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Sectarian Insertions

I will write occasional posts instead of being on a regular schedule.  The reasons: There are more contributors than positions. Newer people to the field have more ambition and belly fire.  I have a number of projects and papers to finish in increasingly limited time and decreasing efficiency.  So have at it. Meanwhile, some non-random thoughts.

I am as concerned with social and political expression of pseudoscience as with its errors.  Health care reformers can be just as pseudoscientific as sectarians who want to restructure the scientific edifice.  Political ideologues want to centralize the medical system without solid evidence that their substitute would work, let alone work better.  Sectarians already see a national government system as an opportunity for expansionism. Mark Hyman, the Functional Medicine promoter, met with the White House staff, displaying his vision of medicine under a federal plan. Word is out that other sects have also had input. Many hold  suspicions that the proposals front for more ambitious formulations. I am suspicious of their confidence – that they can fix a complex, fluxing system using epidemiology, mathematical models, treatment paradigms, and top-down control.  I might accept some proposals if it were not that all constructed systems are intrinsically inefficient, political, and corruptible. The closer the agents of control are to the controlled, the more control the controlled have over the controllers – if you can follow that.

Centralized medical systems are based on the assumptions that physicians cannot control costs and their own behavior, and are self-serving at others’ expense.  That is true to some extent. But any correction of abuse must demonstrate that itself will have fewer abuses.

I’ve been on both sides of the control line – a review corporation CEO, a medical director of another, a private insurance and HMO utilization reviewer, a Medicaid (Medi-Cal) reviewer, consultant to the state,  and co-designer of computerized diagnostic paradigms. At the time I thought medical practice could be disciplined and subject to templates. I concluded that one can only design generalized paradigms. One cannot successfully replace physician thinking and patient perceptions and desires. In this country, anyway.

My point here is that pseudo-medicine and pseudoscience can anchor themselves in government controlled systems in ways not available in the private area. They resist ousting. Homeopathy in Europe, now a folkway, had a headlock on the European Union medical systems and the physicians there have struggled to convince the EU commission to deny payments for it.  It’s the same in UK. In Canada, some provinces allow payment for acupuncture, chiropractic, and herbalism, some not. In the US, these sects have inserted themselves into legitimacy through political pressures.  It’s through political systems that sects seek equality and can bypass science and reason.  

In the 1960s – 70s, Laetrile was not legal, and use was driven south of the border.  But it was gradually legalized in 27 states, and it took years and a Supreme Court decision to send it back.  A US District Court judge in Oklahoma contributed to one of the largest monetary scams in US history.  Before legalization, insurance companies denied payment for Laetrile. During legalization, traffic became a national scandal, reaching the tens to hundreds of millions of dollars.  Physicians and private insurance had previously made decisions of non-payment and illegitimacy with few challenges .

Licensing of chiropractors, acupuncturists, naturopaths in US states lends legitimacy. Those occupations got licensing through political pressure and a lot of campaign contributions.

Once included in a federal system, they will be more difficult to expel. If we can meet sectarianism in the open field, I think they have lesser chance for success. But once entwined in the net of the law, they are barely reachable.

This is why I am interested in some of the “higher order” sociological and political manifestations of sectarianism. I hope for a better understanding of how sectarians operate on that level, and how the public perceives, welcomes, or rejects them. How they operate and gain their benign face before they approach legislatures. We have to study sectarian strategies while we meet them on their playing field. I‘d like to identify other territories where they are more vulnerable, and other methods of dislodging them.

Sectarians are busy devising their new strategies – the concept of “CAM” was one, the funding of medical schools another, and others – the domination of funding and government agencies, the capturing of the Press through the “pantomime horse“ technique. New strategies will have to be based on the behavior and plans of the sectarians and their funders, and their  ideological agendas, their designs on the system. While this study proceeds, their incarnations will still have to be met head-on in blogs such as this. Have at it.

