The Doctor Weighs In

Brian Klepper

Those who wait, ever hopefully, for real health reform might want to take a deep breath and take stock of a few realities.

First, think about the fact that when the Democrats retook Congress, they tweaked but did not fundamentally change the lobbying rules that trade money for influence over policy. In fact, most contributors have now adjusted their contributions to favor the current, rather than the past, majority party. As it turns out, Democrats, like Republicans, are only too eager to allow special interests to trump the common interest, so long as the transactions fetch a good price.

Take a long hard look at the chart below, taken from an April 15th report published by OpenSecrets, which tracks the impacts money has on politics and policy, put together by the Center for Responsive Politics. In 2007, the health care industry spent $445 million lobbying Congress, providing 16 percent of the total $2.8 billion spent to sway Congressional actions, more than any other economic sector for two years running.

$227 million, or 51% of that $445 million, came from the drug, device and medical products sector. General Electric alone spent almost $24 million courting our Senators and Representatives. PhRMA, the drug industry association, contributed another $22.1 million. The AMA also spent $22.1 million.

These dollars are spent to obtain specific results. David Beier, Amgen's head lobbyist and, formerly, Vice President Al Gore's chief domestic policy advisor, explained his company's 2007 $16.3 million lobbying expense very nicely in a Washington Post article last April. "We face a lot of legislative and regulatory issues. We resourced our advocacy to match our challenges."

Anyone watching the lobbying frenzy leading up to last week's vote, the President's veto, and Congress' rejection of that veto, pitting funding for Medicare Advantage plans against funding for physician reimbursement - the blow-by-blow was eloquently described by Bob Laszewski - could only marvel at the resources that can be brought to bear when money or other perceived interests are on the line.

Of course, there's nothing new here. For decades, the health care industry has leveraged its money and influence, shaping policy to its own ends. Last December I recounted that, upon hearing that the US Department of Health and Human Services had appealed a court ruling calling for CMS to release Medicare physician data, American Medical News quoted the AMA's Board Chair Ed Langston MD, "The Association is pleased that HHS is taking its advice." (This quote has since been expunged from the online version of the article.)

Or remember when the Employers' Coalition on Medicare, a powerful business interest group, teamed with PhRMA and the Republican Congress to pass Medicare D? The resulting legislation provided for a significant portion of the largess to be allocated to large firms (in the form of retiree prescription subsidies) in exchange for their support for the program. Retirees and taxpayers, of course, didn't fare quite as well in the deal.

Then there is the longstanding sole-advisor relationship between CMS and the AMA on the issue of physician reimbursement, in which the specialist-heavy society has continually called for, and CMS has continually delivered, increased reimbursements to specialists at the expense of America's primary care physicians, who are now in deep crisis as a result.

There are endless examples, all of which beg a couple important questions. Let's take the health care question first:

In a policy-making environment that is so clearly and openly influenced by money, how likely is it that Congress will pass be able to achieve health care reforms that are in the public interest?

There is broad expert consensus that one-third to one-half of all health care expenditure is waste. Talk privately with most health care professionals - physicians, hospital execs, health plan administrators, benefits managers, supply chain execs - and there is reasonable agreement on critical principles that are necessary to re-establish the system's stability and sustainability: some form of universal coverage for at least basic health services; a comprehensive and compatible IT infrastructure; a transition from fee-for-service to some form of performance-based reimbursement; pricing and performance transparency; and much more.

Such changes could drive tremendous savings for individual, corporate and governmental purchasers, but at significant cost to health care firms and professionals. Revenues and profitability would plummet. As the struggles over health care resources intensify, the efforts to protect and enhance each interest's position through policy will intensify as well.

It isn't as as though there aren't credible and influential people sounding the alarm. Take this comment from Peter Orszag, Director of the Congressional Budget Office, while testifying to the US Senate Finance Committee in June 2007.

“If [Medicare and Medicaid’s] costs continue growing at the same rate over the next four decades [as they have over the last four decades, at 2.5%/year higher than per capita GDP], federal spending on those two programs alone would rise from 4.5% of GDP today to about 20% by 2050. That amount would represent roughly the same share of the economy as the entire federal budget does today.”

Alarming? Sure. But that kind of "let's not burn the house down" warning tends to get lost against arguments for more dollars, backed by the nearly half-billion dollars the industry spent last year - an average of about $832,000 for each Senator and Representative!

Pass real reforms? I'd be surprised. Delighted! But surprised.

But that brings us to the biggest question.

America has a slew of important problems that cry out to be addressed: the obesity epidemic, energy, education, the environment, poverty, infrastructure replacement. What will it take for Congress to mount serious, public interest efforts that focus on these issues?

To a one, these problems are structurally identical to those we face in health care. Congress' current lobbying system means that money-for-influence relationships with lawmakers continually spin policy to favor special interests rather than the common interest.

Take the obesity epidemic. Here's a wonderful graphic I show in all my presentations. It shows that 31% of adult Americans are obese, with a body mass index of greater than 30. We're the leaders among developing countries on this problem. Mexico and England are a distant 2nd and 3rd, at 24% and 23%. The ridiculously industrious Japanese and Koreans are at 3%. I have two arguments here.

First, we have the worst obesity of any country because agribusiness and the fast, prepared and junk food industries have convinced Congress to provide concessions, ranging from corn subsidies to open-field running with advertising techniques that seduce our children. Sure, individual choices by parents factor into this, but whatever your philosophical position on that point, it is important to acknowledge that the current approach isn't working and we're losing the battle. And nationally, we HAVEN'T drawn a line in the sand as, for example, the Japanese recently did in deciding to mount an effort that measures waistlines. From their perspective, that effort is undoubtedly an investment in their national future.

Second, since weight is important to fitness, fitness is important to overall health, health is an important component of productivity, and productivity drives competitiveness, the US' future prospects are already lousy and headed south. In terms of our health AND our competitiveness, we're committing slow suicide.

And we can't seem to mount approaches like the Japanese seemingly did so easily. We're stymied due to policies that thwart the common interest in favor of the special interest. We wouldn't want to reduce choice for our consumers or our vendors, or be forced to reinvest in exercise programming, or compromise the profitability of agribusiness or the prepared food sectors.

And so we are paralyzed in our ability to problem-solve in virtually every area of societal endeavor.

As far as I can tell, there are two - and only two - solutions here. Both are highly improbable.

One is for America's largest corporations, the organizations that drive national policy through lobbying now, to galvanize to preserve the common interest. This is tough. Currently, most organizations focus their lobbying within their own core competency areas. Microsoft lobbies on IT, but not health. Marriott lobbies on hospitality policy, but not education.

