Two small clusters of drug resistance don't a public health crisis make. But experts worry they could signal the development of a Tamiflu-resistant pandemic virus with the ability to spread from person to person -- at least under certain circumstances.

Health officials are investigating two unrelated clusters of hospital patients -- four patients in North Carolina, five in Wales who've been infected with swine flu viruses resistant to the mainstay antiviral drug Tamiflu.

All of the involved patients reportedly had weakened immune systems. That may have enabled the pandemic virus to replicate in their systems more freely. If these immuno-compromised patients had been given Tamiflu, that combination of factors may have led the virus to develop a point mutation conferring resistance against the drug.

That's what happened with that other H1N1 flu virus -- the one that causes seasonal flu. It's almost 100 percent resistant to Tamiflu and its cousin Zanamivir.

Seasonal H1N1 viruses carry the same mutation that has popped up so far in all the pandemic H1N1 resistant viruses, according to the World Health Organization.

The WHO recently published a review of 39 Tamiflu-resistant cases -- the number it had counted as of October 22. Seven of them were immuno-compromised patients, like the recent clusters.

Now, it's not a foregone conclusion that the pandemic virus will become widely resistant to Tamiflu. It hasn't yet, and presumably it's had lots of opportunity. But when the CDC's Anne Schuchat was asked Friday about the Welsh cluster she said: "That's the kind of report we take seriously."

She was less concerned about another swine flu mutation that popped up in three Norwegian flu victims. http://www.who.int/csr/disease/swineflu/notes/briefing_20091120/en/index.html

That mutation seems to enable the virus to glom onto cells deeper in the lung. Two of the Norwegian patients died and the third is critically ill.

"This mutation has been seen sporadically here and there around the world -- sometimes in people who had mild disease and sometimes in fatal disease," Schuchat says. "It's an important finding for virologists, but I don't think it yet has the public health implications we would worry about."

The firestorm generated by the U.S. Preventive Services Task Force recommendations on mammography quickly moved to Capitol Hill this week where members of Congress took to the floor to express their outrage. But historians and medical newshounds with long memories might remember this is hardly the first time politics and breast cancer have become entangled.

The white arrow points out cancer in this mammogram. (NIH via Wikimedia Commons)

Dr. Barron Lerner of Columbia University College of Physicians & Surgeons and the author of "The Breast Cancer Wars: Hope, Fear and the Pursuit of a Cure in Twentieth-Century America," knows that history all too well. In an interview with Kaiser Health News, he harked back to the "early 1990s, when there was some suggestion that if you did something called a bone marrow transplant, or stem cell transplant - which was a very aggressive treatment for metastatic breast cancer - that women live longer."

Lerner says the studies were extremely preliminary but when word got out, women demanded the procedure because they thought it could save or prolong their lives. "The power of that lobby was so strong that insurance companies began to pay for the procedure, even though it was still experimental and its value hadn't been proven," he says.

He also remembers the in 1998 when "a report came out criticizing mammograms, Congress actually voted to rebuke that scientific report." The vote count? 424-0.

Congress -- or even regular people --often see new medical studies and rush to judgment. "But if you don't look at the data and you're acting based on your heart, or your gut instinct, you often make the wrong decision," Lerner says.

The obesity epidemic has come to this, a Pennsylvania college is telling students to shape up--or else.

People who are obese are more susceptible to other diseases, one college is trying to make its students healthier. ( Justin Sullivan/Getty Images)

Entering freshmen at Lincoln University have to get their body mass index, or BMI, measured. And if the result comes back above 30, the threshold for obesity, the students have to take a physical education class called "HPR 103 Fitness Walking/ Conditioning" or they can't graduate. Details here.

The requirement kicked in for students who enrolled at Lincoln in the fall of 2006. That class is now in its senior year, and most are looking forward to their graduation this spring. But for 80 seniors, graduation will hinge upon their taking phys ed or passing the required BMI test, according to minutes of a Nov. 3 faculty meeting at Lincoln.

Some of the faculty were concerned about the legality of enforcing the requirement, DeBoy told us in an interview. "After all this is virgin territory," he said. "But we want to be proactive about this issue."

Lincoln, a historically black university, the issue of medical disparity makes the obesity epidemic particularly concerning. "Minority folks are particularly vulnerable to diseases associated with obesity," he said.

