Death by Medicine Part 2

[Guest guest]

http://www.lef.org/magazine/mag2004/mar2004_awsi_death_04.htm

 

Death by Medicine

By Gary Null, PhD; Carolyn Dean MD, ND; Martin Feldman, MD; Debora Rasio, MD;

and Dorothy Smith, PhD

What constitutes the “best care”? The CDC does not elaborate and ignores the

latest research on the dozens of nutraceuticals that have been scientifically

proven to treat viral infections and boost immune-system function. Will doctors

recommend vitamin C, echinacea, elderberry, vitamin A, zinc, or homeopathic

oscillococcinum? Probably not. The CDC's common-sense recommendations that most

people follow anyway include getting proper rest, drinking plenty of fluids, and

using a humidifier.

 

The pharmaceutical industry claims it supports limiting the use of antibiotics.

The drug company Bayer sponsors a program called “Operation Clean Hands” through

an organization called LIBRA.(57) The CDC also is involved in trying to minimize

antibiotic resistance, but nowhere in its publications is there any reference to

the role of nutraceuticals in boosting the immune system, nor to the thousands

of journal articles that support this approach. This tunnel vision and refusal

to recommend the available non-drug alternatives is unfortunate when the CDC is

desperately trying to curb the overuse of antibiotics.

 

Drugs Pollute Our Water Supply

 

We have reached the point of saturation with prescription drugs. Every body of

water tested contains measurable drug residues. The tons of antibiotics used in

animal farming, which run off into the water table and surrounding bodies of

water, are conferring antibiotic resistance to germs in sewage, and these germs

also are found in our water supply. Flushed down our toilets are tons of drugs

and drug metabolites that also find their way into our water supply. We have no

way to know the long-term health consequences of ingesting a mixture of drugs

and drug-breakdown products. These drugs represent another level of iatrogenic

disease that we are unable to completely measure.(58-67)

 

Specific Drug Iatrogenesis: NSAIDs

 

It's not just the US that is plagued by iatrogenesis. A survey of more than

1,000 French general practitioners (GPs) tested their basic pharmacological

knowledge and practice in prescribing NSAIDs, which rank first among commonly

prescribed drugs for serious adverse reactions. The study results suggest that

GPs do not have adequate knowledge of these drugs and are unable to effectively

manage adverse reactions.(68)

 

A cross-sectional survey of 125 patients attending specialty pain clinics in

South London found that possible iatrogenic factors such as “over-investigation,

inappropriate information, and advice given to patients as well as misdiagnosis,

over-treatment, and inappropriate prescription of medication were common.”(69)

 

Specific Drug Iatrogenesis: Cancer Chemotherapy

 

In 1989, German biostatistician Ulrich Abel, PhD, wrote a monograph entitled

“Chemotherapy of Advanced Epithelial Cancer.” It was later published in shorter

form in a peer-reviewed medical journal.(70) Abel presented a comprehensive

analysis of clinical trials and publications representing over 3,000 articles

examining the value of cytotoxic chemotherapy on advanced epithelial cancer.

Epithelial cancer is the type of cancer with which we are most familiar, arising

from epithelium found in the lining of body organs such as the breast, prostate,

lung, stomach, and bowel. From these sites, cancer usually infiltrates adjacent

tissue and spreads to the bone, liver, lung, or brain. With his exhaustive

review, Abel concluded there is no direct evidence that chemotherapy prolongs

survival in patients with advanced carcinoma; in small-cell lung cancer and

perhaps ovarian cancer, the therapeutic benefit is only slight. According to

Abel, “Many oncologists take it for granted that response to

therapy prolongs survival, an opinion which is based on a fallacy and which is

not supported by clinical studies.”

 

Over a decade after Abel's exhaustive review of chemotherapy, there seems no

decrease in its use for advanced carcinoma. For example, when conventional

chemotherapy and radiation have not worked to prevent metastases in breast

cancer, high-dose chemotherapy (HDC) along with stem-cell transplant (SCT) is

the treatment of choice. In March 2000, however, results from the largest

multi-center randomized controlled trial conducted thus far showed that,

compared to a prolonged course of monthly conventional-dose chemotherapy, HDC

and SCT were of no benefit, (71) with even a slightly lower survival rate for

the HDC/SCT group. Serious adverse effects occurred more often in the HDC group

than the standard-dose group. One treatment-related death (within 100 days of

therapy) was recorded in the HDC group, but none was recorded in the

conventional chemotherapy group. The women in this trial were highly selected as

having the best chance to respond.

 

Unfortunately, no all-encompassing follow-up study such as Dr. Abel's exists to

indicate whether there has been any improvement in cancer-survival statistics

since 1989. In fact, research should be conducted to determine whether

chemotherapy itself is responsible for secondary cancers instead of progression

of the original disease. We continue to question why well-researched alternative

cancer treatments are not used.

 

Drug Companies Fined

 

Periodically, the FDA fines a drug manufacturer when its abuses are too glaring

and impossible to cover up. In May 2002, The Washington Post reported that

Schering-Plough Corp., the maker of Claritin, was to pay a $500 million dollar

fine to the FDA for quality-control problems at four of its factories.(72) The

indictment came after the Public Citizen Health Research Group, led by Dr.

Sidney Wolfe, called for a criminal investigation of Schering-Plough, charging

that the company distributed albuterol asthma inhalers even though it knew the

units were missing the active ingredient.

 

The FDA tabulated infractions involving 125 products, or 90% of the drugs made

by Schering-Plough since 1998. Besides paying the fine, the company was forced

to halt the manufacture of 73 drugs or suffer another $175 million fine.

Schering-Plough's news releases told another story, assuring consumers that they

should still feel confident in the company's products.

 

This large settlement served as a warning to the drug industry about maintaining

strict manufacturing practices and has given the FDA more clout in dealing with

drug company compliance. According to The Washington Post article, a federal

appeals court ruled in 1999 that the FDA could seize the profits of companies

that violate " good manufacturing practices. " Since that time, Abbott

Laboratories has paid a $100 million fine for failing to meet quality standards

in the production of medical test kits, while Wyeth Laboratories paid $30

million in 2000 to settle accusations of poor manufacturing practices.