What's needed is a national business coalition that collaboratively focuses on what's good public policy for the country - what's in our common short- and long-term interest. It could both support democratic institutions and, equally important, place sanctions on rogue organizations, like Enron, that would hurt the system through excesses or very poor performance at public expense. (By the way, I'm not advocating for government run by corporations - the formal definition of fascism. I'm simply explaining how things appear to already work, and how they might be redirected.)

They might do this because they realize that, if the components of the fabric that has made America strong - a focus on education and an informed populace, fairness and social justice, creativity, financial independence, productivity - are lost, then it will be more and more difficult to successfully pursue the special interest, at least from here.

The other solution would require a new Congress, under new leadership, to resolve to rid itself of its lobbying cancer, and to do so in a way that is highly visible and publicized. There would be ferocious opposition from industry. Hence the need for visible, articulate leadership from key political and business leaders.

Like I said, both are improbable. But they're also key our ability to turn the nation around.

In the meantime, we're all health care people. Go to the New York Times Health Page, and you'll see five sub-sections. The center one is "Money and Policy." Think that's clever, or simply precise?

By Dov Michaeli MD, Ph.D

We all heard this refrain; drug addicts kicking the habit, only to go through a lifetime of a constant battle to stay clean.

Why is it so hard? Why is it getting progressively harder within days after quitting? Who is the “devil that made them do it”?

The received wisdom for many years was that the reward system in the brain, which is the seat of all manners of addiction, is driven exclusively by dopamine receptors. But frankly, this belief had some problems. Here is a big one: the dopamine system is geared to maintaining homeostasis, which is the property of a living organism to regulate its internal environment so as to maintain a stable, constant condition. For example, exposure of dopaminergic neurons to increased concentrations of cocaine results in increased effects inside the cells. To maintain a constant internal environment inside the cell, the neuron responds by reducing the number of dopamine receptors. However, when the drug effect wanes, the addict feels depressed, and to get the same “high” in the face of reduced density of receptors he’d have to take an even higher dose of the drug, which would, in turn, result in yet another lowering of receptor density on the cell membrane. This is the basis of addiction; progressively elevated doses of the stimulus needed to obtain the same effect. Dopaminergic neurons respond in the same fashion to cessation of the stimulus, only in the opposite direction – the density of receptors increases back to the normal level. If the dopamine neurons were the sole ones involved, then this should be the end of addiction syndrome. But we know that this is not true.

We know that recovered addicts have to constantly battle the urge to go back on the drug. The dopamine receptor system does not explain this behavior.

The neurobiological basis of faltering resistance

Marina Wolff wanted to see if the neurons bearing the glutamate receptor have something to do with the difficulties addicts encounter after withdrawing from the drug. So she and her colleagues examined the glutamate neurons in the nucleus accumbens, which is part of the reward system and is involved in motivation and learning. They trained rats to self-administer cocaine by poking their noses into a hole when given a cue. As expected, the rats’ cocaine-seeking beahvior was more pronounced 45 days after the cocaine supply was cut off than after the first day. Examining the rats’ nucleus accumbens, they found something totally unexpected. Compared with rats in early withdrawal, rats deprived of cocaine for 45 days had incredibly high levels of a glutamate receptor of an unusual composition (called GluR2-lacking AMPA receptors). This unusual receptor promotes an inordinately strong response to glutamate. Indeed, if the new glutamate receptors were blocked in rats 45 days after cocaine withdrawal, their response to drug cues was cut by almost 50%. The conclusion according to Marina Wolff is obvious: the neurons were making new receptors in response to withdrawal, which explains the increased response to cocaine cues.

The implications

The obvious implication is that this receptor should be a powerful target for drugs designed to help in withdrawal from drug addiction.

But did you notice that this craving after withdrawal and the increasing difficulty in resisting cues is also an affliction of serial dieters? Indeed, eating stimulates the reward system just like any recreational drug; and overeating has all the hallmarks of addictive behavior. So, the obvious next step is to examine the levels of this unusual glutamate receptor in animals trained to overeat. It may be the answer to the losing battles millions of people wage every day in a desparate attempt to avoid re-gaining the weight they had lost.

Lastly, one more thought. Until only very few years ago it was believed that complex behaviors could never be explained by “simple”chemistry. Books and articles were written about the uniqueness of the brain, as if it obeyed different laws of physics. Here we have a receptor of a known composition, whose level in the brain controls a complex behavioral pattern. Can the day be far when we would be speaking of all human behavior in molecular terms?

By Dov Michaeli MD, Ph.D

“What makes the human superior to field animals”? So mused King Solomon, the wisest man of his times (10^th century BCE), in Proverbs. Since then this question has occupied the best minds of the human race, from Plato in the 5^th century BCE to the molecular biologists, neurobiologists, neuropsychologists and philosophers of the 21^st century. For a long while we thought that intelligence set us apart. We now know better; whales, dolphins, crows, parrots, and apes, to name a few, have been shown to possess a high level of intelligence. Is it our self-awareness that makes us unique? Not quite. Apes are showing various degrees of self-awareness. Is it our communication skills? They are indeed highly developed, but they are not unique; whales and dolphins, birds and apes – all communicate via quite complex languages. It has been suggested that our capacity to feel and show empathy is uniquely human. Have you seen a mother elephant grieving over her dead infant? Have you ever seen the whole herd commiserating with her? Have you heard of the African buffaloes who form a protective shield around a female who is giving birth, to ward off predators and vultures? In short, we are becoming increasingly aware that all these “human” traits started evolving millions of years before the first human descended from the trees to take his first tentative steps in the African savannah.

Glycobiology

In an article in Nature magazine, Bruce Lieberman reviewed the fascinating work of Ajit Varki of the University of California , San Diego . Dr. Varki is trying to uncover the mystery of human uniqueness. Now, if you guessed that Dr. Varki is a trained anthropologist, or a neurobiologist, or even a philosopher – I wouldn’t blame you; these are the usual suspects in this field. But a glycobiologist? What’s that anyway?

Glycobiology is the study of sugars in biology. Until quite recently this field was the backwater of biochemical research. And why not? DNA could crow about its function in storing all our genetic information. RNA could claim to be the crucial bridge between the information stored in DNA and the formation of proteins. And proteins had bragging rights as the machinery of life, performing all the functions that are critical for any living organism. But sugars? These molecules can be solitary or monosaccharides, such as glucose or fructose, or can form chains called polysaccharides. But they are totally unglamorous; glucose provides energy to the cell. Polysaccharides mainly cover the cell surface. Basically dumb molecules; none of the sophisticated functions of information storage or enzymatic activity.

Now bear with me for a second, and don’t get intimidated by the chemical terminology; you’ll be rewarded with an amazing insight.