DeBoy acknowledges the controversy. "We knew that it was potentially a political quagmire but we believe that it's that important," he said. "Do we have the answer? No. Are we trying? Yes. Will we stumble? Probably."

DeBoy says he will let the administration deal with the legal issues, but he is busy looking out for student health. "As health educators we're concerned with the whole student, not just the academic part, but all the components that make up health and wellness."

An op-ed in the latest issue of The Lincolnian, the campus newspaper, put a point on the problem with the headline: 'Too Fat To Graduate.' The author says she'll take a phys ed class, even though her BMI was in the acceptable range.

Why? "Not because Lincoln is requiring me to," she wrote, "but rather, because I would like to be healthier. This was a decision that I made... and that's the way it ought to be."

Republicans' attacks on the Senate Democrats' health bill kicked off with criticism about process as much as substance.

Senate Minority Leader Mitch McConnell at an October press conference in Washington. ( John Moore/Getty Images)

Majority Leader Harry Reid, D-Nev., spent weeks forging the bill "behind closed doors," charged the Republican leader Mitch McConnell, of Kentucky and his deputy, Jon Kyl, of Arizona, in statements right after the bill became public.

What about it? Squawking aside, secretive legislative engineering is business as usual for the Senate, say open-government advocates and former congressional aides, including one Republican. While the legislative process is often opaque (smoke-filled rooms, anyone?) nothing Reid did while combining bills from two Senate committees is beyond the pale, these Senate-watchers told us .

So, why bring it up now? President Obama was asking for it, said Bill Allison, of the Sunlight Foundation. During a Democratic primary debate last year, Obama said his approach to health reform would be "not negotiating behind closed doors, but bringing all parties together, and broadcasting those negotiations on C-SPAN so that the American people can see what the choices are."

Those words have been derisively quoted on conservative Web sites, and by Republican lawmakers in earlier statements, after Obama held a series of, well, closed-door meetings with health industry groups such as insurers and drugmakers.

While Obama's pledges may hold little sway over how Reid behaves in office, Allison argues it may be a good time to revisit transparency in the legislative branch. "We have no access to what's going on with Congress," he said, noting that freedom of information laws don't apply to the legislative branch, and the congressional record gets murky when it comes to committee debates.

More transparency in crafting legislation would help the public understand which lawmakers are promoting controversial provisions as legislators weigh their options, he said, singling out a clause in an earlier Medicare bill that benefited pharmaceutical companies by banning the government form negotiating drug prices. "That's a good thing to know," he said

For the second time in a week, a group of medical experts has recommended that some women can be tested less frequently for cancer.

A new guideline suggesting that less testing for cervical cancer makes more medical sense comes as a separate recommendation that women delay the start of routine mammograms until age 50 has become embroiled in the debate over health care reform.

The American College of Obstetricians and Gynecologists just recommended that young women can hold off until 21 before getting their first Pap smear and get them every two years through the rest of their 20s, instead of annually. Previously, the doctor group had said young women should get a Pap smear three years after first having sex or age 21, whichever came earlier.

How is it that the Pap smear rollback came out just as mammography and fears about of rationing of care under changes to health care caught fire?

"It's just pure coincidence that these guidelines have been released now," Dr. David Soper, the Chairman of ACOG's Gynecology Practice Bulletin Committee, told NPR.

They new guideline has been in the works for years and reflects evolving scientific evidence that shows, for instance, the risks of cervical cancer developing in young women is quite low. Indeed, the vast majority of abnormalities found on Pap tests in very young women clear up on their own.

More broadly, Soper told NPR, "You don't improve cancer detection by doing annual smears in women in the different age groups. Performing the Pap test every other year in women between the ages of 21 and 29, and every three years in women over 30 is just as good as doing the test annually. "There's no danger in this new guidance," he said.

Should Santa Claus be allowed to cut the line for swine flu vaccine?

David Oelerich rents Santa suits in New Hampshire. Santas this year want more than just a suit, they want a swine flu vaccine. ( Jim Cole/AP)

Santa America, a group of 200 santas who visit sick children year-round, say they should. "Santa" Ernest Berger, president of Santa America, wants his cheery colleagues considered for the vaccine in the same way as schoolteachers and other caregivers are.

