Sid Wolfe had become the great hematology biochemist predicted by his mentor at the National Institutes of Health. But the 1960s activism still present in his blood-the spirit that had once led him to disrupt a convention of the American Medical Association because its president pronounced that "health care is a privilege, not a right" - that spirit was latent.
Then, in 1971, Wolfe got a call in his lab that abruptly changed his life. A physician he knew from his internship in Cleveland was frantic. Contaminated intravenous fluids were causing an outbreak of deaths and life-threatening infections in hospitals, yet hospitals were being told to keep using them. A joint statement by Abbott Laboratories (the drug company that made the fluids), the Centers for Disease Control, and the Food and Drug Administration advised hospitals that the fluids could be used, unless the patient got sick.
"You know Ralph Nader," the colleague said. "Can you do something about this?"
Wolfe read the evidence and decided to try to get the intravenous fluids recalled right away. But Abbott, which made half of all the intravenous fluids in the United States, had persuaded the Government that a recall would leave a deficiency and people would die from that.
Wolfe rounded up other fluid manufacturers to fill the void. With Nader, he wrote a letter to the FDA Commissioner and promptly released it to the press. The letter made the evening news, and the FDA recalled the toxic fluids forty-eight hours later.
Wolfe and Nader began getting letters and phone calls. "If you think that's important," they'd read or hear, "what about this? What about this?"
Wolfe thought: This kind of work has an impact on the health of a larger number of people than what I can do at NIH or in the private practice of internal medicine.
So Public Citizen Health Research Group was born. By now it has issued some 1,200 reports, most combatively critical, on drugs, food, health-care delivery, medical devices and products, and occupational safety. Wolfe's in-your-face tactics have taken red dye number two off the market, forced aspirin makers to put labels on bottles warning about the drug's danger to small children, and raised the public's consciousness - and the health-care industry's ire - about the risk of toxic shock syndrome from super-absorbent tampons and cancer from silicon-gel breast implants.
"Somebody," says this man who describes himself as "controversy personified," "has to look out for people who are being manipulated by the hospitals, doctors, insurance and drug companies."
Q: The Commerce Department says health care will cost the nation $939.9 billion this year - almost a quarter of the national debt. If nothing is done, we will spend over $1 trillion by 1994 and $2 trillion by 1999! Yet thirty-five million Americans are uninsured and, as you've pointed out, sixty million people are underinsured. How did we get into this fix?
Sidney Wolfe: The cost of health care was a fraction of what it is now when I was in medical school in the early 1960s. You didn't have this flow of money into waste - unnecessary services, unnecessary hospital beds, unnecessary angiograms and Caesarean sections, administrative waste - $200 billion of waste. Money that could be spent taking care of patients.
Hospitals spend a quarter of their revenues on administration and billing - hospitals in Canada don't do any billing. Doctors in this country are going crazy with paperwork; with 1,500 different health insurers, you guarantee that will happen.
Q: Whose fault is this?
Wolfe: It's the fault of everyone associated with the health-care system. No sector of the economy in the history of this country has ever been more of a lure for charlatans and committers of fraud and greed - greedy insurance companies, drug companies, medical-supply companies, hospitals, and physicians - than the health-care system. You tell a bunch of people, "Hey, we've got $939 billion to spend. You want a piece of it?" And everyone comes running and does everything you can imagine, legal and otherwise, to get a piece of it.
Q: What kinds of illegal things?
Wolfe: Doctor bribing by major U.S. drug companies. One company essentially offered doctors 1,200 bucks in cash for prescribing an antibiotic for every twenty patients. This is criminal activity.
We did a little investigation three years ago into the business of hospitals buying up doctors' practices. A third of hospital beds are empty, so if you can get the doctor on your team - ask him to refer patients to your hospital - you'll fill your beds and balance your books better. But you just don't convince doctors out of the goodness of their hearts to do that; you buy up their practice, all the furniture and equipment, or you pay them a consulting fee. Transactions can involve $50,000, $100,000, $200,000, a million dollars.
Q: You favor the single-payer or "Canadian-style" system that would insure care for all Americans and eliminate profiteering by not allowing hospitals, nursing homes, HMOs, and other health-care-delivery facilities to make a profit. President Bill Clinton, however, seems to favor some form of "managed competition."
Wolfe: It's totally unacceptable. Whenever The New York Times writes an editorial advocating managed care - they've written fifteen, twenty editorials about it in the last year and a half - they omit the fact that a brand new layer of bureaucracy will be introduced, whereas the single-payer plan eliminates three layers, beginning with the health-insurance industry.
