Monthly Archives: November 2008

Ich Habe Genug on Thanksgiving

It’s Thanksgiving and I’m feeling ‘Ich habe genug’ (I have enough). I’d like to share some poetry, music, and a film while continuing the ‘death’ theme of my last blog post.

First the film, Wit, starring Emma Thompson and directed by Mike Nichols. It’s the story of Vivian, a woman with ovarian cancer who spends the end of her life in a hospital. Talk about aggressive treatment of the terminally ill. She’s basically a guinea pig for an experimental drug that has no chance of saving her life. The young doctor who oversees her treatment will get a publication out of the case. He’s a resident planning a career in research and has no interest in ever seeing patients again. He’s only there because it’s one of the requirements on the road to becoming an MD

Wit is based on a Pulitzer Prize-winning play. Very minimal. Lots of monologue. Vivian was a professor of English literature and quotes the metaphysical poet John Donne (of “Death be not proud” fame) throughout the film. The contrast between the poetry and the setting is beautifully done. Donne had much to say about death, but he lived in an era when death had a different meaning. Or more precisely, when death had a meaning.

Sounds a bit gloomy, I know, but it’s an excellent film. Watch it with a friend, if you can. It’s very thought provoking. This is exactly the way we don’t want to die. The more we’re aware of what we don’t want, the more we’ll be motivated to change the way things are.

Next, a poem by Jacques Prevert, “Pater Noster.” The poem received some publicity when Meadow Soprano read the first few lines to her Level 1 ICU-docked Dad: “Our father, which art in heaven, stay there. And we shall stay on earth, which is sometimes so pretty.”

Here is the French version. And here’s an English translation.


Philip Larkin’s poem “The Building” is about a hospital. Here’s the complete poem, and here are the last few lines:

All know they are going to die.
Not yet, perhaps not here, but in the end,
And somewhere like this. That is what it means,
This clean-sliced cliff; a struggle to transcend
The thought of dying, for unless its powers
Outbuild cathedrals nothing contravenes
The coming dark, though crowds each evening try

With wasteful, weak, propitiatory flowers.

I’ve been partial to Larkin ever since I read “This be the verse” at an impressionable age.

And continuing the theme of Genug, here’s the Bach Cantata, “Ich habe genug”.

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Death be not visible

science-cheat-deathThis may seem like a ‘Debbie downer‘ subject to bring up right before a holiday, but I’d like to say a few words about death. Death is the elephant in the room whenever we talk about health, medicine, or healthcare. When we ‘eat right’ and exercise, we engage in a modern ritual that we hope will prevent something that’s 100 percent certain. Even the transhumanists, who hope to prolong life indefinitely, admit that eventually everyone will succumb to an übervirus or accidentally cross the path of a flying car.

The high tech flash of post-industrial medicine encourages this illusion, and that creates interesting problems. How do you allow someone to die a dignified and peaceful death when the focus of medicine is to keep everyone alive, even the terminally ill? What does it mean to die when modern medicine can keep us technically ‘alive’? Claus von Bulow’s wife Sunny has been in a coma for 28 years. It may seem crass to think about economics when we’re talking about a human life, but a high tech death in an ICU has implications for the high cost of healthcare.

The natural death: Genug Syndrome or Zahl Kam Rauf

It’s now rare to die of ‘natural’ causes in one’s own home. There are small pockets of resistance, however. A recent essay in JAMA called “Genug Syndrome” told the story of an elderly woman named Lisa. She had been cared for at home for eight years and died peacefully, sitting in her candy-apple-red wheelchair, surrounded by family and friends. When it came time to fill out the death certificate, the family decided she had died of genug syndrome. Genug is Yiddish for “Enough!” or “Enough, already!” When someone inquired about the actual cause of death, Lisa’s daughter objected. She didn’t want her mother’s life summed up by a medical diagnosis. The doctor agreed:

Should I mar the identity of this complex person with such a rich life and legacy by reducing her to a medical diagnosis at the end – when, really, it was just genug? When end-of-life care transcends the medical model to be truly a natural part of life, as this family had achieved, listing a medical-model cause of death seemed incongruent with her whole life and spirit.

The bureaucracy is stacked against doctors who resist filling out death certificates with a ‘medical-model’ cause of death. Fortunately this particular doctor (Jennifer Soyke) practiced in Oregon, a state that legalized euthanasia in 1994. She mentions a recent Oregon obituary that lists the cause of death as “the common form of Zahl Kam Rauf.” ‘Zahl kam rauf’ literally means ‘number came up.’