He tells NPR's Melissa Block on Thursday's All Things Considered that Santas should be considered seriously for the vaccine because of their close contact with large groups of children.

Santa America's Santas will show kids how to keep their hands clean, too. Berger explains:

Besides being around a lot of kids, Santas have another case to make for vaccine.The telltale belly on most Santas mean they're likely in another high-risk flu group as well. Berger told the Associated Press that he estimates about two-thirds of American Santas are obese, and one-third are morbidly obese.

Hey, Big Pharma, get ready for a bunch of questions about your prices.

( iStockphoto.com )

Some heavy-hitting Democrats in the House, including Energy & Commerce Chairman Henry Waxman, have asked the Government Accountability Office to look into pricing trends for common prescription drugs just as soon as possible.

You can see the letter here.

The Dems want the info right away, before plowing ahead with health overhaul. At issue is whether drugmakers preemptively jacked up prices, undercutting an $80 billion savings deal the brand-name pharmaceutical industry struck with the administration.

The congressmen are suspicious and cited a GAO report in 2007 that found big price hikes on drugs before a 2003 law added drug coverage to Medicare. The legislators also read a New York Times front-page story the other day about recent price increases.

After the initial report is done, the letter from Waxman and his colleagues wants GAO to come up with a way to monitor drug prices and report those findings to Congress periodically.

The drug trade group PhRMA defended its members' pricing. "It's pretty obvious that the calls to hold hearings or involve GAO are based on the misleading use of statistics and sensationalized media reports," spokesman Ken Johnson said in a written statement.

The first two deaths from the swine flu virus on college campuses were reported this week by an organization tracking the virus at schools around the country.

Click on image to see full-size chart. (AHCA)

But the week that ended Nov. 13 also showed a drop in the number of cases of H1N1 swine flu virus reported to the American College Health Association, from 29 cases per 10,000 students to 21.3. Still, the two deaths reported to the organization were the first since they began tracking the virus.

"Though pandemic flu remains generally mild among college students, these two deaths are harsh reminders of the rare but tragic consequences of influenza," Dr. James Turner, president of the ACHA, said.

In September, there were four flu-related deaths, according to Inside Higher Ed. The first two were a freshman at Troy University and a continuing student at the University of Nebraska. On Sept. 11 a student at Cornell died from complications due to the flu. In late Sept. the flu took another victim, a freshman at Miami University in Ohio.

More campuses are receiving the H1N1 vaccine. However, Turner points out that the institutions who are receiving vaccine have only received small amounts. Cases dropped in all parts of the country except for Idaho, Louisiana, Missouri, New Jersey and the District of Columbia.

Take a step back from the heated debate over when to start routine mammography and consider the broader implications for efforts, championed as part of health care overhaul, to root medical decisions in the best available science.

The white arrow points out cancer in this mammogram. (NIH via Wikimedia Commons)

You probably know by now about the American Cancer Society's disagreement with a federal task force's recommendation that women start routine mammograms at age 50 instead of 40.

Dr. Otis Brawley, the cancer group's chief medical officer, called the guideline a "step backward" in an editorial in Thursday's Washington Post because it overestimates the risk and underestimates the benefits of mammography for fortysomething women.

What's more, Health and Human Services Secretary Kathleen Sebelius declared the task force guidelines won't alter federal payment for mammograms. The U.S. Preventive Services Task Force, she said Wednesday, "does not set federal policy, and they don't determine what services are covered by the federal government."

Too bad, writes health journalist Merrill Goozner, a voice for the dissent. Of the 4,000 or so breast cancer deaths of women in their 40s annually, mammography would save 600, at the most. But to get that benefit, more than 1 million women a year would have to be screened for a decade.

That sort of mass screening is expensive, and by the calculation Goozner explains in his blog post, would run more than $2 billion annually. Just think what could be done if that money was used more wisely--free mammograms for women at high risk and cancer prevention, he says.

New Hampshire internist Dr. Kevin Pho, who writes and blogs prolifically, sees the backlash against the recommendation as a broader blow to work on grounding medicine in the best evidence.