Posted in: Health Fraud, History, Medical Ethics, Politics and Regulation, Science and Medicine

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27 thoughts on “Sectarian Insertions

  1. OZDigger says:

    What a load of unethical, biased nonsense!!!!!!!!!!!!!!!
    The largest, most powerful sect in the U.S.A. is the medical profession, supported by pharmaceutical and insurance companies.
    Individually some of the most wonderful and brilliant people I know. I am not biased in that respect. But to call any other group a sect is unadulterated rubbish.
    You cannot achieve a “higher order”, unless you remove your own bigotry.
    The U.S.A. has one of the worst health care systems in the world, per capita. Great if you can afford it, great if you have insurance, pathetic for over 45million of its population. Help these people, before becoming all pious about CAMS, sects and other health care groups. Prove your own integrity before criticizing others!!!!!!!!!!!!!1

  2. Michelle B says:

    Very interesting article. All I could think was about Oprah and how she is a contagious spreader and entrencher of woo. With Oprah, America does not need what Europe has done (nationalize CAM into science-based medicine). And yes, when I lived in England, acupuncture, chiropractic, and especially homeopathy was shamelessly used. In France, where I live now, a little less. In any case, I always say, no thank you, I want science based medicine please. I also say no thank you to the samples of prescription drugs shoved on me by medical doctors, unless they can present a solid case on why I should take them. The dentists seem to be worse in that regard, you got a little pain, here take this little packet of antibiotic.

    Of course, rather than embrace hopelessness, it is much better to study the modalities of CAM infection and much better not to be ignorant about one’s opponent’s abilities and strategies so the most effective counter approaches can be identified and applied.

    The American medical profession, despite its significant problems in terms of how medicine is practiced and distributed in America, is solidly based on science-based medicine. If you are an determined medical consumer, you can cut through a lot of the crap that some medical doctors throw at you and eventually find a doctor with whom you can trust and work with. With CAM, that quest is impossible as those practitioners do woo, that is, non-effective treatments. Geesh, life is not easy and one needs not to make it harder by throwing science-based medicine out of the window just because some individual medical doctors are aholes and some professional organizations have their own agenda.

  3. Michelle B says:

    OZDigger, The lack of integrity present in the application of science-based medicine does not invalidate the integrity of science-based medicine itself just like Social Darwinism does not negate the validity of evolution. And should the scientists that do conduct their evolutionary studies properly stop because some do not? I don’t think so, thusly the doctors at this site are ethical in their thrashing woo and the bad that it does. They do not have to be quiet in their criticism just because their own field can be justly criticized for other aspects than the science itself.

  4. David Gorski says:

    The American medical profession, despite its significant problems in terms of how medicine is practiced and distributed in America, is solidly based on science-based medicine.

    Of course, the AMA shot itself in the foot by being too clearly about protecting its turf, which poisons its stands against CAM.

  5. OldGene says:

    ‘My point here is that pseudo-medicine and pseudoscience can anchor themselves in government controlled systems in ways not available in the private area’

    So the government just might be daft enough to allow some whackery here in the UK (the politicians aren’t trained in science) but that doesn’t mean our medics will begin prescribing herbal tea or visits to the magical unicorn.

    The medics will just ignore it. No one tells my doctor how to diagnose and treat me, or that he should refer me to any kind of quack. He merely chooses a generic drug, advises me my illness will pass with the help of my own body or refers me to a specialist if needed. Doctors in the NHS are pretty smart professional people, not poorly programmed robots!

    If any politico or administrator tried to do dictate, I’d like to be there to take a video his response (that would be truly priceless!).

    I, like the medics here in the UK await the first prosecution of whackery by Trading Standards Officers (‘Most alternative medicine is illegal’ on DCs improable science blog).

    Having experience both US and UK medical systems, I moved back to the UK as quickly as possible rather than put my health in the arms of administrators running a highly ineffective, poor and outrageously expensive system of healthcare. You should come over and take a look at how we provide healthcare for all. You’ll be impressed.

  6. AgnosticOracle says:

    The US is one of the only high income countries that doesn’t guarantee health-care to its citizens. Are we to believe the SCAM medicine is less common in the US than the rest of the developed world? If so please show me hard statistical evidence, not cherry picked anecdotes.

    If our goal is better medical standards then the only thing that can enforce medical standards is the government. That SCAM providers would try to lobby the government to allow their woo is to be expected. That is how democracies work. Our job is lobby better.