 

UNNECESSARY SURGICAL PROCEDURES

 

In 1974, 2.4 million unnecessary surgeries were performed, resulting in 11,900

deaths at a cost of $3.9 billion.(73,74) In 2001, 7.5 million unnecessary

surgical procedures were performed, resulting in 37,136 deaths at a cost of $122

billion (using 1974 dollars).(3)

 

It is very difficult to obtain accurate statistics when studying unnecessary

surgery. In 1989, Leape wrote that perhaps 30% of controversial surgeries—which

include cesarean section, tonsillectomy, appendectomy, hysterectomy, gastrectomy

for obesity, breast implants, and elective breast implants(74)— are unnecessary.

In 1974, the Congressional Committee on Interstate and Foreign Commerce held

hearings on unnecessary surgery. It found that 17.6% of recommendations for

surgery were not confirmed by a second opinion. The House Subcommittee on

Oversight and Investigations extrapolated these figures and estimated that, on a

nationwide basis, there were 2.4 million unnecessary surgeries performed

annually, resulting in 11,900 deaths at an annual cost of $3.9 billion.(73)

 

According to the Healthcare Cost and Utilization Project within the Agency for

Healthcare Research and Quality(13), in 2001 the 50 most common medical and

surgical procedures were performed approximately 41.8 million times in the US.

Using the 1974 House Subcommittee on Oversight and Investigations' figure of

17.6% as the percentage of unnecessary surgical procedures, and extrapolating

from the death rate in 1974, produces nearly 7.5 million (7,489,718) unnecessary

procedures and a death rate of 37,136, at a cost of $122 billion (using 1974

dollars).

 

In 1995, researchers conducted a similar analysis of back surgery procedures,

using the 1974 “unnecessary surgery percentage” of 17.6. Testifying before the

Department of Veterans Affairs, they estimated that of the 250,000 back

surgeries performed annually in the US at a hospital cost of $11,000 per

patient, the total number of unnecessary back surgeries approaches 44,000,

costing as much as $484 million.(75)

 

Like prescription drug use driven by television advertising, unnecessary

surgeries are escalating. Media-driven surgery such as gastric bypass for

obesity “modeled” by Hollywood celebrities seduces obese people to think this

route is safe and sexy. Unnecessary surgeries have even been marketed on the

Internet.(76) A study in Spain declares that 20-25% of total surgical practice

represents unnecessary operations.(77)

 

According to data from the National Center for Health Statistics for 1979 to

1984, the total number of surgical procedures increased 9% while the number of

surgeons grew 20%. The study notes that the large increase in the number of

surgeons was not accompanied by a parallel increase in the number of surgeries

performed, and expressed concern about an excess of surgeons to handle the

surgical caseload.(78)

 

From 1983 to 1994, however, the incidence of the 10 most commonly performed

surgical procedures jumped 38%, to 7,929,000 from 5,731,000 cases. By 1994,

cataract surgery was the most common procedure with more than 2 million

operations, followed by cesarean section (858,000 procedures) and inguinal

hernia operations (689,000 procedures). Knee arthroscopy procedures increased

153% while prostate surgery declined 29%.(79)

 

The list of iatrogenic complications from surgery is as long as the list of

procedures themselves. One study examined catheters that were inserted to

deliver anesthetic into the epidural space around the spinal nerves for lower

cesarean section, abdominal surgery, or prostate surgery. In some cases,

non-sterile technique during catheter insertion resulted in serious infections,

even leading to limb paralysis.(80)

 

In one review of the literature, the authors found “a significant rate of

overutilization of coronary angiography, coronary artery surgery, cardiac

pacemaker insertion, upper gastrointestinal endoscopies, carotid

endarterectomies, back surgery, and pain-relieving procedures.”(81)

 

A 1987 JAMA study found the following significant levels of inappropriate

surgery: 17% of coronary angiography procedures, 32% of carotid endarterectomy

procedures, and 17% of upper gastrointestinal tract endoscopy procedures.(82)

Based on the Healthcare Cost and Utilization Project (HCUP) statistics provided

by the government for 2001, 697,675 upper gastrointestinal endoscopies (usually

entailing biopsy) were performed, as were 142,401 endarterectomies and 719,949

coronary angiographies.(13) Extrapolating the JAMA study's inappropriate surgery

rates to 2001 produces 118,604 unnecessary endoscopy procedures, 45,568

unnecessary endarterectomies, and 122,391 unnecessary coronary angiographies.

These are all forms of medical iatrogenesis.

MEDICAL AND SURGICAL PROCEDURES

It is instructive to know the mortality rates associated with various medical

and surgical procedures. Although we must sign release forms when we undergo any

procedure, many of us are in denial about the true risks involved; because

medical and surgical procedures are so commonplace, they often are seen as both

necessary and safe. Unfortunately, allopathic medicine itself is a leading cause

of death, as well as the most expensive way to die.

 

Perhaps the words “health care” confer the illusion that medicine is about

health. Allopathic medicine is not a purveyor of health care but of disease

care. The HCUP figures are instructive,(13) but the computer program that

calculates annual mortality statistics for all US hospital discharges is only as

good as the codes entered into the system. In email correspondence, HCUP

indicated that the mortality rates for each procedure indicated only that

someone undergoing that procedure died either from the procedure or from some

other cause.

 

Thus there is no way of knowing exactly how many people die from a particular

procedure. While codes for “poisoning & toxic effects of drugs” and

“complications of treatment” do exist, the mortality figures registered in these

categories are very low and do not correlate with what is known from research

such as the 1998 JAMA study(1) that estimated an average of 106,000 prescription

medication deaths per year. No codes exist for adverse drug side effects,

surgical mishaps, or other types of medical error. Until such codes exist, the

true mortality rates tied to of medical error will remain buried in the general

statistics.

