OVERTREATEDWhy Too Much Medicine Is Making Us Sicker and Poorer
BLOOMSBURYCopyright © 2007 Shannon Brownlee
All right reserved.ISBN: 978-1-58234-580-2
Introduction......................................1One: Too Much Medicine............................13Two: The Most Dangerous Place.....................43Three: Your Local Hospital........................72Four: Broken Hearts...............................96Five: The Desperate Cure..........................117Six: The Limits of Seeing.........................142Seven: The Persuaders.............................175Eight: Money, Drugs, and Lies.....................210Nine: The Doctor Isn't In.........................238Ten: Less Is More.................................267Acknowledgments...................................305Notes.............................................309Index.............................................331
Chapter One Too Much Medicine
John E. Wennberg is one of the heroes of modern medicine, but not because he discovered a new treatment or invented a lifesaving medical device. His career spans American medicine's shift from a collection of solo practitioners at midcentury to one of the largest single industries in the world, and his life is a parable for both the power of individual doctors to heal the sick and the capacity of medicine to cause harm. At the heart of the story is New England, where he has spent the better part of his adult life, and where doctors in small towns in Vermont, New Hampshire, and Maine showed him that more medicine is not necessarily the best way to improve America's health.
Wennberg, who goes by Jack, lives in Hanover, New Hampshire, just a few miles down the road from Dartmouth Medical School, where he has been a professor for thirty years. He is both a physician and a Ph.D. in public health. Above the fireplace in his living room hangs a photograph of him as a small boy, bundled in a heavy jacket, with short wooden skis strapped with leather bindings to his feet. Peeking out from under a woolen cap with flaps over his ears, Wennberg smiles shyly for the camera-his head enormous on his little boy's body. The photo was taken in 1937, on the slopes near his hometown of Bellows Falls, Vermont, where his father managed the paper mill. A Norwegian immigrant, the elder Wennberg made his son read the plays of the great Norwegian writer Henrik Ibsen. The family snow-shoed and skied in the long New England winters; Wennberg fished in the summers. When he was ten years old, the family moved to Vancouver, Washington, a raw Western mill town in the shadow of Mount Saint Helens. Wennberg spent his summers at Spirit Lake, on the flanks of the volcano, fishing and working at a YMCA camp. In the winters, as a teenager, he served on the ski patrol on Mount Hood. Although Wennberg excelled in science and math, he graduated from Stanford in 1956 with a degree in literature, intending to get his Ph.D. in German literature and teach. But when it came time to read the Bible in Gothic, Wennberg realized he was more interested in science than words. By the time he graduated from McGill University Faculty of Medicine in Montreal, in 1961, he had grown into a handsome man of middling height, with wavy dark hair covering his large head, broad shoulders, and a heavy jaw. He had also met his first wife, Emma Ottolenghi, who was also a medical student at McGill, and they had their first child, David, the year Wennberg graduated.
In 1962, the family moved to Baltimore, where Wennberg had won a prestigious residency at Johns Hopkins, long one of the premier academic medical centers in the country. He thought he wanted to study the kidney, with its microscopic tubules that maintain a perfect balance of fluids and salts in the blood, but he was a terrible experimentalist. "I wasn't good at pipetteing and the careful work and the clean desks," he would later say. At Hopkins, he split his time between the dialysis ward and classes in epidemiology. The Wennbergs' third child, Diana, was born at Johns Hopkins with what at first appeared to be pyloric stenosis, a defect in the muscular valve that sits at the bottom of the stomach. Because they can't pass food from the stomach to the small intestine, babies with pyloric stenosis vomit everything they eat. Surgery introduced in the early twentieth century had transformed pyloric stenosis from an almost invariably fatal condition into a curable disorder. But when Diana's surgeon, Jacob Handelsman, known as "Jake the Snake" for reasons that have been lost over time, cut open the Wennberg baby's tiny abdomen, he found her pyloric valve was normal; her vomiting was completely inexplicable. Handelsman refused to give up. Over the course of two more operations, he realized her small intestine was missing a layer of muscle, and he invented a way to bypass the defective section of her gut, giving her the ability to pass food in the right direction. When she needed a transfusion during the third surgery, one of Wennberg's fellow residents whose blood type matched Diana's gave her a transfusion directly from his own vein. Wennberg never forgot the kindness of the doctors at Johns Hopkins, or the miracle of his daughter's cure.