The mammogram mess bodes poorly for the nascent efforts to make comparative effectiveness research an important tool in health overhaul to sort worthwhile health care from the wasteful and inferior.

As Pho concludes:

If recommendations from an entity like the USPSTF -- as non-partisan and robust as it gets -- gets so much resistance from doctors, patients, and even the government itself, findings from a comparative effectiveness body stand absolutely no chance of changing medical practice.

Senate Democrats' plan to overhaul health came in longer but cheaper than many people expected Wednesday. Still, with a cost of $849 billion and 2,074 pages of legalese, it's a bear of a bill to digest.

Sen. Harry Reid unveils his plan for health overhaul. ( Win McNamee/Getty Images)

Senate Majority Leader Harry Reid, principal architect of the legislation that melds the work of two Senate committees, got creative to pay for the proposed expansion of health coverage, estimated to reduce the ranks of the uninsured by 31 million over a decade.

Here are some of the ways he plans to raise the dough:

• A "botax": Brace yourselves, denizens of Hollywood, Miami and Park Avenue, for a 5 percent tax on elective cosmetic procedures and surgery. Doesn't matter if you pay out of pocket or have insurance coverage, the tax applies across the board. Details start on page 2045 of the bill. Could raise $5.8 billion over a decade.
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• Increase in Medicare payroll tax: Adds half a percent to the Medicare payroll tax for the well-to-do. Individuals making more than $200,000 a year and couples making more than $250,000 would have to pay 1.95 percent in Medicare taxes instead of 1.45 percent. The tax hike could raise $53.8 billion over 10 years.
• Taxes on "Cadillac" health plans: If the insurance you get on the job has premiums of $8,500 or more for individual coverage or $23,000 for the family, then Reid wants to slap a 40 percent excise tax on the plans. The thresholds are higher than those proposed by the Senate Finance Committee of $8,000 for individuals and $21,000 for a family.

For the official cost and savings scorecard, see the letter the Congressional Budget Office fired off to Sen. Reid Wednesday.

Update: For a rundown of the taxes in the Senate bill, check out this summary from the Joint Committee on Taxation. Hat tip to WSJ Health Blog. The grand total, by the way, comes to $371.9 billion over 10 years.

Some Republican lawmakers say the Democrats' health overhaul could land uninsured people behind bars, but it's a claim rooted in a rigid reading of the law around tax evasion that seems quite a stretch.

Rep. Peter Roskam of Illinois waves handcuffs during a floor speech. (YouTube)

The Wall Street Journal reports that House conservatives are saying "people who refuse to buy health insurance could spend five years in prison," an overhaul critique that has also cropped up in the Senate on the eve of its own floor debate. Like an earlier accusation that reform would create government "death panels," the claim doesn't stand up to scrutiny.

During the House debate early this month, Rep. Peter Roskam, R-Ill., said the individual mandate to buy health insurance in the Democrats' plan could mean jail time: "I'm not talking about figurative handcuffs," he added, waving a pair of shiny, police-style manacles as he spoke. "I'm talking about criminal penalties."

People convicted of such crimes "shall be fined not more than $100,000 ($500,000 in the case of a corporation), or imprisoned not more than 5 years, or both, together with the costs of prosecution," according to the code.

The Joint Committee on Taxation described the possible penalties in response to a request by Rep. David Camp, R-Mich., for information about how the mandate might be enforced.

It's worth noting that the Senate Finance Committee's version of the bill includes an amendment specifying that no one could be imprisoned or face civil penalties for ignoring the tax.

In any event, imprisonment of tax evaders is usually reserved for the most outrageous cases. The letter to Camp notes that the Internal Revenue Service usually pursues unpaid taxes through the civil process -- meaning no jail time. In 2008, fewer than 500 people were incarcerated because of the penalties the Republicans are fretting about.

Weaver is a reporter for Kaiser Health News, a nonprofit news service.

What happens when Democrats and Republicans on Capitol Hill reach a historic agreement on a legislation that's been the subject of decades of battle? Sometimes nothing. At least not right away.

The ground beef scare might be a thing of the past, if the Senate has the energy to deal with the bill. (iStockphoto)

Yet while some Senators are engaged in agonizing arguments over a health overhaul bill, the Senate HELP committee quickly and fairly quietly put its bipartisan stamp of approval on a bill to dramatically change food safety laws. But it is not a sure bet that the bill will become law this year, as NPR's Joanne Silberner has reported on the issue.