Vive le petit difference

What kind of polysaccharides cover the cell surface? In humans the most common is a type of sialic acid called N-acetyl neuraminic acid, or Neu5Ac. But Dr Varki discovered that we are the only animal that has this molecule exclusively. All other animals have a different sialic acid on their cell surface, called N-glycolyl neuraminic acid or Neu5Gc.

Look at the molecules. You don’t have to be a chemist to realize that the difference between us and the rest of the animal kingdom is tiny – one oxygen molecule!

In fact, Varki found that a mutation in the enzyme involved in the synthesis Neu5Gc rendered it inactive, and that’s how we humans ended up with Neu5Ac.

One small step in glycobiology – one giant step for humanity.

How so? For that we should ask a question that is basic to evolution: why did this mutation survive? What selective advantage did it confer on the newly minted humans?

The answer is not known yet, but Varki points out a tantalizing clue. Humans are not susceptible to the malaria organism that afflicts other species, Plasmodium reichenowi. This parasite attaches itself to the cell surface by binding to Neu5Gc, and we don’t have it. But on the other hand, chimpanzees are not susceptible to Plasmodium falciparum, the human malaria organism. So the overall picture is becoming clear: a single mutation allowed us to escape from at least one devastating disease, and may be more. This is an enormous selective advantage.

No free lunch

But after all we do get malaria, albeit from a different species (P. falciparum). Interestingly, genetic analysis of this species shows that the species evolved in Africa , alongside the evolving humans, and it accompanied the bands of early humans as they migrated out of Africa.

This is not the only disease we acquired by becoming human. Asthma is pretty unique to us, as is rheumatoid arthritis, and Alzheimer, and Parkinson’s, and the list goes on and on. Does the sialic acid mutation play a role in all those uniquely human diseases? We don’t know yet. But what we do know is that sialic acid, carpeting the cell surface, is critical to interactions between cells. And such interactions are critical to the immune response, to communication between neurons, to hormones binding to their target cells, etc, etc. It would not be surprising to find this molecule in the center of physiological and pathological processes that are, well, uniquely human.

So there you have it: one tiny difference in a single molecule, and what momentous consequences it has wrought.

By Dov Michaeli MD, Ph.D

Did this question ever bother you? This is a question that falls into the category of “gee, I never thought of that” or “stupid, everybody knows that arthritis involves joints” followed by the plaintive counter “yes (mom/dad/ Bill/ doc), by why”? Indeed why? This question actually did occupy me for many years during my research career. Alas, I had no answer. Now, when I read a report in Science, I slapped my forehead as if to say “but of course, why didn’t I think of it”? But I am not writing this as a confessional; the findings are important for any sufferer from this dread disease, whether in its severe and debilitating forms, or the mild one that is just occasionally bothersome.

What is a synovium?

The normal synovium is a thin membrane that lines a joint, like the knee or elbow, or finger. It looks like the white membrane under the shell of a chicken egg; and it is just as exciting. That is, until recently.

A closer examination of this “boring” thin membrane revealed that it consists of a lining layer that is only a few cells thick and a sublining layer that consists of loose connective tissue, like collagen. The lining layer contains cells that look like fibroblasts (these are cells found in the skin and their function is to make collagen, the major skin protein), and are called synovial cells ( synovicytes). It also contains macrophages. These are the scavenger cells whose function is to pick up the tissue debris left by the destructive inflammatory process. But paradoxically, they also secrete protein molecules called cytokines, which cause the inflammation. Thus, macrophages both cause inflammation and form the cleanup brigade after the damage is done. If there is such a thing as a hypocritical cell, this is it.

What happens in arthritis?

Before I disclose the secret, here is one more crucial fact: on their surface, synovial cells have a protein molecule called Cadherin 11. This molecule is responsible for the adherence (hence the name) of the synovial cells to each other, organizing themselves into the synovial tissue. Take away the cadherin and the cells become disorganized. Not only that: remove the cadherin, and induction of inflammation becomes very difficult. Conclusion: an organized synovial tissue is necessary for inflammation to occur. And cadherin 11 is responsible for keeping these cells organized.

This is new knowledge, and it opens a brand new way to treat rheumatoid arthritis.

How so?

Cadherin is a surface molecule, and therefore available for therapeutic intervention. Cadherin 11 is absolutely necessary for the propagation of the inflammatory response and for the joint damage that ensues. So its manipulation, for instance blocking it with a drug, would result in “insulating” the joint tissue from the destructive forces of inflammation. And given the new tools of drug development, synthesizing a tailor-made drug that would do just that should be a relatively simple affair.

But wait, wait, there is more

People who study the intimate molecular events that occur in solid tumors like stomach, or colon cancers have long known that cadherin on the surface of the tumor cells is important in some way in the development of the cancer, and in its metastatic spread. We also know that the inflammation that occurs around the tumor is instrumental in its spread. Can we “insulate” the tumor from the effect of inflammation, and hence inhibit the metastatic spread, by manipulating the tumor cadherin? We don’t know yet, but this arthritis study is very suggestive.

So there we are: from an esoteric surface molecule on a seemingly inert cell residing in a “boring” membrane, to arthritis and to cancer. Doesn’t science does work in wonderfully unexpected ways?

By MICHAEL L. MILLENSON

The American Medical Association has now added a second pillar to its national health care reform plan. The first pillar, of course, has always been “Don’t sue,” a sturdy principle that over the decades has led the AMA to alliances with such notable victims of overzealous attorneys as tobacco companies. (For historical perspective, see Howard Wolinsky and Tom Brune’s 1994 book, The Serpent on the Staff.)

The second health reform pillar, it has now become clear, is: “Pay what’s due,” shorthand for “Give us what we ask for, and do it quickly.” This is also consonant with deeply held AMA beliefs.

A newly released study commissioned by the association found that insurance company bureaucracy and a “chaotic” claims process is draining time from patient care, diverting as much as 14 percent of physician revenue and costing “as much as $210 billion annually, without creating value.” Claims payment must be made “cost-effective and transparent,” the AMA asserts. And what could be more cost-effective than quickly writing a check for whatever the doctor asks for?

While I’m all in favor of cost-effectiveness and transparency, the AMA study does seem a tad harsh. Surely, one of the thousands of claims-processing cubicle dwellers corralled into windowless buildings on bucolic insurance company campuses must occasionally uncover an honest mistake or two in coding? As we know, even doctors’ office staffs aren’t perfect.

Although the AMA study found large variation in how quickly insurers paid, the problem of variation among doctors went unaddressed. Frankly, some are non-compliant, refusing to follow insurer instructions despite repeated phone counseling by highly trained high-school graduates. Alas, no insurance executive attempted to explain-away poor claims-processing marks by proclaiming, “My doctors are different.”