  7. Several of you have missed one of the points here, which is that a government should not mislead its citizens by formally endorsing quackery–any more than it should formally endorse a religion. How common SCAM medicine is in the US is a separate issue. I, for one, believe that people in a democracy have a right to make foolish choices as long as they don’t harm others in so doing; I don’t believe that the government ought to be encouraging such foolish choices. More precisely, I don’t believe that government ought to be suggesting to citizens that such choices are not foolish, but are equivalent to rational choices. I also don’t believe that I should be required to pay the salaries of quacks.

    And yes, Dr. Sampson is certainly correct that once sCAMmery is made part of a NHS, it is very difficult to remove it. Better for it to be left in the private domain, where it will sink or swim depending on appropriate market forces in a free society: its success or failure in convincing people that it’s worth buying, our success or failure in convincing people that it’s not worth buying, it being exposed as fraud in some cases, etc.

    Some medics in the UK do prescribe visits to magical unicorns: homeopathy, for example. You, OldGene, are paying for homeopaths’ new cars and plasma TVs. Did you know that?

    The argument for universal access to affordable health care is a strong one. So is the argument that free people ought to be able to choose how their money is spent and whether or not their government is in the business of duping its citizens. Universal access does not necessarily require a NHS, which has, whether we like it or not, a characteristic that makes it antithetical to the second argument: each citizen must tolerate and pay for whatever its government dictates. This is not limited to SBM vs. sCAM, but to other obvious issues: should people who truly believe that abortion is murder be required to pay for other people’s abortions? Should smokers be allowed to drain resources for end-of-life care for the cancers that they brought on themselves? What about plastic surgery procedures in the hazy area between ‘cosmetic’ and ‘reconstructive’? And more.

    The issue is not how you or I or Dr. Sampson responds to each of those controversies. The issue is that we all must acknowledge that they inevitably arise when we relinquish freedom of choice in favor of governmental fiat. Like it or not: you can be for a NHS–you may be surprised to hear that I almost am, at this point, for a number of reasons–but to deny this trade-off is to be intellectually dishonest.

  8. KirinDave says:

    While a legitimate complaint, I think we’re past the point where we can deny government healthcare because we’re concerned about how charlatan medicine might abuse it. People cannot get the legitimate health care they need, let alone the fake kind.

    And quite frankly, CAM thrives right now, especially on the poor and uneducated. Once we can make SBM more available then we have a toehold to start educating people and showing them viable alternatives rather than saying, “Don’t use that, but it sure is a shame you can’t afford the things that do work.”

    Public Option plans may not be the best format for these changes, but they’re by far the most supported. Americans, as a country and a voting public, have allowed our representatives to dither and choke on this issue for far too long, and instead of being able to carefully architect a solution we are now faced with a crisis breaking point. It’s unfortunate, but I have to accept we reap what we sew, politically.

  9. OldGene says:

    kirinDave,

    Our government does not ‘dictate’ an NHS to us. The Tories tie themselves in knots trying to find ways of wiping out the NHS, but they know the electorate will not stand for it. Didn’t the notice the public outrage and solid expression of support for our NHS a week or so ago, when certain republican politicians began to mis-represent our healthcare system to the American public? We have the NHS because that is what we want, and not as a result of having it forced on us by a government.

    The people voted for a government that went on to provide a social structure after the devastation of the Second World War. We wanted it (culturally we do not see governments as being so bad, in contrast to American culture).

    It is up to the people of the US what kind of system will best meet their needs. Using an argument of whackery creep to argue against government involvement is sad, really. Sad for those who can not afford the private insurance and the frightening costs of the entire US health system. All the government need to do is say evidence-based medicine will be made available under the scheme.

    Yes, and we do know what is beginning to be given to a very small minority of patients, and yes, if you take the time to look, you will see there are many of us fighting to stop this whackery creep. Many of us.

    NICE until recently has worked to ensure recommendations are evidence-based – there has been one sad case where they failed to prevent whackery. We face, I fear, an eternal battle with those who cannot understand the NHS will not and can not provide medicine as prescribed by some cheap, scandal-dreaming journalist that has no proven efficacy. We are working on it… just as sure as the whacks are working away.

