The Price of Colonoscopy, NY Tiimes Letter to Editor

February 22, 2011
http://www.nytimes.com/2011/02/23/opinion/l23colon.html?_r=1&ref=opinion&pagewanted=print

To the Editor:

“States Aim Ax at Health Cost of Retirement” (front page, Feb. 14) describes steps taken by cities and states to control employee health care costs. One city, Wauwatosa, Wis., requires its employees to undergo “colonoscopy at age 50, to help forestall cancer and potentially high treatment costs,” you report.

Colon cancer screening with colonoscopy — viewing the entire colon — has almost completely replaced more limited sigmoidoscopy, which costs as little as one-tenth as much. Yet studies have repeatedly failed to show that colonoscopy reduces the risk of death from colon cancer more effectively than sigmoidoscopy.

Indeed, two national multidisciplinary task forces state that sigmoidoscopy is just as effective. Nonetheless, the American College of Gastroenterology recommends colonoscopy over sigmoidoscopy, and national health care legislation mandates that new coverage include screening colonoscopy.

And therein lies a clue to controlling health care costs. To do that, we need the discipline to apply scientifically based medical knowledge, without commercial interference.

John Abramson
Ipswich, Mass., Feb. 15, 2011

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Drug Giant AstraZeneca to Pay $520 Million to Settle Fraud Case, ABC News

ABC News story. John Abramson is quoted

http://abcnews.go.com/Politics/Health/astrazeneca-pay-520-million-illegally-marketing-seroquel-schizophrenia/story?id=10488647

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What Does It Take to Break Through the Commercial Spin?

Investigative Reporting on Medical Science: What Does It Take to Break Through the Commercial Spin?

By John Abramson

‘… it is almost impossible to get the story right when the fundamentally commercial goals for which the study has been done are covered up with so much industry-sponsored expertise.’

http://www.nieman.harvard.edu/reportsitem.aspx?id=100952

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Forbes Article - Eat Your Statins

Matthew Herper with Robert Langreth 11.16.08, 6:00 AM ET

Want to avoid a heart attack? Stop taking your vitamins and switch to a cholesterol-lowering statin drug instead.
...
One statin critic not backing down is John Abramson, author of Overdosed America. He points out that patients on Crestor had the same rate of serious illnesses requiring hospitalization as those on placebo. "You haven't improved their net health," says Abramson. Instead, he argues, you're trading heart attacks and strokes for other serious illnesses. And he contends that not offering weight-loss counseling to an overweight population created an "artificial situation" that exaggerated the benefits of the drug. He's not alone. Stephen Colbert of Comedy Central's fake news show The Colbert Report joked the study was "a great breakthrough in the battle to find things to prescribe to people who don't need them."

http://www.forbes.com/2008/11/15/statins-crestor-jupiter-biz-healthcare-cx_mh_rl_1116statins.html

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Dose of bias is unhealthy

By John Abramson / As You Were Saying | Saturday, May 31, 2008 | Boston Herald | Op-Ed

Though the pharmaceutical industry does an excellent job of convincing doctors and the public that its mission is to improve our health, don’t be fooled - its real job is to sell drugs for the highest price.

I recently testified at a hearing in federal court concerning alleged illegal marketing activities that resulted in overpayment of several billion dollars for the drug in question. The judge opened the hearing by quoting the highly respected American Law Institute’s statement that the fundamental purpose of a corporation is to maximize profits and return those profits to its shareholders.

Though the pharmaceutical industry does an excellent job of convincing doctors and the public that its fundamental mission is to improve our health, don’t be fooled - its real job is to sell the most drugs for the highest price. And they do so by capitalizing on every opportunity to influence our beliefs about the need for and benefit of their products.

Providing gifts to physicians and financial support to hospitals for continuing medical education are an integral part of the drug industry’s strategy to achieve this goal. If these were the only sources of bias in what doctors believe is the best way to treat their patients, the legislation to ban these activities - courageously passed by the state Senate and pending in the House - would still be vital, but not of such critical urgency.

