Summary:
1974: 2.4 million unnecessary surgeries performed annually resulting in 11,900 deaths at an annual cost of $3.9 billion. (73,74)
2001: 7.5 million unnecessary surgical procedures resulting in 37,136 deaths at a cost of $122 billion (using 1974 dollars). (3)
It’s very difficult to obtain accurate statistics when studying unnecessary surgery. Dr. Leape in 1989 wrote that perhaps 30% of controversial surgeries are unnecessary. Controversial surgeries include Cesarean section, tonsillectomy, appendectomy, hysterectomy, gastrectomy for obesity, breast implants, and elective breast implants. (74)
Almost thirty years ago, in 1974, the Congressional Committee on Interstate and Foreign Commerce held hearings on unnecessary surgery. They found that 17.6% of recommendations for surgery were not confirmed by a second opinion. The House Subcommittee on Oversight and Investigations extrapolated these figures and estimated that, on a nationwide basis, there were 2.4 million unnecessary surgeries performed annually, resulting in 11,900 deaths at an annual cost of $3.9 billion. (73)
In 2001, the top 50 medical and surgical procedures totaled approximately 41.8 million. These figures were taken from the Healthcare Cost and Utilization Project within the Agency for Healthcare Research and Quality. (13) Using 17.6% from the 1974 U.S. Congressional House Subcommittee Oversight Investigation as the percentage of unnecessary surgical procedures, and extrapolating from the death rate in 1974, we come up with an unnecessary procedure number of 7.5 million (7,489,718) and a death rate of 37,136, at a cost of $122 billion (using 1974 dollars).
Researchers performed a very similar analysis, using the 1974 ‘unnecessary surgery percentage’ of 17.6, on back surgery. In 1995, researchers testifying before the Department of Veterans Affairs estimated that of 250,000 back surgeries in the U.S. at a hospital cost of $11,000 per patient, the total number of unnecessary back surgeries each year in the U.S. could approach 44,000, costing as much as $484 million. (75)
The unnecessary surgery figures are escalating just as prescription drugs driven by television advertising. Media-driven surgery such as gastric bypass for obesity “modeled” by Hollywood personalities seduces obese people to think this route is safe and sexy. There is even a problem of surgery being advertised on the Internet. (76) A study in Spain declares that between 20 and 25% of total surgical practice represents unnecessary operations. (77)
According to data from the National Center for Health Statistics from 1979 to 1984, there was a 9% increase in the total number of surgical procedures, and the number of surgeons grew by 20%. The author notes that there has not been a parallel increase in the number of surgeries despite a recent large increase in the number of surgeons. There was concern that there would be too many surgeons to share a small surgical caseload. (78)
The previous author spoke too soon - there was no cause to worry about a small surgical caseload. By 1994, there was an increase of 38% for a total of 7,929,000 cases for the top ten surgical procedures. In 1983, surgical cases totaled 5,731,000. In 1994, cataract surgery was number one with over two million operations, and second was Cesarean section (858,000 procedures). Inguinal hernia operations were third (689,000 procedures), and knee arthroscopy, in seventh place, grew 153% (632,000 procedures) while prostate surgery declined 29% (229,000 procedures). (79)
The list of iatrogenic diseases from surgery is as long as the list of procedures themselves. In one study epidural catheters were inserted to deliver anesthetic into the epidural space around the spinal nerves to block them for lower Cesarean section, abdominal surgery, or prostate surgery. In some cases, non-sterile technique, during catheter insertion, resulted in serious infections, even leading to limb paralysis. (80)
In one review of the literature, the authors demonstrated “a significant rate of overutilization of coronary angiography, coronary artery surgery, cardiac pacemaker insertion, upper gastrointestinal endoscopies, carotid endarterectomies, back surgery, and pain-relieving procedures.” (81)
A 1987 JAMA study found the following significant levels of inappropriate surgery: 17% of cases for coronary angiography, 32% for carotid endarterectomy, and 17% for upper gastrointestinal tract endoscopy. (82) Using the Healthcare Cost and Utilization Project (HCUP) statistics provided by the government for 2001, the number of people getting upper gastrointestinal endoscopy, which usually entails biopsy, was 697,675; the number getting endarterectomy was 142,401; and the number having coronary angiography was 719,949. (13) Therefore, according to the JAMA study 17%, or 118,604 people had an unnecessary endoscopy procedure. Endarterectomy occurred in 142,401 patients; potentially 32% or 45,568 did not need this procedure. And 17% of 719,949, or 122,391 people receiving coronary angiography were subjected to this highly invasive procedure unnecessarily. These are all forms of medical iatrogenesis.