But what’s really shocking about the AMA study is that $210 billion figure. While at first glance it seems to draw on a methodology known as “throw in the kitchen sink,” I realized it actually fit quite well with a separate examination of health system bureaucracy. With a little searching, I found it:

“Because the U.S. does not have a unified system that serves everyone, and instead has thousands of different insurance plans, each with its own marketing, paperwork, enrollment, premiums, and rules and regulations, our insurance system is both extremely complex and fragmented…With a universal health care system we would be able to cut our bureaucratic burden in half and save over $300 billion annually.”

That analysis comes from Physicians for a National Health Program (PNHP), long-time flag-wavers for a Canadian-style single-payer system. As for the costs imposed by lawsuits, most Canadian doctors “receive malpractice protection from the Canadian Medical Protective Association, which tracks the number of legal actions launched and the amounts paid out to successful cases,“ according to the Canadian Health Services Research Foundation. Since 1995, the foundation added, there has been a steady and “startling” drop in the number of lawsuits filed and a steady increase in judgments favoring doctors in those lawsuits that do go to trial.

As it happens, there is a calculation of wasted dollars that dwarfs either the PNHP or AMA numbers, but it has nothing to do with paperwork. A 2005 Medical Care study by Terry S. Field et al. (Medical Care 43(12):1171-1176) examined annual costs related to adverse drug events in the ambulatory setting.
It concluded: “Across the entire population of Medicare enrollees age 65 and older in 2000, we estimate the annual cost for adverse drug events occurring in the ambulatory setting was more than $2 billion, of which $887 million was associated with preventable adverse drug events.”

The authors did not suggest report cards to help patients pick the safest doctor. But the methodology does suggest that one AMA concern was addressed.  Since the study was done at a large HMO, at least the doctors didn’t have to worry about getting paid.

By MICHAEL L. MILLENSON

Everyone wants universal health coverage, right?

Not quite. As I pointed out in a recent opinion piece for the Washington Post, the yearning for universal health care is far from universal. The reaction to that article – about 160 posted comments or direct emails to me  – confirmed that assessment.  So did the lack of reaction from certain quarters (more on that below).

In the article, I wrote:

Here's a cold truth: Despite much media hand-wringing on the subject, most of us give about as much thought to those who lack health coverage as we do to soybean subsidies. The major obstacle to change? Those of us with insurance simply don't care very much about those without it. It's only when health care costs spike sharply, the economy totters or private employers begin to cut back on benefits that the lack of universal health care comes into focus. Noticing the steadily growing ranks of the uninsured, the broad American public – "us" – begins to worry that we'll soon be joining the ranks of "them."

News media and interest group profiles of uninsured individuals focus disproportionately on middle-class whites, I charged. The reality, however, is this:

Two-thirds of those without health insurance are poor or near poor, according to the Kaiser Family Foundation. And there are clear disparities in how different racial and ethnic groups are affected. Only 13 percent of non-Hispanic white Americans are uninsured, compared with 36 percent of Hispanics, 33 percent of Native Americans, 22 percent of blacks and 17 percent of Asians/Pacific Islanders…

If a lack of health insurance were truly a white middle-class crisis, then conservatives and liberals would long ago have joined together, carved out a compromise and done something.

After criticizing Republicans and Democrats, minority group political leaders and prominent health care foundations, I concluded, in part:

Over the years, our society has gradually provided a medical safety net for the elderly and disabled (Medicare), the poor (Medicaid) and veterans. At one time, these commitments were controversial, and there's no doubt that they're expensive. Yet…[i]t's our willingness to be our brothers' keepers that in part defines who we are as Americans.

OK, I admit it: the truth is more nuanced. Compassion is just one of our traits. The theme of rugged individualism and self-reliance, for example, plays a large role in our national myth. Back in 1949, the New York State Journal of Medicine bemoaned the way advocates of health insurance (versus 100 percent self-pay) ignored the lessons of Darwin:

Any experienced general practitioner will agree that what keeps the great majority of people well is the fact that they can’t afford to be ill. This is a harsh, stern dictum, and we readily admit that under it a certain number of cases of early tuberculosis and cancer, for example, may go undetected. Is it not better that a few such should perish rather than that the majority of the population should be encouraged on every occasion to run sniveling to the doctor?

None of the comments on my article went quite that far, but the gist of many was similar: the uninsured either wouldn’t need insurance if they better managed their own health or would be able to afford it if they better managed their money. So why should I help bail them out?

Others simply invoked the dreaded specter of “socialism.” The canard that universal coverage equates to “socialism” was reportedly instituted by an American Medical Association PR consultant during the Truman administration, but it continues to be wielded cynically today. Pointing out that every other nation in the industrialized world has some form of universal coverage has little impact on an electorate socialized, as it were, to ignore the examples of Germany, Switzerland and a host of other nations.

Of course, there were respondents who called for a Canadian-style system, blamed all evils on insurance company greed or said we needed first to solve the problem of soaring costs. Others were simply grateful that the problem of the uninsured had been highlighted.

But here’s what nobody said: No one addressed the issues of race, class and political and economic self-interest that were at the heart of the article. Indeed, I saw no comments or emails from anyone identifying themselves as black or Hispanic.

Physicians, meanwhile, continue to almost as fragmented as the general public. While a recent survey in the Annals of Internal Medicine found that 59 percent said they support legislation to establish a national health insurance program, while 32 percent opposed it, there were glaring gaps among specialties. For example, psychiatrists were overwhelmingly in favor, while general surgeons were barely so.

Meanwhile, in a less-publicized study by the firm LocumTenens, 63 percent of respondents said they would “continue practicing like they do today,” if universal health care were implemented, 11 percent would change occupations and nine percent said they would retire.

Even if the answers are skewed towards self-selected respondents, a distressing number of physicians continue to react to universal care less like, “I am my brother’s keeper” and more like, “Don’t tread on me.” So do their patients.

By Dov Michaeli MD, Ph.D

As a physician and scientist I have an abiding interest in the politics of Science policy; yes, I mean Science with a capital S. Science is central to our national well-being; with the emergence of the threats of global climate change, as well as the “old” threats of environmental degradation and inadequate health care, it assumed existential importance to the whole human race. This is why I have been railing against our present administration; to the infinite frustration of scientists worldwide, this administration has been run by ideologues who did not shy away from muzzling its own scientists, who had the audacity to appoint party hacks as censors and final arbiters of professionals eminent in their respective fields.

Obama vs. McCain

What can we expect from the new administration? There will definitely be a vast improvement, whoever is elected. As the British Nature magazine put it, “ there can be little doubt that the next US administration will be more science-friendly than the present one. Both of the expected nominees, Obama and Republican Senator John McCain, have put forth platforms that represent major breaks from the policies of President George W. Bush. No matter who is elected, the United States will almost certainly repeal its ban on federal funding for research on human embryonic stem cells using fresh cell lines. The new president will endorse mandatory reductions in greenhouse-gas emissions and work with Congress to enact meaningful climate legislation. And new leadership appointments at key agencies can only mean that morale at places such as the Environmental Protection Agency will improve.”

