5 Remedies for Sleep Problems
By Rachel Johnson, Ph.D, M.P.H., R.D.
Can anything we eat or drink help? Here’s what the science says.
Unrelenting insomnia has become a part of my life. Colleagues joke about my 3 a.m. e-mails; my husband groans at my late-night online shopping. (He knows I’ve had a bad stretch when packages pile up at the door.) There are weeks when I’d give just about anything for a good night’s sleep. I also know that I’m not alone.
Fifty to 70 million Americans suffer from insomnia. It’s more common among women (I know the hot flashes keeping me awake are caused by declining estrogen and hopefully will pass as my hormones even out). It is also common among people who are obese or have high blood pressure, anxiety or depression. And more and more studies are linking weight gain with sleep loss. A new study in the Journal of Clinical Sleep Medicine suggests that adults should sleep eight to nine hours per night to help maintain a healthy weight. One theory is that lack of sleep disrupts hormones, such as leptin and insulin, which regulate appetite and body weight. Another explanation is that sleep deprivation leaves us too tired for exercise. And since losing sleep can also make us moody, we may turn to food to cheer us up.
I could take one of the many sleep medications touted on TV, but I’d rather not; their long-term use can lead to headaches and possible dependency. Instead, I’m channeling my late-night energy into researching the science behind some common advice.
Drink some warm milk before bedtime
Decades ago, scientists looked into this folk remedy and posited that tryptophan, an amino acid in milk (and turkey), might be responsible for its supposed sleep-inducing effects. Earlier research had shown that when tryptophan is released into the brain, it produces serotonin—a serenity-boosting neurotransmitter. But when milk (and other tryptophan-rich foods) were tested, they failed to affect sleep patterns. “Tryptophan-containing foods don’t produce the hypnotic effects pure tryptophan does, because other amino acids in those foods compete to get into the brain,” explains Art Spielman, M.D., an insomnia expert and professor of psychology at the City University of New York. Warm milk at bedtime may be comforting, but it won’t boost sleep-promoting serotonin.
Have a bedtime snack
A light bedtime snack can stave off hunger, a known sleep robber. But eating high-glycemic-index (GI) carbohydrates—hours earlier at dinner—might also help. (High-GI foods cause a greater rise in blood sugar and insulin than do lower-GI foods.) A recent paper in the American Journal of Clinical Nutrition found that when healthy sleepers ate carbohydrate-rich suppers of veggies and tomato sauce over rice, they fell asleep significantly faster at bedtime if the meal included high-GI jasmine rice rather than lower-GI long-grain rice. While the authors aren’t sure how it happened, they speculated that the greater amounts of insulin triggered by the high-GI meals increased the ratio of tryptophan relative to other amino acids in the blood, allowing proportionately more to get into the brain. Save high-GI carbs for dinnertime, when their side effect—drowsiness—is a plus.
Drink herbal tea
Chamomile, lemon balm, hops and passionflower are all touted for their sleep-promoting properties. You’ll often find them in “sleep-formula” tea blends, but unfortunately their effectiveness hasn’t been proven in clinical studies, according to the American Academy of Sleep Medicine. “I don’t doubt these teas work for some. A warm liquid before bed may produce sleepiness by generating body heat,” speculates Spielman. Beware: drinking liquids close to bedtime can mean nocturnal trips to the bathroom. A cup of “sleep-time” tea might be worth a try…if you have a strong bladder.
Take a ‘sleep supplement’
Shelves in supplement stores are stacked with sleep formulas. According to one NIH survey conducted in 2002, 1.6 million people tried complementary or alternative therapies like these, and over half of them reported their insomnia improved “a great deal.” However, those glowing anecdotes haven’t been backed up by rigorous scientific study; evaluations of most nutritional supplements haven’t shown any effects whatsoever. The one exception is valerian root, which seemed to help improve sleep with rare, and mild, side effects, such as stomach upset. But finding an effective formulation of valerian root is tricky, since the FDA doesn’t regulate herbal supplements. Don’t waste your money on sleep supplements; hold off on using valerian until standardized formulations become available.
Have a nightcap.
Though a glass of wine may help you fall asleep, excessive alcohol use can make you wake up in the night. One theory is that alcohol suppresses the REM (rapid eye movement) sleep state that’s critical to a good night’s sleep, says Spielman. “One of my insomnia patients became remarkably better when he reduced his alcohol intake from 20 to three drinks per week.” Drink moderately, if at all; avoid drinking within a few hours of bedtime.
Comment
The side effect of my blood pressure medication is drowsiness, so I take it at night and sleep like a baby. I take a smaller dose during the day so I wont be too sleepy to function, but will still have the medication lowering my blood pressure. Milk sometimes works for me too.
Saturday, October 31, 2009
Tuesday, October 27, 2009
Visiting Your Doctor Online Is a Virtual Reality
Technologies that let patients consult with physicians via the Web are spreading rapidly
By Megan Johnson
Posted October 27, 2009
Donita Gano woke up one Sunday morning with a problem. The 59-year-old public-health nurse had fallen and gashed her elbow about 10 days before. Now it was warm and inflamed, signs of probable infection. She logged on to an online clinic launched early this year by her health plan, Hawaii Medical Service Association, and chose an available physician. She clicked on "Connect now," and soon she and the doctor were engaged in an online chat about her symptoms. If she'd had a webcam and if the doctor had been amenable, she could have displayed her elbow for his inspection. He ordered an antibiotic, which she picked up right after logging off. "Pretty painless," says Gano.
It's easy and convenient for the nearly 150 Hawaii doctors who have signed up for HMSA's Online Care program, too. On a Maui beach near his office, internist Irving Harper towels off, picks up his cellphone, and handles questions from patients he's never seen. At home, he pulls up their medical records and E-mails them his recommendations. He has occasional video chats with patients but prefers to do those from his office, dressed more professionally than on the beach.
Patients in the Hawaii program receive care from doctors scheduled to be reachable at that moment. A 10-minute "visit" costs $10 for members and $45 for nonmembers, paid with a credit card. HMSA says thousands of patients have registered. Health plan members like Gano are pre-enrolled; nonmembers create an account and key in their medical history and other data to establish a record.
Gano and Harper are surfing a new wave of patient-friendly, relatively inexpensive, Web-based healthcare. The technology behind the HMSA program, created by American Well, a Boston company, is being picked up by other health insurance plans. Blue Cross & Blue Shield of Minnesota launched a pilot version this fall and plans to offer it to all members by mid-2010. A recent partnership between American Well and OptumHealth, a division of UnitedHealth Group, will take Online Care nationwide to all consumers, regardless of insurance provider. Then there is MDLiveCare, a national service with more than 100,000 members who may or may not be covered by a healthcare plan and who pay a flat $35 per online visit to consult with primary-care providers, specialists, and therapists in the network.
Some healthcare plans, such as Kaiser Permanente, already let members E-mail doctors, review lab tests, make appointments, and refill prescriptions online. But virtual doctor visits are in real time and don't have to adhere to office hours. In Hawaii, some of the most remote patients now have 24-7 access to basic healthcare.
Such services offer more than convenience, however. An online encounter often is a substitute for an expensive trip to the ER. It's also likely to be cheaper than an office visit, plus it confers nearly instant access to a patient's choice of available doctors and—a boon for employers—may trim the number of workdays missed for minor maladies. Ninety-five percent of Harper's patients using the Hawaii service can be managed without a face-to-face visit, says the physician.
Many Americans are would-be prospects for online care. Half say they would be interested in using the Internet not only as an information source but to receive healthcare directly, according to a recent survey by an arm of PricewaterhouseCoopers. Consumers soon may be able to choose from a range of services.
About 10,000 individuals, most of them residents of the New York metropolitan area, can already get an online (or phone) emergency consultation with one of 34 ER physicians who have signed on with a company called SwiftMD. CEO Elliot Justin, a doctor, has diagnosed a fungal infection by webcam (and a case of hemorrhoids, he says with amusement).
Patients in Brooklyn, N.Y., who don't have health insurance (and physicians who don't want to deal with insurance claims) have the option of joining Hello Health. After an initial face-to-face visit, patients pay $100 to $200 an hour for each encounter, whether it's in person or online. In addition, the $35 monthly membership fee covers unlimited E-mail exchanges with Hello Health doctors. Online, patients can see their doctor's schedule and make their own appointments. If they run late, they can whip out a BlackBerry or iPhone and post a message on a Facebook-like "wall" on the physician's Web page. Hello Health internist Sean Khozin figures he spends as much as 40 percent of his time online—following up with chronic disease cases, for example, to coordinate care. Hello Health is in the process of rolling out nationally.
Comment
Could this be a partial answer to the 46 million without insurance? Like the clinics that are springing up at WalMart and other places, staffed with nurse practicioners, this could help provide the services that 95% of the people need, and save the more complicated tasks for the doctors.
By Megan Johnson
Posted October 27, 2009
Donita Gano woke up one Sunday morning with a problem. The 59-year-old public-health nurse had fallen and gashed her elbow about 10 days before. Now it was warm and inflamed, signs of probable infection. She logged on to an online clinic launched early this year by her health plan, Hawaii Medical Service Association, and chose an available physician. She clicked on "Connect now," and soon she and the doctor were engaged in an online chat about her symptoms. If she'd had a webcam and if the doctor had been amenable, she could have displayed her elbow for his inspection. He ordered an antibiotic, which she picked up right after logging off. "Pretty painless," says Gano.
It's easy and convenient for the nearly 150 Hawaii doctors who have signed up for HMSA's Online Care program, too. On a Maui beach near his office, internist Irving Harper towels off, picks up his cellphone, and handles questions from patients he's never seen. At home, he pulls up their medical records and E-mails them his recommendations. He has occasional video chats with patients but prefers to do those from his office, dressed more professionally than on the beach.
