bad for your health!

On October 25, 2021 I wrote about ‘Medicare Advantage, Direct Contracting Entities, and other scams to transfer your money to insurance companies’. In the interim, it has become clear that the impact, and even existence, of DCEs is not well known among Medicare recipients, physicians, members of Congress, and many policy analysts. Indeed, it involves a lot more than insurance companies, particularly “private equity” (a newish term for “venture capitalists” including hedge funds, that maybe sounds better). While DCEs are still an ‘experimental’ program by the Centers for Medicare and Medicaid Innovation (CMMI) it is significant that the Biden administration has continued this Trump-initiated policy. As, presumably, part of its experimental nature, it has not had much publicity; few Medicare recipients know about it and it is just getting known to Congress, particularly with Senate Finance Committee hearings on February 2, 2022. It is probably worth calling attention to again, even if this piece repeats some of what I wrote in October.

Medicare was established in 1965, and the first two cards were issued, by President Johnson, at the Truman Library in Independence, MO to Harry and Bess Truman, in recognition of Truman’s efforts to pass national health insurance during his presidency. It meant that for the first time in American history, older adults would not suffer and die just because they could not afford medical care. It remains, along with Social Security, the most popular program in the US, in every poll, by almost everyone (except of course the rich elites, who believe the best programs are the ones that funnel money directly into their pockets, but more on that later).

Medicare has been a rousing success, but there are two problems. The real and serious problem, as seen from the point of view of Medicare recipients, or for that matter anyone who claims to be a decent non-narcissistic human being, is that it does not comprehensively over health care costs. For starters, there are several important health conditions it does not cover, including vision, hearing, and long-term care. Also, even for the conditions (most hospitalizations and office visits) it does cover, it does not cover the entire cost. Generally, for hospitalization, it covers 80% of the Medicare-approved fee (which is always less than hospital charges, but which is in fact all the hospital can charge Medicare patients). This puts patients on the hook for the other 20%, which as anyone who has been hospitalized knows can be a lot of money.

The other problem, perceived as egregious by the small but powerful group of very wealthy investors (not regular people at all) is the same as with all effective government programs: it doesn’t put money in their pockets. Medicare is funded by different sources; Part A is for hospitalization and comes from the Medicare tax on your paycheck. Part B is for outpatient care and is funded from general revenue funds, plus a monthly charge to Medicare recipients (a minimum of about $135 now, which can go quite a bit higher for high-income people and be waived for low income). Part D is the drug plan that each recipient is required to buy. We’ll talk about Part C later.

Medicare, as a public (government) program that is in the business of paying for health care rather than generating shareholder profit operates very efficiently, with about a 2% overhead for administrative costs. As a taxpayer, I’d think this is good. But for the small number of powerful wealthy investors (for short, let’s call them GNPs, for Greedy Narcissistic Pukes) it represents an opportunity; if they could control it they could reap profit from it!

So, of course, while the fact that it is not making rich people even richer is not a problem for most of us, the problem we have is the solution that the government has come up with in service to the GNPs. It has been regularly altering Medicare to help them make money from it. First Congress created Medicare Part C, or Medicare Advantage (MA), which, if you choose it, basically enrolls you in an HMO. You get everything paid for plus other stuff that traditional Medicare (TM) doesn’t cover, like hearing and dental and maybe gym memberships. This is good for you provided you don’t get sick. If you do, you don’t have the choice of virtually all doctors and hospitals that you do with TM, just those “in network” (an even greater problem if you don’t spend all your time in the same area, since those networks are geographic). Also, since, if you are sick, those MA programs would just as soon you left went to TM so  they don’t have to pay your bills, and they have a variety of tricks to encourage you to do so. MA may be good for basically healthy seniors, unless they travel, until they’re not healthy. MA plans also don’t pay for long-term care – that’s expensive and would cost too much; gym memberships are cheap. And they can – and do -- pocket overhead and profits of up to 15%. (The insurance term is that their “medical loss ratio” -- the amount that they have to spend on actually providing medical care – has to be 85%, while in TM with its 2% overhead, it is effectively 98%.) Medicare Part D, the required drug coverage was another gift, this time to big pharmacies and pharmacy benefit managers (PBMs) who make big profit from them.