It is instructive to know the mortality rate associated with different medical and surgical procedures. Even though we must sign release forms when we undergo any procedure, many of us are in denial about the true risks involved. We seem to hold a collective impression that since medical and surgical procedures are so commonplace, they are both necessary and safe. Unfortunately, partaking in allopathic medicine itself is one of the highest causes of death as well as the most expensive way to die.
Shouldn’t the daily death rate of iatrogenesis in hospitals, out of hospitals, in nursing homes, and psychiatric residences be reported like the pollen count or the smog index? Let’s stop hiding the truth from ourselves. It’s only when we focus on the problem and ask the right questions can we hope to find solutions.
Perhaps the word “healthcare” gives us the illusion that medicine is about health. Allopathic medicine is not a purveyor of healthcare but of disease-care. Studying the mortality figures in the Healthcare Cost and Utilization Project (HCUP) within the U.S. government’s Agency for Healthcare Research and Quality, we found many points of interest. (13) The HCUP computer program that calculates the annual mortality statistics for all U.S. hospital discharges is only as good as the codes that are put into the system. In an email correspondence with HCUP, we were told that the mortality rates that were indicated in tables and charts for each procedure were not necessarily due to the procedure but only indicated that someone who received that procedure died either from their original disease or from the procedure.
Therefore there is no way of knowing exactly how many people died from a particular procedure. There are also no codes for adverse drug side effects, none for surgical mishap, and none for medical error. Until there are codes for medical error, statistics of those people who are dying from various types of medical error will be buried in the general statistics. There is a code for “poisoning & toxic effects of drugs” and a code for “complications of treatment.” However, the mortality figures registered in these categories are very low and don’t compare with what we know from studies such as the JAMA 1998 study (1) that said there were an average of 106,000 prescription medication deaths per year.
In 1978, the U.S. Office of Technology Assessment (OTA) reported that, “Only 10%-20% of all procedures currently used in medical practice have been shown to be efficacious by controlled trial." (83) In 1995, the OTA compared medical technology in eight countries (Australia, Canada, France, Germany, Netherlands, Sweden, United Kingdom, and the United States) and again noted that few medical procedures in the U.S. had been subjected to clinical trial. It also reported that infant mortality was high and life expectancy was low compared to other developed countries. (84) Although almost ten years old, much of what was said in this report holds true today. The report lays the blame for the high cost of medicine squarely at the feet of the medical free-enterprise system and the fact that there is no national health care policy. It describes the failure of government attempts to control health care costs due to market incentive and profit motive in the financing and organization of health care including private insurance, hospital system, physician services, and drug and medical device industries. Whereas we may want to expand health-care, expansion of disease-care is the goal of free enterprise. “Health Care Technology and Its Assessment in Eight Countries” is also the last report prepared by the OTA, which was shut down in 1995. It’s also, perhaps, the last honest, in-depth look at modern medicine. Because of the importance of this 60-page report, we enclose a summary in the Appendix.
Just hours before completion of this paper, statistics on surgical-related deaths became available. A October 8, 2003 JAMA study from the U.S. government’s Agency for Healthcare Research and Quality (AHRQ) documented 32,000 mostly surgery-related deaths costing $9 billion and accounting for 2.4 million extra days in the hospital in 2000. (85) In a press release accompanying the JAMA study, the AHRQ director, Carolyn M. Clancy, M.D., admitted, “This study gives us the first direct evidence that medical injuries pose a real threat to the American public and increase the costs of health care.” (86) Hospital administrative data from 20% of the nation’s hospitals were analyzed for eighteen different surgical complications including postoperative infections, foreign objects left in wounds, surgical wounds reopening, and post-operative bleeding. In the same press release the study’s authors said that, “The findings greatly underestimate the problem, since many other complications happen that are not listed in hospital administrative data.” They also felt that, "The message here is that medical injuries can have a devastating impact on the health care system. We need more research to identify why these injuries occur and find ways to prevent them from happening." One of the authors, Dr. Zhan said that improved medical practices, including an emphasis on better hand-washing, might help reduce the morbidity and mortality rates. An accompanying JAMA editorial by health-risk researcher Dr. Saul Weingart of Harvard’s Beth Israel Deaconess Medical Center said, “Given their staggering magnitude, these estimates are clearly sobering.” (87)
When X-rays were discovered, no one knew the long-term effects of ionizing radiation. In the 1950’s monthly fluoroscopic exams at the doctor’s office were routine. You could even walk into most shoe stores and see your foot bones; looking at bones was an amusing novelty. We still don’t know the ultimate outcome of our initial escapade with X-rays.