Patients in the Hawaii program receive care from doctors scheduled to be reachable at that moment. A 10-minute "visit" costs $10 for members and $45 for nonmembers, paid with a credit card. HMSA says thousands of patients have registered. Health plan members like Gano are pre-enrolled; nonmembers create an account and key in their medical history and other data to establish a record.
Gano and Harper are surfing a new wave of patient-friendly, relatively inexpensive, Web-based healthcare. The technology behind the HMSA program, created by American Well, a Boston company, is being picked up by other health insurance plans. Blue Cross & Blue Shield of Minnesota launched a pilot version this fall and plans to offer it to all members by mid-2010. A recent partnership between American Well and OptumHealth, a division of UnitedHealth Group, will take Online Care nationwide to all consumers, regardless of insurance provider. Then there is MDLiveCare, a national service with more than 100,000 members who may or may not be covered by a healthcare plan and who pay a flat $35 per online visit to consult with primary-care providers, specialists, and therapists in the network.
Some healthcare plans, such as Kaiser Permanente, already let members E-mail doctors, review lab tests, make appointments, and refill prescriptions online. But virtual doctor visits are in real time and don't have to adhere to office hours. In Hawaii, some of the most remote patients now have 24-7 access to basic healthcare.
Such services offer more than convenience, however. An online encounter often is a substitute for an expensive trip to the ER. It's also likely to be cheaper than an office visit, plus it confers nearly instant access to a patient's choice of available doctors and—a boon for employers—may trim the number of workdays missed for minor maladies. Ninety-five percent of Harper's patients using the Hawaii service can be managed without a face-to-face visit, says the physician.
Many Americans are would-be prospects for online care. Half say they would be interested in using the Internet not only as an information source but to receive healthcare directly, according to a recent survey by an arm of PricewaterhouseCoopers. Consumers soon may be able to choose from a range of services.
About 10,000 individuals, most of them residents of the New York metropolitan area, can already get an online (or phone) emergency consultation with one of 34 ER physicians who have signed on with a company called SwiftMD. CEO Elliot Justin, a doctor, has diagnosed a fungal infection by webcam (and a case of hemorrhoids, he says with amusement).
Patients in Brooklyn, N.Y., who don't have health insurance (and physicians who don't want to deal with insurance claims) have the option of joining Hello Health. After an initial face-to-face visit, patients pay $100 to $200 an hour for each encounter, whether it's in person or online. In addition, the $35 monthly membership fee covers unlimited E-mail exchanges with Hello Health doctors. Online, patients can see their doctor's schedule and make their own appointments. If they run late, they can whip out a BlackBerry or iPhone and post a message on a Facebook-like "wall" on the physician's Web page. Hello Health internist Sean Khozin figures he spends as much as 40 percent of his time online—following up with chronic disease cases, for example, to coordinate care. Hello Health is in the process of rolling out nationally.
Comment
Could this be a partial answer to the 46 million without insurance? Like the clinics that are springing up at WalMart and other places, staffed with nurse practicioners, this could help provide the services that 95% of the people need, and save the more complicated tasks for the doctors.
Identifying the enemy within
A potential anti-cancer therapy
Sep 22nd 2009
From Economist.com
An implant that instructs the immune system to fight cancer
How do you do, granulocyte-macrophage colony-stimulating factor? CANCER is deadly because it comes from within and evades the body’s natural defences. Attempts to train the immune system to recognise and attack cancers have so far failed. But a new technique that uses doped implants is showing promise.
The implants in question are tiny biodegradable discs, just millimetres across, that are impregnated with a substance called granulocyte-macrophage colony-stimulating factor which attracts dendritic cells, the main orchestrators of immune responses. Dendritic cells normally latch on to bacteria and viruses before migrating to the lymph nodes, where they present the alien material to the immune system’s “killer” T-cells that seek and destroy such invaders. But dendritic cells do not normally recognise cancer cells as dangerous.
Omar Ali and his colleagues at Harvard University have found a way to teach the dendritic cells to identify cancer. They do this by taking molecules from a biopsy of a patient’s tumour and attaching them to the implant, along with a substance called cytosine-guanosine oligonucleotide that dendritic cells recognise as being associated with infection. Attracted by the granulocyte-macrophage colony-stimulating factor, the dendritic cells are temporarily captured by pores in the spongy implant and exposed to the chemical cocktail that prompts them to take the cancer cells to the T-cells so that they can be destroyed.
The Harvard team has tested its system on mice with skin cancer. All of the murines with melanoma that had not received an implant died within 25 days; 90% of those with implants survived. The study was published in Nature Materials earlier this year.
The group has now repeated the experiments in mice with gliomas, which are tumours that start in the brain or spine. Although the results are not due to be published until later this year, Dr Ali describes them as “very encouraging” and similar to those achieved in melanomas. He adds that experiments on the use of the implants in mice with breast cancers have been positive, although those with lung cancer were not. Early experiments also suggest that the discs are effective even against some late-stage forms of cancer in mice. Clinical trials of the implants in human patients with late-stage skin cancer are due to begin in June 2010.
America’s Food and Drug Administration has already approved both the polymer the implant is made from and the active agents it uses. Although approval for the implants will still be required, the process could be relatively quick. David Mooney, one of Dr Ali’s colleagues, has established a spin-off biotech company called InCytu to commercialise the technology.
Dr Mooney, who has previously worked on implants to stimulate blood-vessel growth and bone regeneration, says such a device could also be used to reduce immune responses, as well as boosting them. He has started tests on animals to investigate whether the implants could be used to combat chronic inflammatory diseases and autoimmune diseases, such as arthritis and diabetes.
Comment
This theory has been around for a while, and is only now coming to fruition. The main benefit is that healthy cells are not attacked, and there are little or no side effects since small doses are given. A biopsy of the tumor is done to get an impression of what the tumor looks and acts like. Since the individuals own immune system is the one doing the work there is no outside alien particles to react to.
Sep 22nd 2009
From Economist.com
An implant that instructs the immune system to fight cancer
How do you do, granulocyte-macrophage colony-stimulating factor? CANCER is deadly because it comes from within and evades the body’s natural defences. Attempts to train the immune system to recognise and attack cancers have so far failed. But a new technique that uses doped implants is showing promise.
The implants in question are tiny biodegradable discs, just millimetres across, that are impregnated with a substance called granulocyte-macrophage colony-stimulating factor which attracts dendritic cells, the main orchestrators of immune responses. Dendritic cells normally latch on to bacteria and viruses before migrating to the lymph nodes, where they present the alien material to the immune system’s “killer” T-cells that seek and destroy such invaders. But dendritic cells do not normally recognise cancer cells as dangerous.
Omar Ali and his colleagues at Harvard University have found a way to teach the dendritic cells to identify cancer. They do this by taking molecules from a biopsy of a patient’s tumour and attaching them to the implant, along with a substance called cytosine-guanosine oligonucleotide that dendritic cells recognise as being associated with infection. Attracted by the granulocyte-macrophage colony-stimulating factor, the dendritic cells are temporarily captured by pores in the spongy implant and exposed to the chemical cocktail that prompts them to take the cancer cells to the T-cells so that they can be destroyed.
The Harvard team has tested its system on mice with skin cancer. All of the murines with melanoma that had not received an implant died within 25 days; 90% of those with implants survived. The study was published in Nature Materials earlier this year.
The group has now repeated the experiments in mice with gliomas, which are tumours that start in the brain or spine. Although the results are not due to be published until later this year, Dr Ali describes them as “very encouraging” and similar to those achieved in melanomas. He adds that experiments on the use of the implants in mice with breast cancers have been positive, although those with lung cancer were not. Early experiments also suggest that the discs are effective even against some late-stage forms of cancer in mice. Clinical trials of the implants in human patients with late-stage skin cancer are due to begin in June 2010.
America’s Food and Drug Administration has already approved both the polymer the implant is made from and the active agents it uses. Although approval for the implants will still be required, the process could be relatively quick. David Mooney, one of Dr Ali’s colleagues, has established a spin-off biotech company called InCytu to commercialise the technology.
Dr Mooney, who has previously worked on implants to stimulate blood-vessel growth and bone regeneration, says such a device could also be used to reduce immune responses, as well as boosting them. He has started tests on animals to investigate whether the implants could be used to combat chronic inflammatory diseases and autoimmune diseases, such as arthritis and diabetes.
Comment
This theory has been around for a while, and is only now coming to fruition. The main benefit is that healthy cells are not attacked, and there are little or no side effects since small doses are given. A biopsy of the tumor is done to get an impression of what the tumor looks and acts like. Since the individuals own immune system is the one doing the work there is no outside alien particles to react to.
Unnatural selection
The financial industry
Sep 10th 2009
From The Economist print edition
Wall Street and the City of London survived thanks to state support. Now they need to be weaned off it.
“WE HAVE a long track record of pulling together when times are tough…We’re on the right track.” Thus spoke the boss of Lehman Brothers on September 10th 2008. Within five days Lehman had gone bust and it quickly became clear that the world’s financial system had problems far beyond a single badly run investment bank and temporarily frozen credit markets. After two decades of expansion and deregulation, and the greatest bull market finance has ever known, many of the world’s banks were dangerously undercapitalised. Governments were forced to step in, providing capital, loans and guarantees to banks. In America, the euro zone and Britain the sums involved so far amount to about one sixth of GDP.
A year on from Lehman that still looks like the right call. After the crash in 1929 America’s economy shrank by a quarter and the unemployment rate hit 25%. This time round, with the banks wrapped in cotton wool, extremely low interest rates and big public-spending packages, the economic distress has been massively smaller. Yet the recession has still been extremely painful, prompting a sense of outrage at the financial industry and in particular the big wholesale banks that execute transactions for clients and trade on their own account. This reflects not just their past sins, but also the perception that nothing has really changed.