The heroic surgery was also tangible evidence for Wennberg of the transformation that had taken place in modern medicine over the previous four decades. The discovery of penicillin meant that by the 1940s patients no longer had to die from infected wounds or a burst appendix, and that abdominal surgery no longer had to be a life-threatening ordeal. The discovery of high-blood-pressure medication prevented strokes, while cortisone transformed the treatment of several illnesses, including Addison's disease, the disorder that afflicted President John F. Kennedy. Without regular cortisone shots, Kennedy would never have been able to serve as president. Routine vaccination for polio, smallpox, and whooping cough meant that losing a child to infectious disease was no longer the norm but a rarity. Hospitals were no longer simply warehouses for the sick and dying, where little more than comfort could be offered; they had become factories whose product was miracles-"gleaming palaces of medical science," as sociologist Paul Starr puts it, where doctors were in the midst of pioneering work that would soon allow them to mend damaged hearts with open-heart surgery, transplant organs, and routinely postpone death with kidney dialysis.
After America's victory in World War II, which was won in part by the invention of such technologies as radar, sonar, and, of course, the atomic bomb, all of science assumed a symbolic as well as practical role in helping shape America's destiny as leader of the free world. Supporting scientific research became a responsibility of government, while American technological know-how-along with the destruction of Europe's economies during World War II-allowed American factories to produce more than half the world's goods, and 80 percent of its automobiles. Medical research held a special place in the scientific pantheon. Americans literally rejoiced in the streets at the news that Jonas Salk had created a vaccine for polio. By 1960, the insecticide DDT had eradicated malaria from the United States, along with yellow fever. Dysentery, typhus, and tetanus were now preventable with vaccines; pneumonia and meningitis could be cured with antibiotics. Newsmagazines ran weekly reports on medicine under hopeful headlines: "Machine of Life," a story about dialysis, and "Hunt for Cancer Vaccine Closes In." Newsweek quoted U.S. Surgeon General Luther L. Terry, who predicted that by 1985 nine out of ten diseases would be eradicated and "spare parts for the human body ... may seem almost commonplace." Television aired shows about heroic doctors, including Dr. Kildare, Ben Casey, and Marcus Welby, M.D., which in 1969 was the nation's favorite program. Americans thought they had the best health care in the world, and doctors were convinced they had the best job in the country.
And yet, patients still died unnecessarily. Wennberg learned this in 1963, midway through his residency, when a middle-aged woman slipped into a coma in the dialysis unit at Johns Hopkins with him attending. In her forties, the woman had undergone surgery for gallstones a few days before and was recovering normally, when her kidneys suddenly began to fail. At that time, dialysis had only been around for a few years and it took a machine the size of a bathtub to accomplish what two little fist-sized organs do in the human body. The woman was lucky to be at Johns Hopkins, which had one of the few dialysis units in the country.
She was on Wennberg's watch for only a short time-he can no longer recall exactly how long. He could find no reason for her to go into acute kidney failure, save one: Before her surgery, the woman had received a dose of the drug Orabilex, which was used to visualize her gallstones on an X-ray. Other drugs in the same class were known to have potentially harmful effects on the kidneys, yet the manufacturer, E. Fougera, neglected to warn doctors that Orabilex shared this drawback. In fact, the drug's label claimed it had "spectacularly low" toxicity and "notable absence of side-effects." To find out if his instinct about Orabilex was right, Wennberg set up a series of experiments in which he injected cats with escalating doses of the drug. After all the cats died of kidney failure, Wennberg went to the Johns Hopkins administrators, persuading them to take Orabilex off the formulary, the hospital's list of approved drugs. But they ignored his suggestion that they put pressure on the FDA to withdraw the drug, saying it was not their responsibility.
The administrators' refusal to protect patients beyond the walls of Johns Hopkins was an "epiphany" Wennberg would recall, a moment that seemed connected both to his future as a doctor and to the political and social upheaval that was occurring in the outside world. Within the gleaming palace of medicine that was Hopkins, Wennberg was still an underling, only twenty-nine years old-hardly in a position to challenge the authority of his employer. On the outside, the Vietnam War was escalating, and the power of authority in American culture was breaking down; students were taking over university buildings and forcing administrators to make changes in curricula; protesters were disrupting political conventions. Wennberg decided it was his duty to ignore his superiors and act. He began canvassing physicians at other hospitals: the University of Maryland; Georgetown University; Sibley Memorial Hospital; George Washington University. Every hospital had seen patients suffer kidney failure after being given Orabilex, including more than twenty-five patients in the Washington, D.C., area alone.
Wennberg wrote to the company, notifying it of his findings. He never received a reply. He later learned that the company had already received several reports of kidney failure and deaths associated with its drug, but had brushed them aside with the argument that physicians had administered too high a dose. The company never passed the reports on to the FDA. Wennberg then wrote to the FDA himself, detailing the cases he had uncovered and citing several papers in medical journals about the drug's potentially deadly side effect. He urged the agency to remove Orabilex from the market. Again, Wennberg got no reply and the agency did nothing.