It was common practice to use X-rays in pregnant women to measure the size of the pelvis, and make a diagnosis of twins. Finally, a study of 700,000 children born between 1947 and 1964 was conducted in thirty-seven major maternity hospitals. The children of mothers who had received pelvic X-rays during pregnancy were compared with the children of mothers who had not been X-rayed. Cancer mortality was 40% higher among the children with X-rayed mothers. (88)
In present-day medicine, coronary angiography combines an invasive surgical procedure of snaking a tube through a blood vessel in the groin up to the heart. To get any useful information during the angiography procedure X-rays are taken almost continuously with minimum dosage ranges between 460 - 1,580 mrem. The minimum radiation from a routine chest X-ray is 2 mrem. X-ray radiation accumulates in the body and it is well-known that ionizing radiation used in X-ray procedures causes gene mutation. We can only obtain guesstimates as to its impact on health from this high level of radiation. Experts manage to obscure the real effects in statistical jargon such as, “The risk for lifetime fatal cancer due to radiation exposure is estimated to be 4 in one million per 1,000 mrem.” (89)
However, Dr. John Gofman, who has been studying the effects of radiation on human health for 45 years, is prepared to tell us exactly what diagnostic X-rays are doing to our health. Dr. Gofman has a PhD in nuclear and physical chemistry and is a medical doctor. He worked on the Manhattan nuclear project, discovered uranium-2323, was the first person to isolate plutonium, and since 1960, he’s been studying the effects of radiation on human health. With five scientifically documented books totaling over 2800 pages, Dr. Gofman provides strong evidence that medical technology, specifically X-rays, CT scans, mammography, and fluoroscopy, are a contributing factor to 75% of new cancers. His 699-page report, updated in 2000, “Radiation from Medical Procedures in the Pathogenesis of Cancer and Ischemic Heart Disease: Dose-Response Studies with Physicians per 100,000 Population” (90), shows that as the number of physicians increases in a geographical area with an increase in the number of X-ray diagnostic tests, there is an associated increase in the rate of cancer and ischemic heart disease. Dr. Gofman elaborates that it’s not X-rays alone that cause the damage but a combination of health risk factors including: poor diet, smoking, abortions, and the use of birth control pills. Dr. Gofman predicts that 100 million premature deaths over the next decade will be the result of ionizing radiation.
In his book, “Preventing Breast Cancer,” Dr. Gofman says that breast cancer is the leading cause of death among American women between the ages of forty-four and fifty-five. Because breast tissue is highly radiation-sensitive, mammograms can cause cancer. The danger can be heightened by a woman’s genetic makeup, preexisting benign breast disease, artificial menopause, obesity, and hormonal imbalance. (91)
Even X-rays for back pain can lead someone into crippling surgery. Dr. Sarno, a well-known New York orthopedic surgeon, found that X-rays don’t always tell the truth. In his books he cites studies on normal people without a trace of back pain that have spinal abnormalities on X-ray. Other studies have shown that some people with back pain have normal spines on X-ray. So, Dr. Sarno says there is not necessarily any association between back pain and spinal X-ray abnormality. (92) However, if a person happens to have back pain and an incidental abnormality on X-ray, they may be treated surgically, sometimes with no change in back pain, or worsening of back pain, or even permanent disability.
In addition, doctors often order X-rays as protection against malpractice claims to give the impression that they are leaving no stone unturned. It appears that doctors are putting their own fears before the interests of their patients.