In a league of its own
That is not entirely true. Many bankers have lost their jobs. Some skyscrapers in Manhattan and London’s Canary Wharf have new signs on them. Famous firms like Merrill Lynch have been swallowed up; the reputations of others such as UBS and Citigroup have been mauled. Plenty of hedge funds have folded. There have been relative winners, too. Many commercial banks have done well (particularly in Spain, Canada and Australia) and JPMorgan Chase, Bank of America and Barclays have expanded their investment banks (see article).
But the dramatic changes in the pecking order mask a lack of more profound change in the system of finance itself. Lehman aside, no big firms have been allowed to fail (as they would have done, unaided). Thanks to state aid, the law for big firms today is what Gordon Gekko, the red-blooded villain of the film “Wall Street”, dubbed “survival of the unfittest”.
Indeed, taken together, financial firms have not even really got smaller. Exclude “useful” loans to the real economy, and over the past year the remaining underlying risk-adjusted assets of the nine biggest investment banks worldwide have been broadly flat. Statistical measures of the maximum trading losses these firms could face on those positions suggest that, in aggregate, they are taking more risk. Their combined balance-sheet is 40% bigger today than in mid-2005. And all this has been amplified into public outrage by the foolish decision to pay out bumper bonuses again.
The fury at “business as usual” in the Temples of Mammon is understandable, but it is a rotten basis for trying to regulate finance. For one thing, the recent return of profits and bonuses has occurred in unusual circumstances: it is easier for healthier banks to make profits when their weaker rivals are cowed. Once competitors are back on their feet and tighter regulations introduced, things will look very different. Far from being the return of the big bonuses, this could be their last hurrah.
And bonuses are, for the most part, the symptom not the disease. They certainly have done damage, persuading traders to load the system with toxic securities and sucking away capital: in the year before its demise, Lehman paid out at least $5.1 billion in cash compensation, equivalent to a third of the core capital left just before it failed. More recently Morgan Stanley promised so much pay in its latest quarter that it almost made an underlying loss. In any other business that would be a risk for shareholders. But finance’s risks are everyone’s because banks rely both directly and indirectly on taxpayers’ support.
The scale of that help is huge. Loans from central banks and debt guarantees alone amount to $2.7 trillion. As with any private industry in receipt of almost unlimited cheap public funds, finance now has every incentive to be as big as possible—beyond the point of usefulness. Change the assumptions behind this weird system, and everything else, including pay and the heads-I-win, tails-you-lose culture, will move too.
Removing the explicit side of the state’s commitment is relatively simple. Some guarantees are still plainly needed now, but a firm deadline of, say, five years for the final expiry of the governments’ various crisis-induced pledges should be set globally. With the world economy in better shape, this looks more realistic than it did six months ago. But even then the implicit assumption will linger that banks will always be bailed out. This is the core problem. There are two possible responses to it: regulate banks to try to make them safer, and attempt to limit the implicit guarantee. Both approaches are now needed.
Taming the beast
On regulation there have been some wacky ideas. Britain’s top financial policeman has endorsed a tax on transactions to cut the industry down to size, an idea that is Utopian and misguided. Similarly, the idea that regulators know the optimal size of the financial sector, or are good at running banks, is a fantasy. Trying to prevent blow-ups in the first place is more sensible with economy-wide “macro-prudential” regulators working to counter bubbles such as the recent housing mania.
Booms and bust will not disappear; hence the crucial importance of bolstering capital, the buffer that banks depend on to absorb losses. At the top of the last cycle, capital levels would have needed to be about double the current permitted floor for America’s banks to have got through the crisis without raising more funds. The Basel club of regulators is working to raise the level and improve the quality of banks’ capital. It may also be possible to vary capital charges to prod banks to shrink, improve liquidity and, yes, curb pay. But capital, a fairly blunt tool, could be asked to do too much.
The same is true of regulators themselves. Last time round they were meant to stop banks from self-harm and make sure they had enough capital. Just because they are trying harder now does not mean they will succeed. Focus only on more rules and the medium-term risk is of a colossal, semi-socialised banking system crawling with outgunned, possibly captive regulators. Hence the importance of the second response: a concerted effort to reduce the implicit state guarantees.
That is easier said than done, especially since the recent bail-outs have reaffirmed the state as a backstop. There are, however, other options. “Living wills” can force banks to plan for their own collapse, which should make it easier to protect depositors while forcing creditors, not taxpayers, to bear the pain. There is also a case for forcing banks to finance themselves with a slice of junior “hybrid” debt (which has never been state-guaranteed). Its cost, and thus banks’ profits, may at least for a while be more sensitive to the risks being taken.
No one should pretend that banking is an industry where pure natural selection takes place. But as guarantees, both explicit and implicit, are withdrawn, the hope is that self-discipline will be imposed on banks, not just swathes of new regulation. There are signs that riskier banks are already paying more to finance themselves. This differentiation must be promoted, so the weak and reckless are gradually forced to shrink and live within their means—and not off taxpayers’ largesse.
Sep 10th 2009
From The Economist print edition
Wall Street and the City of London survived thanks to state support. Now they need to be weaned off it.
“WE HAVE a long track record of pulling together when times are tough…We’re on the right track.” Thus spoke the boss of Lehman Brothers on September 10th 2008. Within five days Lehman had gone bust and it quickly became clear that the world’s financial system had problems far beyond a single badly run investment bank and temporarily frozen credit markets. After two decades of expansion and deregulation, and the greatest bull market finance has ever known, many of the world’s banks were dangerously undercapitalised. Governments were forced to step in, providing capital, loans and guarantees to banks. In America, the euro zone and Britain the sums involved so far amount to about one sixth of GDP.
A year on from Lehman that still looks like the right call. After the crash in 1929 America’s economy shrank by a quarter and the unemployment rate hit 25%. This time round, with the banks wrapped in cotton wool, extremely low interest rates and big public-spending packages, the economic distress has been massively smaller. Yet the recession has still been extremely painful, prompting a sense of outrage at the financial industry and in particular the big wholesale banks that execute transactions for clients and trade on their own account. This reflects not just their past sins, but also the perception that nothing has really changed.
In a league of its own
That is not entirely true. Many bankers have lost their jobs. Some skyscrapers in Manhattan and London’s Canary Wharf have new signs on them. Famous firms like Merrill Lynch have been swallowed up; the reputations of others such as UBS and Citigroup have been mauled. Plenty of hedge funds have folded. There have been relative winners, too. Many commercial banks have done well (particularly in Spain, Canada and Australia) and JPMorgan Chase, Bank of America and Barclays have expanded their investment banks (see article).
But the dramatic changes in the pecking order mask a lack of more profound change in the system of finance itself. Lehman aside, no big firms have been allowed to fail (as they would have done, unaided). Thanks to state aid, the law for big firms today is what Gordon Gekko, the red-blooded villain of the film “Wall Street”, dubbed “survival of the unfittest”.
Indeed, taken together, financial firms have not even really got smaller. Exclude “useful” loans to the real economy, and over the past year the remaining underlying risk-adjusted assets of the nine biggest investment banks worldwide have been broadly flat. Statistical measures of the maximum trading losses these firms could face on those positions suggest that, in aggregate, they are taking more risk. Their combined balance-sheet is 40% bigger today than in mid-2005. And all this has been amplified into public outrage by the foolish decision to pay out bumper bonuses again.
The fury at “business as usual” in the Temples of Mammon is understandable, but it is a rotten basis for trying to regulate finance. For one thing, the recent return of profits and bonuses has occurred in unusual circumstances: it is easier for healthier banks to make profits when their weaker rivals are cowed. Once competitors are back on their feet and tighter regulations introduced, things will look very different. Far from being the return of the big bonuses, this could be their last hurrah.
And bonuses are, for the most part, the symptom not the disease. They certainly have done damage, persuading traders to load the system with toxic securities and sucking away capital: in the year before its demise, Lehman paid out at least $5.1 billion in cash compensation, equivalent to a third of the core capital left just before it failed. More recently Morgan Stanley promised so much pay in its latest quarter that it almost made an underlying loss. In any other business that would be a risk for shareholders. But finance’s risks are everyone’s because banks rely both directly and indirectly on taxpayers’ support.
The scale of that help is huge. Loans from central banks and debt guarantees alone amount to $2.7 trillion. As with any private industry in receipt of almost unlimited cheap public funds, finance now has every incentive to be as big as possible—beyond the point of usefulness. Change the assumptions behind this weird system, and everything else, including pay and the heads-I-win, tails-you-lose culture, will move too.
Removing the explicit side of the state’s commitment is relatively simple. Some guarantees are still plainly needed now, but a firm deadline of, say, five years for the final expiry of the governments’ various crisis-induced pledges should be set globally. With the world economy in better shape, this looks more realistic than it did six months ago. But even then the implicit assumption will linger that banks will always be bailed out. This is the core problem. There are two possible responses to it: regulate banks to try to make them safer, and attempt to limit the implicit guarantee. Both approaches are now needed.
Taming the beast
On regulation there have been some wacky ideas. Britain’s top financial policeman has endorsed a tax on transactions to cut the industry down to size, an idea that is Utopian and misguided. Similarly, the idea that regulators know the optimal size of the financial sector, or are good at running banks, is a fantasy. Trying to prevent blow-ups in the first place is more sensible with economy-wide “macro-prudential” regulators working to counter bubbles such as the recent housing mania.
Booms and bust will not disappear; hence the crucial importance of bolstering capital, the buffer that banks depend on to absorb losses. At the top of the last cycle, capital levels would have needed to be about double the current permitted floor for America’s banks to have got through the crisis without raising more funds. The Basel club of regulators is working to raise the level and improve the quality of banks’ capital. It may also be possible to vary capital charges to prod banks to shrink, improve liquidity and, yes, curb pay. But capital, a fairly blunt tool, could be asked to do too much.