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The first clinical trial: Eat your vegetables

The first ‘clinical’ trial may have been 2600 years ago. According to the Book of Daniel, King Nebuchadnezzar held Israelites in captivity in Babylon after the siege of Jerusalem in 597 BC. The king selected an elite group of prisoners to serve him in the future. They were to receive the same “choice” food and wine as the king.

Now Daniel determined not to contaminate himself by touching the food and wine assigned to him by the king, and he begged the master of the eunuchs not to make him do so. … [T]he master … said to him, ‘I am afraid of my lord the king: he has assigned you your food and drink, and if he sees you looking dejected, unlike the other young men of your own age, it will cost me my head.’ Then Daniel said to the guard … ‘Submit us to this test for ten days. Give us only vegetables to eat and water to drink; then compare our looks with those of the young men who have lived on the food assigned by the king, and be guided in your treatment of us by what you see.’ The guard … tested them for ten days. At the end of ten days they looked healthier and were better nourished than all the young men who had lived on the food assigned them by the king. Daniel 1: 8-16

This was not a blind, randomized trial, so we can’t rule out the placebo effect. Also, there were only four subjects. But evidently the idea of a test group and a control group has been around a long time.

The word for ‘vegetable’ in this passage is sometimes translated as ‘pulse.’ Pulses are things like beans, peas, lentils, and chickpeas. They contain 20 to 25% protein by weight. So Daniel knew a healthy diet when he saw one. An early example of a “healthy lifestyle.”

I came across this story not by reading the Bible, but by reading Ben Goldacre’s Bad Science, an excellent book. It’s not yet available in the US, but you can get a like-new, paperback copy from Amazon (USA) through a third party reseller.


(Hover over book titles for more info. Links will open in a separate window or tab.)

Ben Goldacre, Bad Science


Will Obama’s health policy survive a Big Pharma challenge?

President-elect Obama has made it clear he wants to change US health policy, and he appears to have widespread public support to do just that. The pharmaceutical industry, on the other hand, likes things just the way they are. We can expect Big Pharma to put up a fight to protect their interests and, in fact, the first shot will be fired this week. But the pharmas need to walk a fine line. Their public relations efforts over the past few years have been an attempt to win public sympathy. Now they need to attack Obama without jeopardizing all that goodwill.

One change in health policy already singled out by Obama is the federal government’s ability to negotiate Medicare drug prices. This particular item could cost the drug industry as much as $30 billion. Not surprisingly, PhRMA, the largest pharmaceutical lobbying group, has been preparing for this moment and last week announced a new public relations campaign.

“We’re going to do an ad campaign that is designed to make people aware of the importance of preserving your free-market health care system.” This from Ken Johnson, a senior VP at PhRMA, quoted in the Washington Times.

In a post titled “Is big pharma preparing to shoot itself in the foot?”, David Williams had this to say:

[The PhRMA ad campaign] may try to have the same impact as the famous Harry and Louise ads of 1993 that undermined the planned Hillary Clinton-led reform bill. … If that’s really the aim, someone is misjudging the mood of the public. People aren’t looking for “free-market” anything at the moment, especially when what the pharmaceutical industry really means by “free market” is pricing freedom for themselves. … Here’s some friendly advice to the pharmaceutical industry: don’t make the mistake of attacking the policies of our new President. Such a move is likely to backfire.

The Harry and Louise ads.

PhRMA polishes its image

PhRMA hasn’t been sitting on the sidelines during the election campaign, waiting to see who wins. PhRMA’s Johnson also had this to say:
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To make more money

I’m so glad September and October are over. In September melamine powder was sold to Chinese farmers and other food producers, allowing everyone along the food supply chain “to make more money,” as one of those arrested later admitted. On the consumer side, tens of thousands of babies were poisoned. That same month In the US, the practices of Wall Street financiers managed to create the worst economic crisis since the Great Depression.

Then in October, the presidential candidates got down to discussing the need for healthcare reform. The US spends almost twice as much per person on healthcare as the average high-income country. If healthcare costs continue to grow faster than the rest of the economy, as they have for the past 30 years, they will be 30% of gross domestic product in another 30 years. Ouch!

The issues surrounding healthcare reform are difficult and complex, but at least part of the problem is something I mentioned in an earlier post: decisions in the healthcare industry are driven not by the needs of patients but, once again, by the need “to make more money.”

All these things — healthcare, the economic crisis, melamine adulteration of the food supply — merged in my election-fevered brain into despair at how the selfish, if not reckless, decisions of a few can jeopardize the health and livelihood of so many. Together, they feed a crisis of confidence in the systems we depend on. In moments like this, it can be hard to be hopeful for the world.