Summary:
8.9 million (8,925,033) people were hospitalized unnecessarily in 2001. (4)
In a study of inappropriate hospitalization 1,132 medical records were reviewed by two doctors. Twenty-three percent of all admissions were inappropriate and an additional 17% could have been handled in ambulatory out-patient clinics. Thirty-four percent of all hospital days were also inappropriate and could have been avoided. (93) The rate of inappropriate admissions in 1990 was 23.5%. (94) In 1999, another study confirmed the figure of 24% inappropriate admissions indicating a consistent pattern from 1986 to 1999 (95), showing steady reporting of approximately 24% inappropriate admissions each year. Putting these figures into present-day terms using the HCUP database, the total number of patient discharges from hospitals in the U.S. in 2001 was 37,187,641. (13) The above data indicate that 24% of those hospitalizations need never have occurred. It further means that 8,925,033 people were exposed to unnecessary medical intervention in hospitals and therefore represent almost 9 million potential iatrogenic episodes. (4)
Briefly, we will look at the medical iatrogenesis of women in particular. Dr. Martin Charcot (1825-1893) was world-renowned, the most celebrated doctor of his time. He practiced in the Paris hospital La Salpetriere. He became an expert in hysteria diagnosing an average of ten hysterical women each day, transforming them into… “iatrogenic monsters,” turning simple ‘neurosis’ into hysteria. (96) The number of women diagnosed with hysteria and hospitalized rose from 1% in 1841 to 17% in 1883. Hysteria is derived from the Latin “hystera” meaning uterus. Dr. Adriane Fugh-Berman stated very clearly in her paper that there is a tradition in U.S. medicine of excessive medical and surgical interventions on women. Only one hundred years ago male doctors decided that female psychological imbalance originated in the uterus. When surgery to remove the uterus was perfected it became the “cure” for mental instability, effecting a physical and psychological castration. Dr. Fugh-Berman noted that U.S. doctors eventually disabused themselves of that notion but have continued to treat women very differently than they treat men. (97) She cites the following:
We would add that as many as one-third of postmenopausal women use HRT. (101,102) These numbers are important in light of the much-publicized Women’s Health Initiative Study, which was forced to stop before its completion because of a higher death rate in the synthetic estrogen-progestin (HRT) group. (103)
In 1983, 809,000 Cesarean sections (21% of live births) were performed, making it the most common obstetric and gynecologic (OB/GYN) surgical procedure. The second most common OB/GYN operation was hysterectomy (673,000), and diagnostic dilation and curettage of the uterus (632,000) was third. In 1983, OB/GYN operations represented 23% of all surgery completed in this country. (104)
In 2001, Cesarean section is still the most common OB/GYN surgical procedure. Approximately 4 million births occur annually, with a 24% C-Section rate, i.e., 960,000 operations. In the Netherlands only 8% of babies are delivered by Cesarean section. Assuming human babies are similar in the U.S. and in the Netherlands, we are performing 640,000 unnecessary C-Sections in the U.S. with its three to four times higher mortality and 20 times greater morbidity than vaginal delivery. (105)
The Cesarean section rate was only 4.5% in the U.S. in 1965. By 1986 it had climbed to 24.1%. The author states that obviously an “uncontrolled pandemic of medically unnecessary Cesarean births is occurring.” (106) VanHam reported a Cesarean section postpartum hemorrhage rate of 7%, a hematoma formation rate of 3.5%, a urinary tract infection rate of 3%, and a combined postoperative morbidity rate of 35.7% in a high-risk population undergoing Cesarean section. (107)
Scientists used the excuse that there were never enough studies revealing the dangers of DDT and other dangerous pesticides to ban them. They also used this excuse around the issue of tobacco, claiming that more studies were needed before they could be certain that tobacco really caused lung cancer. Even the American Medical Association (AMA) was complicit in suppressing results of tobacco research. In 1964, the Surgeon General's report condemned smoking, however the AMA refused to endorse it. What was their reason? They needed more research. Actually what they really wanted was more money and they got it from a consortium of tobacco companies who paid the AMA $18 million over the next nine years, during which the AMA said nothing about the dangers of smoking. (108)
The Journal of the American Medical Association (JAMA), "after careful consideration of the extent to which cigarettes were used by physicians in practice," began accepting tobacco advertisements and money in 1933. State journals such as the New York State Journal of Medicine also began to run Chesterfield ads claiming that cigarettes are, "Just as pure as the water you drink… and practically untouched by human hands." In 1948, JAMA argued "more can be said in behalf of smoking as a form of escape from tension than against it… there does not seem to be any preponderance of evidence that would indicate the abolition of the use of tobacco as a substance contrary to the public health." (109) Today, scientists continue to use the excuse that they need more studies before they will lend their support to restrict the inordinate use of drugs.