The same is true of regulators themselves. Last time round they were meant to stop banks from self-harm and make sure they had enough capital. Just because they are trying harder now does not mean they will succeed. Focus only on more rules and the medium-term risk is of a colossal, semi-socialised banking system crawling with outgunned, possibly captive regulators. Hence the importance of the second response: a concerted effort to reduce the implicit state guarantees.
That is easier said than done, especially since the recent bail-outs have reaffirmed the state as a backstop. There are, however, other options. “Living wills” can force banks to plan for their own collapse, which should make it easier to protect depositors while forcing creditors, not taxpayers, to bear the pain. There is also a case for forcing banks to finance themselves with a slice of junior “hybrid” debt (which has never been state-guaranteed). Its cost, and thus banks’ profits, may at least for a while be more sensitive to the risks being taken.
No one should pretend that banking is an industry where pure natural selection takes place. But as guarantees, both explicit and implicit, are withdrawn, the hope is that self-discipline will be imposed on banks, not just swathes of new regulation. There are signs that riskier banks are already paying more to finance themselves. This differentiation must be promoted, so the weak and reckless are gradually forced to shrink and live within their means—and not off taxpayers’ largesse.
What a waste
Oct 15th 2009
From The Economist print edition
Barack Obama’s reforms should avoid squandering a rare opportunity, but probably won’t.
LAST year, when he was still the head of the independent Congressional Budget Office, Peter Orszag used to warn bleakly that the rising costs of health care would, if not subjected to radical reform, one day bankrupt the government. Over the past few decades, these costs have risen at a consistent 2.5 percentage points above the growth rate of the economy. Projected out to 2050, he reckoned, Medicare and Medicaid (the government schemes that insure the elderly and the poor) would together consume some 20% of America’s GDP, almost as much as the entire federal budget of today.
Perhaps Mr Orszag, now the budget director in Barack Obama’s White House, is about to storm out of his grand new office. For the health bill that this week moved a big step closer to Mr Obama’s desk (see article) fails—not completely, but very largely—to address the government-exploding problem of cost inflation. Instead, its focus rests squarely on the long-cherished Democratic Party goal of making sure that virtually everyone in America has some form of health coverage; at the moment, over 46m people have none. Even on this score, the plan that finally emerged from the Senate Finance Committee on October 13th looks incomplete (by 2019, 25m people are expected to remain uninsured), is likely to cost much more than has been claimed, and is paid for with hypothetical savings that are sure to be found wanting.
Mr Obama and his team will naturally declare victory if any health bill at all makes it out of Congress, as it now looks rather more likely that one will. They have some grounds for doing so. Anything that mitigates the obscenity of so rich a country leaving so many people without coverage will be a change for the better. But the bill also looks likely to represent a terribly wasted opportunity. Perverse incentives constantly drive up the costs of American health care, and the legislation will do little to remove them. Mr Obama and his Democratic colleagues on Capitol Hill are in grave danger of throwing away a rare chance. Health-care entitlements are by far the biggest chunk of America’s out-of-control budget, and it will probably be another decade, perhaps two, before anyone again dares to tackle them. A president with a big personal mandate, solid majorities in both chambers of Congress and a silver tongue ought to have been much braver.
Courage, Mr President
That braver president could have demanded far more. The worst flaw in the Finance Committee’s bill is its failure to address the way that providers of health care are paid. Most payments to doctors and hospitals are made on a “fee-for-service” basis—which means that, unconstrained either by medical necessity or value for money, the industry’s revenues rise with every test it does, procedure it carries out and prescription it writes. Yes, the bill provides funds for research into electronic record-keeping, comparative effectiveness research and other good things. But it should mandate these practices, not just encourage study of them. None of the five different bills that have been passed by various House and Senate committees and are now on the way to being melded into a single compromise version includes anything like the sort of root-and-branch overhaul that would see health care paid for by results.
Nor do any of the bills do anything much to tackle the other big distortion in health-provision—tax exemption for employer-provided private health-insurance. By subsidising the health plans of those lucky enough to have them, this encourages over-consumption and amounts to a distorting taxpayer-funded subsidy for the well-off. The latest bill merely sets a very high cap (of $8,000 per person, or $21,000 for a family) on this exemption, and the House of Representatives will try to water down even this feeble effort at the behest of the unions whose members enjoy some of the most lavish policies. It may also dilute the administration’s only really good proposal, for a committee of experts empowered to order changes to the way Medicare payments are made. Finally, the bills make no attempt to address the matter of greedy lawyers forcing doctors to practise expensive “defensive medicine” for fear of being sued to kingdom come.
What was produced this week was not the final outcome; the legislation will change as the work of reconciling the different versions of the bill continues. There is no shortage of good ideas that might yet find their way into the final one. Payments by the government could, for instance, be tied to best national practice, and Mr Obama has already said that he is open to the idea of medical tort reform. But time is running out.
Comment
Can you mandate that a doctor make his records electronic? doctors order a lot of tests because, if they don't, and something untoward happens, they can be sued. There ARE some lousy doctors out there, and those should be weeded out. There are also predatory lawyers out there, who will sue for any reason, legitimate or not. Incentives should be given to hospitals to switch to electronic record keeping. The VA has had electronic record keeping for well over a decade and would provide the database for research into its effectiveness. Perhaps a 3 year window to switch over would work, like the digital TV requirement.
From The Economist print edition
Barack Obama’s reforms should avoid squandering a rare opportunity, but probably won’t.
LAST year, when he was still the head of the independent Congressional Budget Office, Peter Orszag used to warn bleakly that the rising costs of health care would, if not subjected to radical reform, one day bankrupt the government. Over the past few decades, these costs have risen at a consistent 2.5 percentage points above the growth rate of the economy. Projected out to 2050, he reckoned, Medicare and Medicaid (the government schemes that insure the elderly and the poor) would together consume some 20% of America’s GDP, almost as much as the entire federal budget of today.
Perhaps Mr Orszag, now the budget director in Barack Obama’s White House, is about to storm out of his grand new office. For the health bill that this week moved a big step closer to Mr Obama’s desk (see article) fails—not completely, but very largely—to address the government-exploding problem of cost inflation. Instead, its focus rests squarely on the long-cherished Democratic Party goal of making sure that virtually everyone in America has some form of health coverage; at the moment, over 46m people have none. Even on this score, the plan that finally emerged from the Senate Finance Committee on October 13th looks incomplete (by 2019, 25m people are expected to remain uninsured), is likely to cost much more than has been claimed, and is paid for with hypothetical savings that are sure to be found wanting.
Mr Obama and his team will naturally declare victory if any health bill at all makes it out of Congress, as it now looks rather more likely that one will. They have some grounds for doing so. Anything that mitigates the obscenity of so rich a country leaving so many people without coverage will be a change for the better. But the bill also looks likely to represent a terribly wasted opportunity. Perverse incentives constantly drive up the costs of American health care, and the legislation will do little to remove them. Mr Obama and his Democratic colleagues on Capitol Hill are in grave danger of throwing away a rare chance. Health-care entitlements are by far the biggest chunk of America’s out-of-control budget, and it will probably be another decade, perhaps two, before anyone again dares to tackle them. A president with a big personal mandate, solid majorities in both chambers of Congress and a silver tongue ought to have been much braver.
Courage, Mr President
That braver president could have demanded far more. The worst flaw in the Finance Committee’s bill is its failure to address the way that providers of health care are paid. Most payments to doctors and hospitals are made on a “fee-for-service” basis—which means that, unconstrained either by medical necessity or value for money, the industry’s revenues rise with every test it does, procedure it carries out and prescription it writes. Yes, the bill provides funds for research into electronic record-keeping, comparative effectiveness research and other good things. But it should mandate these practices, not just encourage study of them. None of the five different bills that have been passed by various House and Senate committees and are now on the way to being melded into a single compromise version includes anything like the sort of root-and-branch overhaul that would see health care paid for by results.
Nor do any of the bills do anything much to tackle the other big distortion in health-provision—tax exemption for employer-provided private health-insurance. By subsidising the health plans of those lucky enough to have them, this encourages over-consumption and amounts to a distorting taxpayer-funded subsidy for the well-off. The latest bill merely sets a very high cap (of $8,000 per person, or $21,000 for a family) on this exemption, and the House of Representatives will try to water down even this feeble effort at the behest of the unions whose members enjoy some of the most lavish policies. It may also dilute the administration’s only really good proposal, for a committee of experts empowered to order changes to the way Medicare payments are made. Finally, the bills make no attempt to address the matter of greedy lawyers forcing doctors to practise expensive “defensive medicine” for fear of being sued to kingdom come.
What was produced this week was not the final outcome; the legislation will change as the work of reconciling the different versions of the bill continues. There is no shortage of good ideas that might yet find their way into the final one. Payments by the government could, for instance, be tied to best national practice, and Mr Obama has already said that he is open to the idea of medical tort reform. But time is running out.
Comment
Can you mandate that a doctor make his records electronic? doctors order a lot of tests because, if they don't, and something untoward happens, they can be sued. There ARE some lousy doctors out there, and those should be weeded out. There are also predatory lawyers out there, who will sue for any reason, legitimate or not. Incentives should be given to hospitals to switch to electronic record keeping. The VA has had electronic record keeping for well over a decade and would provide the database for research into its effectiveness. Perhaps a 3 year window to switch over would work, like the digital TV requirement.
Obama's war
The war in Afghanistan
Oct 15th 2009
From The Economist print edition
Why the Afghanistan war deserves more resources, commitment and political will.
AP EIGHT years after the deceptively swift toppling of the Taliban, the prospects for the NATO-led mission in Afghanistan seem worse than ever. Every Western casualty, every reinforcement and every pious political homily on the “justness” and “necessity” of the war seem only to leave the mission floundering deeper and more hopelessly. Already battered by mounting casualties, Western support for the war has been further dented by an Afghan presidential election in August, wildly rigged in favour of the incumbent, Hamid Karzai. Against this gloomy backdrop, Barack Obama is faced with a request from the American and NATO commander in Afghanistan, General Stanley McChrystal, for large numbers of new troops (see article). The decision may define his presidency. Despite the difficulty—indeed, because of the difficulty—he should give the general what he needs.