Wennberg continued to collect cases involving the drug, uncertain what to do next. Then, in November 1963, President Kennedy was assassinated, an event that left Wennberg shaken yet more determined than ever to do what he believed was right, to stop other physicians from killing patients with Orabilex. In May 1964, he sent a letter to Senator Hubert H. Humphrey, urging him to go to the FDA about the drug. Writing that he was "embarrassed [a letter] was necessary," Wennberg told the senator that neither the company nor the FDA seemed willing to take the drug off the market in order to protect patients. Extrapolating from his data for the Washington, D.C., area, he estimated that at least one hundred people had died around the country from a drug that was still being touted by its manufacturer as entirely safe. Humphrey took Wennberg's letter to the White House. When managers at E. Fougera learned that the Johnson administration was preparing to call a meeting with FDA officials over Orabilex, the company voluntarily withdrew the drug.
The Orabilex episode set Wennberg on a new course. He realized that there was more to being a doctor than simply treating one patient at a time; that doing the right thing, asking what he could do for his country, meant working to improve the health of communities.
Medicine itself was also setting out on a new course, one that would lead to the dramatic expansion of the health care industry, to more cases like Orabilex, and to many of the problems that would reach crisis proportions by the turn of the next century. In 1965, Congress passed the Medicare Act, which for the first time provided the elderly with free hospital insurance and coverage for physicians' fees. The act's passage was the culmination of one of the most bitter, divisive, drawn-out fights in congressional history, during which the American Medical Association spent fifty million dollars campaigning against what it called at various times, a "dangerous device, invented in Germany," a "communist plot," and "socialized medicine."
The AMA's opposition dated back to the time of the Progressive Party and President Teddy Roosevelt, who supported many forms of social insurance, including universal health insurance, on the grounds that no nation could be strong if its citizens were impoverished and sick. At that time, opposition to universal coverage came largely from private life insurance companies, which had begun to market health insurance too. Many physicians supported government-provided insurance at first, until they realized that the Progressives didn't want simply to insure citizens; they intended to encourage doctors to form prepaid, group practices, modeled after early HMOs like the Mayo Clinic. Doctors at Mayo, and later Kaiser Permanente, in California, and Group Health Cooperative of Puget Sound, in Seattle, worked in multispecialty groups and accepted salaries rather than fees for their services. Several European countries, notably Germany, had already successfully adopted a government health system modeled on group practices, making affordable, modern medical care available to all citizens, many for the first time in their lives. Despite the success in other countries, by the late 1930s the AMA was arguing that the government should never intrude on the "sacred doctor-patient relationship." The AMA maintained that salaried doctors would lose their "professionalism," the code of conduct embodied in the Hippocratic oath.
The most pressing reason for the AMA's opposition to universal health insurance boiled down to money. As medicine's star was rising during the twentieth century, so were physician incomes, so that by the mid-1960s, doctors were among the highest-paid professionals, earning an average of $22,000 a year, or about $141,000 in today's dollars. The AMA leadership persuaded the rank and file that one of the effects of "socialized medicine" would be to lower their incomes. As the chairman of a California commission set up to look into a statewide health insurance program wrote in 1938, "My own experience in speaking to physicians is that the only questions they ask are ... how much money they would get, whether they would have to get up nights at the demand of whoever called them ..."
Only a few decades before, doctors were paid little more than the laborers they took care of. Like blacksmiths, pharmacists, and later auto- and dockworkers, they depended upon collective action to raise their status and their income. The AMA was in effect a labor union, and its message to the public was, and still is, that patients do best when doctors are paid fairly (according to their own definition of fair) and left alone, to practice as they were trained to do. Like most Americans, doctors wanted to be free to earn a good income; to work where, when, and with whom they liked. By the 1950s, the AMA, as the profession's political mouthpiece, had beaten back universal health insurance proposals in several states, including California and New York, along with a string of bills in Congress, including one that was heavily favored by President Harry Truman.
But the AMA's efforts to quash national health insurance accomplished something the group never intended: They stirred a national debate among Americans about the right to health care. Most workers had health insurance through their employers by the 1960s, largely as a result of collective bargaining by unions, but there were two groups of Americans who were still "going bare": children and the elderly. Two thirds of the more than thirteen million Americans who were over age sixty-five had incomes of less than one thousand dollars a year-a third less than the rest of the population-yet their medical needs were roughly three times higher. Only half of the elderly had any form of health insurance, and many of them were living and dying without benefit of any medical care at all. Social Security, which was enacted in the 1940s, was a hugely popular program, inspiring proponents of universal health insurance to narrow their sights shrewdly on getting coverage for the aged poor; they would worry about children and the rest of the population later. When Kennedy made the medical plight of the elderly a pivotal issue in his 1960 presidential campaign, Medicare became, in the words of an editorial in Life magazine, "the hottest political potato" of the year.