Adverse Drug Reactions
The Lazarou study (1) was based on statistical analysis of 33 million U.S. hospital admissions in 1994. Hospital records for prescribed medications were analyzed. The number of serious injuries due to prescribed drugs was 2.2 million; 2.1% of in-patients experienced a serious adverse drug reaction; 4.7% of all hospital admissions were due to a serious adverse drug reaction; and fatal adverse drug reactions occurred in 0.19% of in-patients and 0.13% of admissions. The authors concluded that a projected 106,000 deaths occur annually due to adverse drug reactions.
We used a cost analysis from a 2000 study in which the increase in hospitalization costs per patient suffering an adverse drug reaction was $5,483. Therefore, costs for the Lazarou study’s 2.2 million patients with serious drug reactions amounted $12 billion. (1,49)
Serious adverse drug reactions commonly emerge after Food and Drug Administration approval. The safety of new agents cannot be known with certainty until a drug has been on the market for many years. (110)
Bedsores
Over one million people develop bedsores in U.S. hospitals every year. It’s a tremendous burden to patients and family, and a $55 billion dollar healthcare burden. (7) Bedsores are preventable with proper nursing care. It is true that 50% of those affected are in a vulnerable age group of over 70. In the elderly bedsores carry a fourfold increase in the rate of death. The mortality rate in hospitals for patients with bedsores is between 23% and 37%. (8) Even if we just take the 50% of people over 70 with bedsores and the lowest mortality at 23%, that gives us a death rate due to bedsores of 115,000. Critics will say that it was the disease or advanced age that killed the patient, not the bedsore, but our argument is that an early death, by denying proper care, deserves to be counted. It is only after counting these unnecessary deaths that we can then turn our attention to fixing the problem.
Malnutrition in Nursing Homes
The General Accounting Office (GAO), a special investigative branch of Congress, gave citations to 20% of the nation's 17,000 nursing homes for violations between July 2000 and January 2002. Many violations involved serious physical injury and death. (111)
A report from the Coalition for Nursing Home Reform states that at least one-third of the nation’s 1.6 million nursing home residents may suffer from malnutrition and dehydration, which hastens their death. The report calls for adequate nursing staff to help feed patients who aren’t able to manage a food tray by themselves. (11) It is difficult to place a mortality rate on malnutrition and dehydration. This Coalition report states that malnourished residents, compared with well-nourished hospitalized nursing home residents, have a five-fold increase in mortality when they are admitted to hospital. So, if we take one-third of the 1.6 million nursing home residents who are malnourished and multiply that by a mortality rate of 20% (8,14), we find 108,800 premature deaths due to malnutrition in nursing homes.
Nosocomial Infections
The rate of nosocomial infections per 1,000 patient days has increased 36% - from 7.2 in 1975 to 9.8 in 1995. Reports from more than 270 U.S. hospitals showed that the nosocomial infection rate itself had remained stable over the previous 20 years with approximately five to six hospital-acquired infections occurring per 100 admissions, which is a rate of 5-6%. However, because of progressively shorter inpatient stays and the increasing number of admissions, the actual number of infections increased. It is estimated that in 1995, nosocomial infections cost $4.5 billion and contributed to more than 88,000 deaths - one death every 6 minutes. (9) The 2003 incidence of nosocomial mortality is quite probably higher than in 1995 because of the tremendous increase in antibiotic-resistant organisms. Morbidity and Mortality Report found that nosocomial infections cost $5 billion annually in 1999. (10) This is a $0.5 billion increase in four years. The present cost of nosocomial infections might now be in the order of $5.5 billion.
