Between 1900 and 2000, life expectancy in the US jumped from forty-seven to seventy-seven years. Many people assume that the thirty-year increase was the result of breakthroughs in modern medicine. But when physician Thomas McKeown studied US mortality rates from the 1700s through the 1900s, he found that 92 percent of the decline in mortality occurred before 1950—the date when the most significant medical advances began to appear. Major increases in life span were the result of declining death rates from eleven infectious diseases, including tuberculosis, pneumonia, and smallpox. And the declines in these diseases actually had less to do with the advent of medicines such as streptomycin and isoniazid than with public health measures, improved housing, and better living standards.391 Beginning in the 1900s, water chlorination and other drinking-water treatments—along with improved sewage disposal, enhanced food safety, organized solid waste disposal, and public education about hygienic practices such as food handling and hand washing—had a strong impact on reducing deaths.391
What’s more, medical care does little to explain the dramatic fifteen-to-twenty-year life-span gap between rich and poor that has continued and widened in the US beginning in the latter part of the twentieth century.390, 394 Sir Michael Marmot, professor of epidemiology at University College London, studied male British civil servants living in Whitehall in the 1970s. After analyzing data about their risk factors for coronary artery disease, he discovered that the higher the man’s social position, the longer he lived. The correlation was in direct proportion to each man’s position in the bureaucratic hierarchy: the number one official was less likely to have a heart attack than the number two official, the number two official was less likely than the number three official, and so on down the line. Men at the lowest employment grade were four times more likely to have a heart attack than those at the highest grade—and these differences were independent of factors like smoking, serum cholesterol levels, and blood pressure.389
A short ride on the Washington, DC, Metro was all it took for Marmot to illustrate the degree of these effects in America. Traveling from downtown’s Union Station to the suburb of Bethesda, Maryland, Marmot demonstrated that each mile traveled was associated with a gain of 1.5 years of life expectancy, which ultimately accounted for a twenty-year difference in life span between the inner city and the affluent suburbs.394
This disparity doesn’t just harm those at the bottom—it harms everyone. British society is less economically unequal than that of the US, as measured by the income gap between pay for CEOs and pay for the lowest-paid worker. When Marmot compared the two societies, he found that the “better-off Americans had more illness than the better-off English…and nearly as much illness as the worst-off English.”
The problem of income inequality is highly complex, and proposing a solution to it is beyond the scope of this book. But there are many social programs that have proved to mitigate the factors that lead to poor health outcomes for disadvantaged people. They include early childhood education programs such as Head Start, reliable child-care programs for working families, nutrition programs, prenatal and postnatal care for mothers, and many others. Most are inadequately funded, and many are under constant pressure in the name of “fiscal responsibility” and “personal self-reliance.” Making a real national commitment to supporting such programs and making them available to all who need them would have a measurable impact on the health of Americans—and save billions in medical costs.
Such a change in attitude is not a matter of altruism. The welfare and health of our neighbors is central to our own well-being and that of our nation, whether in terms of our ability to protect ourselves from the spread of infectious diseases or industry’s need for a healthy workforce.
As a nation, we have agreed to designate certain things that benefit the whole society as common goods. They include basic education, roads and other infrastructure, clean air and drinking water, and services like firefighting and policing. These common goods produce a level of civilization that makes life in America worth living for all citizens. Healthcare should be added to this list. And just as we expect police officers and firefighters to risk their lives for fair salaries, we should expect physicians and medical researchers to work for a fair salary and thus be insulated from the biasing effects of lucre—and to truly work for the common good.
As a young medical-school graduate in the early 1970s, Jerry Hoffman made a decision that was highly unusual at the time: he declined a lucrative offer to give talks around the country for a drug company. In the 1970s, doctors who spoke on behalf of drug companies weren’t just highly respected, they were also often revered as the brightest boys on the block. Many were honored speakers at grand rounds and at international conferences and were very well paid with red-carpet perks.
Hoffman turned all this down. He explains, “I’ve always thought that for a physician, being professional means you have to put your patients’ needs first, before your own. As I thought about this offer to join a speakers bureau, I realized that doing so would cripple my ability to make impartial judgments about drugs or research. It became crystal clear to me that I couldn’t ever take money or gifts from a drug company without violating the core obligation of my profession.”
In Hoffman’s view, doctors can’t take money and stay unbiased—and a doctor who takes money from industry is no different from a judge who takes money from an attorney who wants to influence the outcome of a case. “It would be considered a bribe in the courtroom,” Hoffman says, “yet it’s entirely accepted in medicine.”
The underlying problem is the fact that we insist upon treating healthcare as a commodity rather than a common good. This philosophy encourages hospitals, medical groups, insurance companies, pharmaceuticals makers, device manufacturers, and other healthcare businesses to put the pursuit of profits ahead of the public welfare. It also encourages ostensibly independent entities, from individual healthcare providers to universities, research institutes, professional associations, scientific journals, and regulatory agencies, to take money from industry, which inevitably biases their judgment.
