Open Heart (54 page)

Second, Rockhill writes,

the labeling of these risk factors as the “causes” of individual cases of disease,
and the implication that responsible individuals who avoid such risk factors will prevent their own case of disease, represent strong denials of the inability of statistics and medical science to predict the future of individuals. Further, the equating of risk factors with the causes of individual cases fosters an indifference to the social determinants of risk factor distribution and thus contributes to ineffectual disease prevention policies at the population level, (pages 367–368)

259
   
Here, for example:
Russell Ross, “Atherosclerosis—An Inflammatory Disease,”
NEJM
340:2 (January 14, 1999), pages 115–126.

259
   
“From a clinical standpoint”:
Muhlestein, “Chronic Infection and Coronary Artery Disease,” page 125.

261
   
“To be precise”:
Taubes, “The Soft Science of Dietary Fat,”
Science
291:5513 (March 30, 2001), pages 2536–2545. See also his companion piece on dietary fat, “What If It's All Been a Big Fat Lie?”
New York Times Magazine
, July 7, 2002, page 22 ff.

261
   
Rich talks frequently:
Regarding the unethical collusions between doctors, hospitals, and drug companies, see, for starters, the articles cited in note xx, chapter x. See also “When Physicians Double as Entrepreneurs,” by Kurt Eichenwald and Gina Kolata,
New York Times
, November 30, 1999; “Study Says Clinical Guides Often Hide Ties of Doctors,” by Sheryl Gay Stolberg,
New York Times
, February 6, 2002; “Drug Companies Profit from Research Supported by Taxpayers,” by Jeff Gerth and Sheryl Gay Stolberg, New
York Times
, April 23, 2000; “Drug Companies and the Third World: A Case Study in Neglect,” by Donald G. McNeil, Jr.,
New York Times
, May 21, 2000; and “How Companies Stall Generics and Keep Themselves Healthy,” by Sheryl Gay Stolberg and Jeff Gerth,
New York Times
, July 23, 2000.

261
   
Although more than 80:
The statistics on direct-to-consumer promotion are from “Promotion of Prescription Drugs to Consumers,” by Meredith B. Rosenthal et al, in
NEJM
346:7, pages 498–505. Regarding the pharmaceutical industry's relation to consumers—and to research—consider this too: two-thirds of prescription medications approved by the FDA from 1989 to 2000 were either modified versions of existing drugs or drugs identical to those already on the market. According to the National Institute for Health Care Management Foundation (which receives 40 percent of its financing from Blue Cross/Blue Shield), medicines “with new chemical ingredients that offer significant improvements over existing drugs” made up only 15 percent of drugs approved during this period (“New Medicines Seldom Contain Anything New, Study Finds,” by Melody Petersen,
New York Times
, May 29, 2002).

For a look at drug companies' promotional techniques, including direct-to-consumer advertising, see “What's Black and White and Sells
Medicine?” by Melody Petersen,
New York Times
, August 27, 2000; and “High-Tech Stealth Being Used to Sway Doctor Prescriptions,” by Sheryl Gay Stolberg and Jeff Gerth, New
York Times
, November 16, 2000.

261
   
“showed no evidence”:
Both LeFanu, page 308, and Taubes, page 2541 of “The Soft Science of Dietary Fat,” make reference to this
Time
magazine article.

262
   
“Snatching victory”:
LeFanu, pages 289–317 [310].

262
   
“After seven years”:
Ibid., page 308.

270
   
“The main discovery”:
Jacob,
Of Flies, Mice, and Men
, page 152.
“chemical weapons”:
The quotation from Waksman, along with the story of his discovery of streptomycin and his evolving views about antibiotics, is drawn, in part, from LeFanu, pages 14–15.

270
   
That Alexander Fleming:
Like Waksman's story, the story of Fleming's discovery of penicillin has been told often. See, for example, LeFanu, pages 6–14, and Porter, pages 454–458.

271
   
“the whole immune system”:
Nesse and Williams, page 116.

271
   
“Inflammation”:
Mary Duenwald, “Body's Defender Goes on the Attack,”
New York Times
, January 22, 2002.