Unfortunately, they are just the tip of the iceberg. It’s what’s beneath the surface that is the real problem.

Over the past 30 years, the funding of clinical trials has been largely removed from the National Institutes of Health and taken over by the drug and medical device industries. Consistent with their fundamental mission, these industries design their research to maximize their return on investment. Medical knowledge itself has become a commodity, produced for its business value rather than its health value.

It’s not just the commercially biased “educational moments” that are the quid pro quo that come with the gifts to doctors. No, the problem starts with the “scientific evidence” that we doctors read in our most respected journals.

More than two-thirds of the clinical trials that are published in our most trusted medical journals are commercially sponsored. And the odds are five times greater that the commercially sponsored studies will conclude that the sponsor’s drug is the treatment of choice compared to non-commercially funded studies of exactly the same drug. (Wouldn’t it be nice to take those odds to the casino?)

In other words, what we naively think of as objective science is more often than not an extension of marketing - an infomercial.

This is an enormous problem and goes a long way toward explaining why Americans pay twice as much for health care as the citizens of the next 21 wealthiest countries, but actually live two and a half fewer years in good health than the citizens of those countries.

The drug industry has so much money and power that even raising these issues is a third rail for American politicians. The head of U.S. operations for drug maker GlaxoSmithKline recently attempted to wield some of that power when he threatened decreased investment in Massachusetts if the proposed ban on gifts is passed.

So if you want your doctor to be as independent of commercial influence as possible when deciding the best treatment for you and your loved ones, the gift ban is a necessary first step.

But we citizens also must be ready to exercise our power as consumers. The drug and medical device companies should know that blocking this legislation or not participating in a voluntary ban on gifts to doctors could result in a consumer boycott of their drugs and devices that have me-too therapeutic equivalents made by companies that are honoring the ban. This is the way to help the medical industry serve its shareholders by better serving the public interest.

Article URL: http://www.bostonherald.com/news/opinion/op_ed/view.bg?articleid=1097650

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Lancet article, Are lipid-lowering guidelines evidence-based?

Are lipid-lowering guidelines evidence-based?
Lancet: Vol 369 January 20, 2007
J Abramson and JM Wright

Harvard Medical School, Cambridge, MA, USA
Department of Anesthesiology, Pharmacology & Therapeutics and Medicine, University of British Columbia, Vancouver, BC, Canada V6T 1Z3

The last major revision of the US guidelines, in 2001, 1 increased the number of Americans for whom statins are recommended from 13 million to 36 million, most of whom do not yet have but are estimated to be at moderately elevated risk of developing coronary heart disease. 2 In support of statin therapy for the primary prevention of this disease in women and people aged over 65 years, the guidelines cite seven and nine randomised trials, respectively. Yet not one of the studies provides such evidence.

For adults aged between 30 and 80 years old who already have occlusive vascular disease, statins confer a total and cardiovascular mortality benefit and are not controversial. The controversy involves this question: which people without evident occlusive vascular disease (true primary prevention) should be offered statins? With about three-quarters of those taking statins in this category, 3 the answer has huge economic and health implications. In formulating recommendations for primary prevention, why do authors of guidelines not rely on the data that already exist from the primary prevention trials?

We have pooled the data from all eight randomised trials that compared statins with placebo in primary prevention populations at increased risk. 4 Unfortunately, our analysis is imperfect because these trials are not solely primary prevention: 8·5% of patients had occlusive vascular disease at baseline. 5 We used two outcomes to estimate overall benefit (benefit minus harm): total mortality and total serious adverse events (SAEs). Total mortality was not reduced by statins (relative risk 0·95, 95% CI 0·89–1·01). In the two trials that reported total SAEs, such events were not reduced by statins (1·01, 0·97–1·05) (data on SAEs from the other trials were not reported). The frequency of cardiovascular events, a less encompassing outcome, was reduced by statins (relative risk 0·82, 0·77–0·87). However, the absolute risk reduction of 1·5% is small and means that 67 people have to be treated for 5 years to prevent one such event. Further analysis revealed that the benefit might be limited to high-risk men aged 30–69 years. Statins did not reduce total coronary heart disease events in 10 990 women in these primary prevention trials (relative risk 0·98, 0·85–1·12). 6 Similarly, in 3239 men and women older than 69 years, statins did not reduce total cardiovascular events (relative risk 0·94, 0·77–1·15). 7