Most fundamentally of all, we need to agree on a new national attitude toward healthcare—one that considers healthcare as a fundamental human right rather than a privilege reserved for those who can afford to buy it.
Hubert Humphrey, in his last speech as vice president, said, “The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life, the sick, the needy, and the handicapped.”
That same test applies not just to government but also to all of us. For as long as we continue to accept the commoditization of medicine in the name of free markets, then Lown’s and Hoffman’s vision of a healthcare system that is dedicated solely to the good of patients will remain out of reach.
* * *
Dennis Fegan’s younger son, Derrick, remembers years ago, when he was a teenager, watching when the entire Corpus Christi fire department came out to honor his dad at his retirement ceremony. Derrick was impressed by the camaraderie and respect shown to his father. He knew his dad would miss his buddies and his work as a paramedic and firefighter.
Two decades later, after all the tribulations brought on by his struggle with the effects of the VNS device implanted in him and his battles for recognition, honesty, and restitution by the American medical system, Derrick’s dad is back to the quiet rhythm of uneventful days at home. He still has brunch on Sunday mornings at the Town & Country Café. He putters in his yard. He enjoys it when his sons, Derrick and Michael, come to visit from time to time.
But too much has changed. Fegan’s family has seen him transformed from an outgoing, active man to a virtual recluse. Now an accountant living in Austin, Michael recalls the changes that occurred over time in his dad. He says that when his father was first released from the hospital after being treated for asystole, he was just happy to be alive. But after lea
rning about the cause of his asystole and encountering an indifferent and dishonest medical establishment, he grew angry. His father began peppering everyone in his network, including family members, with e-mails about the dangers of the VNS device.
Now that his anger has been transformed into ongoing efforts to seek change, Fegan tries not to worry about the VNS wire in his jugular vein or think about the clot that could detach and cause a pulmonary embolus and kill him at any moment. Or, worse, leave him crippled and dependent on others for his daily needs.
Reaching out to the world in the one way he can, Fegan continues his lonely work. He doesn’t earn any money for it. He can’t win anything for himself. But he can, maybe, help others.
The same desire that led him to become a firefighter and paramedic continues to motivate him, keeping him at his computer surveying the FDA data on the VNS device long after all hope for his own case has been destroyed. Fegan will receive no restitution, not even an apology. He continues to scan the medical literature and scrutinize the MAUDE database, updating other people with epilepsy by posting his findings on the VNS message board. He keeps looking for the right piece of information, the right person or agency that will help protect others from the device that nearly killed him—a task that has become even more important to him since he learned that the military is experimenting with the VNS device as a potential way to treat traumatic brain injuries and post-traumatic stress disorder, among other problems, in soldiers returning home from war.395, 396
Mike recalls when his dad’s passion for the cause was at its height. “For a while, I got eight to ten e-mails a day. They would be little short e-mails, or just links. After a while, I was like, ‘I get it.’ But then one day I actually read some of the material, and I thought, wow, he’s on to something. I think if it saves even just one life, it’s worth it.”
Dennis Fegan’s sons understand that, although he can no longer go out on ambulance calls as a paramedic and firefighter, their father is still fighting to save lives.
And he’s still the hero they looked up to as kids.
Dennis Fegan with his grandchildren. (Photograph courtesy of the Fegan family)
Industry-Independent Organizations,
Publications, and Patient Advocacy
and Support Groups
Resources for Patients and Healthcare Providers
Advocating Safety in Healthcare E-Sisters: U.S.-based online group with a special focus on Essure implants
http://www.ashesnonprofit.com/
Alliance for Human Research Protection: “Advancing Honest and Ethical Medical Research” (USA)
www.ahrp.org
Breast Cancer Action: An “independent voice [and] activist watchdog organization” (USA)
http://bcaction.org
Breast Cancer Action Quebec: “The only independent breast cancer organization in Canada whose mission is to work for the prevention of breast cancer and the elimination of environmental toxicants linked to the disease” (Canada)
http://www.bcam.qc.ca/
Campaign Zero: Offers “quick information and checklists” to help patients and their families avoid being harmed in the hospital (USA)
http://www.campaignzero.org/
Canadians for Vanessa’s Law: Promotes the Protecting Canadians from Unsafe Drugs Act (Canada)
Contact David Carmichael at [email protected]
The Carlat Psychiatry Report: “An eight-page monthly newsletter (in both print and online form) that provides clinically relevant, unbiased information on psychiatric practice. We receive no corporate funding, which allows a clear-eyed evaluation of all available treatments” (USA)
www.thecarlatreport.com
Center for Medical Education: “Committed to providing the highest standard in continuing medical education since 1977.” Includes lectures and commentary by Jerome Hoffman, among others, in primary care and emergency medicine (USA)
https://courses.ccme.org/
Citizens for Patient Safety: “Improving health literacy and engaging and empowering patients and families to manage their own health” (USA)
http://www.citizensforpatientsafety.org/
Cochrane Collaboration: Provides meta-analyses and systematic reviews. Cochrane fails to be as fully industry-independent as its guidelines suggest, and some of its recommendations appear compromised as a result, but many provide the highest-quality evidence and analyses available in multiple languages (UK)
http://www.cochrane.org/
Device Events: Uses the FDA’s adverse-events database reaching back twenty years (USA)
www.deviceevents.com
Essure Procedure: Online support and advocacy for women harmed by Essure, hosted by Erin Brockovich (USA)
http://essureprocedure.net/
Foundation for Integrity and Responsibility in Medicine: Publishes Health Care Renewal, a blog that provides superb clinical and policy analyses focused on distortions created by conflicts of interest (USA)
http://www.firmfound.org/
http://hcrenewal.blogspot.com
gtprevencaoquaternaria’s Blog: Brazil. “We are an industry-independent group, mainly working on quaternary prevention.”