Outpatient Iatrogenesis
Dr. Barbara Starfield in a 2000 JAMA paper presents us with well-documented facts that are both shocking and unassailable. (12)
Dr. Starfield warns that one cause of medical mistakes is the overuse of technology, which may create a "cascade effect" leading to more treatment. She urges the use of ICD (International Classification of Diseases) codes which have designations called: "Drugs, Medicinal, and Biological Substances Causing Adverse Effects in Therapeutic Use" and "Complications of Surgical and Medical Care" to help doctors quantify and recognize the magnitude of the medical error problem. Starfield says that, at present, deaths actually due to medical error are likely to be coded according to some other cause of death.
She concludes that against the backdrop of our abysmal health report card compared to the rest of the Westernized countries, we should recognize that the harmful effects of health care interventions account for a substantial proportion of our excess deaths.
Starfield cites Weingart’s 2000 article, “Epidemiology of Medical Error” on outpatient iatrogenesis. And Weingart, in turn, cites several authors and provides statistics showing that between 4% to 18% of consecutive patients in outpatient settings suffer an iatrogenic event leading to: (112)
Unnecessary Surgeries
There are 12,000 deaths per year from unnecessary surgeries. However, results from the few studies that have measured unnecessary surgery directly indicate that for some highly controversial operations, the fraction that are unwarranted could be as high as 30%. (74)
A survey published in the Journal of Health Affairs pointed out that between 18% and 28% of people who were recently ill had suffered from a medical or drug error in the previous two years. The study surveyed 750 recently-ill adults in five different countries. The breakdown by country showed 18% of those in Britain, 25% in Canada, 23% in Australia, 23% in New Zealand, and the highest number was in the U.S. at 28%. (113)
A recent finding by the Institute of Medicine is that the 41 million Americans without health insurance have consistently worse clinical outcomes than those that are insured, and are at increased risk for dying prematurely (114)
Insurance Fraud
When doctors bill for services they do not render, advise unnecessary tests, or screen everyone for a rare condition, they are committing insurance fraud. The U.S. General Accounting Office (GAO) gave a 1998 figure of $12 billion dollars lost to fraudulent or unnecessary claims, and reclaimed $480 million in judgments in that year. In 2001, the Federal government won or negotiated more than $1.7 billion in judgments, settlements, and administrative impositions in healthcare fraud cases and proceedings. (115)
It is only fitting that we end this report with acknowledgement of our elders. The moral and ethical fiber of society can be judged by the way it treats its weakest and most vulnerable members. Some cultures honor and respect the wisdom of their elders, keeping them at home – the better to continue participation in their community. However, American nursing homes, where millions of our elders die, represent the pinnacle of social isolation and medical abuse.
Important Statistics about Nursing Homes
Congressman Waxman reminded us that “as a society we will be judged by how we treat the elderly" when he presented a report that he sponsored, "Abuse of Residents is a Major Problem in U.S. Nursing Homes," on July 30, 2001. The report uncovered that one third - 5,283 of the nations’ 17,000 nursing homes - were cited for an abuse violation in the two-year period studied, January 1999 - January 2001. (116) Waxman stated that “the people who cared for us, deserve better." He also made it very clear that this was only the tip of the iceberg and there is much more abuse occurring that we don’t know about or ignore. (116a)
The major findings of "Abuse of Residents is a Major Problem in U.S. Nursing Homes," were:
Dangerously understaffed nursing homes lead to neglect, abuse, overuse of medications, and physical restraints. An exhaustive study of nurse-to-patient ratios in nursing homes was mandated by Congress in 1990. The study was finally begun in 1998 and took four years to complete. (120) Commenting on the study, a spokesperson for The National Citizens’ Coalition for Nursing Home Reform said, “They compiled two reports of three volumes each thoroughly documenting the number of hours of care residents must receive from nurses and nursing assistants to avoid painful, even dangerous, conditions such as bedsores and infections. Yet it took the Department of Health and Human Services and Secretary Tommy Thompson only four months to dismiss the report as ‘insufficient.’” (121) Bedsores occur three times more commonly in nursing homes than in acute care or veterans’ hospitals. (122) But we know that bedsores can be prevented with proper nursing care. It shouldn’t take four years for someone to find out that proper care of bedsores requires proper staffing. In spite of such urgent need in nursing homes where additional staff could solve so many problems, we hear the familiar refrain “not enough research” - one that merely buys time for those in charge and relegates another smoldering crisis to the back burner.