But wait! A lot of people were and are still choosing TM, and not all of them are the high-cost really sick people that the MA plans don’t want! While the insurance companies and GNPs are glad that they are in TM when they are sick and costly, there are still a lot of them who we could make money on. How can we do that? Well, let’s get the Center for Medicare and Medicaid Innovation (CMMI), which is supposed to come up with innovative programs that improve quality and save the government money, to implement an “innovation” that lets us pocket money from even those who chose TM! Cool! So they did, without even having to have Congress approved it. These are called Direct Contracting Entities (DCEs). If your primary care clinician is affiliated with a DCE, the DCE collects all your money from Medicare, and – this is a really good part – they only have a medical loss ratio requirement of 60%, so they can keep 40% if they can deny you enough care! A better deal (for them!) than even Medicare Advantage! And since most primary care physicians are now employees or part of large groups, the DCEs can just contract with the group, not with each physician. And even better, the DCEs, the majority of which are now owned by “private equity” (a particularly noxious form of GNP), can just buy the primary care groups! Voilà! The group is now owned by the DCE, your doctor is part of it, and you are part of it and being hosed. Your only recourse is to change your primary care doctor. Which you may not want to because you may like and trust your doctor…

Of course, the two problems I mentioned are mirror images of each other. Medicare does not pay for all your care because Congresspeople and Wise Policy Analysts say that would be bad because it would cost too much. They see it as much better to spend lots of money on further enriching the insurance companies, PBNs, DCEs, and other GNPs. Why? Because they contribute a lot of money to Congress, and because many congresspeople are heavily invested in these; often they are also GNPs, either before entering Congress or as a result of it (how they get so rich on a Congressional salary is another story).

By the way, in case I haven’t been clear in what I think, these are all both bad and evil programs, taking money that should be spent on your healthcare. They are healthcare examples of the impact of “gangster capitalism”, or in another term I’ve heard, Götterdämmerung capitalism, which describes our current situation where the GNPs would rather destroy the world that stop acquiring all its wealth. And if they are willing to destroy the world, how much weight do you think your health and life have? These programs are not developed by accident; they are purposely designed to take what you have (as in the cost of health insurance premiums) or have previously been recognized as social benefits (as Medicare) and transfer them to the richest people in society.

The only – maybe, hopefully -- good news is that Congress has recently started holding hearings on DCEs, recently by the Senate Finance Committee, with outstanding testimony by many experts including Dr. Susan Rogers, current president of Physicians for a National Health Program (PNHP), whose website has lots of good information on DCEs. At the end of the hearing, Sen. Elizabeth Warren (D, MA) urged the Biden administration in the strongest terms to have CMMI end this “innovative experiment” (or perhaps you prefer grift or scam). Maybe they will.

Let your Congresspeople know what you think. And everyone else.

Why do we have to wait so long to see the doctor? It's all about the money...

I have seen a number of articles describing the difficulty of getting doctor’s appointments in the era of COVID-19. In many parts of the country it was difficult to get a quick appointment even before the pandemic, but it has become much worse. I hear from friends in a several different cities that they cannot get into their doctors offices for weeks or, commonly, months. This is not OK for routine care; it is certainly not ok when something urgent, or relatively urgent, or even a little bit “needs to happen before I get really sick” is going on. A recent article in the Wall Street Journal by Devorah Goldman (‘The doctor’s office becomes an assembly line’, December 30, 2021) describes a woman who came to her father’s Brooklyn office from New Jersey because she couldn’t get an appointment for 8 months!

There are Emergency Rooms, of course, but waiting (frequently for hours!) in them increases your risk of acquiring COVID infection. And, as in “regular” times, they should be for emergencies, not for care for chronic diseases or minor acute disease. Of course, if you cannot get regular care for your chronic disease, it can become an emergency. And, as I have written before (Emergency services, COVID, and the health system: Your life could well be at risk, Jan 19, 2021), when you have an emergency, like a ruptured appendix, waiting in an ER for hours is also very dangerous, and the more “non-emergent” people waiting the more likely this is to happen. There are Urgent Care Clinics, but these have their own issues: they can only take care of a limited (and variable by location) menu of problems, most of which are those your mother used to take care of, and they may not take your insurance (if you have it). Also the prices and profit margins are very high.