The alternative is not, as some opponents of an Afghan “surge” suggest, less intensive, more surgical “counter-terrorism”, relying on unmanned air raids and assassination. Mr Obama seems, rightly, to have ruled that out. General McChrystal, a special-forces veteran, is emphatic it would not work. On its own, it is more likely to kill civilians and create new enemies than to decapitate and disable al-Qaeda. A counter-terrorist strategy is a euphemism for withdrawal—which is what plenty of Westerners think should happen.
Surge or surgical?
If the West is wearying of its Afghan adventure, it is hardly surprising. The country’s unruly tribes and mountainous landscape make the place hard to pacify. Voters thousands of miles away struggle to remember why their soldiers are dying there. Reminders that they are depriving al-Qaeda of the base from which it plots the West’s destruction stretch credulity when the terrorists do just that from Pakistan’s tribal areas.
Yet the arguments for staying remain strong. First, the West has a security interest in preventing the region from slipping into a maelstrom of conflict. Pakistan, with 170m people and nuclear weapons, is vulnerable to the Taliban’s potent mixture of ethnic-Pushtun nationalism and extremist Islam (see article). Anarchy in Afghanistan, or a Taliban restoration, would leave it prey to permanent cross-border instability. Second, defeat for the West in Afghanistan would embolden its opponents not just in Pakistan, but all around the world, leaving it open to more attacks. And, third, withdrawal would amount to a terrible betrayal of the Afghan people, some of whose troubles are the result of Western intervention.
Millions of refugees have returned and millions of children have the chance to go to school. But the West has failed to protect civilian lives, to bring the development it promised, to wean the economy off its poppy-addiction and to ensure fair elections—and failed even to agree about what it is trying to do in the country. The Western-dominated United Nations mission has fractured in a public row between its two senior officials. Locally, NATO forces have done fine and heroic work. But too often the best initiatives are dropped when the best commanders end their tours. The Afghan conflict, it is often said, has been not an eight-year war, but eight one-year wars. NATO comes off worse each time. And so to the fourth and most important reason for persisting in Afghanistan: the coalition can do much better.
General McChrystal is an impressive soldier with a coherent plan. The West’s forces have got to know their enemies: not just the Taliban but also other terrorist networks and countless local warlords and thugs. The coalition’s leaders, at least, seem to have grasped that it must behave not as an occupying army but as a partner, whose aim is to build up the local forces that will ultimately ensure Afghanistan’s security. And soldiers and civilians are beginning to understand that development aid can benefit local people rather than foreign consultants and contractors.
The coalition, however, lacks three essential components of a successful strategy. It needs a credible, legitimate government to work with, the resources to do the job and the belief that America’s president is behind this war.
Many Afghans find it bizarre that the West should devote so much money to Mr Karzai, yet be unable to hold him to account over something so basic as stuffing ballot boxes on an industrial scale. For most, however, the local and provincial leaders matter more than the distant central government.
That is where the constitution drawn up after the overthrow of the Taliban went wrong. It envisages a centralised state. Provincial governors, for example, are appointed by the president. This flawed framework needs to be replaced with one which reflects the reality of a diverse, decentralised country. Agreeing on a new constitution would also help shift the focus of political debate and get around the election debacle.
If you’re going to do it, do it properly
As for resources, it is worth remembering that in 2006, before the American surge, prospects in Iraq looked far bleaker than they do now in Afghanistan, even though the allies had many more foreign and local troops. General McChrystal is believed to have offered a range of proposals to increase the number of American forces—at present about 62,000 out of a total of some 100,000 foreign troops—by between 10,000 and 60,000 troops. Mr Obama may be tempted to compromise—to show military resolve by acceding to the commander’s request, yet appease anti-war opinion by picking the lowest number.
This would be a mistake. General McChrystal says that the core of his strategy is its first stage: to regain the initiative. To do that, a substantial surge is needed. Gordon Brown’s announcement of an extra 500 is a welcome gesture, but will make little difference. Mr Obama should send at least 40,000 more.
Most of all, Mr Obama needs to fight this war with conviction. His wobbles over the last month have done more to comfort his enemies and worry his allies than any recent losses on the ground. Only if he persuades his troops, his countrymen and the Taliban that America is there for the long haul does he have a chance of turning this war around.
Comment
This is an opinion piece from The Economist magazine, which I happen to subscribe to, and value their opinions. As I have said before I have moved my Green topics to GreenGuy1700@blogspot, and will put articles I find interesting here dealing with health, politics, etc. Feel free to comment as you wish. I am not putting any more labels because Google will only allow 2000 labels per blog, and I have hit that limit.
Oct 15th 2009
From The Economist print edition
Why the Afghanistan war deserves more resources, commitment and political will.
AP EIGHT years after the deceptively swift toppling of the Taliban, the prospects for the NATO-led mission in Afghanistan seem worse than ever. Every Western casualty, every reinforcement and every pious political homily on the “justness” and “necessity” of the war seem only to leave the mission floundering deeper and more hopelessly. Already battered by mounting casualties, Western support for the war has been further dented by an Afghan presidential election in August, wildly rigged in favour of the incumbent, Hamid Karzai. Against this gloomy backdrop, Barack Obama is faced with a request from the American and NATO commander in Afghanistan, General Stanley McChrystal, for large numbers of new troops (see article). The decision may define his presidency. Despite the difficulty—indeed, because of the difficulty—he should give the general what he needs.
The alternative is not, as some opponents of an Afghan “surge” suggest, less intensive, more surgical “counter-terrorism”, relying on unmanned air raids and assassination. Mr Obama seems, rightly, to have ruled that out. General McChrystal, a special-forces veteran, is emphatic it would not work. On its own, it is more likely to kill civilians and create new enemies than to decapitate and disable al-Qaeda. A counter-terrorist strategy is a euphemism for withdrawal—which is what plenty of Westerners think should happen.
Surge or surgical?
If the West is wearying of its Afghan adventure, it is hardly surprising. The country’s unruly tribes and mountainous landscape make the place hard to pacify. Voters thousands of miles away struggle to remember why their soldiers are dying there. Reminders that they are depriving al-Qaeda of the base from which it plots the West’s destruction stretch credulity when the terrorists do just that from Pakistan’s tribal areas.
Yet the arguments for staying remain strong. First, the West has a security interest in preventing the region from slipping into a maelstrom of conflict. Pakistan, with 170m people and nuclear weapons, is vulnerable to the Taliban’s potent mixture of ethnic-Pushtun nationalism and extremist Islam (see article). Anarchy in Afghanistan, or a Taliban restoration, would leave it prey to permanent cross-border instability. Second, defeat for the West in Afghanistan would embolden its opponents not just in Pakistan, but all around the world, leaving it open to more attacks. And, third, withdrawal would amount to a terrible betrayal of the Afghan people, some of whose troubles are the result of Western intervention.
Millions of refugees have returned and millions of children have the chance to go to school. But the West has failed to protect civilian lives, to bring the development it promised, to wean the economy off its poppy-addiction and to ensure fair elections—and failed even to agree about what it is trying to do in the country. The Western-dominated United Nations mission has fractured in a public row between its two senior officials. Locally, NATO forces have done fine and heroic work. But too often the best initiatives are dropped when the best commanders end their tours. The Afghan conflict, it is often said, has been not an eight-year war, but eight one-year wars. NATO comes off worse each time. And so to the fourth and most important reason for persisting in Afghanistan: the coalition can do much better.
General McChrystal is an impressive soldier with a coherent plan. The West’s forces have got to know their enemies: not just the Taliban but also other terrorist networks and countless local warlords and thugs. The coalition’s leaders, at least, seem to have grasped that it must behave not as an occupying army but as a partner, whose aim is to build up the local forces that will ultimately ensure Afghanistan’s security. And soldiers and civilians are beginning to understand that development aid can benefit local people rather than foreign consultants and contractors.
The coalition, however, lacks three essential components of a successful strategy. It needs a credible, legitimate government to work with, the resources to do the job and the belief that America’s president is behind this war.
Many Afghans find it bizarre that the West should devote so much money to Mr Karzai, yet be unable to hold him to account over something so basic as stuffing ballot boxes on an industrial scale. For most, however, the local and provincial leaders matter more than the distant central government.
That is where the constitution drawn up after the overthrow of the Taliban went wrong. It envisages a centralised state. Provincial governors, for example, are appointed by the president. This flawed framework needs to be replaced with one which reflects the reality of a diverse, decentralised country. Agreeing on a new constitution would also help shift the focus of political debate and get around the election debacle.
If you’re going to do it, do it properly
As for resources, it is worth remembering that in 2006, before the American surge, prospects in Iraq looked far bleaker than they do now in Afghanistan, even though the allies had many more foreign and local troops. General McChrystal is believed to have offered a range of proposals to increase the number of American forces—at present about 62,000 out of a total of some 100,000 foreign troops—by between 10,000 and 60,000 troops. Mr Obama may be tempted to compromise—to show military resolve by acceding to the commander’s request, yet appease anti-war opinion by picking the lowest number.
This would be a mistake. General McChrystal says that the core of his strategy is its first stage: to regain the initiative. To do that, a substantial surge is needed. Gordon Brown’s announcement of an extra 500 is a welcome gesture, but will make little difference. Mr Obama should send at least 40,000 more.
Most of all, Mr Obama needs to fight this war with conviction. His wobbles over the last month have done more to comfort his enemies and worry his allies than any recent losses on the ground. Only if he persuades his troops, his countrymen and the Taliban that America is there for the long haul does he have a chance of turning this war around.