 

AN HONEST LOOK AT US HEALTH CARE

 

In 1978, the US Office of Technology Assessment (OTA) reported: “Only 10-20% of

all procedures currently used in medical practice have been shown to be

efficacious by controlled trial. " (83) In 1995, the OTA compared medical

technology in eight countries ( Australia , Canada, France, Germany, the

Netherlands, Sweden, the UK, and the US ) and again noted that few medical

procedures in the US have been subjected to clinical trial. It also reported

that US infant mortality was high and life expectancy low compared to other

developed countries.(84)

 

Although almost 10 years old, much of what was written in the OTA report holds

true today. The report blames the high cost of American medicine on the medical

free-enterprise system and failure to create a national health care policy. It

attributes the government's failure to control health care costs to market

incentives and profit motives inherent in the current financing and organization

of health care, which includes such interests as private health insurers,

hospital systems, physicians, and the drug and medical-device industries.

“Health Care Technology and Its Assessment in Eight Countries” is the last

report prepared by the OTA, which was disbanded in 1995. It also is perhaps the

US government's last honest, detailed examination of the nation's health care

system. An appendix summarizing this 60-page report follows this article.

SURGICAL ERRORS FINALLY REPORTED

An October 2003 JAMA study from the US government's Agency for Healthcare

Research and Quality (AHRQ) documented 32,000 mostly surgery-related deaths

costing $9 billion and accounting for 2.4 million extra hospital days in

2000.(85) Data from 20% of the nation's hospitals were analyzed for 18 different

surgical complications, including postoperative infections, foreign objects left

in wounds, surgical wounds reopening, and post-operative bleeding.

 

In a press release accompanying the study, AHRQ director Carolyn M. Clancy, MD,

noted: “This study gives us the first direct evidence that medical injuries pose

a real threat to the American public and increase the costs of health care.”(86)

According to the study's authors, “The findings greatly underestimate the

problem, since many other complications happen that are not listed in hospital

administrative data.” They added: " The message here is that medical injuries can

have a devastating impact on the health care system. We need more research to

identify why these injuries occur and find ways to prevent them from happening. "

The study authors said that improved medical practices, including an emphasis on

better hand washing, might help reduce morbidity and mortality rates. In an

accompanying JAMA editorial, health-risk researcher Dr. Saul Weingart of

Harvard's Beth Israel-Deaconess Medical Center wrote, “Given their staggering

magnitude, these estimates are clearly sobering.”(87)

 

UNNECESSARY X-RAYS

 

When x-rays were discovered, no one knew the long-term effects of ionizing

radiation. In the 1950s, monthly fluoroscopic exams at the doctor's office were

routine, and you could even walk into most shoe stores and see x-rays of your

foot bones. We still do not know the ultimate outcome of our initial fascination

with x-rays.

 

In those days, it was common practice to x-ray pregnant women to measure their

pelvises and make a diagnosis of twins. Finally, a study of 700,000 children

born between 1947 and 1964 in 37 major maternity hospitals compared the children

of mothers who had received pelvic x-rays during pregnancy to those of mothers

who did not. It found that cancer mortality was 40% higher among children whose

mothers had been x-rayed.(88)

 

In present-day medicine, coronary angiography is an invasive surgical procedure

that involves snaking a tube through a blood vessel in the groin up to the

heart. To obtain useful information, X-rays are taken almost continuously, with

minimum dosages ranging from 460 to 1,580 mrem. The minimum radiation from a

routine chest x-ray is 2 mrem. X-ray radiation accumulates in the body, and

ionizing radiation used in X-ray procedures has been shown to cause gene

mutation. The health impact of this high level of radiation is unknown, and

often obscured in statistical jargon such as, “The risk for lifetime fatal

cancer due to radiation exposure is estimated to be 4 in one million per 1,000

mrem.”(89)

 

Dr. John Gofman has studied the effects of radiation on human health for 45

years. A medical doctor with a PhD in nuclear and physical chemistry, Gofman

worked on the Manhattan Project, discovered uranium-233, and was the first

person to isolate plutonium. In five scientifically documented books, Gofman

provides strong evidence that medical technology—specifically x-rays, CT scans,

and mammography and fluoroscopy devices—are a contributing factor to 75% of new

cancers. In a nearly 700-page report updated in 2000, “Radiation from Medical

Procedures in the Pathogenesis of Cancer and Ischemic Heart Disease:

Dose-Response Studies with Physicians per 100,000 Population,”(90) Gofman shows

that as the number of physicians increases in a geographical area along with an

increase in the number of x-ray diagnostic tests performed, the rate of cancer

and ischemic heart disease also increases. Gofman elaborates that it is not

x-rays alone that cause the damage but a combination of health risk

factors that include poor diet, smoking, abortions, and the use of birth

control pills. Dr. Gofman predicts that ionizing radiation will be responsible

for 100 million premature deaths over the next decade.

 

In his book, “Preventing Breast Cancer,” Dr. Gofman notes that breast cancer is

the leading cause of death among American women between the ages of 44 and 55.

Because breast tissue is highly sensitive to radiation, mammograms can cause

cancer. The danger can be heightened other factors including a woman's genetic

makeup, preexisting benign breast disease, artificial menopause, obesity, and

hormonal imbalance.(91)

 

Even x-rays for back pain can lead someone into crippling surgery. Dr. John E.

Sarno, a well-known New York orthopedic surgeon, found that there is not

necessarily any association between back pain and spinal x-ray abnormality. He

cites studies of normal people without a trace of back pain whose x-rays

indicate spinal abnormalities and of people with back pain whose spines appear

to be normal on x-ray.(92) People who happen to have back pain and show an

abnormality on x-ray may be treated surgically, sometimes with no change in back

pain, worsening of back pain, or even permanent disability. Moreover, doctors

often order x-rays as protection against malpractice claims, to give the

impression of leaving no stone unturned. It appears that doctors are putting

their own fears before the interests of their patients.