Our analysis suggests that lipid-lowering statins should not be prescribed for true primary prevention in women of any age or for men older than 69 years. High-risk men aged 30–69 years should be advised that about 50 patients need to be treated for 5 years to prevent one event. In our experience, many men presented with this evidence do not choose to take a statin, especially when informed of the potential benefits of lifestyle modification on cardiovascular risk and overall health. 8 This approach, based on the best available evidence in the appropriate population, would lead to statins being used by a much smaller proportion of the overall population than recommended by any of the guidelines. 9

Why the disagreement? The current guidelines are based on the assumption that cardiovascular risk is a continuum and that evidence of benefit in people with occlusive vascular disease (secondary prevention) can be extrapolated to primary prevention populations. This assumption, plus the assumption that cardiovascular risk can be accurately predicted, leads to the recommendation that a substantial proportion of the healthy population should be placed on statin therapy.

A similar set of assumptions underlie the conclusions of the Cholesterol Treatment Trialists' (CTT) collaboration, a group that undertakes periodic meta-analyses of individual participants' data on morbidity and mortality from all relevant large-scale randomised trials of lipid-modifying treatment. 5 The CTT Collaborators included seven trials of statins for secondary prevention and seven trials of statins for mostly primary prevention. However, instead of analysing these two groups of studies separately, they combine all the studies and report the overall effect. Because they have individual participants' data, the CTT Collaborators have the unique opportunity to analyse the data for the 41 354 people in the true primary prevention group that they have identified as included in these studies. 5 However, they do not report on this pure primary prevention population. Instead they calculate and report the absolute benefit of statins in 47 925 patients with no coronary heart disease at baseline; however, this group includes about 6570 patients with pre-existing cerebrovascular or peripheral vascular disease. Combination of these secondary prevention patients (5-year frequency of major vascular events 25–30%) with the true primary prevention group (5-year incidence of major vascular events 9%) inflates the estimate of absolute benefit from 1·5% (our estimate) to 2·5%.

The CTT collaborators have primary prevention outcome data that can resolve the issues we raise. Subpopulations of particular interest include: men, women, men aged 70 years or older, women below the age of 70 years, people with diabetes mellitus, 20% of people with the lowest bodyweight, people taking more than five drugs, and tertiles of cardiovascular risk at baseline. The following are the outcomes that would be most informative: total mortality, total SAEs, total incidence of cancer, and total cardiovascular events. This analysis would answer the key outstanding questions. First, do the data on primary prevention confirm that there is no overall benefit in adult women of any age and in men aged 70 years and older? And, second, is there significant heterogeneity between the statin treatment effect in primary prevention subgroups compared with that in secondary prevention subgroups?

If the answer to both these questions is yes, the assumption that the benefits for secondary prevention populations can be extrapolated to primary prevention populations is false and the cholesterol treatment guidelines based on this assumption should be revised.

JMW declares no conflict of interest. JA is an expert consultant to plaintiffs' attorneys on litigation involving the drug industry, including Pfizer for its marketing of atorvastatin.


References

1 Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood pressure in adults (adult treatment panel III) final report: table II.2-3 http://www.nhlbi.nih.gov/guidelines/cholesterol (September, 2002) (accessed Jan 2, 2007)..

2 Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults, Adult treatment panel III, final report http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3full.pdf (September, 2002) (accessed Jan 2, 2007)..

3 I Savoie and A Kazanjian, Utilization of lipid-lowering drugs in men and women: a reflection of the research evidence?, J Clin Epidemiol 55 (2002), pp. 95–101. SummaryPlus Full Text + Links PDF (61 K)

4 C Jauca and JM Wright, Therapeutics letter: update on statin therapy, Int Soc Drug Bull Newsletter 17 (2003), pp. 7–9.

5 Cholesterol Treatment Trialists' (CTT) Collaborators, Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90 056 participants in 14 randomised trials of statins, Lancet 366 (2005), pp. 1267–1278.

