Overkill: the Dangerous World of American Medicine

	Book review on Overtreated by Shannon Brownlee (2007) Reviewed by Martin Lockley, 2009 published in Network Review No 101
	(order this book from amazon.co.uk)

Given the raging debate over American health care, I might have titled this review "Who Killed Michael Jackson?"  Is it really true that 50,000 Americans are killed every year by iatrogenic disease, as Deepak Chopra claimed in The New Physics of Healing (1990).   In Overtreated, Shannon Brownlee gives the lesser total  of 30,000 victims of  "unnecessary" (i.e., lethal) over-treatment - still twice the annual murder rate!  Moreover, Americans pay a huge individual and collective ($700 million) price for the dubious privilege of often "brutal, dangerous and extravagantly-priced" treatment such as "high dose chemotherapy with bone marrow transplant" given to 40,000 women for breast cancer. According to Browlee 9,000 died as a direct result before the procedure was found to be "no better than standard treatment."  "No better" evidently may again mean lethal.

The plot of the Hollywood thriller The Fugitive (Warner Bros 1993) has a pharmaceutical corporation covering up test evidence of the dangerous side effects of their powerful drugs. Brownlee's first chapter chronicles just such a real-life, 1960s episode involving David Wennberg who tried to blow the whistle on Orabilex. This drug  was linked to 25 cases of kidney failure in Washington DC hospitals alone, but the corporation never passed on hospital reports to the FDA (Food and Drug Administration), nor did the FDA respond when Wennberg reported to them directly. The drug was only withdrawn after Wennberg took the evidence to the Senate and White House. As I write Pfizer has just been fined 2.3 billion by the FDA for marketing unapproved drugs

Continued failure to institute 'universal' health insurance and health care is deep rooted, and began in the post war decade with strong AMA opposition.  Wennberg again made doctors "mad as hell" by exposing far too many unnecessary procedures. "Practically every woman over the age of fifty" in the area around the University of Vermont Department of Obstetrics  and Gynaecology  "had been relieved of her uterus." Wennberg dubbed such local medical industries the "surgical signatures" of a region. As doctors began raising fees, Medicare costs and insurance premiums rose until, today, the inflationary spiral is out of control driven by for-profit hospitals and insurance lobbyists. A sure sign of trouble manifests where hospitals "began hiring vice presidents for marketing and branding, and approving construction of VIP suites."

Chapter 2 brands the hospital as "the most dangerous place" to find oneself. Conservative estimates put "preventable," unforced hospital error as a leading cause of death, ahead even of >43,000  automobile fatalities. Wrong drugs, wrong dosages and lethal cocktails do the most damage. California Cardiologists Chae Hyun Moon and Fidel Realyvasquez performed such aggressive, invasive and unnecessary operations that "167 patients died during cardiac surgery or shortly after." Eventually, in 2006, the State Medical Board revoked these doctor's licenses, and the practice's parent company paid some $60 million to settle charges of Medicare fraud, and another $395 million in restitution to victims. Meanwhile between 1993 and 2003 hospitals closed 425 Emergency Rooms that were losing money through treating too many uninsured patients. Frighteningly, those who attempted to bring costs down, or expose fraud, as in the California case, were punished or ostracised while the "for-profit" culture continued to blossom. 

Emil Frei and William Peters were ardent advocates of high dose chemotherapy and bone marrow transplants, which only rarely arrest or cure cancer. Treatments costing between $150-500K caused insurance companies to balk. When patients trawled the medical literature to find justification for the efficacy of procedures the floodgates were opened. But as insurance companies were forced to pay they raised premiums and denied coverage to high risk patients. Meanwhile lawyers learned that most patients did not need the procedures and that they would virtually all die within a few years.

American medicine loves expensive gadgets and has a "slavish belief in technology."  Hospitals demand the latest CT and MRI equipment. Drug and equipment reps encourage patients to ask for scans and drugs, paying some doctors - labelled  "drug whores" - to give public lectures promoting corporate products. Although, in the 1980s most pharmaceutical companies were against direct advertising to the consumer because of the "very real possibility of causing harm to the patient. " lobbyists "whittled" away the rules in the name of  "commercial free speech" until legislation actually allowed corporations to fund the FDA!!. By 2005 drug companies were spending $3 billion a year (more than the 2009 Pfizer fine) on direct advertising to consumers. "Calling [this] 'advertising' is like calling D-Day a bunch of guys wading in the surf." The profit potential by 2002 gave the top 10 pharmaceutical companies profits equal to all other 490 Fortune 500 companies.  This is irresistible to unscrupulous and unregulated corporations. Soon the gullible public was warned that it was suffering from a slew of new diseases ranging from insomnia, restless leg syndrome, social anxiety disorder and yes! - even erectile dysfunction. The latter is soothingly and euphemistically labelled as E.D., with the ambiguous message read rapidly in the ad's final seconds "consult your doctor for an erection lasting more than four hours."  (Great prime-time T.V viewing for the kids)!   In case such arousal creates a social anxiety disorder, there is always the possibility of a cocktail of drugs that could quite literally terminate both conditions by inducing heart attack or liver failure!

All this 'corporate creation of disease" begins as a marketing ploy and ends in a lethal reality for which the perpetrators are not held responsible (though perhaps Michael Jackson's doctors will not get off scot-free). It is ironic and frightening that the medical profession is responsible for such new vocabulary as 'elder abuse' and for ignoring the fact that 'the challenges of the very old  are spiritual, not medical.' The problem is that "somebody needs to keep watch on the whole patient."

Such a broken system highlights the urgent need for change, and thank goodness we see signs of what Leonard Cohen called America's  'spiritual thirst' for authentic democratic 'change.' This manifests in films, outrage, books like this one, and Overdo$ed America, (Abramson 2004), journals that at last begin to root out and reject bogus corporate-funded studies, and constructive grass roots efforts to create evidence- and patient-based medicine. Some systems like the Veteran's Health Administration actually work well, and recently desperate Americas have looked to Europe and Canada to find systems that actually work, and in comparison with America, save their nations as much as 10% of GNP.  Without radical change America could spend 50% of its GNP on health care by 2050. Yet 68% of Republicans and 32% of Democrats claim the country had the "best health care in the world." What world is this? A world where revered artists like Michael Jackson are killed by drug overdoses administered by their own doctors - who then face murder charges!?

(order this book from amazon.co.uk)