 

UNNECESSARY HOSPITALIZATION

 

Nearly 9 million (8,925,033) people were hospitalized unnecessarily in 2001.(4)

In a study of inappropriate hospitalization, two doctors reviewed 1,132 medical

records. They concluded that 23% of all admissions were inappropriate and an

additional 17% could have been handled in outpatient clinics. Thirty-four

percent of all hospital days were deemed inappropriate and could have been

avoided.(93) The rate of inappropriate hospital admissions in 1990 was

23.5%.(94) In 1999, another study also found an inappropriate admissions rate of

24%, indicating a consistent pattern from 1986 to 1999.(95) The HCUP database

indicates that the total number of patient discharges from US hospitals in 2001

was 37,187,641,(13) meaning that almost 9 million people were exposed to

unnecessary medical intervention in hospitals and therefore represent almost 9

million potential iatrogenic episodes.(4)

 

WOMEN'S EXPERIENCE IN MEDICINE

 

Dr. Martin Charcot (1825-1893) was world-renowned, the most celebrated doctor of

his time. He practiced in the Paris hospital La Salpetriere. He became an expert

in hysteria, diagnosing an average of 10 hysterical women each day, transforming

them into “iatrogenic monsters” and turning simple “neurosis” into hysteria.(96)

The number of women diagnosed with hysteria and hospitalized rose from 1% in

1841 to 17% in 1883. Hysteria is derived from the Latin “hystera” meaning

uterus. According to Dr. Adriane Fugh-Berman, US medicine has a tradition of

excessive medical and surgical interventions on women. Only 100 years ago, male

doctors believed that female psychological imbalance originated in the uterus.

When surgery to remove the uterus was perfected, it became the “cure” for mental

instability, effecting a physical and psychological castration. Fugh-Berman

notes that US doctors eventually disabused themselves of that notion but have

continued to treat women very differently than they

treat men.(97) She cites the following statistics:

 

Thousands of prophylactic mastectomies are performed annually.

One-third of US women have had a hysterectomy before menopause.

Women are prescribed drugs more frequently than are men.

Women are given potent drugs for disease prevention, which results in disease

substitution due to side effects.

Fetal monitoring is unsupported by studies and not recommended by the

CDC.(98) It confines women to a hospital bed and may result in a higher

incidence of cesarean section.(99)

Normal processes such as menopause and childbirth have been heavily

“medicalized.”

Synthetic hormone replacement therapy (HRT) does not prevent heart disease or

dementia, but does increase the risk of breast cancer, heart disease, stroke,

and gall bladder attack.(100)

 

As many as one-third of postmenopausal women use HRT.(101,102) This number is

important in light of the much-publicized Women's Health Initiative Study, which

was halted before its completion because of a higher death rate in the synthetic

estrogen-progestin (HRT) group.(103)

 

 

Cesarean Section

 

In 1983, 809,000 cesarean sections (21% of live births) were performed in the

US, making it the nation's most common obstetric-gynecologic (OB/GYN) surgical

procedure. The second most common OB/GYN operation was hysterectomy (673,000),

followed by diagnostic dilation and curettage of the uterus (632,000). In 1983,

OB/GYN procedures represented 23% of all surgery completed in the US.(104)

 

In 2001, cesarean section is still the most common OB/GYN surgical procedure.

Approximately 4 million births occur annually, with 24% (960,000) delivered by

cesarean section. In the Netherlands, only 8% of births are delivered by

cesarean section. This suggests 640,000 unnecessary cesarean sections—entailing

three to four times higher mortality and 20 times greater morbidity than vaginal

delivery(105)—are performed annually in the US.

 

The US cesarean rate rose from just 4.5% in 1965 to 24.1% in 1986. Sakala

contends that an “uncontrolled pandemic of medically unnecessary cesarean births

is occurring.”(106) VanHam reported a cesarean section postpartum hemorrhage

rate of 7%, a hematoma formation rate of 3.5%, a urinary tract infection rate of

3%, and a combined postoperative morbidity rate of 35.7% in a high-risk

population undergoing cesarean section.(107)

 

NEVER ENOUGH STUDIES

 

Scientists claimed there were never enough studies revealing the dangers of DDT

and other dangerous pesticides to ban them. They also used this argument for

tobacco, claiming that more studies were needed before they could be certain

that tobacco really caused lung cancer. Even the American Medical Association

(AMA) was complicit in suppressing the results of tobacco research. In 1964,

when the Surgeon General's report condemned smoking, the AMA refused to endorse

it, claiming a need for more research. What they really wanted was more money,

which they received from a consortium of tobacco companies that paid the AMA $18

million over the next nine years during which the AMA said nothing about the

dangers of smoking.(108)

 

The Journal of the American Medical Association (JAMA), " after careful

consideration of the extent to which cigarettes were used by physicians in

practice, " began accepting tobacco advertisements and money in 1933. State

journals such as the New York State Journal of Medicine also began to run

advertisements for Chesterfield cigarettes that claimed cigarettes are " Just as

pure as the water you drink… and practically untouched by human hands. " In 1948,

JAMA argued " more can be said in behalf of smoking as a form of escape from

tension than against it… there does not seem to be any preponderance of evidence

that would indicate the abolition of the use of tobacco as a substance contrary

to the public health. " (109) Today, scientists continue to use the excuse that

more studies are needed before they will support restricting the inordinate use

of drugs.

 

ADVERSE DRUG REACTIONS

 

The Lazarou study(1) analyzed records for prescribed medications for 33 million

US hospital admissions in 1994. It discovered 2.2 million serious injuries due

to prescribed drugs; 2.1% of inpatients experienced a serious adverse drug

reaction, 4.7% of all hospital admissions were due to a serious adverse drug

reaction, and fatal adverse drug reactions occurred in 0.19% of inpatients and

0.13% of admissions. The authors estimated that 106,000 deaths occur annually

due to adverse drug reactions.

 

Using a cost analysis from a 2000 study in which the increase in hospitalization

costs per patient suffering an adverse drug reaction was $5,483, costs for the

Lazarou study's 2.2 million patients with serious drug reactions amounted to $12

billion.(1,49)

 

Serious adverse drug reactions commonly emerge after FDA approval of the drugs

involved. The safety of new agents cannot be known with certainty until a drug

has been on the market for many years.(110)

 

BEDSORES

 

Over one million people develop bedsores in U.S. hospitals every year. It's a

tremendous burden to patients and family, and a $55 billion dollar healthcare

burden. (7) Bedsores are preventable with proper nursing care. It is true that

50% of those affected are in a vulnerable age group of over 70. In the elderly

bedsores carry a fourfold increase in the rate of death. The mortality rate in

hospitals for patients with bedsores is between 23% and 37%. (8) Even if we just

take the 50% of people over 70 with bedsores and the lowest mortality at 23%,

that gives us a death rate due to bedsores of 115,000. Critics will say that it

was the disease or advanced age that killed the patient, not the bedsore, but

our argument is that an early death, by denying proper care, deserves to be

counted. It is only after counting these unnecessary deaths that we can then

turn our attention to fixing the problem.