Fair enough. But the Brits may be a bit naїve when it comes to American politics. Politicians in this country are held in the lowest esteem possible, and for  good reason—they dissemble, prevaricate, and plain lie. In British politics such behavior invites furious attacks by the press, scathing questioning by TV interviewers, and cynical dismissal by the average bloke on the street. No so here. The most outrageous untruths are reported in an "even handed" manner. False "balance" masquerades as fairness. Read an article that deals with the “ controversial” theory of evolution and invariably you’d find the obligatory quotes from “dissenting scientists” , for the sake of “balance”. How can regular Jo and Jane, who most probably have never had the subject of evolution taught in their high school, form and informed opinion? No wonder none of the Republican candidates raised their hands in one of the early debates when asked who among them believed in evolution. Including John McCain!

Which brings me to the main point I want to make. Now that we don’t have Tim Russert to expose the crooks, to flush out the intellectual frauds – we need to do the hard work ourselves. Russert’s success owed much to his exhaustive preparation; no detail escaped his attention, no nuance was overlooked. But I think his real genius was in exploring and exposing how his interviewee’s mind works. And this is what is going to be important in deciding who is going to be our next president. There is no way we can predict how the president is going to act in different situations. But we could make an educated guess if we knew how his mind works. Does he listen to a handful of ideology-driven advisers in making key decisions? Or does he look facts in the face and base his conclusions on all the available evidence? If it's the latter, then that is the candidate who is in sync with science at a level far more meaningful than any immediate argument over research budgets or competitiveness.

I would like to hear the candidates talk about the role of faith in policy-making. I would look for clues how their mind works by asking them about their stands on teaching evolution in our schools, on stem cell research, on control of carbon emissions, on health care (“specifically senator, how many people will be covered by your plan? how will you pay for it? What assumptions are these estimates based on”?).

For this type of questions we need educated journalists with probing minds, involved scientists and engineers, and above all an informed electorate. Alas, on all these counts the political landscape is not very promising .

 We are at a critical juncture in our history. We desparately need to look into the minds of our would be leaders.

Russert, we need you now.

By Dov Michaeli MD, Ph.D

You had to live in a cave not to get the message that drinking wine in moderation is good for your heart, good for your HDL (good cholesterol) levels, and good for the soul. In fact, its salutary effect on the heart and soul is mentioned in Proverbs of the Old Testament (“Wine makes the heart of Man rejoice”, or something like that).

But the ancients also knew that drinking had to be done in moderation. The classical Greeks used to have “symposia” or dinner parties, in which the guests would recline on beds (“triclinium”) placed around the room, drink wine and discuss philosophical and political issues. After the discussion, a gastronomical feast would be served that could last into the wee hours of the night. How could they talk philosophy after drinking wine? It was diluted 3:1 with water; drinking undiluted wine was considered déclassé. The Bible also frowns on excessive or undiluted wine drinking. Wine production is first mentioned in the book of Genesis: “Noah, who was the first tiller of the soil, planted a vineyard. He drank so much of the wine that he became drunk and lay naked inside his tent.” (Genesis, 9. 20-21.)

New evidence

People at risk for coronary heart disease are often at risk for nonalcoholic fatty liver disease (NAFLD). Not surprisingly, people with metabolic syndrome often progress to NAFLD. Researchers at UC San Diego investigated whether modest wine consumption is associated with decreased prevalence of nonalcoholic fatty liver disease, evaluating participants from the Third National Health and Nutrition Examination Survey. The participants reported either no alcohol consumption or preferentially drinking wine with total alcohol consumption up to 10 g per day (1 glass of wine). A total of 7,211 nondrinkers and 945 modest wine drinkers comprised the study sample.

The team identified suspected nonalcoholic fatty liver disease in 3 percent of nondrinkers and 0.4 percent of modest wine drinkers.

This is a striking difference indeed, and given the size of study population, it is not only statistically significant—it is highly persuasive as well.

What does it mean in “real life”?

Quite a bit. First, it is an independent corroboration of the repeated observation that drinking a moderate amount of wine is cardioprotective.

Second, it may sound heretical, but given the effect of moderate amounts of wine on the heart, on HDL levels, and now on nonalcoholic fatty liver disease, it raises the need to study the possible role of moderate drinking in the management of metabolic syndrome. I know I am going to get hate mail for that, but doesn’t a daily glass of wine beat daily medications?

If a little is good, why not more?

Here we are on solid empirical grounds. There is plenty of clinical evidence that excessive drinking (4 drinks or more a day) results in heart disease and alcoholic fatty liver disease (AFLD). As a bonus, throw in increased risks of certain cancers and you’ve got a deadly combination.

Going back to the ancients again, I think it was Aristotle who said in his Golden Rule: "Everything in moderation. Nothing to excess."

So heed Aristotle's wisdom and go get yourself a glass of wine. But don’t overdo it!

Le’Chaim (to life)!

By Dov Michaeli MD, Ph.D

We recently had to make a large (really large) purchase – a condominium. What went through my mind in making the bid? This question, in a more general sense, is the subject of a new field – psychoeconomics and neuroeconomics. In 2002, Daniel Kahneman, of Princeton and the Hebrew University, received the Nobel Prize in Economics “for having integrated insights from psychological research into economic science, especially concerning human judgment and decision-making under uncertainty”.

So I put myself on the couch, and pretended to be Prof. Kahneman. What was I thinking when I made the bid?

Here are my thoughts when I saw the asking price: no @#$% way! After all, the real estate market is crumbling. On the other hand, not in this town…On the other hand, I am going to feel like an idiot paying the asking price, although it was actually quite reasonable…On the other hand, the sellers are loaded, they don’t even live in the condo, a low bid will probably not faze them…On the other hand, if I come with a really low-ball offer I may push them to respond emotionally (i.e. become insulted and angry) and cut off the negotiation. You get the point: negotiation is a complex psychological process, and neuroscience wants to understand it.

The neural basis of decision- making

Exactly five years ago, a paper in Science, bearing the above title, explored the neurological brain circuits that are involved in economic decision-making. They used two well-known techniques: functional magnetic resonance imaging (fMRI) to investigate neural substrates of cognitive and emotional processes involved in economic decision-making, and the Ultimatum Game. In the Ultimatum Game, two players are offered a chance to win a certain sum of money. All they must do is divide it. The proposer suggests how to split the sum. The responder can accept or reject the deal. If the deal is rejected, neither player gets anything. The rational solution, suggested by game theory, is for the proposer to offer the smallest possible share and for the responder to accept it. If humans play the game, however, the most frequent outcome is a fair share. Unfair offers elicits activity in brain areas related to both emotion (anterior insula, INS) and cognition (dorsolateral prefrontal cortex, DLPFC).