  10. OldGene says:

    kirinDave,

    Our government does not ‘dictate’ an NHS to us. The Tories tie themselves in knots trying to find ways of wiping out the NHS, but they know the electorate will not stand for it. Didn’t the notice the public outrage and solid expression of support for our NHS a week or so ago, when certain republican politicians began to mis-represent our healthcare system to the American public? We have the NHS because that is what we want, and not as a result of having it forced on us by a government.

    The people voted for a government that went on to provide a social structure after the devastation of the Second World War. We wanted it (culturally we do not see governments as being so bad, in contrast to American culture).

    It is up to the people of the US what kind of system will best meet their needs. Using an argument of whackery creep to argue against government involvement is sad, really. Sad for those who can not afford the private insurance and the frightening costs of the entire US health system. All the government need do is say evidence-based medicine will be made available under the scheme. Isn’t that what patients want, either privately or otherwise, at the end of the day?

    Yes, and we do know what is beginning to be given to a very small minority of patients, and yes, if you take the time to look, you will see there are many of us fighting to stop this whackery creep. Many of us.

    NICE until recently has worked to ensure recommendations are evidence-based – there has been one sad case where they failed to prevent whackery. We face, I fear, an eternal battle with those who cannot understand the NHS will not and can not provide medicine as prescribed by some cheap, scandal-dreaming journalist that has no proven efficacy. We are working on it… just as sure as the whacks are working away.

  11. weing says:

    I for one do not support the public option. It creates at least a two tier system. One for the privileged, and one for the hoi polloi. The public option should be no more and no less than what our humble servants, the members of Congress have. If it’s good enough for them, then it’s good enough for the rest of us.

  12. Dacks says:

    From oregonlive.com:

    “members of Congress use the same health care program as every other federal employee, whether that employee works as a Forest Service manager in the Deschutes National Forest, as a meteorologist for NOAA in Hawaii, or as a janitor in the Bureau of Engraving in D.C.”

    This website details the coverage:

    http://www.fepblue.org/benefitplans/standard-option/medical-benefits.html

  13. Isn’t this a bit like NRA nuts who argue that any gun control legislation will lead to a loss of Second Amendment rights? Or that we shouldn’t have a military because it might be co-opted by believers in pseudo-science and the paranormal (ala General Stubblebine)?

  14. David Gorski says:

    Several of you have missed one of the points here, which is that a government should not mislead its citizens by formally endorsing quackery–any more than it should formally endorse a religion. How common SCAM medicine is in the US is a separate issue. I, for one, believe that people in a democracy have a right to make foolish choices as long as they don’t harm others in so doing; I don’t believe that the government ought to be encouraging such foolish choices. More precisely, I don’t believe that government ought to be suggesting to citizens that such choices are not foolish, but are equivalent to rational choices. I also don’t believe that I should be required to pay the salaries of quacks.

    And yes, Dr. Sampson is certainly correct that once sCAMmery is made part of a NHS, it is very difficult to remove it. Better for it to be left in the private domain, where it will sink or swim depending on appropriate market forces in a free society: its success or failure in convincing people that it’s worth buying, our success or failure in convincing people that it’s not worth buying, it being exposed as fraud in some cases, etc.

    No, I don’t think I’ve missed the point here at least. Here’s the problem. Wally is correct to oppose the intrusion of CAM into the government in the form of NCCAM and efforts by Tom Harkin to get any new health care reform measure into any health care reform bill that may pass this year. There’s no argument there. Where the argument develops is when Wally uses the intrusion of CAM into government health programs as a reason to oppose government health programs completely.

    And, yes, that’s exactly what Wally appears to me to be doing here and in other posts he’s done. He’s made it very clear that politically he is utterly opposed to any further government involvement in health care beyond what already exists , be that new involvement single payer, a public option, or increased government regulation of health insurance requiring everyone to be insured. That’s all well and good; he may hold whatever political views that fit his beliefs. However, as much as he is correct that we should oppose the infiltration of CAM into government-funded research and health plans, the question of whether the government should reform health care in the first place and, if so, how is a separate question from the problem of preventing the sectarians from getting their agenda attached to health care reform. Wally conflates the two issues and uses that conflation to argue that we should never have a government health care system, when all the issue of CAM in government health care should argue for is that, if we as a nation decide to have a government option for health care, we have to fight really hard to make sure it’s done right and we have to be aware that politics may dictate that some woo may end up being covered no matter how much we fight it. The question is whether the benefits of a government health insurance plan outweigh this and other potential problems.