Comment
This is an opinion piece from The Economist magazine, which I happen to subscribe to, and value their opinions. As I have said before I have moved my Green topics to GreenGuy1700@blogspot, and will put articles I find interesting here dealing with health, politics, etc. Feel free to comment as you wish. I am not putting any more labels because Google will only allow 2000 labels per blog, and I have hit that limit.
Bank bonuses
Compensation claim
Oct 22nd 2009
From The Economist print edition
Banks are booming on the back of public support. That subsidy should be clawed back
WATCHING an industry committing political suicide is ugly. That is what investment banks are doing by paying bumper bonuses a year after they were saved by state intervention. Goldman Sachs is set to award staff a near record $20 billion this year. Firms making losses for shareholders, such as Citigroup and Bank of America, are still paying hefty bonuses.
Such rewards, in the face of public protest, feed the impression that banks are victims of what some call “employee capture”. The top ten investment banks at the start of 2008 made an average return on equity of just 8% between 1999 and 2008. Four made cumulative losses. Staff got four times as much as shareholders did in profits. In 2008 Merrill Lynch paid cash to staff equivalent to over 100% of the capital left by the year-end.
Normally, for a liberal newspaper, that would be a problem for shareholders alone. But Merrill and many others got bailed out. The new bonuses make a mockery of banks’ claim that higher equity buffers are too expensive to contemplate. Some governments still own stakes in banks, so decisions on pay are directly theirs. Worst of all, bonuses are being paid in part from subsidies: this is not a free market, but a perversion of it.
Some banks deny this, so it is worth revisiting how much policy has been skewed in their favour. It is not just that they were saved from destruction. They got public capital (much of it now repaid), short-selling bans on their shares and rescues of counterparties, such as American International Group, which the public otherwise had no interest in saving. Today they enjoy laxer accounting, loose collateral rules at central banks, explicit debt guarantees and asset-purchasing schemes. And, critically, they can borrow cheaply because they are deemed too big to fail. All of them—from comparatively healthy Goldman to the nationalised weaklings—are being subsidised by the rest of us. As a way to keep cash flowing to the wider economy and help banks rebuild their capital, this subsidy made sense; nobody intended it to go to employees.
In the longer term the bonus mess underlines the importance of getting the state out of finance: setting a time limit for the explicit guarantees and finding ways to lessen the implicit promise of support through living wills and the like. In the shorter term the political provocation of the bonus payouts is likely to increase demand for a windfall tax on bonuses or salary caps. Both look mistaken. Retrospective taxes are usually bad news. They distort incentives, and scare investors in other industries who fear they may be next. A wholesale cap on pay would lead regulators further into the swamp of micromanagement. And symbolic caps on a few top executives, as the White House is threatening, are too feeble a response.
A better alternative would be to claw back the subsidy banks get through being too big to fail. Taxing bonuses is a poor proxy for this. It may be possible to capture it more accurately. Assume that America’s top five investment banks would pay two percentage points more on unsecured borrowings without an implicit guarantee. On that basis the subsidy is $36 billion a year (compared with pay this year of perhaps $120 billion). Providing banks have built up adequate capital, they could face a funding “premium” in much the same way that they already pay premiums for deposit insurance. This would have to be paid before bonuses. Regulators should cap bonuses only to the extent they cause losses which erode capital, but assuming shareholders, including governments, show some spine, pay would be squeezed at profitable banks. If some traders left weaker banks to join unguaranteed hedge funds, so much the better for the taxpayer.
That still leaves some tricky questions. Some banks might be unable to afford the annual subsidy premium. They could be permitted to defer its payment, but if it were for more than a couple of years it would be a good indication they should be wound down. There would be hellish choices about which banks are perceived to be too big to fail, and whether lower-risk retail banks should be charged less. Still, these are dilemmas capital regulators are already grappling with. A funding premium could piggyback off their work.
The premium would last at least until the state guarantees are withdrawn. The longer-term debate may yet move from wishy-washy living wills to breaking up banks (as the governor of the Bank of England suggested on October 20th—see article). Ideally investment banks would have no public guarantee, their profits would reflect private endeavour alone, and their pay would be decided by their owners. But the opposite exists today—which is why any right-thinking capitalist should want to see that subsidy clawed back.
Comment
The banks are using the money we loaned them to save their businesses, to give themselves bonuses. The shareholders lose their butts while the executives further pad their nest with impugnity. They should not only pay us back, but pay us back with interest. paying the premium before taxes would leave less for bonuses and give us some return on our money.
Oct 22nd 2009
From The Economist print edition
Banks are booming on the back of public support. That subsidy should be clawed back
WATCHING an industry committing political suicide is ugly. That is what investment banks are doing by paying bumper bonuses a year after they were saved by state intervention. Goldman Sachs is set to award staff a near record $20 billion this year. Firms making losses for shareholders, such as Citigroup and Bank of America, are still paying hefty bonuses.
Such rewards, in the face of public protest, feed the impression that banks are victims of what some call “employee capture”. The top ten investment banks at the start of 2008 made an average return on equity of just 8% between 1999 and 2008. Four made cumulative losses. Staff got four times as much as shareholders did in profits. In 2008 Merrill Lynch paid cash to staff equivalent to over 100% of the capital left by the year-end.
Normally, for a liberal newspaper, that would be a problem for shareholders alone. But Merrill and many others got bailed out. The new bonuses make a mockery of banks’ claim that higher equity buffers are too expensive to contemplate. Some governments still own stakes in banks, so decisions on pay are directly theirs. Worst of all, bonuses are being paid in part from subsidies: this is not a free market, but a perversion of it.
Some banks deny this, so it is worth revisiting how much policy has been skewed in their favour. It is not just that they were saved from destruction. They got public capital (much of it now repaid), short-selling bans on their shares and rescues of counterparties, such as American International Group, which the public otherwise had no interest in saving. Today they enjoy laxer accounting, loose collateral rules at central banks, explicit debt guarantees and asset-purchasing schemes. And, critically, they can borrow cheaply because they are deemed too big to fail. All of them—from comparatively healthy Goldman to the nationalised weaklings—are being subsidised by the rest of us. As a way to keep cash flowing to the wider economy and help banks rebuild their capital, this subsidy made sense; nobody intended it to go to employees.
In the longer term the bonus mess underlines the importance of getting the state out of finance: setting a time limit for the explicit guarantees and finding ways to lessen the implicit promise of support through living wills and the like. In the shorter term the political provocation of the bonus payouts is likely to increase demand for a windfall tax on bonuses or salary caps. Both look mistaken. Retrospective taxes are usually bad news. They distort incentives, and scare investors in other industries who fear they may be next. A wholesale cap on pay would lead regulators further into the swamp of micromanagement. And symbolic caps on a few top executives, as the White House is threatening, are too feeble a response.
A better alternative would be to claw back the subsidy banks get through being too big to fail. Taxing bonuses is a poor proxy for this. It may be possible to capture it more accurately. Assume that America’s top five investment banks would pay two percentage points more on unsecured borrowings without an implicit guarantee. On that basis the subsidy is $36 billion a year (compared with pay this year of perhaps $120 billion). Providing banks have built up adequate capital, they could face a funding “premium” in much the same way that they already pay premiums for deposit insurance. This would have to be paid before bonuses. Regulators should cap bonuses only to the extent they cause losses which erode capital, but assuming shareholders, including governments, show some spine, pay would be squeezed at profitable banks. If some traders left weaker banks to join unguaranteed hedge funds, so much the better for the taxpayer.
That still leaves some tricky questions. Some banks might be unable to afford the annual subsidy premium. They could be permitted to defer its payment, but if it were for more than a couple of years it would be a good indication they should be wound down. There would be hellish choices about which banks are perceived to be too big to fail, and whether lower-risk retail banks should be charged less. Still, these are dilemmas capital regulators are already grappling with. A funding premium could piggyback off their work.
The premium would last at least until the state guarantees are withdrawn. The longer-term debate may yet move from wishy-washy living wills to breaking up banks (as the governor of the Bank of England suggested on October 20th—see article). Ideally investment banks would have no public guarantee, their profits would reflect private endeavour alone, and their pay would be decided by their owners. But the opposite exists today—which is why any right-thinking capitalist should want to see that subsidy clawed back.
Comment
The banks are using the money we loaned them to save their businesses, to give themselves bonuses. The shareholders lose their butts while the executives further pad their nest with impugnity. They should not only pay us back, but pay us back with interest. paying the premium before taxes would leave less for bonuses and give us some return on our money.
Monday, October 26, 2009
Time Magazine -How Drug-Industry Lobbyists Won on Health-Care
How Drug-Industry Lobbyists Won on Health-Care
By Karen Tumulty and Michael Scherer Thursday, Oct. 22, 2009
Jim Greenwood, President and CEO of the Biotechnology Industry Organization.
Richard A. Bloom
In Congress, committee chairmen are known as the old bulls for a reason: it's unwise to provoke them. So it isn't often that you see one get rolled by his own committee — especially when the chairman in question is the formidable and canny Henry Waxman and the issue in question is one that matters a lot to him. But that was what happened on July 31 as the House Energy and Commerce Committee was putting the final touches on health-reform legislation. Waxman's fellow California Democrat Anna Eshoo offered a last-minute amendment that Waxman opposed. Knowing he would lose, Waxman decided to save face with a quick voice vote. But Eshoo insisted on a roll call, which would put every member on record. Waxman snapped at her, "You promised you wouldn't do that!" The final tally was 47-11 against the chairman.
(Read "Understanding the Health-Care Debate: Your Indispensable Guide.")
