Category Archives: Health Care

Too many laws, too many prisoners

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prison cellThe troubling overcriminalization of American life has been a frequent topic on this blog, so this excellent Economist article on the subject caught my eye.

After beginning with the example of the absurdly over-the-top local federal criminal case against local orchid importer George Norris, the article hammers home the stark statistics:

Justice is harsher in America than in any other rich country. Between 2.3m and 2.4m Americans are behind bars, roughly one in every 100 adults. If those on parole or probation are included, one adult in 31 is under correctional supervision. As a proportion of its total population, America incarcerates five times more people than Britain, nine times more than Germany and 12 times more than Japan. Overcrowding is the norm. Federal prisons house 60% more inmates than they were designed for. State lock-ups are only slightly less stuffed.

The system has three big flaws, say criminologists. First, it puts too many people away for too long. Second, it criminalises acts that need not be criminalised. Third, it is unpredictable. Many laws, especially federal ones, are so vaguely written that people cannot easily tell whether they have broken them.

In 1970 the proportion of Americans behind bars was below one in 400, compared with today’s one in 100. Since then, the voters, alarmed at a surge in violent crime, have demanded fiercer sentences. Politicians have obliged. New laws have removed from judges much of their discretion to set a sentence that takes full account of the circumstances of the offence. Since no politician wants to be tarred as soft on crime, such laws, mandating minimum sentences, are seldom softened. On the contrary, they tend to get harder.

Of course, America’s dubious drug prohibition policy fuels a substantial part of the prison industrial complex. Check out how supposedly enlightened Massachusetts handles certain drugs:

Massachusetts is a liberal state, but its drug laws are anything but. It treats opium-derived painkillers such as Percocet like hard drugs, if illicitly sold. Possession of a tiny amount (14-28 grams, or ¬Ω-1 ounce) yields a minimum sentence of three years. For 200 grams, it is 15 years, more than the minimum for armed rape. And the weight of the other substances with which a dealer mixes his drugs is included in the total, so 10 grams of opiates mixed with 190 grams of flour gets you 15 years.

And don’t think for a moment that the ubiquitous law of unexpected consequences isn’t at play with regard to this mess:

Severe drug laws have unintended consequences. Less than half of American cancer patients receive adequate painkillers, according to the American Pain Foundation, another pressure-group. One reason is that doctors are terrified of being accused of drug-trafficking if they over-prescribe. In 2004 William Hurwitz, a doctor specialising in the control of pain, was sentenced to 25 years in prison for prescribing pills that a few patients then resold on the black market. Virginia’s board of medicine ruled that he had acted in good faith, but he still served nearly four years.

Here are previous posts dealing with the sad case of Dr. Hurwitz. And it gets worse:

There are over 4,000 federal crimes, and many times that number of regulations that carry criminal penalties. When analysts at the Congressional Research Service tried to count the number of separate offences on the books, they were forced to give up, exhausted. Rules concerning corporate governance or the environment are often impossible to understand, yet breaking them can land you in prison. In many criminal cases, the common-law requirement that a defendant must have a mens rea (ie, he must or should know that he is doing wrong) has been weakened or erased. [. . .]

“You’re (probably) a federal criminal,” declares Alex Kozinski, an appeals-court judge, in a provocative essay of that title. Making a false statement to a federal official is an offence. So is lying to someone who then repeats your lie to a federal official. Failing to prevent your employees from breaking regulations you have never heard of can be a crime. A boss got six months in prison because one of his workers accidentally broke a pipe, causing oil to spill into a river. “It didn’t matter that he had no reason to learn about the [Clean Water Act’s] labyrinth of regulations, since he was merely a railroad-construction supervisor,” laments Judge Kozinski.

One of the most encouraging moments in the most recent presidential campaign was then-candidate Obama’s willingness to address the overcriminalization problem by considering reform of America’s abhorrent drug prohibition policy.

One of the most disappointing aspects of Obama’s Presidency is his abandonment of that issue.