    Universal access does not necessarily require a NHS, which has, whether we like it or not, a characteristic that makes it antithetical to the second argument: each citizen must tolerate and pay for whatever its government dictates. This is not limited to SBM vs. sCAM, but to other obvious issues: should people who truly believe that abortion is murder be required to pay for other people’s abortions? Should smokers be allowed to drain resources for end-of-life care for the cancers that they brought on themselves? What about plastic surgery procedures in the hazy area between ‘cosmetic’ and ‘reconstructive’? And more.

    So how is this any different from pacifists objecting to having their tax dollars funneled to the military? Or from people who don’t think government should pay for education having to pay taxes for that? Or even at the local level, childless or retired people paying taxes to support the school system, even though they will never use it? Etc. As I think you are arguing (but am not sure), they aren’t, and in fact they are no more contentious issues than many other programs that the government funds. That’s why I always find this objection a bit curious. That’s what the political process is for, to work through these objections.

    In any case, I used to think a lot like Wally. I used to be inexorably opposed to single payer or a public option. All it took was a decade in practice caring for cancer patients in areas with a lot of uninsured working poor to cure me of my philosophical objection to such a program.

  15. OZDigger says:

    It intrigues me how arrogant some of the contributors are. Using terminology such as “sCAMer, chiro-quacktor etc”, to describe someone who has a model of health care that is not the same as theirs. There is a presumption that people who practice CAMs are not evidence based etc.
    It would be just as offensive to you pseudo-scientific SBM-ers to be referred to as “legalised drug pedallers, clinical toxicologists, etc”. I use the words “pseudo-scientific”, as science can be mis-used to prove anything one wants it to.
    So, pick up your game, respect the others for doing a job in health care that is demanded by the population (patient autonomy) and look at your own failings to see why the U.S. population rejects your rigid, unbending and soul-less approach to health-care

  16. Harriet Hall says:

    OZDigger reads this blog, but he apparently does not understand what he reads.

  17. Joe says:

    OZDigger on 06 Sep 2009 at 5:49 pm “So, pick up your game, respect the others for doing a job in health care …”

    What job would that be? Are you a crystal healer, a psychic surgeon, a reiki master, a chiropractor, a homeopath, an intuitive healer etc. …

    They are all good, no?

  18. Joe says:

    OZDigger on 04 Sep 2009 at 12:19 am “What a load of unethical, biased nonsense!!!!!!!!!!!!!!!”

    You use that word “unethical”- I don’t think that word means what you think it means …

  19. OZDigger says:

    Typical of you, Harriet, you do not like what you read, so you revert to insults.
    Hardly ethical, hardly honest, but very expected.
    Think carefully as to why the U.S. population rejects your rigidness. Think carefully on why medicine is failing to help millions of Americans each year. Think carefully why in excess of 190,000 Americans die each year of Iatrogenic causes. Think about why the U.S. has such a plethora of diseases that relate back to the society one lives in e.g. obesity, diabetes, heart disease, cancers, smoking related disorders. Sort out those problems first before you resort to insulting other practitioner groups who do care for their patients, who do have the confidence of their patients and who do have a positive effect on their patients.
    You no longer live in the times of Dr.Kildare and Marcus Welby M.D., The doctor does not always “know what is best “, The patients know it, and are walking with their feet and chequebooks.
    Patient autonomy is very important in the health care systems that exist. Respect it and work with it. Do not force things on people and respect their opinions.

  20. Harriet Hall says:

    OZDigger is the one who resorts to insults (“hardly ethical, hardly honest” etc.). I just made an observation that his comments are incompatible with an understanding of what this blog is all about.

    He apparently rejects science because it can “be misused to prove anything” and his argument for using CAM is that the public demands it, not that it is safe, effective, or better than other treatments (or even as good). His attacks on medicine are one-sided: he lists problems but doesn’t consider all the good done, the lives saved. He implies that CAM is evidence-based, but he doesn’t offer evidence; and he doesn’t seem to understand that this blog is all about why we need to go beyond evidence-based medicine to science-based medicine.

