Overdosed America (37 page)

What does the research show that we can do to increase our chances of staying healthy? On an individual basis, the answers are remarkably simple. In 2002 the medical journal of the American Heart Association,
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Circulation,
published an article that reviewed the important studies on coronary heart disease prevention through diet and lifestyle interventions. The article concluded that by following the
recommendations that emerge from the scientific evidence
, “coronary heart disease can be eliminated to a large extent” among people less than 70 years of age. From the studies presented in this chapter, we see that these same recommendations also apply to the prevention of type 2 diabetes, osteoporosis, and stroke, and help prevent cancer and depression as well. With slight modifications and the inclusion of safety recommendations, here is the list:

1. Avoid tobacco.

2. Exercise moderately for at least 30 minutes or more on most days, engaging in activities such as brisk walking, biking, or gardening.

3. Consume alcohol in moderation, if at all.

4. Eat a healthy diet:

• Cut down on red meat in favor of chicken, fish (including fatty fish at least once a week)
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, and vegetable proteins.

• Eat at least a pound of vegetables and fruits every day.

• Limit salt to less than a teaspoon a day.

• Cut down on sugar.

• For cooking, use vegetable oils such as canola and olive oil.

• Minimize intake of saturated fats and cholesterol.

• Consume less than 2 percent of calories in trans fat (the “partially hydrogenated oil” found in many margarines and many baked goods, cookies, crackers, candy bars, and breakfast cereals; check ingredient labels). The optimal daily intake of trans fat: none.

5. Keep your body mass index (BMI) from going over 25 (meaning, don’t be overweight for your height). The good news is that if you do the other things on this list, your weight will be much easier to keep in check.

6. Use seat belts and bike helmets. Most important, don’t drink and drive; and do work within your community to help create a social climate that discourages those most at risk—young adults between the ages of 16 and 25—from drinking and driving.

7. Don’t engage in unsafe sex.

This may sound quite formidable at first, but two studies show just how simple and effective healthy habits can be. A study published in the
New England Journal of Medicine
followed the activity level and health of
retired, nonsmoking men in Honolulu
between the ages of 61 and 81. During the 12 years of the study, almost twice as many of the men who walked less than 1 mile each day died (41 percent) as the men who walked more than 2 miles per day (24 percent).

Another study, published in the
Journal of the American Medical Association
in 2003, followed the health of
9700 independently living women
, age 65 and older, for up to 12 years. (This study was originally designed to determine risk factors for fractures in older women.) Among the women who were walking 2 miles or less each week at the beginning of the study, those who increased their walking to at least 1 mile per day cut their death rate in half compared with those who remained sedentary. (Both of these studies are observational and could be biased by underlying differences that led to healthier people walking more, though the researchers took all possible measures to exclude this possibility.)

Just knowing these recommendations, however, is not enough: Making positive changes is often complicated by personal inertia and social, economic, and environmental factors beyond the control of individuals and even whole communities. This is where ongoing relationships with primary care doctors and other medical professionals can help to bridge the gap between the science that informs preventive health care and the personal resistance that can make change so difficult. Still, the obesity and diabetes epidemics show that the focus of medicine cannot be limited to the health of individuals. The cultural environment in which our lives unfold also plays a major role in determining our health. Pediatricians and family doctors, for example, cannot possibly stem the tide of childhood obesity by themselves when advertisements for fast food and snack foods and vending machines containing high-calorie snacks saturate children’s environment, presenting a far more compelling message.

Hopefully, in the years to come we will look back and see how ridiculous we were to have believed that biomedicine alone—without considering the health consequences of how we live our lives—could possibly provide optimal health. The measure of America’s recovery from this era of commercially distorted medicine will be the extent to which real and effective encouragement of healthy ways of living is reintegrated into the best medical care available—not replacing, but supported by, the appropriate clinical application of biomedical science.

There was a
time not so long ago when breakthroughs in medical science were driven more by health needs than by the search for corporate profits. Perhaps the best example is the research that produced the polio vaccine, one of the truly great breakthroughs of modern medicine. In 1955, amid the great fanfare that accompanied the initial release of the vaccine,
Dr. Jonas Salk
was asked who owned the patent. He replied, “Well, the people, I would say. Could you patent the sun?”

American medicine has changed a lot since then, especially in the last 10 or 15 years. Many of these changes come not from medical science itself, but from the changed purpose for which medical knowledge is created and disseminated. Most of us take for granted that the well-established rules of science ensure the validity of medical research, regardless of the purpose for which the research is undertaken or the context in which it is performed. Nothing could be further from the truth.

The privatization of the majority of clinical research, the
diminished role of universities
as impartial overseers of medical knowledge, and the drug and medical-device industry’s growing influence on government have all contributed to the changed role of medical knowledge in our society. The goal of performing rigorous medical studies is often replaced by the goal of creating the perception that rigorous medical studies call for increased use of the sponsors’ products.

In this climate, the editors of the most respected medical journals have warned that they cannot protect their readers from the pro-industry bias seeping into many of the scientific articles they publish. Nonetheless, publication in respected medical journals still anoints research findings as the scientific evidence upon which good doctors confidently base their clinical decisions. It is not simply due to the “play of chance” that the odds are five times greater that new products will be supported by commercially sponsored studies than by studies with noncommercial sponsorship. The bias is, at best, difficult and often impossible for even the most careful readers to spot, let alone unravel. And simply knowing that it exists is not enough to protect readers from being misled.