 

MALNUTRITION IN NURSING HOMES

 

The General Accounting Office (GAO), a special investigative branch of Congress,

cited 20% of the nation's 17,000 nursing homes for violations between July 2000

and January 2002. Many violations involved serious physical injury and

death.(111)

 

A report from the Coalition for Nursing Home Reform states that at least

one-third of the nation's 1.6 million nursing home residents may suffer from

malnutrition and dehydration, which hastens their death. The report calls for

adequate nursing staff to help feed patients who are not able to manage a food

tray by themselves.(11) It is difficult to place a mortality rate on

malnutrition and dehydration. The Coalition report states that malnourished

residents, compared with well-nourished hospitalized nursing home residents,

have a fivefold increase in mortality when they are admitted to a hospital.

Multiplying the one-third of 1.6 million nursing home residents who are

malnourished by a mortality rate of 20%(8,14) results in 108,800 premature

deaths due to malnutrition in nursing homes.

 

Nosocomial Infections

 

The rate of nosocomial infections per 1,000 patient days rose from 7.2 in 1975

to 9.8 in 1995, a 36% jump in 20 years. Reports from more than 270 US hospitals

showed that the nosocomial infection rate itself had remained stable over the

previous 20 years, with approximately five to six hospital-acquired infections

occurring per 100 admissions, a rate of 5-6%. Due to progressively shorter

inpatient stays and the increasing number of admissions, however, the number of

infections increased. It is estimated that in 1995, nosocomial infections cost

$4.5 billion and contributed to more than 88,000 deaths, or one death every 6

minutes.(9) The 2003 incidence of nosocomial mortality is quite probably higher

than in 1995 because of the tremendous increase in antibiotic-resistant

organisms. Morbidity and Mortality Report found that nosocomial infections cost

$5 billion annually in 1999,(10) representing a $0.5 billion increase in just

four years. At this rate of increase, the current cost of

nosocomial infections would be around $5.5 billion.

 

Outpatient Iatrogenesis

 

In a 2000 JAMA article, Dr. Barbara Starfield presents well-documented facts

that are both shocking and unassailable.(12) The U.S. ranks 12th of 13

industrialized countries when judged by 16 health status indicators. Japan,

Sweden, and Canada were first, second, and third, respectively. More than 40

million people in the US have no health insurance, and 20-30% of patients

receive contraindicated care.

 

Starfield warns that one cause of medical mistakes is overuse of technology,

which may create a " cascade effect " leading to still more treatment. She urges

the use of ICD (International Classification of Diseases) codes that have

designations such as " Drugs, Medicinal, and Biological Substances Causing

Adverse Effects in Therapeutic Use " and " Complications of Surgical and Medical

Care " to help doctors quantify and recognize the magnitude of the medical error

problem. Starfield notes that many deaths attributable to medical error today

are likely to be coded to indicate some other cause of death. She concludes that

against the backdrop of our poor health report card compared to other

Westernized countries, we should recognize that the harmful effects of health

care interventions account for a substantial proportion of our excess deaths.

 

Starfield cites Weingart's 2000 article, “Epidemiology of Medical Error,” as

well as other authors to suggest that between 4% and 18% of consecutive patients

in outpatient settings suffer an iatrogenic event leading to:

 

116 million extra physician visits

77 million extra prescriptions filled

17 million emergency department visits

8 million hospitalizations

3 million long-term admissions

199,000 additional deaths

$77 billion in extra costs(112)

 

Unnecessary Surgeries

 

While some 12,000 deaths occur each year from unnecessary surgeries, results

from the few studies that have measured unnecessary surgery directly indicate

that for some highly controversial operations, the proportion of unwarranted

surgeries could be as high as 30%.(74)

 

MEDICAL ERRORS: A GLOBAL ISSUE

 

A five-country survey published in the Journal of Health Affairs found that

18-28% of people who were recently ill had suffered from a medical or drug error

in the previous two years. The study surveyed 750 recently ill adults. The

breakdown by country showed the percentages of those suffering a medical or drug

error were 18% in Britain, 23% in Australia and in New Zealand, 25% in Canada,

and 28% in the US.(113)

 

HEALTH INSURANCE

 

The Institute of Medicine recently found that the 41 million Americans with no

health insurance have consistently worse clinical outcomes than those who are

insured, and are at increased risk for dying prematurely (114).

 

When doctors bill for services they do not render, advise unnecessary tests, or

screen everyone for a rare condition, they are committing insurance fraud. The

US GAO estimated that $12 billion dollars was lost to fraudulent or unnecessary

claims in 1998, and reclaimed $480 million in judgments in that year. In 2001,

the federal government won or negotiated more than $1.7 billion in judgments,

settlements, and administrative impositions in health care fraud cases and

proceedings.(115)

 

WAREHOUSING OUR ELDERS

 

One way to measure the moral and ethical fiber of a society is by how it treats

its weakest and most vulnerable members. In some cultures, elderly people lives

out their lives in extended family settings that enable them to continue

participating in family and community affairs. American nursing homes, where

millions of our elders go to live out their final days, represent the pinnacle

of social isolation and medical abuse.

 

In America, approximately 1.6 million elderly are confined to nursing homes.