The investigators scanned players as they responded to fair and unfair proposals. Indeed, unfair offers elicited increased activity in the anterior insula, as expected. This suggests an important role for emotions in decision-making, a nice confirmation of what we knew all along: there is an emotional component in any negotiation, and the perception of unfairness tends to increase the role of emotions, at the expense of rational analysis.

Better life through chemistry

This study provided the anatomical locations where decision-making takes place. But what about function? What makes these neurological circuits come to life and contribute to decision-making? Knowing how things happen is in a way even more important than knowing where they happen. We know, for instance, that neurons communicate with each other through chemicals called neurotransmitters. So it would be nice to identify the neurotransmitters involved in decision-making. Once we understand how things work, or which chemicals are involved, it allows us to intervene, to modulate and modify the process. This remained unknown until a publication in Science magazine this month shed light on the mystery. In a paper titled “Serotonin Modulates Behavioral Reactions to Unfairness” scientists from Cambridge University in the U.K. found that serotonin (5 hydroxytryptamine, or 5HT) is it!

Serotonin has long been implicated in social behavior and impulsivity, but the mechanisms through which it modulates self-control remain unclear. The Cambridge scientists observed the effects of manipulating serotonin function on behavior in the Ultimatum Game. Normally, if the first player proposes to keep the lion’s share for himself, the second player will accept the deal about 50% of the time. He may resent the inequity, but he realizes that a small share is better than nothing. In this experiment, half the participants had low serotonin levels, and half had normal levels. Participants with depleted serotonin levels rejected 80% of unfair, but not fair offers. You would guess they were depressed, or cranky; but no, they were not; they showed no changes in mood or fairness judgments. “Lower levels of serotonin selectively alter reactions to unfairness…[it] increased retaliation to perceived unfairness ”, concluded the authors. Or more generally, these results suggest that serotonin plays a critical role in regulating emotion during social decision-making.

Can brain serotonin levels be increased?

Serotonin (5 HT) is secreted by a neuron (called presynaptic neuron) into the space (synapse) between it and the adjacent neuron (the postsynaptic neuron). The serotonin in the synapse is taken up by the postsynaptic neuron and metabolized. This is how the nervous system maintains a constant level of serotonin. Various agents can raise the level of serotonin in the brain through inhibition of serotonin reuptake by postsynaptic neurons. These include MDMA (ecstasy), amphetamine, cocaine, dextromorphan(an antitussive or anti cough agent), tricyclic antidepressant (TCAs), like valium, and selective serotonin reuptake inhibitors (SSRIs), like Prozac and Paxil.

The three-martini lunch, and more

So now we can begin to understand the concept of a “business lunch”. Food and alcohol stimulate the reward circuits in the brain, and serotonin is one of the neurotransmitters involved. Everybody is in an agreeable frame of mind, anger is muted and negotiations flow smoothly. Even weighty life-and-death decisions could be affected. Could have Osama bin Laden been a nicer person had his religion permit something stronger than yogurt? Could the course of history have changed had Bush-Cheney-Rumsfeld had a pleasant three martini lunch before deciding to go to war? Should we pass a constitutional amendment barring teetotalers from the presidency? All important questions that, as scientists are fond of saying, require further study.

Oh yes, that condo negotiation? Our offer was accepted as is, no counter-offer. My initial reaction  was surprise and elation. On the other hand, did we offer too much?... On the other hand, had we offered a lower price would we have made them angry?... On the other hand…

A glass of wine resolved all my doubts: we are simply great negotiators.

by Pat Salber

A number of months ago, I wrote about a contest, Inspired by Diabetes, being sponsored by the American Diabetes Association and Eli Lilly and Company. The idea was that people living with or touched by diabetes would share their experiences via art.

And, the US Grand Prize winners are:

Health Professional Category: Theresa Garnero, a San Francisco nurse and Certified Diabetes Educator (CDE) who loves to draw - cartoons! Her "Pin the Pancreas on the Piggy" is a tool she uses with her clients, young children with diabetes. Her use of a pig is a reminder that prior to recombinant technology, pigs were a major source of insulin used to treat insulin-requiring diabetics.

“As a certified diabetes educator, I continue to witness the impact diabetes has on the people living with it, their families and global health,” Garnero said in her accompanying narrative. “I am continually inspired to provide humorous, educational resources that unite the individual, the family and our international professional community using positive and visually fun ideas.”

Adult with Diabetes Category: Betsy Ray,of Colorado, who has been
managing her diabetes for 43 years. She is currently working on a master’s degree in psychology to serve as a resource to newly-diagnosed children with diabetes. Her winning essay is called “The Journey.” Hopefully, it will eventually be posted on the Inspired by Diabetes website.

Child with Diabetes Category: Erin Tetreault of Idaho. Tetreault, 17, was diagnosed with diabetes at age 9. Inspired by her experiences at diabetes summer camp – where she first learned about the Inspired by Diabetes campaign – Tetreault hopes that more young people with diabetes can benefit from the emotional and educational support that these specialty camps provide. Her painting, “Self-Acceptance,” depicts a young woman wearing an insulin pump.

“Four years ago I would have been too self-conscious to paint my bare stomach with my pump proudly displayed,” she wrote in her accompanying narrative. But because of diabetes camp, “I’ve learned to be myself and not worry if I’m different or not accepted.”

Family Member or Friend Category: Teresa Ollila, Colorado. Ollila is a mother of two and an avid photographer. Inspired by her son’s diabetes diagnosis at age 3, she took an interest in capturing the complexity of living with diabetes by photographing others with the condition in her community. Ollila’s collection of photographs, titled “Living with Diabetes,” reveals the emotional impact of diabetes on people’s lives.

U.S. Grand Prize winners will have their submissions entered into the global competition. Winners of the global contest will be announced this fall.

The Inspired by Diabetes Creative Expression Competition will begin accepting entries again this summer. To learn more about Inspired by Diabetes and how to enter the competition, please visit: inspiredbydiabetes.com.

Michael L. Millenson

Maybe no one at Consumer Reports has a mother.

The first rule of effective consumer information is “tell it to Mom;” that is, explain why something is important in the kind of language you would use if speaking to your mother. Unfortunately, the folks at Consumers Union have now, for the second time, put out purportedly pro-consumer health care information that no one’s mother could love. Their latest offering is at best mildly helpful and at worst seriously misleading. The only explanation I can think of is that the CU folks believe so firmly in their own good intentions that they ignore the impact of what they are actually doing.