Managed competition amounts to letting the marketplace take care of things and having large pools of purchasers of health insurance band together. The competition comes in if they've got several different collections of providers to purchase the services from. It's a fantasy. It's about like using the concepts of Eighteenth Century capitalism and free enterprise in Twentieth Century, monopolistic, oligopolistic America. Say you've got four or five HMOs competing for your dollar. The way they compete is to cut their price. And the way to cut the price is to cut services and screw people. There's too much of a tendency to have managed competition turned into managing to deliver as little or as poor quality of services as they can get away with. It assumes that without budgetary controls, as in the Canadian single-payer plan, you're somehow magically going to cut costs. There's too much greed and too much money to be made in the health-care system now for people to relinquish it.
Q: Is it really fair to use Canada, with its relatively tiny population, as a model?
Wolfe: Yes. It's twenty-six million instead of 250 million, to be sure. But they have urban centers very similar to ours and a lot of rural areas just as we do. And their values with respect to health are almost identical to ours in terms of "should the government insure that everyone has health care?" "are you willing to pay more taxes for it?" and so on. There was massive opposition there in the late 1960s and early 1970s when they decided essentially to abolish the health-insurance industry as a provider of basic health services in favor of the single-payer plan, but they did it.
Q: Are we going to have national health insurance before too long?
Wolfe: Something will pass, but it is almost certain that it will be the wrong thing. And the pain and suffering and evidence that any plan that doesn't control costs like a single-payer plan will soon be forthcoming.
Q: What is the biggest change in health care since you founded the Health Research Group?
Wolfe: Patients are much more inquisitive than they used to be. That makes for a more informed patient and a more cautious physician. We sold almost a million copies of Best Pills, Worst Pills, which has led to an enormous number of conversations between patients and doctors that might not otherwise have occurred.
Q: Yet increasingly, when I ask doctors questions these days, they say, "I don't know the answer."
Wolfe: That's an improvement, because if the answer is "I don't know the answer," then the dogma of insisting on this operation or that drug is attenuated somewhat. It's very important for uncertainty, when it's legitimate, to be known to the patients because the patient is much less likely to yield to pronouncements from arrogant doctors - "You've got to have this operation because it will clearly do this." Sometimes that's true but sometimes it isn't. Same with drugs. Healthy skepticism grounded on uncertainty will prevent lots of patients from being subjected to possibly unnecessary operations or drugs.
Q: We are talking here about middle-, middle-upper-class people, aren't we?
Wolfe: Not entirely. They may be the recipients of what we do - the books and all that - but we also do regulatory things. So if a drug that has killed a large number of people, or a heart valve that's killed a thousand people, is taken out of circulation, anyone who potentially would have been killed or injured by them has benefited independent of economic class.
Q: How many doctors practicing today are incompetent?
Wolfe: Impossible to say. How many obstetricians are doing unnecessary C-sections? Half the C-sections by our estimates are unnecessary. The ob-gyn answer: "We're doing them because if we don't do one we'll get sued." The most generous and probably overstated estimate of the costs of medical malpractice, by the way, is about $5 billion a year, significantly under 1 per cent of health-care expenditures.
How many doctors are misprescribing or overprescribing drugs? A large proportion of them. We estimate that two-thirds of the prescriptions for drugs for older people are wrong. Either there should have been no drug prescribed or a better pill instead of a worse pill, or a lower dose.
Q: Do doctors misprescribe or overprescribe because they don't know?
Wolfe: They don't know. And into the vacuum of not knowing comes lots of drug-company promotion. There is a grossly inadequate amount of training in medical school, in internship, in residency. We are trying to work with the FDA and to get Georgetown University to introduce some more information on "Beware student and doctor on how you're going to get plagued by the drug industry."
Q: You've written frequently about the failure of the FDA to enforce rules. Why is this tolerated?
Wolfe: We've had an industry-oriented, or non-consumer-oriented, FDA commissioner up until the time Dr. David Kessler got in. He's good but had inadequate enforcement powers and got heavy-handed pressure from the Bush White House and Office of Management and Budget and from the battalions of Washington lawyers representing drug and medical-device companies and the battalions of professors from medical schools the companies hire, hounding and nudging the FDA not to take this drug off the market or to approve it more quickly or not to put a warning label on it. The public side has me and our staff. So the Government, instead of protecting the public from these characters, often protects the companies from public scrutiny and criminal prosecution. If we had had a good attorney general over the last twelve years, a much larger number of drug companies would have been convicted of crimes, such as withholding data from the FDA.