By 2050, that number could be 6.6 million.(11,116)

Twenty percent of all deaths from all causes occur in nursing homes.(117)

Hip fractures are the single greatest reason for nursing home

admissions.(118)

Nursing homes represent a reservoir for drug-resistant organisms due to

overuse of antibiotics.(119)

 

Presenting a report he sponsored entitled " Abuse of Residents is a Major Problem

in U.S. Nursing Homes " on July 30, 2001, Rep. Henry Waxman (D-CA) noted that “as

a society we will be judged by how we treat the elderly. " The report found

one-third of the nation's approximately 17,000 nursing homes were cited for an

abuse violation in a two-year period from January 1999 to January 2001.(116)

According to Waxman, “the people who cared for us deserve better. " The report

suggests that this known abuse represents only the “tip of the iceberg” and that

much more abuse occurs that we aware of or ignore.(116a) The report found:

 

Over 30% of US nursing homes were cited for abuses, totaling more than 9,000

violations.

10% of nursing homes had violations that caused actual physical harm to

residents or worse.

Over 40% (3,800) of the abuse violations followed the filing of a formal

complaint, usually by concerned family members.

Many verbal abuse violations were found.

Occasions of sexual abuse.

Incidents of physical abuse causing numerous injuries such as fractured

femur, hip, elbow, wrist, and other injuries.

 

Dangerously understaffed nursing homes lead to neglect, abuse, overuse of

medications, and physical restraints. In 1990, Congress mandated an exhaustive

study of nurse-to-patient ratios in nursing homes. The study was finally begun

in 1998 and took four years to complete.(120) A spokesperson for The National

Citizens' Coalition for Nursing Home Reform commented on the study: “They

compiled two reports of three volumes each thoroughly documenting the number of

hours of care residents must receive from nurses and nursing assistants to avoid

painful, even dangerous, conditions such as bedsores and infections. Yet it took

the Department of Health and Human Services and Secretary Tommy Thompson only

four months to dismiss the report as ‘insufficient.'”(121) Although preventable

with proper nursing care, bedsores occur three times more commonly in nursing

homes than in acute care or veterans hospitals.(122).

 

Because many nursing home patients suffer from chronic debilitating conditions,

their assumed cause of death often is unquestioned by physicians. Some studies

show that as many as 50% of deaths due to restraints, falls, suicide, homicide,

and choking in nursing homes may be covered up.(123,124) It is possible that

many nursing home deaths are instead attributed to heart disease. In fact,

researchers have found that heart disease may be over-represented in the general

population as a cause of death on death certificates by 8-24%. In the elderly,

the overreporting of heart disease as a cause of death is as much as

twofold.(125)

 

That very few statistics exist concerning malnutrition in acute-care hospitals

and nursing homes demonstrates the lack of concern in this area. While a survey

of the literature turns up few US studies, one revealing US study evaluated the

nutritional status of 837 patients in a 100-bed subacute-care hospital over a

14-month period. The study found only 8% of the patients were well nourished,

while 29% were malnourished and 63% were at risk of malnutrition. As a result,

25% of the malnourished patients required readmission to an acute-care hospital,

compared to 11% of the well-nourished patients. The authors concluded that

malnutrition reached epidemic proportions in patients admitted to this

subacute-care facility.(126)

 

Many studies conclude that physical restraints are an underreported and

preventable cause of death. Studies show that compared to no restraints, the use

of restraints carries a higher mortality rate and economic burden.(127-129)

Studies have found that physical restraints, including bedrails, are the cause

of at least 1 in every 1,000 nursing-home deaths.(130-132)

 

Deaths caused by malnutrition, dehydration, and physical restraints, however,

are rarely recorded on death certificates. Several studies reveal that nearly

half of the listed causes of death on death certificates for elderly people with

chronic or multi-system disease are inaccurate.(133) Even though 1 in 5 people

die in nursing homes, an autopsy is performed in less than 1% of these

deaths.(134).

 

Overmedicating Seniors

 

Dr. Robert Epstein, chief medical officer of Medco Health Solutions Inc. (a unit

of Merck & Co.), conducted a study in 2003 of drug trends among the

elderly.(135) He found that seniors are going to multiple physicians, getting

multiple prescriptions, and using multiple pharmacies. Medco oversees

drug-benefit plans for more than 60 million Americans, including 6.3 million

seniors who received more than 160 million prescriptions. According to the

study, the average senior receives 25 prescriptions each year. Among those 6.3

million seniors, a total of 7.9 million medication alerts were triggered: less

than one-half that number, 3.4 million, were detected in 1999. About 2.2 million

of those alerts indicated excessive dosages unsuitable for seniors, and about

2.4 million alerts indicated clinically inappropriate drugs for the elderly.

Reuters interviewed Kasey Thompson, director of the Center on Patient Safety at

the American Society of Health System Pharmacists, who noted: “There are

serious and systemic problems with poor continuity of care in the United States

..” He says this study represents only “the tip of the iceberg” of a national

problem.

 

According to Drug Benefit Trends , the average number of prescriptions dispensed

per non-Medicare HMO member per year rose 5.6% from 1999 to 2000, - from 7.1 to

7.5 prescriptions. The average number dispensed for Medicare members increased

5.5%, from 18.1 to 19.1 prescriptions.(136) The total number of prescriptions

written in the US in 2000 was 2.98 billion, or 10.4 prescriptions for every man,

woman, and child.(137)

 

In a study of 818 residents of residential care facilities for the elderly, 94%

were receiving at least one medication at the time of the interview. The average

intake of medications was five per resident; the authors noted that many of

these drugs were given without a documented diagnosis justifying their use.(138)

 

Seniors and groups like the American Association for Retired Persons (AARP) are

demanding that prescription drug coverage be a basic right.(139) They have

accepted allopathic medicine's overriding assumption that aging and dying in

America must be accompanied by drugs in nursing homes and eventual

hospitalization. Seniors are given the choice of either high-cost patented drugs

or low-cost generic drugs. Drug companies attempt to keep the most expensive

drugs on the shelves and suppress access to generic drugs, despite facing stiff

fines of hundreds of millions of dollars levied by the federal

government.(140,141) In 2001, some of the world's largest drug companies were

fined a record $871 million for conspiring to increase the price of

vitamins.(142)

 

Current AARP recommendations for diet and nutrition assume that seniors are

getting all the nutrition they need in an average diet. At most, AARP suggests

adding extra calcium and a multivitamin and mineral supplement.(143)

 

Ironically, studies also indicate underuse of proper pain medication for

patients who need it. One study evaluated pain management in a group of 13,625

cancer patients, aged 65 and over, living in nursing homes. While almost 30% of

the patients reported pain, more than 25% received no pain relief medication,

16% received a mild analgesic drug, 32% received a moderate analgesic drug, and

26% received adequate pain-relieving morphine. The authors concluded that older

patients and minority patients were more likely to have their pain

untreated.(144)

 

WHAT REMAINS TO BE UNCOVERED

 

Our ongoing research will continue to quantify the morbidity, mortality, and

financial loss due to:

 

X-ray exposures (mammography, fluoroscopy, CT scans).