6 JME Walsh and M Pigame, Drug treatment of hyperlipidemia in women, JAMA 291 (2004), pp. 2243–2252. Full Text via CrossRef

7 J Shepherd, GJ Blauw and MB Murphy et al., Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial, Lancet 360 (2002), pp. 1623–1630. SummaryPlus Full Text + Links PDF (113 K)

8 SE Chiuve, ML McCullough, FM Sacks and EB Rimm, Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid lowering and antihypertensive medications, Circulation 114 (2006), pp. 160–167. Full Text via CrossRef

9 DG Manuel, K Kwong and P Tanuseputro et al., Effectiveness and efficiency of different guidelines on statin treatment for preventing deaths from coronary heart disease: modelling study, BMJ 332 (2006), pp. 1419–1422.

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"When Health Policy is the Problem" with Bruce Spitz in The Journal of Health Policy, Politics, and Law (editorial)

"The contribution by Spitz and Abramson...might be best thought of as an admonitory tract, the sort of piece that Thomas Paine was prone to write in prior to the American Revolution.

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Cold-hearted tug fails women

Cold-hearted tug fails women: 'Go Red' overlooks all the hidden risks
By JOHN ABRAMSON and JUDY NORSIGIAN

[This article was originally published in the Atlanta Journal-Constitution on February 2, 2007, in response to the "Go Red for Women Day" campaign.]

The "Go Red for Women Day" campaign today to increase awareness of heart disease and stroke should be called "See Red for Women Day."

Despite being endorsed by some of our most trusted institutions like the American Heart Association and the National Heart, Lung, and Blood Institute, this event isn't just about protecting your health. It's also about exploiting your concerns about health.

Remember that it was only a few years ago that post-menopausal women and their doctors were being told that hormone replacement therapy would help women live longer and prevent heart disease, stroke, and Alzheimer's Disease. And for women unconvinced by these promises, celebrity icons of female allure, like Lauren Hutton, were hired to make the case a different way.

Women with access to the best health care—better educated, wealthier, receiving more preventive care —were the most likely to be among the many millions of women without menopausal symptoms who took hormones believing they were protecting their health. But these women probably weren't aware that, notwithstanding the definitive recommendations of many experts, there hadn't been a single gold standard clinical trial showing these near-miraculous claims to be true. The Women's Health Initiative finally debunked these grandiose claims and led to the reduction in hormone use that is almost certainly the reason for the recent drop in breast cancer incidence.

Back to the present and the Go Red for Women campaign with its slogan, "Fight the Number 1 Killer of U.S. Women." Yes, heart disease is the number one killer, but at some point, hopefully at a ripe old age, all of our hearts will stop beating. For women under the age of 75, cancer claims 78 percent more women's lives than heart disease. Yes, you should "know your numbers," as the Go Red campaign suggests, but not the ones you're probably thinking of - your cholesterol levels and the thresholds set by the National Cholesterol Education Program's guidelines for starting a cholesterol-lowering statin drug.

These guidelines recommend that women without heart disease who have two or more risk factors and a "moderately high" risk of heart disease be "offered" statin therapy, if their bad cholesterol (LDL) level is 100 or higher. The experts who formulated the guidelines insist that their recommendations are based on scientific evidence from recent clinical trials.

But it's just like the hormone replacement therapy story. The experts who wrote the guidelines cite seven studies that they claimed show cholesterol-lowering statins to be beneficial for such women with a 10-20 percent risk of developing heart disease in the next 10 years. But, as one of us (JA) pointed out in a recent peer-reviewed article in the respected British medical journal the Lancet, there has never been a single clinical trial showing that statin therapy is beneficial for women who don't already have heart disease or diabetes. Not one. Even the guideline authors admit that clinical evidence to support their recommendations is "generally lacking" and that their recommendations are made by "extrapolation of data from men."

