News Capsules (January/February 2000)

Physician, Heal Thyself!

The 56th annual AAPS meeting held October 13-16, 1999 in Coeur D'Alene, Idaho was an outstanding success. We had the largest attendance since AAPS' resurgence of 1993-1994. The meeting was approved for CME credit and included discussions on "Getting out of managed care," by Dr. Melissa Clements; "Hepatitis B and other mandatory vaccines," by Drs. Kristine Severyn and Bonnie Dunbar; Dr. Lawrence R. Huntoon was fortuitously exonerated in his mock trial for fraud and abuse. We also learned about CPT coding (M. Tray Dunaway, M.D.) as well as issues of ethical peer review, physician assisted suicide, and private contracting. We participated in a delightful boat cruise on the beautiful Coeur D'Alene lake while listening to stories told by Mark Train (Stephen Dow, M.D.). In addition, we were entertained at a banquet with film critic Michael Medved, and at a luncheon on the lake with author David Horowitz. On a more sobering note, we watched the movie "Waco: Rules of Engagement" with its producer Dan Gifford. Audio and video tapes of the meeting are available from AAPS.

E&M Guidelines and the AMA

As a reason for the E&M guidelines and enforcement of the CPT coding system, Joe Tilghman, a Kansas City Regional Administration official, stated in testimony on April 9, 1998 that enforcement of the E&M guidelines and the CPT coding system "will also help us ensure the accuracy and thoroughness of history taking and examinations, and thus enhance the quality of care received by Medicare beneficiariesIf Medicare billing codes seem complex, it is because medicine is complex. The codes we use were developed by, and in fact belong to, the American Medical Association." (http://www.hcfa.gov/testmony/1998/98%5F0409.htm)

The AAPS News (November 1999) correctly added that the AMA CPT Editorial Panel delivered the new E&M guidelines to HCFA last summer, which will be tested beginning in January 2000. According to former HCFA administrator Bruce Vladeck, continuing attempts at revising the E&M guidelines are a problem for HCFA. "This is fundamentally, an insoluble policy.As long as RBRVS is tied to CPT you're going to have an impossible policy."

Rotavirus Vaccine

On October 15, 1999, American Home Products Corp. abruptly pulled the RotaShield vaccine off the market because of a link to intussusception in infants. Writing in The Wall Street Journal (Oct. 18, 1999), Gardiner Harris stated: "Over the past year, two babies died, 53 had surgery and another 47 required medical care after receiving American Home's RotaShield vaccine and then developing bowel obstructions." On October 26, 1999 it was further reported in the WSJ that the rotavirus vaccine (RotaShield) "would have killed 12 to 20 infants a year --- about as many lives as it was predicted to save --- if it had been given to every American infant, according to an emergency government study." This prompted a member of the vaccine-advisory panel of the CDC, Dr. Charles Helms, to admit, "We have got a bit of a black eye here and a possible problem with the future confidence of vaccines."

Indeed the withdrawal of RotaShield is the first time a vaccine for a common childhood illness has been taken off the market in the United States after having received FDA approval. The article also goes on to state that the FDA may have also lapsed by the fact that it was not aware of a 1989 test of a similar vaccine in China, in which a number of babies also suffered intussusception. It also elucidated the fact that while intussusception can usually be cured with enemas, in the case of vaccinated infants, surgery was required because of the severity of these cases in which part of the bowel had infarcted and had to be removed.

The paper also quoted Roger Glass, "a top CDC researcher who was involved in both the China trial and RotaShield's approval." Apparently remaining skeptical about the link, Dr. Glass was quoted as saying: "I am concerned that by throwing out this vaccine or damning it with the intussusception issue, we'll lose the opportunity to examine whether it could be a lifesaver in developing countries as well as a major preventer of hospitalization in the U.S."

Indeed the RotaShield withdrawal marks another setback for American Home, based in Madison, N.J. which has also recently agreed to pay as much as $4.83 billion to settle diet-pill litigation.