Since many nursing home patients suffer from chronic debilitating conditions, their assumed cause of death is often unquestioned by physicians. Some studies show that as many as 50% of deaths due to restraints, falls, suicide, homicide, and choking in nursing homes may be covered up. (123,124) It is quite possible that many nursing home deaths are attributed, instead, to heart disease, which, until our report, was the number one cause of death. In fact, researchers have found that heart disease may be over-represented in the general population as a cause of death on death certificates by 7.9% to 24.3%. In the elderly the over-reporting of heart disease as a cause of death is as much as two-fold (125)
When elucidating iatrogenesis in nursing homes, some critics have asked, “To what extent did these elderly people already have life-threatening diseases that led to their premature deaths anyway?” Our response is that if a loved one dies one day, one week, one year, a decade, or two decades prematurely, thanks to some medical misadventure, that is still a premature, iatrogenic death. In a legalistic sense perhaps more weight is placed on the loss of many potential years compared to an additional few weeks, but this attitude is not justified in an ethical or moral sense.
The fact that there are very few statistics on malnutrition in acute-care hospitals and nursing homes shows the lack of concern in this area. A survey of the literature turns up very few American studies. Those that do appear are foreign studies in Italy, Spain, and Brazil. However, there is one very revealing American study conducted over a 14-month period that evaluated 837 patients in a 100-bed sub-acute-care hospital for their nutritional status. Only 8% of the patients were found to be well nourished. Almost one-third (29%) were malnourished and almost two-thirds (63%) were at risk of malnutrition. The consequences of this state of deficiency were that 25% of the malnourished patients required readmission to an acute-care hospital compared to 11% of the well-nourished patients. The authors concluded that malnutrition reached epidemic proportions in patients admitted to this sub-acute-care facility. (126)
Many studies conclude that physical restraints are an underreported and preventable cause of death. Whereas administrators say they must use restraints to prevent falls, in fact, they cause more injury and death because people naturally fight against such imprisonment. Studies show that compared to no restraints, the use of restraints carries a higher mortality rate and economic burden. (127-129) Studies found that physical restraints, including bedrails, are the cause of at least 1 in every 1,000 nursing-home deaths. (130-132)
However, deaths caused by malnutrition, dehydration, and physical restraints are rarely recorded on death certificates. Several studies reveal that nearly half of the listed causes of death on death certificates for older persons with chronic or multi-system disease are inaccurate. (133) Even though 1-in-5 people die in nursing homes, the autopsy rate is only 0.8%. (134) Thus, we have no way of knowing the true causes of death.
Over-medicating Seniors
The CDC may be focused on reducing the number of prescriptions for children but a 2003 study finds over-medication of our elderly population. Dr. Robert Epstein, chief medical officer of Medco Health Solutions Inc. (a unit of Merck & Co.), conducted the study on drug trends. (135) He found that seniors are going to multiple physicians and getting multiple prescriptions and using multiple pharmacies. Medco oversees drug-benefit plans for more than 60 million Americans, including 6.3 million senior citizens who received more than 160 million prescriptions. According to the study, the average senior receives 25 prescriptions annually. In those 6.3 million seniors, a total of 7.9 million medication alerts were triggered: less than one-half that number, 3.4 million, were detected in 1999. About 2.2 million of those alerts indicated excessive dosages unsuitable for senior citizens, and about 2.4 million alerts indicated clinically inappropriate drugs for the elderly. Reuters interviewed Kasey Thompson, director of the Center on Patient Safety at the American Society of Health System Pharmacists, who said, “There are serious and systemic problems with poor continuity of care in the United States.” He says this study shows “the tip of the iceberg” of a national problem.