We think this is exploitation not extrapolation.

Women are different from men in many ways, including heart disease risk. Furthermore, the experts who have access to the results of all the major clinical trials know whether the combined data really show whether statins benefit women who don't already have heart disease or diabetes. But the experts aren't saying. With 13 out of 14 of these studies sponsored by drug companies that market statins, one would have expected widespread publicity if the data do, in fact, show a significant benefit for women.

There are much more important numbers for women to focus on, such as: how many times a week they exercise (ideally at least several times); how many servings of fruits and vegetables we eat daily (ideally five or more); how often we eat red meat (ideally less than a pound a month); how many grams of trans fats we eat (ideally 0); and how often we smoke (ideally never) or drink (ideally not more than two alcoholic drinks in a day).

Taking statin pills certainly requires less effort than living a healthier lifestyle. And taking a statin would almost certainly lower your cholesterol numbers. But there's no evidence that it would achieve the real goal: reducing your risk of heart disease or improving your overall health.

With this much confusion, we'd like to be able to turn to our doctors for advice. But they, too, are influenced by the drug companies' spin as well as pressure to follow the guidelines' exaggerated recommendations. They also may be unaware of the growing evidence pointing to adverse effects of these drugs.

Complicating the statin issue even more for women, the five studies of statins that examined the risk of breast cancer found a 33 percent higher rate in women taking statins than in those taking placebos. There were not enough women in these studies to make this increase statistically significant, but clearly more research is needed here. In fact, a large clinical trial based at the University of California, San Diego, is now quantifying the extent to which statin users experience a variety of adverse effects.

Pfizer, one of the sponsors of the "Go Red for Women" campaign and the maker of the best-selling drug of all time – the cholesterol-lowering drug Lipitor—may want you to think that taking statins is the best way to avoid heart disease. But what you can do for yourself is much more important than what any pill can do for you.

John Abramson MD is the author of "Overdosed America," a clinical instructor at Harvard Medical School, and serves as an expert consultant to plaintiffs' attorneys in litigation involving the drug industry. Judy Norsigain is executive director of Our Bodies Ourselves, a nonprofit women's health education and advocacy organization.

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Radio Interview, Florida NPR

"9 out of 10 Americans are concerned about the cost of health insurance".

"Medical student debt is pushing idealist young students toward specialties instead of primary care..."

"To insure all Americans would cost about two hundred billion dollars, and we're wasting six hundred and fifty billion on health care that's unnecessary or harmful".

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op-ed from the LA Times: "Healthcare Code Blue"

Not only do Americans spend more than anyone else on health care, much of what we buy isn't the best stuff.
By John Abramson

JOHN ABRAMSON, a clinical instructor at Harvard Medical School, is the author of "Overdosed America."

November 3, 2006

IF AMERICAN MEDICINE were a patient, he would weigh 350 pounds and be gaining fast. Despite being repeatedly counseled about the dangers of morbid obesity, he would be making at best half-hearted attempts to mend his gluttonous ways. Meanwhile, his doctors, insurance company, politicians and regulators would remain in a deep state of denial, clutching the illusion that their patient, other than being a bit overweight, was in tip-top health.

Truth be told, the U.S. medical system is headed for multiple organ failure.

The spiraling cost of healthcare is well known: $7,100 per person this year, projected to increase to $12,000 in 2015 and compounding at more than double the rate of inflation. Already, medical care gobbles up one-sixth of the GDP. Even so, we ask ourselves, how better to spend our money than on the best healthcare in the world?

Not so fast. The facts show that these enormous expenditures may be buying us the best amenities in medical care — but not the best health.

For example, Canada spends only 60% as much per person on healthcare as the United States . Yet, since 1980, the longevity of all Canadians has improved more rapidly than that of only white Americans. (In other words, these statistics aren't skewed by the unconscionable racial and socioeconomic disparities in U.S. health and healthcare.) Yes, the "queues" in Canada can involve delays in nonemergency care. But these could be shortened with relatively small increases in funding. An article in the U.S. journal Health Affairs investigating the number of Canadians who come here to avoid these waits found the number so small that it asked, "A tip with no iceberg?"