Advocates for food safety reform have been pushing the legislation hard in recent weeks, and many in the food industry support it. In the wake of many high-profile foodborne illness outbreaks tied to foods as common as spinach and peanut butter that sickened millions, a similar bill passed the House in July.

Republican Sen. Mike Enzi of Wyoming, the top HELP committee Republican, asked for swift action on the bill. "I'm hoping the bipartisan approach will continue right on through the floor work," he said.

Most senators withdrew amendments they had intended to offer in order to keep action moving in committee. The bill passed by unanimous consent.

But with healthcare legislation on the verge of hitting the Senate floor any day now, the rest of the congressional year might just be spoken for.

If Senate Majority Leader Harry Reid succeeds in moving a health bill onto the Senate floor, Republican Tom Coburn of Oklahoma has threatened to make the clerk read the whole thing aloud before debate can begin. Yikes!

Even if the Senate Democrats' bill comes in quite a bit slimmer than then nearly 2,000-page House version, the task could take days. So wouldn't it be nice to have a showbiz pro do the reading job?

We got to thinking about the possibilities after reading some fairly inspired suggestions put forth on Twitter. It's hard to top @pourmecoffee's idea of William Shatner, but @ezraklein gave it a go with Christopher Walken. Nice!

After kicking around some other names, we offer this slate for your vote.

The rumors are flying fast and furious that Senate Majority Leader Harry Reid will soon unveil to the world the health overhaul bill he's been working on for months after one last effort to rally the recalcitrant troops behind closed doors at 5 p.m. today.

Health overhaul poses a leadership challenge for Sen. Harry Reid. ( Brendan Hoffman/Getty Images)

Reid hopes to bring the bill--ostensibly a combination of the bills approved by two different Senate committees earlier this year--to the full Senate to begin debate as early as this weekend.

He's fighting not only the calendar -- Republicans have vowed to prolong debate for at least several weeks, probably pushing a final vote right up to the Christmas holidays -- but also his own caucus.

It is a clear challenge to his leadership.

To entice some of the fence-sitters, Reid has reportedly added some of his own bells and whistles to the bill that were not included in either of the committee products. To pacify liberals, he will include in the basic bill a so-called "public option." It would let individuals who don't get insurance on the job and small businesses choose a government-sponsored plan as one option in the new insurance "exchanges" the bill will create. To mollify moderates, states would be able to "opt out" of offering the public option if they want to.

But until now, it hasn't been enough.

Meanwhile, Republicans remain united in their opposition. Maine's Olympia Snowe, who once poked her toe in the water by voting for the Finance Committee bill, says she is opposed to any version of a public option, which the Reid bill is expected to include. Oklahoma's Tom Coburn has gone so far as to threaten to require the entire bill to be read aloud, which could ensure that everyone who has access to C-SPAN-2 will know exactly what is -- and isn't -- included in the Senate legislation.

Could make for some must-see TV this weekend.

For a sneak preview comparing the House bill with the one likely to emerge in the Senate, see this side-by-side chart from NPR's Kathleen Masterson and Kaiser Health News' Mary Agnes Carey.

If you think the uproar over the recent recommendation by a federal panel against routine mammography for women in their 40s is something new, think again.

A doctor points to a mammogram. (Rui Vieira/AP)

Way back in 1997, a committee of a dozen experts convened by the National Institutes of Health heard testimony, reviewed the scientific literature and mulled what to tell doctors and women in their 40s about screening for breast cancer.

After weighing the risks and benefits, they concluded:

[T]he data currently available do not warrant a universal recommendation for mammography for all women in their forties. Each woman should decide for herself whether to undergo mammography.

Sound familiar?

The two doctors said the majority report, "understates the benefits of mammography for women ages 40-49 and overstates the potential risks."

That was just the beginning of the uproar. As the Washington Post reminds us today, Congress held hearings and the Senate voted unanimously to challenge the recommendations then.

In 2002, the U.S. Preventive Services Task Force, the same panel that just issued the controversial advice against screening mammograms, came out in favor of those tests every 1 to 2 years for women age 40 and older.