So why are the waits so long, and what can be done about it? Goldman’s emphasis is the takeover of physician private practices by hospital systems and large groups; she notes that, according to the AMA, 75% of physicians owned their own practices in 1983, but by 2018 it was 46%. This is part of the problem; even if an individual physician is compassionate and caring, the big corporation they work for probably is not. Another part is the maldistribution of physician specialists. Studies of efficient and effective health care systems indicate that 40-50%+ of physicians should be in primary care, seeing people for most problems, providing continuity of care for a patient panel, and diagnosing “undifferentiated patients” (those who do not have a specific diagnosis) and caring for them or appropriately referring them. In the US, however, it is less than 30% and dropping. Quite reasonably, subspecialists want to see people with the problems that they know how to take care of; this works well when they are referred by family physicians and other primary care clinicians, and much less well when people have to self-refer, essentially having to diagnose themselves. Such direct self-referral also backs up the subspecialist practices with patients whose problems could have been well taken care of by a primary care clinician (not everyone with a heart needs a cardiologist!) making it more difficult for those with complicated or rarer conditions that need the subspecialist’s care to get in. Medicare’s reimbursement method figures prominently in Goldman’s article; she identifies ways that it tends to give preference (i.e., pays more) to large, and especially hospital-owned, medical groups. And, of course, since COVID the demand for care has gone up, and the number of clinicians available (because of sickness and overwork) has gone down.

Many other articles claim to provide the reasons for this problem, and some even have proposed solutions, but most of them examine only one aspect of it. I am reminded of the old Indian story about the blind men and the elephant, each touching a different part of the beast and thus presuming, based on contact with the trunk, the tail, or a leg, that they knew what the whole elephant looked like. Often this is influenced by the agenda of the writer and whether (like, e.g., Goldman) they get their information mainly from groups like the AMA (“oh, for the days of physician-owned private practice!”), hospital associations (“consolidation is good!”), government agencies (“reimbursement policy is governed by competing needs”), or academics, think tanks, or nonprofits like the Commonwealth Fund, Kaiser Family Foundation, and Pew Trusts, often with their own biases. To me, it is clear what the whole elephant looks like, what is the common factor in this equation, what can be seen behind all of the decisions that have led us to where we are (and continue to make it worse) and, by implication, could show us the way out: Money. Corporate profit.

We live in a profit-driven capitalist society. More than that, we have moved well beyond simple “Adam Smithian” capitalism to what Noam Chomsky identifies as “gangster capitalism”. In this stage, merely making money is not sufficient – the only goal becomes to make ever more money, by any and every means possible, no matter who, or what is destroyed. This includes people, animals, plants and the earth itself -- it hurts, screws, destroys, even though neither those who control it nor their descendants could ever spend it all. Fewer and fewer people control more and more and it would be naïvete to assume this is not the case in health care.

Virtually all the systemic bad things (as opposed to the much less common individual error) in healthcare derive from corporate owners’ efforts to make more money, and to game the system to maximize profit. While huge practice groups owned by hospitals or investors could operate more efficiently to improve both the quality of and access to care for patients, they don’t since they are interested in squeezing every dollar of profit. Conversely, small physician-owned practices couid do better than they do, but often, in pursuit of income, do not care for significant portions (poor, uninsured, badly insured) of the population. Explicitly for-profit (as opposed to ostensibly non-profit, but still fixated on making as much as possible) healthcare entities, whether large hospitals and hospital systems or more ‘niche’ services like dialysis, physical therapy, and long-term care, are the worst. There is certainly plenty of blame to go around – healthcare systems blame insurance companies for not paying them enough and insurance companies blame healthcare systems for demanding too much, but both are seeking to earn money for themselves, not to ensure all people get the highest quality health care.

Pharmaceutical companies are notoriously rapacious. For example, see Aduhelm® (FDA approves Alzheimer's drug against the recommendation of its scientific panel. Be very concerned, June 21, 2021); every (60 million!) Medicare recipient’s Part B payments will now rise $11/month so some Alzheimer’s patients can receive this drug that, though probably ineffective, costs a huge amount (now, graciously, reduced to only $28,200/year!). It was approved by the FDA over the recommendation of its scientific advisory panel in a move completely reminiscent of the fraudulent labeling of Oxy-Contin® described in the film “Dopesick”, which I recently discussed ("Dopesick": The story of the marketing of killer opioids will really make you sick. Don't trust any of them!, Dec 7, 2021).