272
   
In an article:
“p53 Mutant Mice That Display Early Ageing-Associated Phenotypes,” by Stuart D. Tyner et al.,
Nature
415 (January 3, 2002), pages 45–53.

274
   
“With the current study”:
Reactions to the
Nature
article on P53 are from the
New York Times:
“In Search of an Extra-Long Life,” January 7,2002 (editorial); and “Cancer Fighter Exacts a Price: Cellular Aging,” by Nicholas Wade, January 8, 2002.

275
   
“During the past”:
Nesse and Williams, page 108.

275
   
One way:
For a discussion of the effects of aging on DNA and life expectancy, see Weatherall, pages 217–219.

276
   
“Genes that reside”:
Ibid., page 190. The estimate of the number of genes in the human genome has changed since Weatherall's book was published in 1995, and continues to change. The generally accepted number is now somewhere between 30,000 and 40,000. See, for example, Nicholas Wade's article in the
New York Times
, “Human Genome Appears More Complicated,” August 24, 2001, and Andrew Pollack's article in the
Times
, “Citing RNA, Studies Suggest a Much Deeper Gene Pool,” May 4,2002.

277
   
“a highly technical”:
Weatherall, page 107.

277
   
John Gibbon:
Gibbon told his story many times. His accounts are consistent, but he elaborated on the experience a bit differently in each new
telling. Basic accounts are given in Klaidman and LeFanu. I am quoting from Gibbon's 1978 essay, “The Development of the Heart-Lung Apparatus,”
American Journal of Surgery
135 (May 1978), pages 608–619.

279
   
“Pessimism”:
Walter Lillehai, “A Personalized History of Extra Corporeal Circulation,”
Transactions of the American Society for Artificial Organs
28 (1982), pages 5–16.

285
   
We know how:
The information on curing a case of TB, on vaccinations against measles, and on annual average health spending in the U.S. and elsewhere is from an editorial, “Health Aid for Poor Countries,”
New York Times
, January 4, 2002. Note, also, that the prevalence of TB in the United States has declined to its lowest level ever, a drop of 39 percent from 1992 to 2000, with the rate of multidrug TB resistance down by 70 percent (“Tuberculosis—The Global View,”
NEJM
346:19 [May 9, 2002], pages 1434–1435).

Data on TB, vaccines, average health spending, and death from preventable diseases are from the
New York Times
, “U.N. Says Millions of Children, Caught in Poverty, Die Needlessly,” by Elizabeth Olson, March 14, 2002.

286
   
The response:
For a sense of the national response concerning global disease and poverty, see Natalie Angier, “Case Study: Globalization; Location: Everywhere; Together in Sickness and in Health,”
New York Times Magazine
, May 6, 2001; and Helen Epstein,
New York Review of Books
(March 14, 2002).

286
   
When the United Nations:
But note President Bush's proposal, in his 2003 State of the Union message, to triple spending for AIDS relief in Africa and the Caribbean.

286
   
In addition, because:
That the illnesses that make up 90 percent of the global burden of disease receive only 10 percent of research money is from a
New York Times
editorial, “The Plagues of Poverty,” March 19, 2002.

287
   
“choice rhetoric”:
Annas, pages x-xv. Annas (page xiv) quotes Jedediah Perdy on the notion that individual choice is always good: “Boundless individualism in which law, community, and every activity are radically voluntary, is an adolescent doctrine, a fantasy shopping trip without end” (“The God of the Digerati,”
American Prospect
, March-April 1998, pages 86–90).

287
   
“Choice and coercion”:
“Introduction,”
Some Choice
, page xv. Annas elaborates:

It has become commonplace for communitarians to argue that liberty or
choice has become the only American value and has overwhelmed our sense of community and of obligations to our fellow citizens. There is something to this, but I think (and argue in this book) that the choices that are honored by our contemporary society very often turn out to be “some choice” in both senses of the words: They do provide another option and with it the illusion of control, but the choice is usually not a particularly good one, and is virtually irresistible because of more powerful factors such as poverty, illness (both mental and physical), and social status.