Britain spends only 40% as much as we do on healthcare. But according to the Journal of the American Medical Assn., middle-class insured Americans "are much less healthy than their English counterparts" (who are insured because all Brits are insured).

In fact, although Americans spend twice as much per person on healthcare as the other 21 wealthiest countries, data from the World Health Organization show that we live the shortest amount of time in good health — 2 1/2 years less than the average in the other countries ( 69.3 versus 71.8 years).

Reviewing a Dartmouth Medical School study that found higher mortality rates in areas that spent the most on Medicare, professor Elliott Fisher concluded that "perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care — and may make things worse." This means that the U.S. is wasting more than $650 billion a year — half again more than the entire Defense Department will spend this year, including the cost of the war in Iraq — on unnecessary and often harmful care.

How can this be? One factor is specialists. Both U.S. and international studies show that the more a healthcare system relies on primary care, the better the outcomes and the lower the cost. But American medicine is heavy on specialists and getting heavier. In just the last eight years, the number of graduates of U.S. medical schools choosing careers in family practice and adult primary care has plummeted by more than half. Americans know they're paying more — and fear they're getting less. A Kaiser Family Foundation poll this month found that nine out of 10 consider the following issues important in determining their vote Nov. 7: problems with quality of their healthcare; the cost of health insurance and prescription drugs (the U.S. is the only industrialized country that lets drug companies charge whatever the market will bear); and the number of uninsured (47 million and growing by 1 million a year).

One would think that politicians would be eagerly tapping into these strong voter sentiments. So why are we hearing so little about healthcare as the election nears? Is this because politicians on both sides of the aisle are being influenced by the powerful medical industries? Certainly this plays a role. But there is an even more basic reason. Our government has become almost fundamentalist in its reliance on market-based, pro-business solutions to social problems. No politician wants to be tarred with the charge of promoting "socialized medicine."

The problem is, our healthcare system is exquisitely well designed to maximize profits but exquisitely poorly designed to provide the best healthcare most efficiently. And even our nonprofit medical institutions shape the care they offer based on their own bottom lines instead of the health needs of the communities they serve.

In Washington, we've got a Food and Drug Administration that's much better at protecting the interests of the drug and medical-device industries than those of patients.

And even in the midst of this pivotal congressional election campaign, few politicians are addressing the crisis in affordable, quality healthcare. Is this any way to run a democracy?

Back to our patient, American medicine. He'll probably end up getting stomach-shrinking surgery at a cost of $27,000. Unless he's one of the unlucky 40% who develop complications, in which case it could cost $65,000 or more. We all deserve better.

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Drug profits infect medical studies (L. A. Times op-ed by Dr. Abramson)

Several of our most venerated scientific journals have recently been besmirched by allegations of scientific misconduct. Shocking? We should be just as shocked as Inspector Renault when he discovered gambling at Rick's Cafe in Casablanca.
(Read the full story at LATimes.com)

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Mistrial in Merck case -- video of Dr. Abramson on CNN/Money

A federal judge declared a mistrial today in a lawsuit brought against Merck and its painkiller, Vioxx. Read the article on CNN/Money, which features a video of Dr. Abramson (Windows Media Player required).

Link

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Interview with Ellen Kagan (mp3 audio)

Audio Recording (mp3 format) of Ellen Kagan's interview with Dr. John Abramson, author of Overdosed America: The Broken Promise of American Medicine, on “Your Health Care - Choice or Chance.”

Mp3 link

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Conflicted Medicine, by Ingfei Chen

Article on collusion between pharmaceutical companies and medical research centers, citing Dr. John Abramson and "Overdosed America."
Chen writes discusses how studies were and are conducted at medical centers with pharmaceutical-company funding, which makes many wonder whether they can trust drug trials anymore.

Link

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Pills to avoid heart attacks? Hard to swallow (Op-Ed article in L.A. Times, by John Abramson and Merrill Goozner)

IS POPPING A PILL the best way to reduce your risk of a heart attack?