I have often advocated for a single-payer health insurance system, such as Medicare for All. The advantage of this would be that 1) everyone in the US is covered, and 2) everyone in the US has the SAME coverage, The second is not a minor point, as it means that the educated and powerful will make sure it works, also helping the disenfranchised and disempowered. A universal health insurance system (or something comparably effective) is necessary, but not sufficient. Medicate for All needs to be an improved and expanded Medicare, as described in the bills introduced by Sen. Bernie Sanders, Rep. Pramila Jayapal and others.(See this good analysis by Sen. Sanders on the “Vulgarity” of the US health system.) It must be expanded to cover not only everyone but everything (mental health, dental, vision, hearing, long-term care) and improved to cover them completely without co-pays, co-insurance, deductibles. This will eliminate the flaws Goldman describes in Medicare payments.

Since we already spend 2-3x as much per capita on health care as any other wealthy country, including premiums, deductibles, co-pays, government benefits, and the profits and administrative costs sucked out of the “healthcare” pool by insurers and providers, we don’t even need to tax the richest a lot more to pay for it. We just need to spend it on actually providing healthcare! Not that we shouldn’t make the billionaires and corporations pay at least their fair share of taxes; we can use that money to providea adequate housing, food and education to all our people – really, the biggest factors in health.

Don’t get distracted by the circuses and diversions created by those with a profit-motivated dog in the fight. Profit has little place in healthcare. Obscene profit has none.

"Dopesick": The story of the marketing of killer opioids will really make you sick. Don't trust any of them!

I have recently been watching “Dopesick”, the Hulu/Disney+ quasi-documentary drama about how the Sackler family-owned Purdue Pharma developed and marketed Oxy-Contin®, and about the efforts of some brave federal prosecutors and DEA and DOJ agents brought them (somewhat) down. Based on the book by Beth Macy, it is a good series, with terrific performances and many sympathetic characters (not the Sacklers, though, none of them) and although I am sure that there fictional elements involving the personalities portrayed, it is essentially factual. It is also infuriating, and nauseating.

If you haven’t watched it, you probably should, but you probably already know the main theme, so what I write won’t be spoilers. It is still worth watching, to understand the extent of the evil, and the way in which the medical profession and federal agencies were “played” successfully as thousands of Americans became addicted and died. A few of the outrages include that when Purdue developed Oxy-Contin, using a delivery scheme developed for MS-Contin®, which was going off patent, they claimed its slow-release delivery mechanism made it essentially non-addictive (less than 1%), and got a first-ever special label for a Class II narcotic from the FDA saying it was less addictive (it was not). They did a very effective job not only marketing (detailing) to physicians with this lie, but created new diseases (conditions) that justified its use. This was also taken from a previous drug and scam, when Arthur Sackler invented the condition “psychic tension” to market Valium®. When, predictably, people first got pain relief, then developed tolerance they invented the condition of “breakthrough pain” which required a higher dose. Then folks got tolerant of that. And when they stopped, they went through awful withdrawal. This is what happens with opiates and opioids. And yet Purdue was able to convince doctors to continue to prescribe it – and prescribe it in increasing amounts.

This was part of a movement going on in the 1990s to address the issue of people not always receiving adequate pain relief. The pain of diseases, such as cancer, that occurs as people approach death, got conflated with the moderate chronic pain that millions have from work related injuries (the focus of the drama is on a mining area of Virginia) and from conditions such as osteoarthritis. These are real problems, but the answer was presented as opioids, and ever increasing doses of them. What was not well-known at the time is that, to a large degree, this “movement” was in fact a campaign funded by Purdue. They funded – and thus heavily influenced -- most of the medical Pain Management groups, as well as the campaign to label pain the “fifth vital sign” (after temperature, pulse, respiration, and blood pressure), an idea they invented. It was a drumbeat that was ubiquitous. The pain movement was essentially, a marketing campaign for a lethal drug. It was successful, in both ways. It made the company, and the family, a lot of money, and it addicted and killed a lot of people.