And as long as we’re awarding demerits to the self-delusional in the Liberal Do-Gooder category (Conservative Market-Worshippers richly deserving a category of their own), save a sigh of exasperation for the creators of something called the Healthcare Equality Index.

A quick disclosure: I am a subscriber to Consumer Reports online, have known some individuals there for years and did some brief consulting to them some years back. Therefore, let me be clear that my criticisms are based exclusively on public information.

CU’s latest offering is a link to the Dartmouth Atlas of Health Care and its analysis of hospital practice variation.

The CU imprimatur suggests this is Major League quality information. The truth is closer to the story of the baseball manager who blurted out about one of his players, “While he can’t hit, neither can he throw.”  In that same vein, while the Dartmouth information is not easy to use, neither is it easy to understand.

The Dartmouth Atlas is a health services research tour de force. It takes an incontrovertible outcome (death from a serious chronic illness) and then applies a complex algorithm to account for all medical resources used during the two years before that outcome. The result is more evidence of practice variation and that “more” care isn’t always “better.” However, expecting this insight alone to prove useful to someone making a decision about their own or a family member’s medical treatment means you’ve spent way too much time in an ivory tower.

How should a CU subscriber interpret the fact that one hospital is “aggressive” and another “conservative” in its resource use? In trying to reassure us that we can choose “conservative” and less costly treatment, CU explains that “aggressive care does not necessarily improve patient outcomes and can sometimes shorten life." But wait: doesn’t that mean aggressive care sometimes does improve patient outcomes and lengthen life? If I listen to CU, there’s no doubt I’ll save money for the federal government (the Atlas uses Medicare data), but if I don’t, I may save my life.

Maybe the folks at CU do have mothers: they just don’t like them very much.

“We’re not at a point yet where we can say which hospitals are bad or good," Dr. John Santa, director of Consumer Reports’ new Health Ratings Center, acknowledged to Chicago Tribune reporter/health blogger Judy Graham.

Whatever happened to, “First, do no harm?”

By the way, the Chicago hospital most aggressive in its use of resources before the patient died was a Catholic one, and the hospital with the lowest score was the public hospital.  However, the Dartmouth Atlas makes no allowances for the impact of religious beliefs in regard to life extension or the impact of patient socio-economic status (or hospital financial status) on intensity of treatment.

This is the second time CU has been unable to distinguish between information that sets the blood of researchers racing and information real people might reasonably rely upon. Its ConsumerReportsHealth site debuted with “Best Treatments” from the Cochrane Collaboration evidence-based medicine reviews. This carefully constructed tool from the folks at Oxford University gives us epistemological categories such as “treatments that work but whose harms may outweigh benefits.”

Come to think of it, that’s a logical precursor to the Dartmouth University rankings of hospitals where the harms (an adverse event that kills you) may also outweigh the benefits. Unless, of course, they don’t.

The good news is that CU plans to put out genuine cost and quality information on hospitals by the end of 2009. I hope no one tells them that some of those evil for-profit have been doing this since the late 20th century.

Now on to the Healthcare Equality Index.  You might assume this is a clever way to call attention to the disparities in care that we know cause serious harm to African-Americans, Hispanics and other minorities. It is not. Instead, it constitutes the responses to a survey designed to measure “how equitably hospitals in the United States treat their gay, lesbian, bisexual and transgender patients and employees.”

The survey was designed by the Human Rights Campaign Foundation Family Project and the Gay and Lesbian Medical Association. A whopping 88 out of roughly 5,000 U.S. hospitals voluntarily responded and agreed to make their names public. Perhaps some folks have had too little exposure to the ivory tower and the idea of “statistical validity.”

Yes, discrimination against GBLT patients and employees can be a problem, and GBLT individuals’ special health care needs certainly can get short-shrifted by uncomfortable straights. But if you want to talk seriously about health care equality, then get serious. The well-educated, well-insured, solidly upper-middle-class white gay couple is far more likely to get the health care they need than the working-class, dark-skinned, Spanish-speaking couple with no health insurance at all.

Even if they have a subscription to Consumer Reports.

Michael Millenson is a consultant, author and policy analyst based in suburban Chicago.

By Pat Salber, MD

We have known about the association between snoring and obesity for a long time. But we now know that sleep-disordered breathing (SBD) -- a sleep disturbance characterized by snoring and episodes of apnea or not breathing for periods of time -- is linked, independent of obesity, to insulin resistance, abnormal glucose metabolism, and Type 2 diabetes.

Sinziana Seicean, MD, MPH and colleagues published results of the Sleep Heart Health Study in the May 2008 issue of Diabetes Care. They studied 209 normal weight and 1,036 overweight/obese individuals who had a diagnosis of SDB, but did not have a diagnosis of diabetes. They found that SDB was associated with all of the manifestations of impaired glucose metabolism, including impaired fasting glucose, impaired glucose tolerance, and occult diabetes. The magnitude of the association between SDB and abnormal glucose metabolism was the same regardless of whether the individual was normal or overweight/obese.

This suggests that obesity is not the common cause of both insulin resistance and sleep-disordered breathing. Rather there appears to be an independent association between SDB and impaired glucose metabolism that is not explained by adiposity.

The authors suggest that the association of SDB with glucometabolic disturbances may relate to the “often-profound physiological stresses that occur overnight with sleep apnea.” They suggest that these stresses may transiently increase autonomic sympathetic activity, increase outpouring of the stress hormone, cortisol, and a decrease insulin sensitivity. Indeed, they point out that a human study of people with sleep apnea demonstrated improved insulin sensitivity after treatment of the SDB with continuous positive airway pressure (CPAP)

Why is this study important? Because it means that individuals with SDB who are normal weight may be at risk of impaired glucose metabolism. It also suggests that therapy aimed specifically at SDB and not just at obesity may be indicated to reverse that risk.

To learn if you are at risk of having SDB, answer the following questions based on the Berlin Questionnaire:

I regularly loan money to global entrepreneurs via Kiva.org (www.kiva.org). To date, I am happy to say, the entrepreneurs have all paid me back. That includes Nora and Yum. Kiva entrepreneurs.

It is so inspirational to get money back from these hard working small business people that once I get a notification of my payback I use the money to loan even more money to Kiva's list of global entrepreneurs. Please note, we are not talking big bucks. The loans I make are from $20.00 to $200.00. This modest amount is usually enough to get one of these small businesses going.