Overuse of antibiotics for all conditions.

Carcinogenic drugs (hormone replacement therapy,* immunosuppressive and

prescription drugs).

Cancer chemotherapy(70)

Surgery and unnecessary surgery (cesarean section, radical mastectomy,

preventive mastectomy, radical hysterectomy, prostatectomy, cholecystectomies,

cosmetic surgery, arthroscopy, etc.).

Discredited medical procedures and therapies.

Unproven medical therapies.

Outpatient surgery.

Doctors themselves.

 

* Part of our ongoing research will be to quantify the mortality and morbidity

caused by hormone replacement therapy (HRT) since the 1940s. In December 2000, a

government scientific advisory panel recommended that synthetic estrogen be

added to the nation's list of cancer-causing agents. HRT, either synthetic

estrogen alone or combined with synthetic progesterone, is used by an estimated

13.5 to 16 million women in the US.(145) The aborted Women's Health Initiative

Study (WHI) of 2002 showed that women taking synthetic estrogen combined with

synthetic progesterone have a higher incidence of ovarian cancer, breast cancer,

stroke, and heart disease, with little evidence of osteoporosis reduction or

dementia prevention. WHI researchers, who usually never make recommendations

except to suggest more studies, advised doctors to be very cautious about

prescribing HRT to their patients.(100,146-150)

 

Results of the “Million Women Study” on HRT and breast cancer in the UK were

published in medical journal The Lancet in August 2003. According to lead author

Prof. Valerie Beral, director of the Cancer Research UK Epidemiology Unit: " We

estimate that over the past decade, use of HRT by UK women aged 50-64 has

resulted in an extra 20,000 breast cancers, estrogen-progestagen (combination)

therapy accounting for 15,000 of these.”(151) We were unable to find statistics

on breast cancer, stroke, uterine cancer, or heart disease caused by HRT used by

American women. Because the US population is roughly six times that of the UK,

it is possible that 120,000 cases of breast cancer have been caused by HRT in

the past decade.

 

 

OFFICE OF TECHNOLOGY ASSESSMENT (OTA)

 

Health Care Technology and Its Assessment in Eight Countries, 1995.

General Facts

In 1990, US life expectancy was 71.8 years for men and 78.8 years for women,

among the lowest rates in the developed countries.

The 1990 US infant mortality rate in the US was 9.2 per 1,000 live births, in

the bottom half of the distribution among all developed countries.

Health status is correlated with socioeconomic status.

Health care is not universal.

Health care is based on the free market system with no fixed budget or

limitations on expansion.

Health care accounts for 14% of the US GNP ($800 billion in 1993).

The federal government does no central planning, though it is the major

purchaser of health care for older people and some poor people.

Americans are less satisfied with their health care system than people in

other developed countries.

US medicine specializes in expensive medical technology; some large US cities

have more magnetic resonance image (MRI) scanners than most countries.

Huge public and private investments in medical research and pharmaceutical

development drive this “technological arms race.”

Any efforts to restrain technological developments in health care are opposed

by policymakers concerned about negative impacts on medical-technology

industries.

Hospitals

In 1990, the US had 5,480 acute-care hospitals, 880 specialty (psychiatric,

long-term care, and rehabilitation) hospitals, and 340 federal (military,

veterans, and Native American) hospitals, or 2.7 hospitals per 100,000

population.

In 1990, the average length of stay for 33 million admissions was 9.2 days.

The bed occupancy rate was 66%. Lengths of stay were shorter and admission rates

lower than other countries.

In 1990, the US had 615,000 physicians, or 2.4 per 1,000 population; 33% were

primary care (family medicine, internal medicine, and pediatrics) and 67% were

specialists.

In 1991, government-run health care spending totaled $81 billion.

Total US health care spending rose to $752 billion in 1991 from $70 billion

in 1950. Spending grew five-fold per capita.

Reasons for increased healthcare spending include:

The high cost of defensive medicine, with an escalation in services solely

to avoid malpractice litigation.

US health care based on defensive medicine costs nearly $45 billion per

year, or about 5% of total health care spending, according to one source.

The availability and use of new medical technologies have contributed the

most to increased health care spending, argue many analysts. These costs are

impossible to quantify.

 

The reasons government attempts to control health care costs have failed

include:

Market incentive and profit-motive involvement in the financing and

organization of health care, including private insurers, hospital systems,

physicians, and the drug and medical-device industries.

Expansion is the goal of free enterprise.

 

 

Health-Related Research and Development

 

The US spends more than any other country on health-related R & D.

In 1989, the federal government spent $9.2 billion on R & D, while private

industry spent an additional $9.4 billion.

Total US R & D expenditures rose 50% from 1983 to 1992.

NIH receives about half of US government R & D funding.

NIH spent more on basic research ($4.1 billion in 1989) than for clinical

trials of medical treatments on humans ($519 million in 1989).

Most of the clinical trials evaluate new treatment protocols for cancer and

complications of AIDS, and do not study existing treatments, even though their

effectiveness is in many cases unknown and questionable.

In 1990, the NIH had just begun to do meta-analysis and cost-effectiveness

analysis.

Pharmaceutical and Medical-Device Industries

About two-thirds of the industry's $9.4 billion budget went to drug research;

device manufacturers spent the remaining one-third.

In addition to R & D, the medical industry spent 24% of total sales on

promoting their products and 15% of total sales on development.

Total marketing expenses in 1990 were over $5 billion.

Many products provide no benefit over existing products.

Public and private health care consumers buy these products.