Vaccines and Autism

The medical controversy over whether vaccines may be linked to a gradual increase in autism continues. At least two studies by British physicians have come to contradictory conclusions about whether there is a link between autism and immunization efforts. While a 1998 study of a dozen children found a correlation between the measles, mumps, and rubella (MMR) vaccine and autism, another study published in June 1999 looked at some 500 children and found no association. Both studies have been criticized by the respective opponents of the debate.

Approximately 400,000 people in the United States, males more often than females, are autistic. The condition has been associated with encephalitis, rubella and epilepsy, and 75 percent of autistics have some degree of mental retardation, according to the CDC.

According to the U.S. Office of Special Education and Rehabilitation Services' 20th Annual Report to Congress, the number of autistic students has risen from 5,415 in 1991-92, the first year autism was counted as a disability, to 34,101 in 1996-97.

While the official report attributes the increase to the change in the classification of autism, Dr. F. Edward Yazbak, a retired pediatrician in Falmouth, Mass., posits that more children are developing autism at least in part because of reactions to vaccines. (Colleen O'Dea, Morris/Sussex Daily Record, August 22, 1999, www.dailyrecord.com) Dr. Yazbak, who has had two autistic grandchildren, fully supports vaccinations but believes that "bombarding an infant's or toddler's immune system with so many vaccines at once can be harmful."

The article by Ms. O'Dea also cited a report by doctors at the University of Medicine and Dentistry in New Jersey which found measles' antibodies nearly 10 times higher than normal in 16 children and concluded, "MMR therefore may play a role in the pathogenesis of autism."

On the other side of the debate, the CDC states there is no convincing evidence any vaccine can cause autism or any kind of behavioral disorder. It cites three studies outside the United States that found no evidence of a link, and counters that between January 1990 and February 1998, only 15 cases of autism after vaccination were reported to the National Vaccine Adverse Events Reporting System. The CDC which reported these findings also concluded those cases "are likely to represent unrelated chance occurrences that happened around the time of vaccination." The final verdict is not yet in.

New Jersey law requires all children to be vaccinated against 10 diseases before they can enter school. They need to receive at least 16 shots or vaccination doses by age 2 and get boosters later. (http://www.deja.com)

Protected Species --- Of Flies and Men

The new wing of a hospital under construction in Los Angeles has been put on hold. The Clinton administration and its appointees at the U.S. Fish and Wildlife Service have demanded that "the construction site be moved 350 feet to the north so that two acres of sand dunes could be set up to protect the 'Delhi Sands flower-loving fly' --- the only fly on the Endangered Species List," reports the American Sentinel (Oct. 1999, p. 9).

The absurd controversy began when eight flies were "discovered" near the construction site. The absurdity has become environmental policy. The directive is expected to add an additional $4 million to the cost of completing the hospital wing, "not to mention any human lives that may be lost due to overcrowding or lack of facilities because of delays."

Incidentally, these sand flies are about an inch long, and if these insects enter your house and you harm them, the fine is $25,000 and two years in jail. Insanity prevails!


Damned If You Do and Damned If You Don't

In the July/August 1998 issue of the Medical Sentinel, we featured a special issue entitled "The Police State of Medicine" (back issues available at www.haciendapub.com). In that issue, Charles Harris, M.D., William E. Hurwitz, M.D., and Tad Lonergan, M.D. described their personal experiences with the criminal justice system regarding pain management. In addition, we also printed a special article "Pain" by Otto Scott, a distinguished commentator on contemporary culture and editor of Compass. He wrote: "Physicians are fearful that if they prescribe narcotics to persons in pain who need pain killers, they will create addicts. They are also afraid they will lose their licenses to practice medicine, because the regulations restricting the use of narcotics for even medical reasons have grown so numerous, so complex, so restrictive that most physicians find it safer to let the patients suffer The war on drugs, in other words, has created such a threatening climate for physicians that they allow even a patient diagnosed with cancer to suffer agony, rather than prescribe pain killers."