So it goes.

The changing face of internal medicine

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health_insuranceAs noted here and here, my internist converted his practice to a successful concierge practice three years ago. In this recent KevinMD.com post, Dr. Steve Knope speculates that soon patients who are not a part of a concierge practice will not know their doctor if they have to go into the hospital:

What are the consequences for patients? What happens to the average person in Tucson, Arizona when he or she gets chest pain, develops pneumonia or has a seizure? Can they reach their internist or family practitioner for a medical emergency? Most patients who call their primary care doctor for a medical emergency can’t even reach his staff during normal office hours. Instead, they will hear a recording on an answering machine, directing them to go to call “911” for any medical emergency.

Once in the ER, the doctorless patient will be admitted to a hospital physician, who is unknown to them. This so-called hospitalist, who is a salaried shift-worker, will put in his 12 hours, and then go home. He is a doctor who knows nothing about the patient’s medical history. He has never met the patient. There will be no call from the hospital doctor to the primary care doctor in the office to get a thorough medical history. There will be no medical records transferred to the hospitalist. The hospitalist will attempt to get the best medical history he can from the patient, make some quick medical decisions, and then pass the patient off to one of his colleagues when his shift ends. And so it goes. No continuity of care, no understanding of the patient; the sick person now becomes a “case of pneumonia” or “the stroke in bed 3” to a group of unknown, rotating professionals.

Knope goes on to predict that as doctors flee from primary care (see earlier post here and here), the vacuum will be filled by nurse practitioners and medical assistants, who are far less trained in diagnostic procedures.

I don’t know about you, but I’m making sure that my payments on my concierge practice account are current.

The largest psychiatric hospital – America’s prisons

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An insightful Fault Lines segment examines how prison systems have become America’s largest psychiatric hospitals, with a substantial focus on the Harris County and Texas prison systems.

"People are actually now sicker as they die"

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End of Life careAs noted in earlier posts here and here — as well as in connection with the final years of Dr. Michael DeBakey — one of the thorniest issues facing reformers of the U.S. health care and health care finance systems is the extraordinary allocation of health care resources to end-of-life care.

This recent Marilynn Marchione/AP article frames the issues well:

Americans increasingly are treated to death, spending more time in hospitals in their final days, trying last-ditch treatments that often buy only weeks of time, and racking up bills that have made medical care a leading cause of bankruptcies.

More than 80 percent of people who die in the United States have a long, progressive illness such as cancer, heart failure or Alzheimer’s disease.

More than 80 percent of such patients say they want to avoid hospitalization and intensive care when they are dying, according to the Dartmouth Atlas Project, which tracks health care trends.

Yet the numbers show that’s not what is happening:

— The average time spent in hospice and palliative care, which stresses comfort and quality of life once an illness is incurable, is falling because people are starting it too late. In 2008, one-third of people who received hospice care had it for a week or less, says the National Hospice and Palliative Care Organization.

— Hospitalizations during the last six months of life are rising: from 1,302 per 1,000 Medicare recipients in 1996 to 1,441 in 2005, Dartmouth reports. Treating chronic illness in the last two years of life gobbles up nearly one-third of all Medicare dollars.

–People are actually now sicker as they die, and some find that treatments become a greater burden than the illness was, said Dr. Ira Byock, director of palliative care at Dartmouth-Hitchcock Medical Center. “Families may push for treatment, but there are worse things than having someone you love die,” he said.

But if your family is facing the prospect of caring for elderly parents in their waning years, don’t miss this extraordinary Katy Butler/NY Times Magazine article on the negative impact that an effective pacemaker had on the quality of her father’s life in the final years of his life:

Until 2001, my two brothers and I — all living in California — assumed that our parents would enjoy long, robust old ages capped by some brief, undefined final illness. Thanks to their own healthful habits and a panoply of medical advances — vaccines, antibiotics, airport defibrillators, 911 networks and the like — they weren’t likely to die prematurely of the pneumonias, influenzas and heart attacks that decimated previous generations. They walked every day. My mother practiced yoga. My father was writing a history of his birthplace, a small South African town.