The Sacklers didn’t seem like the meanest of billionaire families (of course, this is a low bar). They were philanthropists, who gave a lot of money to the arts, and to Israel and Jewish organizations, and health care, and even funded a medical school, the Sackler School of Medicine, part of Tel Aviv University and located in Israel but chartered in NY state. It still exists. They were, however, and remain, avaricious and essentially amoral, continuing to refuse to recognize their evil-doing, while remaining #30 on the Forbes wealthiest list, and managing to retain and hide nearly $11B in their own private money despite the $8.3B settlement. And thousands of people are dead and addicted. The people most affected were poor and working class people, those who work with their bodies and most often experience chronic pain, such as those the series focuses on, miners.

But the story cannot end with the Sacklers, Purdue, and Oxy-Contin. While some of their tactics were particularly creative and perfidious, the effort to market drugs with high profit margins (even when they are often less effective and more dangerous than other existing drugs) is the Holy Grail of the pharmaceutical industry. What Purdue did was possibly more insidious – and effective -- but it was typical in being multi-pronged, targeting consumers, physicians and the federal government.

The government was targeted by lying to them, and knowing they were unlikely to be caught as the FDA’s staff (as the staffs of almost all regulatory agencies) had been decimated by cuts beginning with the Reagan administration, aimed at allowing corporations to have freer rein – to lie, cheat, and profit at the public’s expense in $$ and, in this as in many cases, their health. It was a flagrant example of the corruption of the ubiquitous “revolving door”, where those who are tasked with regulating industries then leave government service and get high-paying jobs in those same industries. Indeed, this is what happened with the FDA official who approved the novel labeling of Oxy-Contin -- he went to work for a big salary at Purdue -- and it happens every day in every field, not just pharmaceuticals. It is, pure and simple, graft.

Doctors were targeted through pharmaceutical sales representatives (“detail” people) who provide them with incomplete and often inaccurate information (e.g., that Oxy-Contin was only 1% addictive), and take them to expensive dinners and even vacation retreats under the guise of medical lectures. And the company, of course, encouraged their own reps to lie with enticements such as vacations. And the public? They present tantalizing, incomplete, and dangerous information through ads, especially on TV.

I have written about TV direct-to-consumer advertising, (e.g, DTC Advertising on TV illustrates the corruption and inequity of the US medical care system, Mar 6, 2021) and think it is pretty much all bad. I think that the marketing of drugs to doctors, to get them to prescribe expensive drugs, is mostly all bad. I have thought that, by the way, pretty much since at least medical school. I didn’t meet with drug reps, was very skeptical of information they provided (which I saw in journal ads and heard from colleagues) and assumed any positive claim was very likely incomplete or untrue. During my career, any number of highly-touted drugs were pulled from the market after causing major morbidity and mortality that was either not predicted in the pre-approval studies or suppressed by the companies. As a teacher of medicine, I sponsored “counter-detailing” to point out the flaws of the pharmaceutical company claims. I was aghast when residents would come back from conferences supposedly sponsored by professional associations but funded by drug companies that recommended the substitution of new expensive drugs for old standards that worked at least as well. This has been recently documented for diabetes (another field in which much of the funding has come from the drug makers) in an article from Reuters, ‘Drugmakers Pushed Aggressive Diabetes Therapy. Patients Paid the Price’, featured by Medscape Nov 5, 2021.

And yet, even so, I was not immune to the campaigns that Purdue funded, especially the idea that pain was being undertreated, although I remained unconvinced that it was the “fifth vital sign”. To be sure, I was much more skeptical than many of my colleagues, and was careful to distinguish between relieving the pain of a terminal cancer patient and addicting a person with chronic moderate pain. But it was a very well-done campaign, and I knew that at least sometimes we were undertreating pain. At Cook County Hospital, where I worked, we saw many patients with sickle-cell pain crises, treated with opiates and opioids, and frequently becoming addicted (interestingly, the chief of pediatric hematology only used aspirin and hydration, but as soon as those children became adults they began to receive narcotics).