If we are to begin to solve the crises in American medicine, we first need to stop pretending that the current organization of the production and dissemination of medical knowledge is serving the public’s interest. The ideal of
“well-ordered science”
(a phrase coined by philosopher Philip Kitcher in his book
Science, Truth, and Democracy
) is often replaced in commercially sponsored medical research by the ideal of profit-maximizing science. Dr. Andrew Bodnar, a senior vice president at Bristol-Myers Squibb, summarized this issue when he told the
New York Times,
“In a science-driven organization
, the notion of marketing versus science is really a false dichotomy.” Disciplined science performed by impartial researchers and openly shared with professional colleagues and the public is often replaced with games of cat and mouse in which corporate sponsors do their best to hide both the ways that their scientific results have been spun, and the results that can’t be spun. But medical research is not a game, and, as Kitcher points out,
the more important the consequences
, the higher the scientific standards should be.

This is the mother of all sleights of hand: the transformation of medical science from a public good whose purpose is to improve health into a commodity whose primary function is to maximize financial returns. As a result of this sleight of hand, the gap is widening between the scientific evidence that impartial experts (not paid or threatened by the medical industry, not biased by other personal concerns, and granted unrestricted access to all of the evidence) would agree upon and the perceptions that actually drive American health care. This growing gap is at the core of the crisis in American medicine. And why are we surprised? The drug companies have no more responsibility to oversee the public’s health than the fast-food industry has to oversee the public’s diet.

The substitution of narrow corporate interests for medical progress has produced some dramatic excesses. When the manufacturer of Paxil performs
nine clinical studies
on the treatment of adolescents for depression and finds that Paxil is no more effective than placebos and, in fact, significantly increases the frequency of “emotional lability” (including suicidal thoughts and attempts), it’s no problem. The company publishes one study that shows a benefit, fails to publish the other eight, and markets away. When British drug authorities spill the beans? No problem. A
task force of the American College of Neuropsychopharmacolgy
is convened, and concludes that the new antidepressants are safe for adolescents after all. Too bad the task force didn’t have access to some of the information that was available to the British drug authorities. But perhaps that didn’t seem like so much of a problem, because, according to the
New York Times,
“Critics of the medicines noted that 9 of the 10 task force members had significant financial ties to the pharmaceutical industry.. . .” (However, the task force insisted that no industry money financed their report.) What to do when the
FDA epidemiologist
in charge of analyzing all the antidepressant studies involving children concludes, just like the British drug authorities, that twice as many children treated with the new drugs (except Prozac, which is available as an inexpensive generic) became suicidal, and that the FDA should therefore discourage doctors from treating children with these drugs? Just bar the expert from testifying at the FDA’s public hearing. Then don’t make him available for an interview with the
New York Times,
which reported the story on April 16, 2004.

You don’t like the way the
study of an expensive drug
for blood pressure is going? A nonissue—just stop the study before the results reach statistical significance.

Endovascular Technologies (a wholly owned subsidiary of Guidant, the company that manufactures implantable defibrillators) manufactured
a $10,000 device to repair aortic aneurysms
that dangerously malfunctioned in a third of the 7600 patients in whom it had been used. Did this frequency of malfunction stop Endovascular Technologies? No. The company reported 7 percent of these events to the FDA and sold on. According to a plea agreement entered into with the United States government in 2003, the company belatedly disclosed another 2628 serious malfunctions and 12 deaths. No problem. It agreed to pay $92 million to cover criminal and civil penalties and then picked up with business as usual on other products.

Your drug company just received an official warning letter from the FDA for the “false and misleading” marketing of Celebrex, Vioxx, Pravachol, or OxyContin? No problem. The FDA’s corrective action is unlikely to displace the false information already firmly planted in the public’s mind.

And the list goes on. Controlling medical costs in this near free-for-all commercial grab is not just impossible, it is a contradiction in terms. Does it make sense to talk about reducing national expenditures for cars or clothes or beer? Medical care, by far the largest consumer commodity in the United States, is now no different.

Like any well-functioning consumer market, the medical industry does its best to stimulate ever-greater demand. In this context, being assured of ongoing access to “the best” medical care is as much a contradiction as controlling medical costs. The Medicare prescription drug bill is a perfect example.
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This bill was supposedly designed to improve senior citizens’ access to the prescription drugs they need. For those with the lowest incomes, it will make prescription drugs more accessible—with the drug companies receiving full price from a segment of the market that would not otherwise have been able to afford these drugs. However, according to the
Consumers Union
and 19 labor union and public interest groups, after the new prescription drug “benefit” takes effect, the average Medicare patient, who spent $2318 out of pocket for prescription drugs in 2003, will spend $2911 out of pocket in 2007. Ostensibly designed to decrease the financial burden of prescription drugs for senior citizens, the legislation will do just the opposite.

How can this happen? Expenditures for prescription drugs have been increasing seven times faster than the rate of inflation, but the 2003 legislation
specifically prohibits
the federal government from using its purchasing power to negotiate prices with drug makers, as is done successfully by the Veterans Health Administration and Defense Department (and by
Canada and the European countries
—which is why their drug prices are so much lower than those in the United States). The U.S. government will pay the full price as set by the drug companies, while the need for the drugs will be determined largely by industry-sponsored research, industry-sponsored guidelines, industry-sponsored continuing education and marketing for doctors, and industry-sponsored advertising and public relations campaigns. At the same time, importation of drugs from countries with lower prices has been effectively blocked.