That's the message Americans and their doctors hear almost every day. The Journal of the American Medical Assn., for instance, reports in its Oct. 12 issue that the growing use of statin drugs in the United States is largely responsible for falling cholesterol levels over the last decade. Coupled with new data showing that the number of heart disease deaths is falling in the U.S., it sounds like great news.

Unfortunately, putting those two facts together gives Americans the wrong prescription for the most effective way to minimize their risk of heart disease.

First of all, cholesterol levels in the U.S. actually fell faster before statins entered widespread use in the early 1990s, as some Americans decreased their consumption of saturated fats. But, despite the falling cholesterol levels, National Institutes of Health data show that the U.S. is still lagging badly behind most of the other industrialized countries in eliminating heart disease as a major cause of premature death.

Not only that, but during the period when statin use exploded in the U.S., the death rate from heart disease was actually falling faster in most of the other countries — which use half as many cholesterol-lowering drugs and a third as many cardiac procedures to open clogged arteries. How can we be taking more than twice as many statins and receiving three times as many cardiac procedures and still have higher death rates from heart disease?

The problem is that while U.S. doctors and public health authorities focus on drug therapy (often working hand in hand with researchers funded by the drug industry), the nation ignores what the scientific evidence really shows to be the most effective way to prevent heart disease: adopting a healthy lifestyle.

For instance, the Nurses Health Study, which began in 1976, shows that women who follow five healthy lifestyle habits — routine exercise, a Mediterranean-style diet (high in fruits, vegetables, unprocessed grains and olive oil; low in dairy fat, red meat and trans fat or partially hydrogenated fat), not smoking, moderate drinking and maintaining a reasonable body weight — develop only 17% as much heart disease as those who don't. Sadly, only 3% of U.S. women do those things.

On the other hand, not a single randomized, controlled study shows that cholesterol-lowering statin drugs benefit women without preexisting heart disease. Yet ubiquitous television and print advertising encourages women to talk to their doctors about cholesterol, and a recent survey showed that two-thirds of Americans have.

How about people over 65, those most likely to be taking a statin? A recent study of European seniors showed that 60% of their deaths from all causes could be attributed to not following simple health habits.

On the other hand, a study published in the British journal the Lancet showed that not treating high-risk seniors with a cholesterol-lowering drug increased their risk of death by an insignificant 3%.

Obviously, healthy lifestyle is far more important for seniors. But they are much more likely to emerge from their doctor visits with a prescription for a statin than a realistic plan to adopt a healthier lifestyle.

There's no doubt that statins can help some people, especially those who already have heart disease and men at very high risk of developing it. But the scientific evidence is clear: Most heart disease results from the way we live our lives, and there's no magic pill to help us change that.

So why all the brouhaha about getting so many people on statins? It's an exquisite example of bank robber Willy Sutton's law: That's where the money is.

JOHN ABRAMSON is the author of "Overdosed America" (Harper Collins, 2004) and a clinical instructor at Harvard Medical School. MERRILL GOOZNER is the author of "The $800 Million Pill" (University of California Press, 2004) and the director of the Integrity in Science program at the Center for Science in the Public Interest.

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"The Effect of Conflict of Interest on Biomedical Research and Clinical Practice Guidelines: Can We Trust the Evidence in Evidence-Based Medicine?"

Journal of the American Board of Family Practice (with Barbara Starfield, Distinguished Professor, Johns Ho

"In this highly commercialized environment, how do we sustain the ideals that brought us to family medicine? We now know enough about the limitations of “evidence” to be much more cautious about what passes for it. Perhaps the family medicine journals, individually or in concert, could start sections of their journals for the specific purpose of critically reviewing the results of published trials. Finally, we family physicians have a professional responsibility to be less naive about the inherent divergence of our patients’ and the drug companies’ best interests. Our patients must come first."

Link

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Harvard doc: You may not need that Lipitor

"American health care may not be the best at improving health most effectively and efficiently but it is certainly the best in the world at generating profits for the drug industry,'' Abramson said.