As a wanna be/wish to be/try to be to be entrepreneur, I want to shout out to Kiva participants:

"Go Global Entrepreneurs. Grow your business. Reap your profits. Have Fun. See your livestock, groceries, homemade goods, crafts, or whatever make their way into your marketplace and meet the needs of your customers. WAY TO GO! and glad to help"

Kiva makes it easy for me to loan money to entrepreneurs around the world. TDWI readers, I encourage you to check out Kiva.org. It is not just about helping an individual entrepreneur. It is about helping small business people around the world grow and develop their marketplace(s). GO KIVA, Go KIVA Entrepreneurs.'

www.kiva.org.

By Dov Michaeli MD, PhD

Democracy, like a sausage, is better enjoyed if you don’t see how it was made. Here is an example. Legislation that would regulate the marketing of flavored cigarettes is wending its way through Congress. The legislation, which would give the FDA the power to oversee tobacco products, would try to reduce smoking’s allure to young people by banning most flavored cigarettes, including clove and cinnamon. So far so good, but wait a minute: there is a curious exemption to the flavors to be banned – menthol is not to be touched! How come? Read on.

Why flavor cigarettes?

In their effort to addict young people to cigarette smoking, tobacco companies realized that flavoring would increase the chance that a beginner would stay with the habit, long enough to cause addiction. How ingenious; neurobiology in the service of tobacco marketing. Young people smoking mocha-flavored cigarettes are likely to recall the wonderful flavor of the chocolate milk they had consumed in childhood – and this recall, stored forever in their brain, would legitimize anything associated with it, including smoking.

There is another reason for the flavoring of tobacco: it masks its harsh flavor. Once you are hooked flavor really doesn’t matter, but those critical initial encounters with smoking need to be as pleasant as possible. Research has shown that nicotine alters several brain structures practically from the first exposure, and by the fourth or fifth smoke—the brain is hooked. And so are you.

The special case of menthol cigarettes

Regulating flavored cigarettes makes a lot of sense, you might say. So why exempt menthol from regulation? After all a growing body of evidence suggests that menthol makes it harder to kick the smoking habit — a view shared even by many scientists who say that menthol in cigarettes is not itself dangerous .

Of 45 million smokers in this country, the American Lung Association identifies about 33 million as non-Hispanic whites and 5 million as African-American. Recent data indicate about the same rate of smoking for both groups — in the 21 to 22 percent range. But:

The use of menthol cigarettes is disproportionately an African-American phenomenon, which critics say has been reinforced by decades of advertising aimed at black consumers. Nearly 75 percent of black smokers use menthol brands, compared with only about 25 percent of white smokers. So, the bottom line is that congress is about to protect white kids from getting hooked on smoking through flavored cigarettes. African American kids need not apply. One might think that this is just an unfortunate coincidence. But think again: getting caught snorting an ounce of cocaine, a “white” habit, will lend you in the county jail for a couple of weeks. One ounce of crack cocaine, a “black” preference, will get you a few years in jail.

Do you smell a rat?

As the New York Times reports, this legislation has been negotiated by Congress with Philip Morris for about 5 years. In the senate it is sponsored by the Ted Kennedy and 56 co-sponsors. Even the head of the National African American Tobacco Prevention Network, a nonprofit group that had been adamantly against menthol, acknowledged that the ingredient needed to be off the bargaining table — for now — because he didn’t want to imperil the bill’s chances. Politics as the art of the possible…

I am all for negotiation and compromise and bipartisanship and Kumbaya. But this deal smells of racism; had the situation been reversed and 75% of white kids smoked mentholated cigarettes, the cool menthol exemption would have had a snowball’s chance in hell of even being considered, let alone passed. How humiliating to all of us, but especially to African Americans.

Another curious twist

Any amateur investigative reporter would smell something funny: how come the negotiation was conducted with one company, Philip Morris, and not with the rest of the industry? What’s PM’s motive? It’s actually not very complicated.

· The legislation could help Philip Morris, with its best-selling Marlboro franchise, further entrench itself as the industry’s dominant player by placing new restrictions on cigarette marketing, making it difficult for rivals to use advertising to catch up. Philip Morris is working on new products that it hopes would be less harmful; the other companies cannot compete with PM’s R&D resources and advertising budget. Any restriction on advertising imposed on all the tobacco companies will put the smaller ones at a marketing disadvantage and will further entrench PM.

· Philip Morris’ menthol brand is only second in market share, and is the fastest growing. By concentrating all its advertising firepower on its mentholated brand it has a better chance to catch up and surpass Newport, the best-selling brand among African-Americans and the menthol market leader over all.

And I, for a moment, thought that Philip Morris was moved by conscience and concern for public health…

Q: Why did it take 5 years to negotiate this deal?

A: Because our legislators have been bought by the tobacco industry. Only after Philip Morris signaled its approval and agreed to lobby for the bill did many senators come out of the woodwork to join as co-sponsors. Of course, the other tobacco companies fiercely oppose the bill. But the weak sisters have less money to lavish on our representatives in Congress - and hence less clout.

This is a lesson they don’t teach in civics classes. Maybe they should.

By Dov Michaeli MD, Ph.D

Wednesday, May 21

Leaving today on a late flight, so there is time to browse in bookstores, sit at a café on the beach overlooking the ancient port of Jaffa, and just plain think. So here are some of the thoughts that went through my mind as I was ready bid adieu.

• In this country, security is both uppermost in everybody’s mind, but is also so intertwined with daily life that hardly anybody gives it a second thought. The soldiers from the paratroop brigade sitting at the beachside café with their Galil and Uzi weapons next to them with seemingly not a shred of worry in their lives,  the reservists who serve a minimum of 30 days every year and simply cannot imagine life without this service (“doesn’t everybody in America have to serve in some capacity or another when they are fighting a war”?)—this is so different, and yet so taken for granted.
• How is that for a paradox? On the Army Radio station they play the music one would expect 18 year olds to like. But they also have a program called “Broadcast University”, in which university professors deliver series of lectures in their respective fields of expertise. The Defense Ministry published those series in a book form. Here are some of the titles I came across in a bookstore. “Military Leadership”, “Nazism”; quite expected from an army, especially an Israeli army. But then consider these titles: “Words as Magic and the Magic Refleced in Words: Reflections on Mesopotamian Literature”, or “Judaism and Idolatry”. Can you imagine similar lectures on our Armed Services radio? Can you imagine the Defense Department publishing such books?
• Everybody knows of the bitter conflict between Israel and the Palestinians. But here is another reality that is thriving in Israel. A general who is in charge of a sector in the Southern front is an Israeli Arab. The Druse, an Arab sect of Sufi Moslems, are some of the best and most dedicated soldiers in the Israeli Defense Forces (IDF). Israel has an affirmative action program for Israeli Arab students; 25% of the medical students at Hadassah Medical School are Arab; Yesterday we added a new member to the research team at the University, with whom I have been collaborating—a Palestinian woman. When I asked an Israeli friend whether he knew these facts, his answer was just as sur