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Waxman's loss that day was a big victory for drug companies, which have spent more than any other segment of the medical industry to make sure that they come out winners in the effort to overhaul the nation's health-care system. It's understandable the drugmakers would want a roll-call accounting of who their friends and enemies are, considering the size of the investment they are making on Capitol Hill: in the first six months of this year alone, drug and biotech companies and their trade associations spent more than $110 million — that's about $609,000 a day — to influence lawmakers, according to figures compiled by the nonpartisan watchdog group Center for Responsive Politics. The drug industry's legion of registered lobbyists numbers 1,228, or 2.3 for every member of Congress. And its campaign contributions to current members of Waxman's committee have totaled $2.6 million over the past three years.
(See 10 players in health-care reform.)
The return on that investment has been considerable, both in the House and in the Senate. "We've done very well," says lobbyist Jim Greenwood, a former Republican Congressman from Pennsylvania who was a member of the Energy and Commerce Committee and now heads the Biotechnology Industry Organization (BIO). "We carried a majority of the Democrats and a majority of the Republicans in each of the committees, and by very clear margins."
Whether the broader public is benefiting from the industry's success is less clear. How Greenwood's group has scored decisive early victories on an obscure but crucial health-care provision is a case study in how interest groups are shaping the contours of health-care reform — and why that's not necessarily good news for consumers.
The Generic Nudge
The question before Waxman's committee last summer was this: How many years of monopoly protection should be afforded to biotechnology drugs, known as biologics, before cheaper alternatives are allowed on the market? These miraculous drugs — which differ from traditional, chemical-based pharmaceuticals because they are derived from living matter — are widely regarded as the future of the pharmaceutical industry and, indeed, of medicine itself. While only 20% of drugs on the market today are biologics, it is expected that, with 633 biotechnology medicines in development last year for more than 100 diseases, half the new drugs approved in 2015 will be. Biologics average more than 20 times the cost of traditional drugs: treating breast cancer with a year's worth of the biologic Herceptin can cost $48,000; Remicade, for rheumatoid arthritis, can cost $20,000 annually. For other, rarer diseases, the price of biologic treatments can be as high as $200,000 a year.
As policymakers look for ways to control health-care costs, the price of biologics is drawing more and more scrutiny. The obvious model for bringing in competition is a 1984 law that Waxman wrote with Republican Senator Orrin Hatch. It lowered the regulatory obstacles that prevented generic drugs from making their way to market. At the time, it was expected that fast-tracking the approval of "bioequivalent" drugs would bring down medical costs by $1 billion a year. But with generics now accounting for more than 70% of prescriptions dispensed in the U.S., "the actual savings have exceeded our wildest expectations," Waxman said in a Sept. 18 speech before the Generic Pharmaceutical Association. "In the last decade alone, generic drugs have saved consumers, businesses and state and federal governments $734 billion."
Can a similar approach work with biotechnology drugs, which were not dealt with in the 1984 law because the industry was then in its infancy? A 2008 analysis by former Clinton Administration official Robert Shapiro, who has consulted for both biologics companies and their would-be generic competitors, suggested that generic versions of the top 12 categories of biologics whose patents have expired or will expire soon could save Americans up to $108 billion in the first 10 years and as much as $378 billion over two decades. "It's the low-hanging fruit," says Mark Merritt, head of the Pharmaceutical Care Management Association, the trade organization for prescription-drug-benefit managers. "If you can't get this right on cost control, what can you get right?"
But there's a dilemma: policymakers want to foster cost-saving competition without killing the financial incentives that have put the U.S. biotechnology industry at the vanguard of medical science and without stifling the development of even more drugs that could save lives and eliminate suffering. Finding that equilibrium goes to the question of how long biotech firms should be guaranteed exclusivity, outside the protection of their patents, before copycats can begin using the data they have developed.
Waxman had pushed to shield biologics for no more than five years — the same amount of time that traditional pharmaceuticals get under the Hatch-Waxman law. President Obama proposed seven years as a compromise.
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Eshoo's successful amendment to the Energy and Commerce Committee bill would extend that to 12 years of exclusivity, as would legislation passed a few weeks earlier by the Senate Health, Education, Labor and Pensions (HELP) Committee. Then-chairman Ted Kennedy, whose state of Massachusetts is home to many biotech firms, had long supported a 12-year exclusivity period. The industry showed its gratitude last year when Amgen, one of the biggest biotech firms, donated $5 million — twice the size of the next largest donation — to a nonprofit educational institute being built in Kennedy's honor.
(Watch TIME's video "Uninsured Again.")
The Federal Trade Commission (FTC), though, argued in June that giving biologics makers any period of exclusivity at all could actually stifle innovation. Biologics are so much more complex and expensive to produce than traditional drugs that the barriers to would-be "biosimilar" competitors are already high, the FTC said. Giving biologics further protection — particularly the 12 years of exclusivity that the industry wants — would merely encourage firms to tinker with what they have rather than drive them toward "new inventions to address unmet medical needs."
Most small biologics companies are still years away from seeing their first profits in this high-risk, high-return business. Their trade association, BIO, says that in the past 11 months, at least 40 of them have cut back or eliminated drug-development programs. The venture capitalists who invest in them "aren't looking to cure Parkinson's disease as much as they are looking for a return on their investments," says Greenwood. "They're just as happy to put their money into the next iPod." But increasingly, the big players in the pharmaceutical industry are moving into the biologics business themselves, either by investing in cutting-edge firms or by acquiring them.
(See the most common hospital mishaps.)
Shifting Politics
That makes the politics — and the lines of political influence — a lot more difficult to sort out. Whereas the traditional pharmaceutical industry is concentrated in just a couple of states, biotech firms have sprung up just about anywhere you find a university with a research hospital, which gives them a broad political base. "I know that vote hurt me at home," says Ohio Senator Sherrod Brown, who led the unsuccessful fight against the 12-year exclusivity in the Senate HELP Committee.
Indeed, the biologics lobby has become one of K Street's most powerful players. Working largely through BIO and the Pharmaceutical Research and Manufacturers of America (PhRMA), it has funded an extensive network that includes not only lobbyists but also think-tank experts and advocacy groups. "You can't get on the phone with someone who isn't getting paid," says an economist who has studied the biologics issue with funding from a drug company. "They give money to everyone and anyone."
That means it can be hard to find a truly independent viewpoint, though it often requires deep digging into the finances of advocacy groups to discover their ties. In July, one calling itself the National Health Council wrote letters to members of Congress "on behalf of 133 million Americans" asking for a minimum of 10 years of data exclusivity. The group boasts a membership that includes 50 of the nation's largest patient-advocacy groups, including the American Cancer Society, Easter Seals and the National Kidney Foundation. But its board of directors reads like a Who's Who of top pharmaceutical executives from Amgen, Pfizer, Novartis and Bristol Myers Squibb. Its 2007 tax filings show that almost half its $2.3 million budget came from PhRMA and drug companies.
Similarly, on Oct. 19, PhRMA put out a statement calling for a "fair period of data protection" of 12 years at a "bare minimum." To defend its position, the group cited Duke University economist Henry Grabowski, whose work it has funded, and two patient groups. One, called RetireSafe, receives regular infusions of "general operating support" from Pfizer and operates out of a small Washington law-firm office. It has been blitzing Capitol Hill with letters arguing that guaranteeing biologics makers fewer than 12 years of exclusivity in the use of their data could cost lives. The other group, the Alliance of Aging Research, is also run by the drug industry. Its chairman is the managing partner of Foxkiser, a drug-company consultant, and its vice chairman is with Novartis.
Among the biologics industry's most high-profile advocates has been former Democratic National Committee chairman Howard Dean, who is consulting for a law firm that has a deep roster of biologics clients. In July he wrote an Op-Ed in the Hill newspaper arguing for a "commonsense and fair approach" to give biologics companies at least 12 years of exclusivity. ("I wouldn't do this if I didn't believe it," Dean, a physician, said in an interview.) His former campaign manager Joe Trippi echoed Dean's views on a Huffington Post blog without disclosing that he had been paid by BIO to create two Web campaigns. (He also says his views predated his paycheck.)
The other side has resources of its own. The biggest generic-drug company, Teva Pharmaceuticals, has spent more than $2 million on lobbying and also sponsored academic work on the issue, aiming to disprove Duke's Grabowski. Generic-drug manufacturers are allied with such powerful organizations as AARP, labor unions, insurance companies, health-maintenance organizations and health-reform advocacy groups. There will be fights on the House and Senate floors and ultimately a House-Senate conference committee, on which Waxman will be a key voice. "The war is not over," he has warned. "If you know me at all, you know that I don't give up that easily."
How it is resolved — in favor of protecting the biotech industry or opening up the market to generics — may say a lot about which interest groups will ultimately reap the windfall of the big-stakes battle in Washington. What it means for consumers is somewhat murkier: Will a miracle cure be there when you need one? And if it is, will you be able to afford it? Those are questions that hinge on whether the rest of us can trust Congress to find proper balance between competition and innovation.
By Karen Tumulty and Michael Scherer Thursday, Oct. 22, 2009
Jim Greenwood, President and CEO of the Biotechnology Industry Organization.
Richard A. Bloom
In Congress, committee chairmen are known as the old bulls for a reason: it's unwise to provoke them. So it isn't often that you see one get rolled by his own committee — especially when the chairman in question is the formidable and canny Henry Waxman and the issue in question is one that matters a lot to him. But that was what happened on July 31 as the House Energy and Commerce Committee was putting the final touches on health-reform legislation. Waxman's fellow California Democrat Anna Eshoo offered a last-minute amendment that Waxman opposed. Knowing he would lose, Waxman decided to save face with a quick voice vote. But Eshoo insisted on a roll call, which would put every member on record. Waxman snapped at her, "You promised you wouldn't do that!" The final tally was 47-11 against the chairman.
(Read "Understanding the Health-Care Debate: Your Indispensable Guide.")
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Q&A: How Much Is A Year of Life Worth?