Link

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Doctor's prognosis: Health care ills rooted in market-based system, by Maryann Ullman, in the Vermont Guardian

The U.S. health care system is in a state of emergency due its focus on commercial, rather than health, values according to a former family doctor turned activist.

Dr. John Abramson, author of the book Overdosed America: The Broken Promise of American Medicine, spoke in Brattleboro Thursday evening at an event sponsored by Vermont Citizens Campaign for Health.

“He’s questioning long-held assumptions held by the medical community,” said Richard Davis, executive director of VCCH, which is sponsoring an ongoing series of talks to help foster support for a single payer health care system in Vermont.

“He’s bucking the trend that health care should be based on profit. He’s providing some very defensible arguments and information for moving to universal health care, and moving to a system that actually keeps people healthy. That’s radical to some people,” Davis said.

One of Abramson’s arguments is that medical spending has little to do with actual quality of care, and may even have an inverse relationship. In a graph of 22 industrialized countries, Abramson showed that Japan spends among the least on health care per person, and has the highest rate of life expectancy. Twenty other countries cluster around the middle, and the United States, in the opposite corner by itself, has the most expensive health care, and the lowest life expectancy.

“We’re the only industrial country that doesn’t have universal health care,” Abramson pointed out. “We’re the only health care system that is run like a free-market entrepreneurial system.”

A lot of money gets wasted on endorsing products and services that don’t necessarily even help people, he said, and sometimes even harm them. For example, he compared the United States to Canada, saying far more people get bypass surgery here who don’t need it, despite the fact that it causes cognitive problems in 50 percent of the elderly. But they do it because hospitals stand to make $20,000 to $40,000 per surgery.

According to Abramson, $600 billion gets spent every year in the United States on unnecessary and often harmful medical care. “You could have universal health care three times over for that,” he said.

He concedes that Canada does need more money in its health care system, but says that’s because the country made a political decision to cap it, not because the system is flawed.

According to the Institute of Medicine, 70 percent of preventable health problems are due to lifestyle and environmental factors. But most of the money goes to direct medical care.

“We’re spending 75 percent of our money on 30 percent of the problem,” said Abramson. “One of the reasons why we don’t do it, why it’s a threat to have universal health care, is that it would threaten the profit structure. We would have to find real determinants of health problems.”

He pointed to 1980, the onset of the Reagan era, when university medical researchers began accepting funding from drug companies for their work, as funding from the National Institutes of Health dropped. “As there’s been this privatization of knowledge, there’s been a weakening of oversight,” he said. “Universities aren’t going to so it anymore. They’re addicted to the drug money. We can’t count on them anymore. Why not just consolidate everything and have the advertising agencies oversee it all?”

According to a 2003 poll by the Kaiser Foundation, 79 percent of Americans favor health coverage for all, even if it means giving up tax cuts.

Two recent polls in Vermont find wide support for universal coverage. One poll, for WCAX-TV, found that 67 percent of Vermonters favored a publicly-funded health care system, and a recent Vermont Public Radio poll found that 42 percent of Vermonters favored such a system.

The Democratically-controlled Vermont Legislature passed a bill that would have moved Vermont toward a universal health care system, but Gov. Jim Douglas, a Republican, has pledged to veto the bill. Despite the veto, the state's 2006 spending plan does include funding for a commission to evaluate various approaches to providing publicly-funded universal health coverage.

“There’s a real failure of our system to implement the will of the people,” said Abramson.

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"When Health Policy is the Problem" with Bruce Spitz in The Journal of Health Policy, Politics, and Law (editorial)

"The contribution by Spitz and Abramson...might be best thought of as an admonitory tract, the sort of piece that Thomas Paine was prone to write in prior to the American Revolution.

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City Club of San Diego Presents Dr. John Abramson (video)

Primary care physician Dr. John Abramson takes aim at the pharmaceutical industry in "Overdosed America," his recent book that questions the biased and, at times, faulty research that leads doctors to over-prescribe medicines to their patients in this address to the Catfish Club and City Club of San Diego.
Watch it now using RealPlayer.

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