We must remember that it was and is not just Purdue. Don’t trust what any drug company (or maybe any company) says in TV ads. Don’t trust what the pharma reps say. And sadly we cannot always trust recommendations of professional organizations when they are getting money from drug companies. This is real conflict of interest, and makes our professional organizations suspect.

It is all about making the most possible money by any means necessary, no matter who gets hurt, what Noam Chomsky calls “gangster capitalism”. You’re better off trusting real gangsters who literally put a gun to your head. At least you know where you stand.

"People will believe anything": Snake oil salesmen and bad health advice

The other day, I took a nephew to see the new Spider Man movie, “Far from home”. No review here; just to say that a big part of the plot revolves around the bad guy using a high-tech virtual reality system to project fake images that everyone takes to be real. Several times in the film he and his henchmen say “people will believe anything”. The parallels to the daily reality of our times, to “fake news” and distrust of science, are too obvious to be coincidental. Of course, in the movie the bad guy loses and the good guy (Spider Man) wins.

It is still far from clear if the “good guys” (and here I speak not of specific individuals, but of those who advocate for truth, a real reality, and science) are going to win in the actual world. The forces of darkness and reaction, wearing the face of Donald Trump and facilitated by the Republican Party, but actually representing and funded by the corporate elite – gangster capitalists – may not wear capes and fly around or use astral projection, but they have enormous resources to control the dialogue, provide misinformation, and serve themselves. They are resilient not only because of their wealth and power, but, sadly, because so many people are happy to try to deal with their own oppression by hating, oppressing, and believing bad things of others.

Health and medicine are clearly not immune from the reach of “fake news” and false beliefs and those willing to exploit our willingness to believe what we want to be true rather than what is. This is often a result of also a logical fallacy, wishful thinking (which is only a fallacy when it is expressed as true; not when it is expressed as a hope or wish) but may be more appropriately called “magical thinking”, a developmentally appropriate stage for young children that is always pathological in adults. Those who promulgate false scientific, medical and health theories and advice can be doing so to make money, to exert power and control, because it derives from a pre-existing belief (sometimes but not always religious). Sometimes it is also self-delusional, especially when the proposed solution is easier, more palatable, less painful, and requires less discipline than the medical alternative (take these simple pills – or snake oil -- and you won’t have to diet/exercise/stop smoking or drinking/have radiation or chemotherapy or surgery and you can be more youthful or beautiful or sexual). I once wrote about a patient who was obsessed with getting mammograms for breast cancer, a condition for which she was not at elevated risk and was far too young for routine screening, but was uninterested in addressing her actual risks resulting from heavy smoking, uncontrolled high blood pressure, and unprotected sex with multiple partners (Healthful Behaviors: Why do people adopt them? Or not?, October 8, 2011). Because, I inferred, it was easier, and would require no real effort or difficulty on her part. This is why it is an attractive option. But it is not a good idea.

The trend toward getting health and medical advice from those who are not medically trained has always been with us, but the same easy dispersion of information (or misinformation) through the Internet that allows us to hear anything we want and, to a large extent, only what we want, impacts health care as well as politics. The “anti-vax” movement is very popular, and promoted by celebrities. (Why should we not get our health advice from those whose qualification is that they are celebrities?) In addition to being wrong, it is very dangerous to the public health. I say that with absolute certainty. The anti-vaxxers are wrong. Period. There is some risk that individuals will have a reaction, very rarely a serious one, but this impact is totally miniscule compared to the benefit of preventing disease through vaccination. Indeed, vaccination is one of the few areas in which we actually can prevent, and thus not have to treat, diseases!

Some celebrities deserve a special call-out for their comprehensive and ubiquitous denial of fact, reason, and science – amazingly, often in conjunction with a profit motive from the brand of snake oil that they are selling; Gwyneth Paltrow is the exemplar. Of course, Ms. Paltrow deserves some credit for being able to convince people that they should do things that are actually unpleasant and painful for the sake of their health and beauty, like getting stung by bees, even though these are of no actual value to her clients. Obviously, they are of financial value to her. And, while I admire much of what she does in the world, Oprah Winfrey is also a big proponent of false health information.