Q: What if the FDA were left alone to do its job?
Wolfe: The very small number of drugs or devices that really advance therapeutic choice for the doctor or patient would actually get on the market more quickly. The overwhelming majority of drugs and devices that are just a way of another company cashing in on a lucrative therapeutic market - ten different sleeping pills and tranquilizers basically all the same, for example - might not get on the market at all. And there would be many fewer instances of a drug coming on the market and then having to be yanked off after two or three hundred people are killed or injured. Most of these drugs that had to come off the market were approved based on the criminal failure of companies to submit data. Lilly and Smith Kline Beecham and Hoechst, the German company, have already pleaded guilty to criminal charges and more are going to. If you put some of these characters in jail instead of slapping them with $50,000 fines, they'll stop.
Q: What is the leading cause of death in this country?
Wolfe: Smoking is far and away the number-one cause of death. It swamps automobile accidents, homicide, things caused by the health-care system. Canada dramatically decreased its smoking rate in the last eight or nine years with its massive excise tax, which is now eight times higher than the U.S. tax. Our smoking decrease has been about half as fast as in Canada. In terms of affecting lives, there is nothing more important than cutting smoking, yet we've never had a President who's taken a leadership role against it.
Q: Former Surgeon General C. Everett Koop took a leadership role in warning of the danger of smoking, but I was surprised that he does not think AIDS can be cured.
Wolfe: I don't think it's going to happen tomorrow, but there's certainly a huge amount of effort being expended. As much as makes any sense. Koop made a major contribution by getting a lot of information out and sending these little letters about AIDS to every household in the country. We've made some strides, more so in the higher socioeconomic classes than the others, to try and get people to do the safe-sex things. This country has certainly done more research to develop successful treatments for the disease once it occurs, although the AIDS community has been exploited mercilessly by all kinds of people claiming that this, this, or this will prevent or treat AIDS. And a lot of it is just junk and some of it is positively dangerous. Still, twenty years ago, there was no treatment for any viral illness. Now there is treatment for herpes. And one day, a vaccine for people at high risk, like hemophiliacs.
Q: Much of your work is aimed at older people, but you don't seem to like the American Association of Retired People very much.
Wolfe: At the high level, it despises me.
Q: Older people swear by AARP.
Wolfe: Not a lot of the old people who write us. They are outraged once they find out what AARP is doing. We got copies of hundreds and hundreds of letters people sent to AARP about an article I wrote in 1991 saying it was the well-paid lackey of the insurance industry. AARP gets a $100 million kickback every year from Prudential. It's more money than AARP gets from its members. It's their major source of money. Prudential gets to be the sole source of selling insurance to AARP's thirty-five million people.
Q: So why join AARP?
Wolfe: One, AARP discounts. But if everyone gave discounts to anyone over fifty, you wouldn't need AARR Two, buying health-insurance policies. Some of them are not bad, but some are just not good buys. Three, lobbying. But members get very little out of the lobbying because on the number-one issue that AARP could be doing something about - national health insurance - it's been completely neutered by Prudential.
AARP does fund some interesting things like this group in Washington that does research and provides educational information to the consumer members of the state medical-licensing boards and the professional review organizations, but it's a tiny, tiny amount of its massive, several-hundred-million-dollar budget. They rent a building in Washington for, I think, $16 million a year.
Q: What is the next major health problem facing us?
Wolfe: Two papers published last year in the Journal of the American Medical Association give a glimpse. One looks at medical problems for which there is very adequate out-patient treatment and for which the person with the problem should rarely if ever be hospitalized. It compares uninsured people with these problems with insured people. The uninsured have a significantly higher rate of hospitalization for things like diabetes out of control, pneumonia, gangrene, asthma, and so on, because they don't have access to primary care. The uninsured finally interact with the health-care system when they're at death's door and wind up in the hospital. So we're socially producing a later stage of disease by not treating it in an earlier stage.
The second paper looks at all these people hospitalized in New York hospitals in 1984 from the perspective of "are they insured or not insured?"
It turned out that even after you adjusted for the nature of the hospital - municipal versus other hospitals - uninsured people are much more likely to be killed or injured by negligence than insured people. We are really causing a massive amount of disease in this country because of not having national health insurance.
Robert Spero is a free-lance writer in Great Neck, New York. His last interview for The Progressive was with Richard J Barnet, December 1992 issue.
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|Title Annotation:||health care activist|
|Date:||Mar 1, 1993|
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