Now, an Oregon doctor has been cited for negligence for under treating pain, and disciplined. "Medical Board leaders said it is the first time a state board has taken such an action. But they added that it is just the latest and most dramatic effort by a disciplinary body to shed the image of state boards as obstacles to the effective treatment of chronic pain through the overly cautious policing of opioid prescribing" (AMNews, Sept. 27, 1999). According to this report, "Paul A. Bilder, M.D., a Roseburg, Oregon, pulmonologist, engaged in 'unprofessional or dishonorable conduct' and 'gross negligence or repeated negligence' according to a stipulated order released by the Oregon Board of Medical Examiners. Among the six patient complaints detailed in the September 1 document are cases in which Dr. Bilder failed to prescribe adequate pain medication for patients, including some who were dying, and removed a catheter from a terminally ill patient over the objections of the patient and his family."

James R. Wynn, M.D., executive vice president of the Federation of State Medical Boards (FSMB), commented: "Any doctor who is practicing this type of medicine can expect to get in trouble if it comes to the attention of the board." But others saw it in a different light. Leigh Dolin, M.D., an internist in Portland and former Oregon Medical Association president, stated that the medical boards were getting involved in this issue because "it's politically correct, and I think they want to curry some favor with the public."

One positive step the FSMB can take in furthering the aims of good pain management is to stop the persecution and prosecution of physicians who use narcotics to control severe pain in their everyday practices. As Dr. Jane Orient stated in her e-mail communication to me dated Oct. 4, 1999: "If you listen only to the talk, you would think that we had become enlightened on pain management: that yes, indeed, God made opiates for pain, and they have been available for centuries if not millennia. For years, we have been trying to fight pain with multidisciplinary clinics that use everything but the one thing [narcotic analgesics] that works for many patients."

FDA Off-Label Drug Usage

Health care experts are beginning to suspect that Food and Drug Administration (FDA) censorship is costing human lives. The FDA considers any company promoting off-label use of any drug it produces and markets to be committing a criminal offense: Drug manufacturers cannot inform physicians a specific drug approved to fight one illness may be useful in fighting another illness for which it was not approved.

Daniel E. Troy (American Enterprise Institute) reveals in The Wall Street Journal (July 23, 1999): "According to the General Accounting Office, 25 percent of anti-cancer drugs are prescribed off-label. And 56 percent of cancer patients have been given at least one drug off-label."

The FDA approves of doctors learning about off-label uses from seminars, textbooks, the Internet or colleagues; but it does not allow physicians to receive literature from pharmaceutical firms.

Despite Judge Royce Lamberth's ruling a year ago striking down FDA restrictions on constitutional free speech grounds, the FDA continues to enforce its gag rule on manufacturers. This has been the case with spironolactone, a drug approved for generalized edema but not for congestive heart failure, although it's effective for both. (http://www.ncpa.org.)

Tobacco War Profiteers

Six countries have now consolidated their cases in federal court in Washington, D.C. They claimed they were "shocked" to learn that American tobacco could be harmful to their citizens. As so, Guatemala, Brazil, Bolivia, Nicaragua, Panama and Venezuela are claiming victimhood, and dozens of other countries, including Russia, are considering lawsuits of their own to claim their share of profits in the tobacco lawsuits. Writing in The Wall Street Journal (Sept. 20, 1999) a few days prior to AG Janet Reno's filing of the Justice Department's federal assault on the tobacco industry, Jonathan Turley states: "In the wake of huge personal-injury awards and the U.S. tobacco companies' settlements with state governments, the war profiteers are racing to court to get their share of the spoils.

Guatemala justifies the litigation by claiming that the U.S. and private companies are responsible for "the country's archaic and unjust socio-economic structure."

