Comfortable and Furious


The people of the United States wonder if true health care reform is in the works at last. As health care costs rise precipitously as the population grows older and sicker, the health care debate rages anew in the halls of Congress and free market philosophy has appeared to have taken a terminal nosedive. Medicare and Medicaid costs hang an albatross around the collective neck of the taxpayer, very few real solutions are proposed beyond the short term, and generally revolve around who will pay for a health care system that provides (according to annual studies by the World Health Organizations and the Commonwealth Fund) mediocre-quality health care.

For those who feel the time is ripe for a fundamental shift towards socialized medicine with an emphasis on prevention over treatment, I take great pleasure in busting your evanescent bubble. Prevention is not profitable. Preventing the development of cancer or heart disease will result in a much higher quality of life, but then those people will not be taking an average of eight medications, going to frequent subspecialist physician visits, having heart catheterizations and other procedures that are billed to insurance for pallets of cash, or being hospitalized for expensive and painful chemotherapy to hold off cancer for a few months.

All that shit is awesomely expensive; even a short hospitalization for chest pain can rack up $20,000 in bills. If you think that anyone has a vested interest in changing this system, then you have never actually received a bill for medical services, or picked up a prescription in your life. Or if you have, you ignored the itemized cost sheet, since insurance took care of everything.

Insurance is an industry based upon spreading the risk and cost across a large population so that expensive events become affordable. Insurance companies profit because, in total, people claim on their insurance less often than they pay premiums. If your car is totalled, no problem: you can get another one, since the next hundred people have not driven into a parked car whilst getting a blowjob.

In health care, this has broken down since the number of people requiring expensive medications and procedures is steadily rising, and so there is nobody among whom the risk and cost can be spread. This will continue, as all of the principal players in the drama are continuing to get paid and Americans rarely do anything unless they are under direct threat or force.

One example of this is an elegant letter written to the Archives of Internal Medicine (see footnote) that reviews the common wisdom behind treatment of diabetes mellitus type 2 (acquired by age, obesity, and sedentary living, rather than type 1, which happens after the pancreas is attacked by the immune system and the body no longer produces insulin). In general, as people with diabetes continue to gain weight and do not change their habits, their blood sugar will rise and when it becomes critically high, they can go into a coma. It has been assumed that in the ensuing years rising blood sugar also destroys blood vessels, nerves, the kidneys, and may promote other end-organ damage.

This hypothesis has been aggressively promoted by the pharmaceutical companies that sell the glucose-lowering drugs, the global market for which was estimated at $21 billion in 2006. There is some incidental evidence that this is the case, but the only way to be sure is by conducting a large randomized placebo-controlled trial. Proof is needed that the damage occurs and can be prevented with a medication that lowers blood glucose. To justify the use of drugs with potentially lethal side effects, you must prove that mortality is lowered with the treatment.

There have been multiple trials of this type that have taken place over the last few decades to show just that, the largest being the ACCORD trial and the UGDP trial. The UGDP trial found that the diabetics taking the drugs died at 2.9 to 4 times the rate of those taking placebos, and there was no effect on organ damage due to elevated blood sugar. Now, this sort of event would normally lead to an immediate cessation of the use of drugs that showed no real benefit, and killed people off generally due to cardiovascular causes, but Big Pharma in this case, the companies that made the medications in the trials – quickly stepped in to help.

With their considerable financial clout, the companies generated so much controversy with a massive media campaign and by influencing the physicians and pharmacists that govern health system formularies and conduct medical training that to this day the UGDP trial is assumed to have been flawed. The National Institute of Health established a special review committee to assess this and their conclusion was that “the criticisms levelled against the UGDP findings are unpersuasive… it remains with the proponents of the oral hypoglycemics to conduct scientifically adequate studies to justify the continued use of such agents.”

This translates as “Everything those Big Pharma guys said was bullshit. Thank you.” This is where physicians everywhere should have been, like, “Damn, that shit was cold!” and stopped prescribing oral hypoglycemics. Instead, the clinicians believed Big Pharma, continued what they were doing despite the proven higher mortality rate and also continued teaching new physicians out of medical school to do the same, while being courted by pharmaceutical reps at complimentary dinners.

The UKPDS trial was started to investigate the same endpoints in the 1970s and the trial was repeatedly lengthened as the clinicians kept looking for a mortality benefit. While one particular drug, metformin, actually decreased mortality, another diabetes drug increased death rates by 96%. The trial failed to find any other clinically beneficial effects, yet still recommended the use of the drugs for… some reason. Many studies make conclusions that are crap, but not all clinicians read the statistical tables. Subsequent trials investigating other newer glucose-lowering drugs found similar increases in mortality with their use, which at this point is tantamount beating the maggots dining upon the dead horse to death.

The ACCORD trial was stopped early due to the 35% increase in mortality among those being treated with glucose-lowering medications. The only trials that have shown any benefit for diabetics have focused on treating blood pressure and cholesterol, which sharply decreased mortality due to cardiovascular causes or stroke. Since the 1970s, these results have been reproducible on a large scale, yet the prevailing wisdom remains to use diabetic drugs in high doses to produce very tight control of blood glucose, increasing the chance of patients dying from a hypoglycemic coma or cardiac cause. Continually, the trials have been ignored in favor of Big Pharma marketing materials.

If the health care industry is unable to abide by the findings of evidence-based medicine, how can it break free of the forces that require returns on investment to the detriment of quality of life? Put simply, physicians do not know half of what they pretend, and the industry has only profit as its guiding principle. While I do not advocate returning to all-natural medicine and shunning the advances of medicine through history, I do recognize that the system has become lost.

Just as stock markets require oversight and regulation to prevent massive heists by free-market charlatans, the health care industry needs a sane hand to redesign it in its entirety. To continue espousing reform while waiting for costs to stabilize is to hope that a sinking ship attains buoyancy by accident. Do not expect your physician, hospital, pharmaceutical company, or politician who is heavily lobbied by all three to suddenly see the light and focus upon prevention and cost-controls out of the fucking blue. This will require a well-educated and pissed-off electorate who would like to see an end to these self-indulgent ways, willing to make sacrifices like paying higher taxes for a socialized health care system with impartial oversight to make it happen. Don’t hold your breath, though…unless you are insured and can afford a pulmonologist.

The ACCORD Trial and Control of Blood Glucose Level in Type 2 Diabetes Mellitus: Time to Challenge Conventional Wisdom. Arch Intern Med. 2009;169(2):150-154.