According to Drug Benefit Trends, the average number of prescriptions dispensed per non-Medicare HMO member per year rose 5.6% from 1999 to 2000 - from 7.1 to 7.5 prescriptions. The average number dispensed for Medicare members increased 5.5% - from 18.1 to 19.1 prescriptions. (136) The number of prescriptions in 2000 was 2.98 billion, with an average per person prescription amount of 10.4 annually. (137)
In a study of 818 residents of residential care facilities for the elderly, 94% were receiving at least one medication at the time of the interview. The average intake of medications was five per resident; the authors noted that many of these drugs were given without a documented diagnosis justifying their use. (138)
Unfortunately, seniors, and groups like the American Association for Retired Persons (AARP), appear to be dependent on prescription drugs and are demanding that coverage for drugs be a basic right. (139) They have accepted the overriding assumption from allopathic medicine that aging and dying in America must be accompanied by drugs in nursing homes and eventual hospitalization with tubes coming out of every orifice. Instead of choosing between drugs and a diet-lifestyle change, seniors are given the choiceless option of either high-cost patented drugs or low-cost generic drugs. Drug companies are attempting to keep the most expensive drugs on the shelves and to suppress access to generic drugs, in spite of stiff fines of hundreds of millions of dollars from the government. (140,141) In 2001 some of the world's biggest drug companies, including Roche, were fined a record £523 million ($871 million) for conspiring to increase the price of vitamins. (142)
We would urge AARP, especially, to become more involved in prevention of disease and not to rely so heavily on drugs. At present, the AARP recommendations for diet and nutrition assume that seniors are getting all the nutrition they need in an average diet. At most, they suggest extra calcium and a multiple vitamin/mineral supplement. (143) This is not enough, and in our next report we will show how to live a healthier life without unnecessary medical intervention.
We would like to send the same message to the Hemlock Society, which offers euthanasia options to chronically ill people, especially those in severe pain. What if some of these chronic diseases are really lifestyle diseases caused by deficiency of essential nutrients, lack of care, inappropriate medication, or lack of love? This question is extremely important to consider when you are depressed or in pain. We must look to healing those conditions before offering up our lives.
Let’s also look at the irony of under use of proper pain medication for patients that really need it. For example, in one particular study pain management was evaluated in a group of 13,625 cancer patients, aged 65 or over, living in nursing homes. Overall, almost 30%, or 4,003 patients, reported pain. However, more than 25% received absolutely no pain relief medication; 16% received a World Health Organization (WHO) level-one drug (mild analgesic); 32% a WHO level-two drug (moderate analgesic); and only 26% received adequate pain relieving morphine. The authors concluded that older patients and minority patients were more likely to have their pain untreated. (144)
The time has come to set a standard for caring for the vulnerable among us - a standard that goes beyond making sure they are housed and fed, and not openly abused. We must stop looking the other way and we, as a society, must take responsibility for the way in which we deal with those who are unable to care for themselves.
Our ongoing research will continue to quantify the morbidity, mortality, and financial loss due to:
*Part of our ongoing research will be to quantify the mortality and morbidity caused by hormone replacement therapy (HRT) since the mid-1940’s. In December 2000, a government scientific advisory panel recommended that synthetic estrogen be added to the nation's list of cancer-causing agents. HRT, either synthetic estrogen alone or combined with synthetic progesterone, is used by an estimated 13.5 to 16 million women in the U.S. (145) The aborted Women’s Health Initiative Study (WHI) of 2002 showed that women taking synthetic estrogen combined with synthetic progesterone have a higher incidence of ovarian cancer, breast cancer, stroke, and heart disease and little evidence of osteoporosis reduction or prevention of dementia. WHI researchers, who usually never give recommendations, other than demanding more studies, are advising doctors to be very cautious about prescribing HRT to their patients. (100,146-150)
Results of the “Million Women Study” on HRT and breast cancer in the U.K were published in the Lancet, August, 2003. Lead author, Professor Valerie Beral, Director of the Cancer Research UK Epidemiology Unit, is very open about the damage HRT has caused. She said, "We estimate that over the past decade, use of HRT by UK women aged 50-64 has resulted in an extra 20,000 breast cancers, oestrogen-progestagen (combination) therapy accounting for 15,000 of these.” (151) However, we were not able to find the statistics on breast cancer, stroke, uterine cancer, or heart disease due to HRT used by American women. The population of America is roughly six times that of the U.K. Therefore, it is possible that 120,000 cases of breast cancer have been caused by HRT in the past decade.
When the number one killer in a society is the healthcare system, then, that system has no excuse except to address its own urgent shortcomings. It’s a failed system in need of immediate attention. What we have outlined in this paper are insupportable aspects of our contemporary medical system that need to be changed - beginning at its very foundations.
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