Three examples presented by two thoughtful commentators who have urged us to curb our “culture of autonomy” are illustrative: 1) a mentally ill street person who is in need of medical care, but is left on the street to die because he tells emergency medical technicians that he refuses treatment; 2) the right of a pregnant woman to refuse to be screened for HIV infection, even though the risks to her future child of contracting AIDS could be significantly reduced if she is infected and takes zibovudine during the pregnancy and childbirth; and 3) the demise of a program to pay teenagers a dollar a day to avoid pregnancy on the basis that this is coercive and thus a denial of their autonomy, (xiv)

289
   
“The demand for autonomy”:
Callahan, “Rationing Medical Progress—The Way to Affordable Health Care,”
NEJM
322:25 (June 21, 1990), pages 1810–1813. For a full elaboration of these ideas, see his book,
What Kind of Life: The Limits of Medical Progress
.

291
   
Do we have any:
The figure on future deaths from tobacco is from Bob Herbert's column, “Death in the Ashes,” New
York Times
, July 26, 2001. According to the World Health Organization, by 2030, tobacco-related deaths will reach 10 million annually (“W.H.O. Treaty Would Ban Cigarette Ads Worldwide,” by Elizabeth Olson,
New York Times
, July 22, 2002).

292
   
“Surely”:
Nuland, “Whoops!” page 11.

293
   
“by excessive”:
Mechanic, “Managed Care as a Target of Distrust,”
JAMA
277:22 (June 11, 1997), pages 1810–1811. Mechanic has written widely and wisely on the subject. See, for example, “Managed Care, Rationing, and Trust in Medical Care,”
Journal of Urban Health: Bulletin of the New York Academy of Medicine
75:1 (March 1998), pages 118–122; and “Responses of HMO Medical Directors to Trust Building in Managed Care,”
Milbank Quarterly
77:3 (1999), pages 283–303. (See also “The Managed Care Backlash: Perceptions and Rhetoric in Health Care Policy and the Potential for Health Care Reform,”
Milbank Quarterly
79:1 [2001], pages 35–54.)

The literature on managed care is enormous. Here, for starters, is a summary description of “The Growth of Managed Care,” from an artiele
by H. T. O. Davies and Thomas G. Randall, “Managing Patient Trust in Managed Care,”
Milbank Quarterly
78:4 (2000), pages 609–624:

Since the late 1980s, a new health care environment has emerged in many parts of the United States. Previously, indemnity insurance and fee-for-service reimbursement prevailed. Independent physicians, hospitals, and other caregivers provided medical services and billed the charges to the patient's insurance company, or government paid with little regard to the appropriateness of services delivered. Physicians had few, if any, constraints on their authority to order tests, perform procedures, make referrals, and prescribe medications. In general, patients perceived that such unbridled authority for physicians to expend resources on their behalf aligned the physicians' interests (autonomy and personal financial gain) with their own (access to all interventions regardless of cost).

In the new health care environment, private employers and the federal and state governments have changed from passive payers to aggressive purchasers of health care. As such, they demand more accountability from health plans with respect to where their insured employees are cared for, what types of services are provided, and how much they will pay. In turn, health insurance companies have devised a variety of managed care plans (e.g., group and network model health maintenance organizations) that shift some of the risk of controlling health care costs to the care providers. When at financial risk for the cost of the services they provide, physicians and hospitals have a strong incentive to manage carefully the entire continuum of care for their enrolled patient population. Hence the origins of the term managed care, (pages 610–611)

294
   
“disturbing issues”:
“Neonatalogists earn more than general pediatricians,” the editorial on neonatal technology informs us. “One of the few investor-owned physician groups to remain financially successful in recent years is Pediatrix. Pediatrix employs nearly 600 neonatologists and fetal-maternal medicine specialists in 185 neonatal intensive care units across the United States and earned more than $30 million in net profits for investors in 2001.” These and the other quotes about neonatal technology are from the editorial “Specialists, Technology, and Newborns—Too Much of a Good Thing,” by Kevin Grumbach,
NEJM
346:20 (May 16, 2002), pages 1574–1575. The study Grumbach is commenting on is “The Relation Between the Availability of Neonatal Intensive Care and Neonatal Mortality,” by D. C. Goodman et al.,
NEJM
346 (2002), pages 1538–1544.