[email protected]
http://blogdoduro.blogspot.com
Harding Center for Risk Literacy: Germany. Excellent group that “researches, develops and disseminates tools” that clearly explain the risks vs. harms of medical interventions.
[email protected]
www.harding-center.mpg.de
Health Action International: “Global network of independent experts in 70 countries share information and expertise in all areas of pharmaceutical policy, including intellectual property, pharmaceutical R&D, free trade, pharmaceutical marketing, clinical trial data transparency and pharmaceutical pricing [so] all people [can] receive the right medicine…at a price they can afford.”
http://haiweb.org
HealthWatch: Quarterly newsletter originally focused on unproved treatments that “now promotes evidence and integrity in all forms of medicine and healthcare” (UK)
https://www.healthwatch-uk.org/about/about-healthwatch.html
Healthy Skepticism: Focuses on “reducing harm from misleading drug promotion.” Has a superb collection of journal articles and information on a variety of topics, including conflicts of interest, and has a global membership (Australia)
http://www.healthyskepticism.org/global
KCE Belgian Health Care Knowledge Centre: Available in multiple languages (Belgium)
http://kce.fgov.be/
Live Life Mesh Free: Online discussion group for individuals living with surgical mesh implants (USA)
https://www.facebook.com/groups/545418218970988/
Lown Institute: “We seek to catalyze a grassroots movement for transforming healthcare systems and improving the health of communities” (USA)
https://lowninstitute.org/
Manufacturer and User Facility Device Experience (MAUDE): The FDA’s medical device adverse events database (USA)
https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm
Mothers Against Medical Error: “Supporting victims of medical harm” (USA)
http://www.mamemomsonline.org/
National Physicians Alliance: “Advancing the Core Values of the Medical Profession: Service, Integrity, and Advocacy” (USA)
http://npalliance.org/
National Women’s Health Network: “Improves the health of all women by developing and promoting a critical analysis of health issues in order to affect policy and support consumer decision-making” (USA)
https://nwhn.org/
No Gracias: “Independent civil organization for transparency, integrity and equity in health policy, healthcare and biomedical research.” “Organización civil independiente por la transparencia, la integridad y la equidad en las políticas de salud, la asistencia sanitaria y la investigación biomédica.” (Spain and Spanish-speaking countr
ies)
http://nogracias.eu/
Nordic Cochrane Centre: See Cochrane Collaboration, above (Denmark)
http://nordic.cochrane.org/
Physicians for a National Health Program: “Non-profit research and education organization of 20,000 physicians, medical students and health professionals who support single-payer national health insurance” (USA)
http://www.pnhp.org/
Prescrire: “Independent information on treatments and healthcare strategies,” available in French and English (France)
http://english.prescrire.org/en/Summary.aspx
ProPublica Patient Safety Community: Online forum for “constructive dialogue about patient harm, its causes and possible solutions” (USA)
https://www.facebook.com/groups/patientharm/?fref=nf
Right Care Alliance: “A coalition to stand up for what healthcare should be,” addressing both undertreatment and overtreatment and advocating for “right care” (USA)
http://rightcarealliance.org/
RxISK: “Free, independent drug safety website to help you weigh the benefits of any medication against its potential dangers” (UK)
https://rxisk.org/
Safe Patient Project: Advocacy arm of Consumers Union (USA)
http://safepatientproject.org/
The NNT: Free evidence reviews using only “the highest quality, evidence-based studies (frequently, but not always Cochrane Reviews), and we accept no outside funding or advertisements” (USA)
http://www.thennt.com/
Therapeutics Initiative: “Independent Healthcare Evidence”; provides excellent evidence reviews (Canada)
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