In short, they were seemingly among the lucky ones for whom the American medical system, despite its fragmentation, inequity and waste, works quite well. Medicare and supplemental insurance paid for their specialists and their trusted Middletown internist, the lean, bespectacled Robert Fales, who, like them, was skeptical of medical overdoing. “I bonded with your parents, and you don’t bond with everybody,” he once told me. “It’s easier to understand someone if they just tell it like it is from their heart and their soul.”

They were also stoics and religious agnostics. They signed living wills and durable power-of-attorney documents for health care. My mother, who watched friends die slowly of cancer, had an underlined copy of the Hemlock Society’s “Final Exit” in her bookcase. Even so, I watched them lose control of their lives to a set of perverse financial incentives — for cardiologists, hospitals and especially the manufacturers of advanced medical devices — skewed to promote maximum treatment. At a point hard to precisely define, they stopped being beneficiaries of the war on sudden death and became its victims.

My family and I have experienced both a sudden death of a still-vibrant parent and a slow one under the painful grip of dementia. There is no question that my mother, a former nurse, did not want to die in the manner that she did. But she did not have that choice.

And that lack of choice is at the root of this vexing problem facing us all.

How important is knowing your Father?

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pandas_zoom2 Maybe pretty darn important, according to University of Texas researchers Karen Clark, Elizabeth Marquardt and Norval D. Glenn:

Each year, an estimated 30,000-60,000 children are born in this country via artificial insemination, but the number is only an educated guess. Neither the fertility industry nor any other entity is required to report on these statistics. The practice is not regulated, and the childrenís health and well-being are not tracked.

In adoption, prospective parents go through a painstaking, systematic review, including home visits and detailed questions about their relationship, finances, even their sex life. With donor conception, the state requires absolutely none of that, and the effects of such a system on the people conceived this way have been largely unknown.

We set out to change that. We teamed up .   .   . to design and field a survey with a sample drawn from more than 1 million American households.

Our study, released this month by the Commission on Parenthoodís Future, focused on how young-adult donor offspring ó and comparison samples of young adults who were raised by adoptive or biological parents ó make sense of their identities and family experiences, how they approach reproductive technologies more generally and how they are faring on key outcomes. The study of 18- to 45-year-olds includes 485 who were conceived via sperm donation, 562 adopted as infants and 563 raised by their biological parents.

The results are surprising. While adoption is often the center of controversy, it turns out that sperm donation raises a host of different but equally complex issues.

Two-thirds of adult donor offspring agree with the statement ìMy sperm donor is half of who I am.î Nearly half are disturbed that money was involved in their conception. About two-thirds affirm the right of donor offspring to know the truth about their origins.

Regardless of socioeconomic status, donor offspring are twice as likely as those raised by biological parents to report problems with the law before age 25. They are more than twice as likely to report having struggled with substance abuse. And they are about 1.5 times as likely to report depression or other mental health problems.

As a group, the donor offspring in our study are suffering more than those who were adopted: hurting more, feeling more confused and feeling more isolated from their families. (And our study found that the adoptees on average are struggling more than those raised by their biological parents.)

Some feel like a ìfreak of natureî or a ìlab experiment.î Others speak of the searching for their biological father in crowds, wondering if a man who resembles them could be ìthe one.î Still others speak of complicated emotional journeys and lost or damaged relationships with their families when they grow up.

Life is complicated.

Michael Shermer on Self-Deception

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Stick with this interesting lecture to the end.

The state of cancer research

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cancer-ribbon Following on these recent posts on the state of cancer research, John Goodman provides this timely and lucid post on the problems with ñ as well as the direction of – cancer research:

Why so little progress [in cancer research despite the large amount of money spent on  it]?