Brazil, the world's leading exporter of tobacco, insists it would have taken steps to protect citizens from tobacco, if only it had known it was addictive...this latest twist in the tobacco war is indisputable proof the first casualty of war is truth --- and American consumers will be paying the price.

Fidel Castro Exporting Socialized Medicine

Remember the fall of 1995 when maximum leader Fidel Castro came to the U.S. for a 5 day celebration of the UN's 50th birthday? Surrounded by Reps. Charles Rangel (D-NY) and Nydia Velázquez (D-NY) at Harlem's Abyssinian Baptist Church, he offered to send Cuban doctors to help in America's ghettos. More recently, on June 30, 1999, Fidel Castro urged the United States and other Western nations to join Cuba in improving health care in the developing world. Castro was speaking in Brazil where he was inaugurating a hospital. "If the United States and the world's wealthy countries put up the medicine, then we are willing to send as many doctors as necessary to the developing world," Castro declared. "However, David Kurakane, spokesman for the U.S. Consulate in Sao Paulo, questioned Castro's statements, noting the United States was already providing a wealth of health care to poor nations around the world, mainly through charitable and non-governmental organizations."

Castro also took the occasion to claim that Cuba hopes to lower its infant mortality rate even further this year, "despite the American blockade and the collapse of the socialist system." What this article doesn't tell you is that in 1957 Cuba already had the lowest infant mortality rate in Latin America at 32 per 1,000 which ranked Cuba 13th in the world, ahead of France, Belgium, West Germany, Israel, Japan, Italy, Spain, and Portugal --- all of which are now ahead of Cuba. While Cuba still has the lowest infant mortality rate in Latin America (12 per 1,000), it has slipped to 24th in the world.

The AP report also doesn't tell readers about a spring 1993 story first reported in The New York Times (May 21, 1993) regarding the embarrassing story of a mystery disease that had caused blindness in nearly 26,000 Cubans. The epidemic was so severe the Cuban government in desperation swallowed their pride in their socialist health care system and invited foreign experts to investigate. The mysterious disease had wreaked havoc in the population for over a year until American experts established the diagnosis. The disease was totally preventable and was caused by the nutritional deficiency of vitamin B1, thiamine. Nevertheless, the Cuban government was prepared to blame the epidemic, to spring "out of the hands of the enemy."

Dr. Maurice Victor, an eminent neurologist, stated "there is nothing mysterious about it --- it's Strachan syndrome," or beri-beri. Physicians began prescribing thiamine and the condition improved in many patients. The condition was caused by the severe food rationing which has worsened since the collapse of trade between Cuba and the former Soviet Union. Consumption of thiamine-rich milk, meat and eggs was and remains severely restricted. These events apparently had no impact on Castro's fervor to export Cuban medicine to the world.

And while we are talking about Cuba, Fidel and the revolution, you may or may not have seen the Human Events (July 2, 1999) report that a member of Castro's elite bodyguard unit defected to the U.S. Embassy in Santo Domingo and told The Miami Herald that Castro worried incessantly about being apprehended in a foreign country and tried for his crimes. He said Castro had given orders he was not to be captured alive. He's terrified of being kidnapped and prosecuted like former Chilean leader Pinochet. Ten percent of the population has fled Cuba, 200,000 are in prison or held in some form of retention, and up to 20,000 Cubans have died at the hands of the communist government for being "enemies of the revolution." Yet, it was the 1996 downing of Brothers to the Rescue plane that killed two Americans for which the Cuban American community most recently has pleaded for justice.

For reading new developments on Cuba, you are invited to link to the following New American articles:
Elián's Odyssey by William F. Jasper and Children of the Gulag by William Norman Grigg

This edition of News Capsules was compiled by Miguel A. Faria, Jr., M.D., Editor-in-Chief of the Medical Sentinel of the AAPS. It appeared in the Medical Sentinel, January/February 2000, Volume 5, No. 1, pp. 4-7. Copyright©2000 Association of American Physicians and Surgeons.