Sometimes, bad policies are advocated by the self-righteous, as is the case with the current Israeli Education Minister, the most recent bigot coming out for “conversion therapy” for gay people. This is an example of falsely medicalizing a condition by suggesting it requires therapy, something that should not be. Sometimes, as in Paltrow’s case and many others, it is at least in part motivated by the opportunity for profit. Often, and this is sad, it is motivated and believed because people do not trust doctors and other health professionals. One reason it is sad is because people eschew treatments that could be of benefit to them in favor of those that will not help and may even hurt. But another major reason is that many doctors and other health professionals have been themselves guilty of pushing treatments that do not benefit, and may hurt, their patients. They do this for the same set of reasons as those I criticize above: to make money themselves, to make money for drug and device makers who pay them directly or in gifts including drug samples, because they are too lazy (or “too busy”) to actually read and evaluate the evidence and so taking the advice of drug or device salespeople is easier, and because they think that because they are doctors everything they think is right. I wish this were not true, but it often is. Holding physicians to a higher standard than non-medical people is appropriate, but this is not an argument for believing people because they are not doctors, no matter how confident. Iit absolutely in no way justifies listening to the advice of non-medical people who know even less!

It is also the case that some “alternative” suggestions for treatment are helpful, and many others are probably benign (except for the cost), even if the evidence is that they are not helpful; one example is taking vitamin supplements. If you can afford them, and don’t take excessive doses, they probably don’t hurt. It is certainly a better way to waste your money than on cigarettes, but if you can’t afford them, skip them. Other medical interventions can be good, and of benefit, but the benefits are often overstated, or reified as totally important. This is especially true when it is promoted as more “natural”, a word so overused as to have almost no consistently definable meaning. One example might be the use of birth attendants, called doulas. For many people, especially those who do not have a support system such as a spouse or parents or siblings or friends (and, likely for some who do) it is very helpful to have a knowledgeable, supportive person during your labor, focused entirely on you. But they are neither magic nor necessary.

Having someone who can help you deliver your baby, like a midwife or physician, is often necessary. A birth support attendant is a nice addition. Nurse-midwives train as registered nurses then do additional years of midwifery training and attend many births, including many doing deliveries under supervision. They can deliver babies as well as support women in labor.  In contrast, becoming a doula, according to https://www.naturalhealers.com/midwifery/doula requires a total of about 2-3 weeks including the need to attend a few births. So what scientific basis could there be for NY State Gov. Cuomo is advocating the expansion of the use of doulas to decrease maternal mortality, something for which there is not only no evidence, but no rational basis for thinking.

Come on, Governor! Come on, people! Not harmful is good, helpful is even better, not breaking the bank is important, and sometimes natural is nice. But let’s not choose magical thinking over science. That helps no one, except the snake oil vendors.

Gangster capitalism and our health: In the US and in the World

There has been a lot written about capitalism. Karl Marx, for example, wrote a multi-volume study of it just about 150 years ago, and since then a lot of the writing has been about what he wrote, supportive and critical. There is no question that it has remained the dominant economic system in the world; it is the linchpin not only of Western “democracies” and totalitarian fascist states but also ostensibly Marxist governments like China. While capitalism has both its defenders and detractors, it is interesting to me that the defenders spend little time defending the amazingly deleterious effects that it has on the quality of life (and even existence of life!) of people, the environment, war, and (to the point of this blog) health.

The problem is that, in pursuit of profit, industries will do and have done almost anything, with no moral compass or conscience, and, worse, with no concern for future generations or the planet. Some of the most obvious and egregious examples in the US at this time include their (largely successful) lobbying of the current administration to roll back on rules to ensure clean air and water and the overall environment so that they (in this case, extraction industries like oil and mining) can further increase their unconscionable profits without worrying about the damage it does. So we have mining and extraction in and near our national parks (“near” is important; air and water do not respect boundaries!), scaling back of national monuments so extraction can take place, poisoning of the water through leaks in oil pipelines (such as Keystone), and poisoning of the air we breathe when fossil fuels are burned. Oh yeah, and the increase in global warming which has already permanently altered the climate and will eventually wipe out life on earth (starting with the lowest lying areas) if nuclear war doesn’t first.