If health care spending is perceived as a problem, a highly profitable drug

industry exacerbates the problem.

Controlling Health Care Technology

The FDA ensures the safety and efficacy of drugs, biologics, and medical

devices.

The FDA does not consider costs of therapy.

The FDA does not consider the effectiveness of a therapy.

The FDA does not compare a product to currently marketed products

The FDA does not consider nondrug alternatives for a given clinical problem.

It costs $200 million in development costs to bring a new drug to market.

AIDS-drug interest groups forced new regulations that speed up the approval

process.

Such drugs should be subject to greater post-marketing surveillance

requirements. As of 1995, these provisions had not yet come into play.

Many argue that reductions in the pre-approval testing of drugs open the

possibility of significant undiscovered toxicities.

Health Care Technology Assessment

Failure to evaluate technology was a focus of a 1978 report from OTA with

examples of many common medical practices supported by limited published data

(10-20%).

In 1978, Congress created the National Center for Health Care Technology

(NCHCT) to advise Medicare and Medicaid.

With an annual budget of $4 million, NCHCT published three broad assessments

of high-priority technologies and made about 75 coverage recommendations to

Medicare.

Congress disbanded NCHCT in 1981. The medical profession opposed it from the

beginning. The AMA testified before Congress in 1981 that “clinical policy

analysis and judgments are better made—and are being responsibly made—within the

medical profession. Assessing risks and costs, as well as benefits, has been

central to the exercise of good medical judgment for decades.”

The medical device lobby also opposed government oversight by NCHCT.

 

Examples of Lack of Proper Management of HealthCare

 

Treatments for Coronary Artery Disease

 

Since the early 1970s, the number of coronary artery bypass surgeries (CABGS)

has risen rapidly without government regulation or clinical trials.

Angioplasty for single vessel disease was introduced in 1978. The first

published trial of angioplasty versus medical treatment was done in 1992.

Angioplasty did not reduce the number of CABGS, as was promoted.

Both procedures increase in number every year as the patient population grows

older and sicker.

Rates of use are higher in white patients and private insurance patients, and

vary greatly by geographic region, suggesting that use of these procedures is

based on non-clinical factors.

As of 1995, the NIH consensus program had not assessed CABGS since 1980 and

had never assessed angioplasty.

RAND researchers evaluated CABGS in New York in 1990. They reviewed 1,300

procedures and found 2% were inappropriate, 90% were appropriate, and 7% were

uncertain. For 1,300 angioplasties, 4% were inappropriate and 38% uncertain.

Using RAND methodologies, a panel of British physicians rated twice as many

procedures “inappropriate” as did a US panel rating the same clinical cases. The

New York numbers are in question because New York State limits the number of

surgery centers, and the per-capita supply of cardiac surgeons in New York is

about one-half of the national average.

The estimated five-year cost is $33,000 for angioplasty and $40,000 for

CABGS. Angioplasty did not lower costs, due to its high failure rates.

Computed Tomography (CT)

The first CT scanner in the US was installed at the Mayo Clinic in 1973. By

1992, the number of operational CT scanners in the US had grown to 6,060. By

comparison, in 1993 there were 216 CT units in Canada .

There is little information available on how CT scans improve or affect

patient outcomes

In some institutions, up to 90% of scans performed were negative.

Approval by the FDA was not required for CT scanners, nor was any evidence of

safety or efficacy.

Magnetic Resonance Imaging (MRI)

MRIs were introduced in Great Britain in 1978 and in the US in 1980. By 1988,

there were 1,230 units and by 1992 between 2,800 and 3,000.

A definitive review published in 1994 found less than 30 studies of 5,000

that were prospective comparisons of diagnostic accuracy or therapeutic choice.

The American College of Physicians assessed MRI studies and rated 13 of 17

trials as “weak,” i.e., lacking data concerning therapeutic impact or patient

outcomes.

The OTA concluded: “It is evident that hospitals, physician-entrepreneurs,

and medical device manufacturers have approached MRI and CT as commodities with

high-profit potential, and decision-making on the acquisition and use of these

procedures has been highly influenced by this approach. Clinical evaluation,

appropriate patient selection, and matching supply to legitimate demand might be

viewed as secondary forces.”

Laparoscopic Surgery

Laparoscopic cholecystectomy was introduced at a professional surgical

society meeting in late 1989. By 1992, 85% of all cholecystectomies were

performed laparoscopically.

There was an associated increase of 30% in the number of cholecystectomies

performed.

Because of the increased volume of gall bladder operations, their total cost

increased 11.4% between 1988 and 1992, despite a 25.1% drop in the average cost

per surgery.

The mortality rate for gall bladder surgeries did not decline as a result of

the lower risk because so many more were performed.

When studies were finally done on completed cases, the results showed that

laparoscopic cholecystectomy was associated with reduced inpatient duration,

decreased pain, and a shorter period of restricted activity. But rates of bile

duct and major vessel injury increased and it was suggested that these rates

were worse for people with acute cholecystitis. No clinical trials had been done

to clarify this issue.

Patient demand, fueled by substantial media attention, was a major force in

promoting rapid adoption of these procedures.

The major manufacturer of laparoscopic equipment produced the video that

introduced the procedure in 1989.

Doctors were given two-day training seminars before performing the surgery on

patients.

Infant Mortality

In 1990, the US ranked 24th in infant mortality of 38 developed countries

with a rate of 9.2 deaths per 1,000 live births.

US black infant mortality is 18.6 per 1,000 live births, compared to 8.8 for

whites.

Screening for Breast Cancer

Mammography screening in women under 50 has always been a subject of debate.

In 1992, the Canadian National Breast Cancer Study of 50,000 women showed

that mammography had no effect on mortality for women aged 40-50.

The National Cancer Institute (NCI) refused to change its recommendations on

mammography.

The American Cancer Society decided to wait for more studies on mammography.

In December 1993, NCI announced that women over 50 should have routine

screenings every one to two years but that younger women would derive no benefit

from mammography.

Summary

The OTA concluded: “There are no mechanisms in place to limit dissemination

of technologies regardless of their clinical value.”

Shortly after the release of this report, the OTA was disbanded.

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