    Patient autonomy is one of the pillars of medical ethics, but patients are not acting autonomously if they are influenced by the false beliefs of others and are given biased information about the effectiveness of various treatments. Medical ethics demands that they be offered the full science-based information needed to give truly informed consent.

    OZDigger’s repeated use of the same logical fallacies on another thread, even after they were pointed out, has exhausted my patience to where I can think of a lot of insults I could resort to, but I won’t. I don’t need to. His comments speak for themselves.

  21. OZDigger says:

    Hi Harriet, this statement of yours is wrong.

    “Medical ethics demands that they be offered the full science-based information needed to give truly informed consent”.

    Bio-ethics requires that the patient is made aware of all the treatment options available, so that they can then make an “informed choice”, as to the type of care they want. More often than not, they go with the person who they trust and is most plausible. Irrespective of whether it be the Family M.D., Chiropractor, Osteopath or Acupuncturist.

    It is the job of all the health-care providers to make the patient aware of these choices. You must remember that you are dealing in a democracy here. Patients may not want to be treated in a certain way, if it does not suit their own paradigm of health.
    The first avenue patients go to for a second opinion is Dr. Google. They are then provided with a myriad of information some of it true and some not.

    “Patient autonomy is one of the pillars of medical ethics, but patients are not acting autonomously if they are influenced by the false beliefs of others and are given biased information about the effectiveness of various treatments”.

    I could not agree more with this statement, but my argument is, that there is so little continuity of care and agreement amongst health-care providers about the type of care to give, that the patient is left in a quandary. For example, the use of anti-biotics for the common cold.
    When you cannot even agree amongst yourselves as to what is scientific, then how can you be a judge of other health-care disciplines. My argument is, that you cannot, as you only look at things with the skills you have in your possession.

    Keep up your insults, close your mind a bit tighter. I can cope.

  22. OZDigger says:

    Hello Harriet

    lets go one step further in the discussion of ethics. May I be so bold as to say that the term “medical ethics” is a dinosaur tautology from the severely paternalistic years of the 1970′s. The term is now “bio-ethics”.
    I would suggest to you that there is now no such thing as the animal, “medical ethics”. One has the overall concept of “ethics”, then one applies it to the discipline one is familiar with. Such that you can have “ethics as it applies to a medical practitioner”, “ethics as it applies to a lawyer, dentist, drainage contractor, builder or whatever”.

    So using the four principles of bio-ethics as you explained in quite a nice article several weeks ago, one must have…
    Beneficence….do some good.
    Nonmalificience do no harm
    Patient autonomy…….informed choice
    Public advocacy……… there must be some good for society in the decisions that are made.

    Most of the writings from you do not take any cognizance of the concept of Patient autonomy. You rely on the over-used term “science”, when this is always in a state of flux. What science proves one day, it can disprove the next.
    You writings on malificicience are one sided. You rarely, if ever talk on the dangers of “scientific medical care”, of which Vioxx is just one. But you are very keen to criticize the dangers of other forms of care e.g. SMT, without adequately comparing it to what else is available. e.g. You are concerned about the risk benefit ratio of SMT, but avoid to answer any questions on the risk benefit ratio on the use of NSAIDS for neck pain.
    In that respect, your writings are unbalanced in opinion and light in equity.

  23. Harriet Hall says:

    OZDigger’s last 2 comments are not worthy of a serious reply. I think our readers can see through the logical fallacies for themselves.

  24. weing says:

    Thieves and con-artists have ethics? Interesting concept.

  25. OZDigger says:

    Sour grapes

  26. mike150160 says:

    @OZDigger

    Bollocks!

    Beneficence….do some good.

    Big SCAM fail

    Nonmalificience do no harm.

    lesser SCAM fail as long as you discount the harm done by diverting people from effective treatments

    Patient autonomy…….informed choice:

    What information should be provided? Scientifically verified treatment modalities. I’m just going to pass over the tired, “science changes its mind all the time” crap

    Public advocacy……… there must be some good for society in the decisions that are made.