Our health and safety is also constantly at risk from aggressive efforts by corporations to increase their profits. This can take the form of producing unsafe products either because it saves money (e.g., dangerous child toys) or costs a lot to not do (e.g., not having lead in our water or asbestos in talcum powder), or by making important and beneficial (and hopefully safe) medications unavailable to many people because of incredible price increases (for the tip of the iceberg, see “Epi-Pen® and Predatory Pricing: You thought our health system was designed for people’s health?, September 3, 2016). We of course know about the ongoing – and largely successful efforts – of the tobacco industry to increase their profits by promoting a product that kills 400,000 people a year in just the US (mainly from cancer and heart disease), including through promoting it to children (e.g., the cartoon character “Joe Camel” – see Fischer et al, “Brand Logo Recognition by Children Aged 3 to 6 Years: Mickey Mouse and Old Joe the Camel”, JAMA 1991;266(22):3145-3148, December 11, 1991).

One of the most vicious and insidious efforts to compromise our health in the interest of profit has been carried on for more than a half-century by the sugar industry. For decades, under the table, sugar producers funded scientific research into the negative effects of a high-fat diet while ignoring the almost-certainly more detrimental effects of a high-carbohydrate, especially simple carbohydrate – sugar – based diet. Soda pop became the national beverage with incredible impact on the rate of obesity, in the US and internationally. A 12-oz can of Coca-Cola® has 140 calories, so what about that 40oz fountain drink at the convenience store? A 2-liter bottle has 812 calories. That’s a lot. So most health professionals, like doctors, tell people to not drink it, or not very much of it. This is, however, competing against the messaging of the industry, which pushes it a lot, and gets the cooperation of many nutritionists through the use of – wait for it – money! I have written about the corruption (or conflict of interest, to put it nicely) of health organizations like the American Academy of Dietetics and Nutrition (AADN) and the American Academy of Family Physicians being funded by Coca-Cola® and other sugar purveyors and having their ads on their websites (The AAFP, Coca-Cola, and Ethics: Serving the public interest?, August 20, 2010). The ads are no longer there, but you can read about the AADN at the fooducate blog, and if you search sugar on the current AADN website, you will find some pieces on limiting sugar, but as many on the potential risks of artificial sweeteners (which, whatever your beliefs,  the FDA rules as safe) and fats.

Of course, as with the case of tobacco, efforts to limit the sugar market in the US (such as Mayor Michael Bloomberg’s failed attempt to limit the size of sugary sodas in NYC), have led the industry to branch out and increase its efforts to profit in the rest of the world, particularly the developing world. While many countries can be targeted, the biggest markets, China, India, and Mexico, have received special attention. The NY Times has an important exposé  on January 9, 2019, ‘Research details how junk food companies influence China’s nutrition policy”, citing work published in BMJ (“Making China safe for Coke: how Coca-Cola shaped obesity science and policy in China”) and the Journal of Public Health Policy (“Soda industry influence on obesity science and policy in China”) on the role of the International Life Sciences Institute (ILSI):

…a worldwide organization with a Washington headquarters, funded by many of the biggest names in snack foods, including Nestlé, McDonald’s, Pepsi Co. and Yum! Brands as well as Coca-Cola. It has 17 branches, most of them in emerging economies like Mexico, India, South Africa and Brazil, and promotes itself as a bridge between scientists, government officials and multinational food companies.

But in China ILSI is so well-placed that it runs its operations from inside the government’s Centre for Disease Control and Prevention in Beijing. In fact, when asked to comment on the studies, the ministry emailed a statement not from a government official but from ILSI’s China director.

Thus China’s health policy, which almost entirely focuses on exercise like “Happy 10 minutes” (good for you!) and ignores the dangers of high-calorie sugar-laden foods for obesity (and there is excellent evidence that diet is probably about 80% of the issue, with exercise critical for the other 20%).

There are those who will argue that it is not capitalism itself, but “unfettered capitalism” that is the problem. There is a lot of truth to that. The blind pursuit of maximal profit with no attention at all to the negative impacts on the world around them is not a necessary part of any profit making endeavor. Indeed, the “Wealth of Nations” by Adam Smith cautions strongly against this sort of excess, and “the only responsibility of business is to make profit for its stockholders” guru Milton Friedman sort of assumed that they wouldn’t do it.

But they do, and “unfettered” – or corporate gangster capitalism – is what is running the world. And it is not good for our health.