Some researchers believe we have been using the wrong model. Weíve been trying to combat cancer the way we fight an infection initiated by the common cold. But cancer is very different from ordinary infections and colds.

Suppose you have strep throat. Your doctor prescribes an antibiotic and the drug immediately goes to work fighting it. Letís say the antibiotic manages to kill 95% of the germs. Thatís enough damage to allow your bodyís natural defenses (white corpuscles) to take over and complete the clean-up job.

Now suppose we try to fight a cancerous tumor the same way. Letís say that through chemotherapy and/or radiation therapy, doctors manage to kill 95% of the cancer cells. In this case, the white corpuscles wonít be able to pull off the clean-up, however. Once cancer cells multiply and become lethal, itís an all-or-nothing proposition. As long as even a single cancer cell remains, it will eventually multiply again. And it will continue multiplying until the fight must be initiated all over again. Eventually the cancer will metastasize (spread all over your whole body), which is a virtual death sentence.

Unlike ordinary germs, therefore, in fighting a carcinogenic tumor you have to kill (or remove) every single cell. If even one cell survives, the cancer will return and become lethal again.

Strange as it may seem, cancer appears to disable the human immune system in much the same way as a fertilized egg in a womanís womb. Why doesnít the bodyís immune system treat a fertilized egg as a foreign invader and try to attack and kill it? Because somehow the immune system is turned off. Cancer cells are able to do much the same thing. Although the ability of women to carry a fertilized egg is pro-life and cancer is anti-life, it seems likely that both phenomena act in the same biochemical way.

Somehow, cancer turns off our bodyís natural defenses. Many researchers believe the most promising response, therefore, is to find a way to turn those defenses back on. By way of encouragement, consider that ìnearly everyone by middle-age or older is riddled withÖcancer cells and precancerous cellsî that do not develop into large tumors. Somehow our bodyís natural defenses are keeping them at bay. Could those same defenses be employed to take on more challenging tasks?

That is a good way of thinking about the two new drugs that were announced last week. Rather than fight cancer the way we fight ordinary infections, fighting cancer by liberating the bodyís natural immune system seems to have much greater promise.

By the way, in case you missed it, U.S. News & World Reportís annual survey of U.S. hospitals recently ranked the University of Texas M.D. Anderson Cancer Center in Houstonís Texas Medical Center as the no. 1 cancer hospital in the country. Texas Childrenís Hospital, which is literally across the street from M.D. Anderson in the Medical Center, is ranked as the no. 5 pediatric cancer hospital in the nation.

Can psychiatry be a science?

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menand_bw

Louis Menandís New Yorker article earlier this year that reviewed a couple of new books on psychiatry in the context of the confusing state of psychiatric literature posed the compelling question that is the title of this post:

You go see a doctor. The doctor hears your story and prescribes an antidepressant. Do you take it?

However you go about making this decision, do not read the psychiatric literature. Everything in it, from the science (do the meds really work?) to the metaphysics (is depression really a disease?), will confuse you. There is little agreement about what causes depression and no consensus about what cures it. Virtually no scientist subscribes to the man-in-the-waiting-room theory, which is that depression is caused by a lack of serotonin, but many people report that they feel better when they take drugs that affect serotonin and other brain chemicals. [.  .  .]

.  .  . As a branch of medicine, depression seems to be a mess. Business, however, is extremely good. Between 1988, the year after Prozac was approved by the F.D.A., and 2000, adult use of antidepressants almost tripled. By 2005, one out of every ten Americans had a prescription for an antidepressant. IMS Health, a company that gathers data on health care, reports that in the United States in 2008 a hundred and sixty-four million prescriptions were written for antidepressants, and sales totalled $9.6 billion.

As a depressed person might ask, What does it all mean?

Following on that provocative article, Russ Roberts’ essential EconTalk series this week presents this fascinating interview of Menand on the state of psychiatric knowledge and the scientific basis for making conclusions about current therapeutic approaches of battling it.