Got Melamine?

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Selling drugs like chewing gum

Drugs are expensive and drive up the cost of health care. The problem with drug companies, however, is not simply that individual drugs are expensive. There’s a story in the news today about how the Obama victory and a Democratic congress may put downward pressure on drug prices. One industry analyst thinks this won’t be a serious problem since drugs have a very high markup: the number of products sold, not their price, drives industry growth. If health coverage expands, drug sales will increase, which is good news for drug companies.

In 1976, the chief executive of Merck told Fortune magazine that he dreamed of marketing drugs the way Wrigley’s markets chewing gum: to as large a market as possible. The real problem with drug companies is their attempt to convince as many people as possible that they need drugs. This is disease mongering: expanding markets by convincing healthy people that they’re sick. Health has come to mean that feeling fine is an illusion easily shattered by the next news cycle or by the next prescription drug you’re encouraged to “ask your doctor about.”

When a patient has a disease and a doctor prescribes treatment, the doctor can observe whether or not the patient responds to the treatment. If the treatment doesn’t work, it’s discontinued. When a healthy patient is at risk for disease and a doctor prescribes treatment, there’s no way to be certain the treatment is working. The patient might never have gotten sick. So the treatment continues indefinitely. This wouldn’t be a problem if pharmaceuticals were harmless, but all drugs have side effects. The more people you treat with preventive pharmaceuticals, the more people there will be who suffer the adverse effects of treatment.

From Iona Heath: “[D]isease mongering exploits the deepest atavistic fears of suffering and death. … Human societies are riven by the effects of greed and fear. The rise of preventive health technologies has opened up a new arena of human greed, which responds to an enduring fear. The greed is for ever-greater longevity; the fear is that of dying. The irony and the tragedy is that the greed inflates the fear and poisons the present in the name of a better, or at least a longer, future. Ultimately, the only way of combating disease mongering is to value the manner of our living above the timing of our dying.”


(Hover over book titles for more info. Links will open in a separate window or tab.)

Iona Heath, Combating Disease Mongering: Daunting but Nonetheless Essential


Why are US health care costs so high?


I just started reading Maggie Mahar’s Money-Driven Medicine: The real reason health care costs so much.
The US spends almost twice as much as Japan on health care, but the Japanese live longer and have a lower infant mortality rate.
Why is health care so expensive in the US? Is it because Americans have access to all the health services they want, including elective surgery? In developed countries where the government limits health care resources, patients can wait months for elective surgery. There are 15 procedures that generate the majority of waiting lists in Canada, the UK, and Australia. Those procedures account for only 3 percent of US health care spending. So that’s not it.
Is it the number of hospital beds, doctors, and CT scanners? Compared to other developed countries in the OECD , the US is below average in both the number of doctors per capita and the number of CT scanners. When you compare beds per capita, the US is in the bottom 25 percent. So it’s not that.
Is it the high cost of malpractice insurance? Malpractice payments account for less than 0.5 percent of health spending. But could it be the unnecessary tests and procedures doctors order to protect themselves in the event of a lawsuit? It’s very difficult to say whether a doctor orders a specific test solely because he believes it is in the patient’s best interest. But other countries with lower health care costs also have malpractice claims, so there’s no reason to assume the US is the only country where doctors practice defensive medicine.
According to Mahar, the reason for rising health care costs in the US has nothing to do with the individual components we single out for blame. It’s a matter of larger economic forces.
“Put simply, over the past 25 years, power in our health care system has shifted from the physician to the corporation. A professional, the physician pledged to put his patients’ interests ahead of his own financial interests. The corporation, by contrast, is legally bound to put its shareholders’ interests first. Thus, many decisions about how to allocate health care dollars have become marketing decisions. Drugmakers, device makers, and insurers decide which products to develop based not on what patients need, but on what their marketers tell them will sell – and produce the highest profit.”


The election, the common good, Starbucks, and driving safely

There’s been plenty of coverage of the Obama and McCain health plans during the presidential election campaign. I debated whether to contribute my opinion and decided against it. I think everyone is exhausted with media coverage. There’s a nice Time Magazine article this week on “The 24-Minute News Cycle.” It was reassuring to read that I’m not alone in refreshing the Google News page.

I can recommend some sources on the health care debate that go deeper than the rivalry of two candidates. There is a page put together by The New England Journal of Medicine (NEJM) called Election 2008. I especially liked the article “Three ‘Inconvenient Truths’ about Health Care” by V. R. Fuchs. I may write about that article later. Health care is not an issue that’s going to disappear simply because the election frenzy is over.
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