    It is good for society not to encourage the promulgation of nonsense by the criminal and criminally deluded

  27. BKsea says:

    First, I would like to thank Dr. Sampson for opening the topic of healthcare reform within the skeptic community. I have been thinking myself that the players have been imposing a desired outcome (e.g. the “public option”) and then looking for evidence to support the plan. Obviously, this approach is anathema to the science-based medicine crowd which seeks to collect evidence of what will work and then devise a plan. Clearly the US healthcare system has its problems, but we should be looking at specific solutions that have evidence that they directly impact the problems.

    Although this is a bit off topic, I am also disturbed by the equivocation and misrepresentation that is used in defense of various sides of the healthcare debate. One specific claim that I find especially bothersome is that despite the high cost of healthcare in the US, we receive low quality care (I followed this link from the science-based medicine blog: http://www.getbetterhealth.com/counter-point-american-healthcare-is-not-the-best-in-the-world/2009.08.31). The implication to me is that even those who have access to medical care are receiving worse care than other developed nations. I found this unbelievable and wanted to find out more.

    Looking into the “evidence” for this, the first claim I ran across is that our healthcare must be bad because our life expectancy is lower than most peer countries (e.g. http://www.cnn.com/2009/HEALTH/06/11/life.expectancy.health.care/index.html). To me, however, this statistic is more relevant to overall health than healthcare per se. Although healthcare plays a role, habits such as shooting each other and eating 5 big macs per week also play a role. Therefore, this statistic does not exactly implicate the quality of care.

    The next piece of evidence quoted is that the WHO ranks the US 37th in an assessment of “Health Systems,” which sounds much more damning. But how is this determined? First, the WHO gave up ranking health systems in 2000 because they decided it was not possible. If you look at the last published result in 2000 (http://www.photius.com/rankings/who_world_health_ranks.html), where the US ranked 37th, the criteria include life expectancy (see previous paragraph) and “fairness of financial contribution” and “distribution of financing.” These latter two factors do not bear at all on the quality of care, but indicate a preconceived bias on how the healthcare system should be set up rather than its functionality. The only criterion that seemed to reflect quality of care was “responsiveness” defined as “a combination of patient satisfaction and how well the system acts.” In that category, the US ranked #1.

    What struck me is that this argument is based on the fallacy of equivocation. Life expectancy indicates health, but that is not the same as healthcare. Likewise, the WHO rankings specify how well a system aligns with their pre-defined definition of perfection, but their “health system” is not the same as healthcare.

    I also wanted to see if there were any metrics that more closely reflected quality of care. I could not find anything general, so I decided to look for a specific example and picked cancer survival as a good metric reflecting a wide-ranging health problem that might be indicative of the overall quality of care. Searching Pubmed, I found a recent article (Coleman et al. Lancet Oncology 2008) that looked at 5-year cancer (breast, colon, prostate, and rectum) survival rates in 26 countries worldwide. The results were tabulated in Table 2, from which I took the average survival rate across all columns as a metric of quality of care. Interestingly, the US came out on top with an average 5-yr survival rate of 66.5%. The UK, for example, landed in spot #19 with a 47.7% average survival.

    Admittedly, this is only one piece of evidence and my interpretations may be flawed to some extent. However, the point is that I would argue that the US healthcare system is the best in the world, once a patient enters the system. It is certainly unfortunate that some people do not have insured access to this great system and I would like to see that changed. Also, we cannot deny that we pay considerably more than any other country for this system. It would be nice to reduce costs without reducing quality. It may, however, only be possible to reduce cost with some loss in quality.

    As a closing remark, I recently saw a blurb (perhaps in New Scientist ?) that sums things up for me. It was remarking on the cost/benefits of a certain secondary treatment or diagnostic used only in the US. If I recall correctly they reported that the procedure cost $1000, but only saved 1 additional person for every 198 receiving the procedure. I realized that the probable British reaction to this would be “How awful! They are dumping $198,000 to save a single life?” On the other hand, the probable US reaction would be “How awful! You mean there are places where people do not get this $1000 procedure that is proven to save lives!” I’m not trying to set up any strawmen, just reflecting on how the same data can be viewed in two different ways. Also, I don’t mean to pick on the Brits – oldGene just rubbed me the wrong way.

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