Although hard and fast conclusions are few, Menand is asking the right questions about a subject that desperately needs better societal understanding. His article and interview are valuable contributions to improving that understanding.

The shameful state of the Incarceration Nation

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mentally ill prisoners The troubling U.S. incarceration rate ñ a direct result of the governmental policy of overcriminalization ñ has been a frequent topic on this blog (here, here, here, here, here,here, here, here, here, here and here).

In this post from last fall, Scott Henson notes that Kings College in London now has available here its latest "World Prison Population List" that reflects that the United States remains a world leader in incarceration rate by a large margin:

The United States has the highest prison population rate in the world, 756 per 100,000 of the national population, followed by Russia (629), Rwanda (604), St Kitts & Nevis (588), Cuba (c.531), U.S. Virgin Is. (512), British Virgin Is. (488), Palau (478), Belarus (468), Belize (455), Bahamas (422), Georgia (415), American Samoa (410), Grenada (408) and Anguilla (401).

Americaís dubious drug prohibition policy is one of the reasons for the high incarceration rate. However, as this Houston Politics/Chronicle blog post notes, this National Sheriffsí Association survey (H/T Doug Berman) reports that the United States imprisons many more mentally ill citizens than treating them in hospitals. This press release on the survey summarizes the sad story:

Americans with severe mental illnesses are three times more likely to be in jail or prison than in a psychiatric hospital, according to "More Mentally Ill Persons Are in Jails and Prisons Than Hospitals: A Survey of the States," a new report by the Treatment Advocacy Center and the National Sheriffs’ Association.

"America’s jails and prisons have once again become our mental hospitals," said James Pavle, executive director of the Treatment Advocacy Center, a nonprofit dedicated to removing barriers to timely and effective treatment of severe mental illnesses. "With minimal exception, incarceration has replaced hospitalization for thousands of individuals in every single state."

The odds of a seriously mentally ill individual being imprisoned rather than hospitalized are 3.2 to 1, state data shows. The report compares statistics from the U.S. Department of Health and Human Services and the Bureau of Justice Statistics collected during 2004 and 2005, respectively. The report also found a very strong correlation between those states that have more mentally ill persons in jails and prisons and those states that are spending less money on mental health services.

Severely mentally ill individuals suffering from diseases of the brain, such as schizophrenia and bipolar disorder, often do not receive the treatment they need in a hospital or outpatient setting. The consequences can be devastating ñ homelessness, victimization, incarceration, repeated hospitalization, and death.

"The present situation, whereby individuals with serious mental illnesses are being put into jails and prisons rather than into hospitals, is a disgrace to American medicine and to common decency and fairness," said study author E. Fuller Torrey, M.D., a research psychiatrist and founder of the Treatment Advocacy Center. "If societies are judged by how they treat their most disabled members, our society will be judged harshly indeed."

Recent studies suggest that at least 16 percent of inmates in jails and prisons have a serious mental illness. According to author and National Sheriffs’ Association Executive Director Aaron Kennard, "Jails and prisons are not designed for treating patients, and law enforcement officials are not trained to be mental health professionals."

Ratios of imprisonment versus hospitalization vary from state to state, as the report indicates. On the low end, North Dakota has an equal number of mentally ill individuals in hospitals as in jails or prisons. By contrast, Arizona and Nevada have 10 times as many mentally ill individuals in prisons and jails than in hospitals.

Among the study’s recommended solutions are for states to adopt effective assisted outpatient treatment laws to keep individuals with untreated brain disorders out of the criminal justice system and in treatment. Assisted outpatient treatment is a viable alternative to inpatient hospitalization because it allows courts to order certain individuals with brain disorders to comply with treatment while living in the community. Studies show assisted outpatient treatment drastically reduces hospitalization, homelessness, arrest, and incarceration among people with severe psychiatric disorders, while increasing adherence to treatment and overall quality of life.  .   .   .

More evidence of the myth of American exceptionalism?