Big Pharma Faces a Crackdown in Europe
A New War on Drugs: Stopping The Counterfeit Medicine Trade
Waxman's loss that day was a big victory for drug companies, which have spent more than any other segment of the medical industry to make sure that they come out winners in the effort to overhaul the nation's health-care system. It's understandable the drugmakers would want a roll-call accounting of who their friends and enemies are, considering the size of the investment they are making on Capitol Hill: in the first six months of this year alone, drug and biotech companies and their trade associations spent more than $110 million — that's about $609,000 a day — to influence lawmakers, according to figures compiled by the nonpartisan watchdog group Center for Responsive Politics. The drug industry's legion of registered lobbyists numbers 1,228, or 2.3 for every member of Congress. And its campaign contributions to current members of Waxman's committee have totaled $2.6 million over the past three years.
(See 10 players in health-care reform.)
The return on that investment has been considerable, both in the House and in the Senate. "We've done very well," says lobbyist Jim Greenwood, a former Republican Congressman from Pennsylvania who was a member of the Energy and Commerce Committee and now heads the Biotechnology Industry Organization (BIO). "We carried a majority of the Democrats and a majority of the Republicans in each of the committees, and by very clear margins."
Whether the broader public is benefiting from the industry's success is less clear. How Greenwood's group has scored decisive early victories on an obscure but crucial health-care provision is a case study in how interest groups are shaping the contours of health-care reform — and why that's not necessarily good news for consumers.
The Generic Nudge
The question before Waxman's committee last summer was this: How many years of monopoly protection should be afforded to biotechnology drugs, known as biologics, before cheaper alternatives are allowed on the market? These miraculous drugs — which differ from traditional, chemical-based pharmaceuticals because they are derived from living matter — are widely regarded as the future of the pharmaceutical industry and, indeed, of medicine itself. While only 20% of drugs on the market today are biologics, it is expected that, with 633 biotechnology medicines in development last year for more than 100 diseases, half the new drugs approved in 2015 will be. Biologics average more than 20 times the cost of traditional drugs: treating breast cancer with a year's worth of the biologic Herceptin can cost $48,000; Remicade, for rheumatoid arthritis, can cost $20,000 annually. For other, rarer diseases, the price of biologic treatments can be as high as $200,000 a year.
As policymakers look for ways to control health-care costs, the price of biologics is drawing more and more scrutiny. The obvious model for bringing in competition is a 1984 law that Waxman wrote with Republican Senator Orrin Hatch. It lowered the regulatory obstacles that prevented generic drugs from making their way to market. At the time, it was expected that fast-tracking the approval of "bioequivalent" drugs would bring down medical costs by $1 billion a year. But with generics now accounting for more than 70% of prescriptions dispensed in the U.S., "the actual savings have exceeded our wildest expectations," Waxman said in a Sept. 18 speech before the Generic Pharmaceutical Association. "In the last decade alone, generic drugs have saved consumers, businesses and state and federal governments $734 billion."
Can a similar approach work with biotechnology drugs, which were not dealt with in the 1984 law because the industry was then in its infancy? A 2008 analysis by former Clinton Administration official Robert Shapiro, who has consulted for both biologics companies and their would-be generic competitors, suggested that generic versions of the top 12 categories of biologics whose patents have expired or will expire soon could save Americans up to $108 billion in the first 10 years and as much as $378 billion over two decades. "It's the low-hanging fruit," says Mark Merritt, head of the Pharmaceutical Care Management Association, the trade organization for prescription-drug-benefit managers. "If you can't get this right on cost control, what can you get right?"
But there's a dilemma: policymakers want to foster cost-saving competition without killing the financial incentives that have put the U.S. biotechnology industry at the vanguard of medical science and without stifling the development of even more drugs that could save lives and eliminate suffering. Finding that equilibrium goes to the question of how long biotech firms should be guaranteed exclusivity, outside the protection of their patents, before copycats can begin using the data they have developed.
Waxman had pushed to shield biologics for no more than five years — the same amount of time that traditional pharmaceuticals get under the Hatch-Waxman law. President Obama proposed seven years as a compromise.
Top 10 Health-Care-Reform Fight Ads
Specials
The 10 Key Players in Health-Care Reform
Stories
Understanding the Health-Care Debate: Your Indispensable Guide
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Time to Vote
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Eshoo's successful amendment to the Energy and Commerce Committee bill would extend that to 12 years of exclusivity, as would legislation passed a few weeks earlier by the Senate Health, Education, Labor and Pensions (HELP) Committee. Then-chairman Ted Kennedy, whose state of Massachusetts is home to many biotech firms, had long supported a 12-year exclusivity period. The industry showed its gratitude last year when Amgen, one of the biggest biotech firms, donated $5 million — twice the size of the next largest donation — to a nonprofit educational institute being built in Kennedy's honor.
(Watch TIME's video "Uninsured Again.")
The Federal Trade Commission (FTC), though, argued in June that giving biologics makers any period of exclusivity at all could actually stifle innovation. Biologics are so much more complex and expensive to produce than traditional drugs that the barriers to would-be "biosimilar" competitors are already high, the FTC said. Giving biologics further protection — particularly the 12 years of exclusivity that the industry wants — would merely encourage firms to tinker with what they have rather than drive them toward "new inventions to address unmet medical needs."
Most small biologics companies are still years away from seeing their first profits in this high-risk, high-return business. Their trade association, BIO, says that in the past 11 months, at least 40 of them have cut back or eliminated drug-development programs. The venture capitalists who invest in them "aren't looking to cure Parkinson's disease as much as they are looking for a return on their investments," says Greenwood. "They're just as happy to put their money into the next iPod." But increasingly, the big players in the pharmaceutical industry are moving into the biologics business themselves, either by investing in cutting-edge firms or by acquiring them.
(See the most common hospital mishaps.)
Shifting Politics
That makes the politics — and the lines of political influence — a lot more difficult to sort out. Whereas the traditional pharmaceutical industry is concentrated in just a couple of states, biotech firms have sprung up just about anywhere you find a university with a research hospital, which gives them a broad political base. "I know that vote hurt me at home," says Ohio Senator Sherrod Brown, who led the unsuccessful fight against the 12-year exclusivity in the Senate HELP Committee.
Indeed, the biologics lobby has become one of K Street's most powerful players. Working largely through BIO and the Pharmaceutical Research and Manufacturers of America (PhRMA), it has funded an extensive network that includes not only lobbyists but also think-tank experts and advocacy groups. "You can't get on the phone with someone who isn't getting paid," says an economist who has studied the biologics issue with funding from a drug company. "They give money to everyone and anyone."
That means it can be hard to find a truly independent viewpoint, though it often requires deep digging into the finances of advocacy groups to discover their ties. In July, one calling itself the National Health Council wrote letters to members of Congress "on behalf of 133 million Americans" asking for a minimum of 10 years of data exclusivity. The group boasts a membership that includes 50 of the nation's largest patient-advocacy groups, including the American Cancer Society, Easter Seals and the National Kidney Foundation. But its board of directors reads like a Who's Who of top pharmaceutical executives from Amgen, Pfizer, Novartis and Bristol Myers Squibb. Its 2007 tax filings show that almost half its $2.3 million budget came from PhRMA and drug companies.
Similarly, on Oct. 19, PhRMA put out a statement calling for a "fair period of data protection" of 12 years at a "bare minimum." To defend its position, the group cited Duke University economist Henry Grabowski, whose work it has funded, and two patient groups. One, called RetireSafe, receives regular infusions of "general operating support" from Pfizer and operates out of a small Washington law-firm office. It has been blitzing Capitol Hill with letters arguing that guaranteeing biologics makers fewer than 12 years of exclusivity in the use of their data could cost lives. The other group, the Alliance of Aging Research, is also run by the drug industry. Its chairman is the managing partner of Foxkiser, a drug-company consultant, and its vice chairman is with Novartis.
Among the biologics industry's most high-profile advocates has been former Democratic National Committee chairman Howard Dean, who is consulting for a law firm that has a deep roster of biologics clients. In July he wrote an Op-Ed in the Hill newspaper arguing for a "commonsense and fair approach" to give biologics companies at least 12 years of exclusivity. ("I wouldn't do this if I didn't believe it," Dean, a physician, said in an interview.) His former campaign manager Joe Trippi echoed Dean's views on a Huffington Post blog without disclosing that he had been paid by BIO to create two Web campaigns. (He also says his views predated his paycheck.)
The other side has resources of its own. The biggest generic-drug company, Teva Pharmaceuticals, has spent more than $2 million on lobbying and also sponsored academic work on the issue, aiming to disprove Duke's Grabowski. Generic-drug manufacturers are allied with such powerful organizations as AARP, labor unions, insurance companies, health-maintenance organizations and health-reform advocacy groups. There will be fights on the House and Senate floors and ultimately a House-Senate conference committee, on which Waxman will be a key voice. "The war is not over," he has warned. "If you know me at all, you know that I don't give up that easily."
How it is resolved — in favor of protecting the biotech industry or opening up the market to generics — may say a lot about which interest groups will ultimately reap the windfall of the big-stakes battle in Washington. What it means for consumers is somewhat murkier: Will a miracle cure be there when you need one? And if it is, will you be able to afford it? Those are questions that hinge on whether the rest of us can trust Congress to find proper balance between competition and innovation.
Sunday, October 25, 2009
Forty Years' War
A Place Where Cancer Is the Norm
Scott Dalton for The New York Times
Virginia Montes heading for treatment at M. D. Anderson Cancer Center, where 90,000 patients will be seen this year. More Photos >
GINA KOLATA
Published: October 24, 2009
HOUSTON — M. D. Anderson Cancer Center has a mission statement, and everyone who works there, from the president to the cleaning crews, can state it like a catechism: to “eliminate cancer in Texas, the nation and the world.”
The Front Line
Articles in this series examine the struggle to defeat cancer.
Scott Dalton for The New York Times
“It feels sometimes like the entire world has cancer,” said Cindy Davis, a nurse in Anderson's breast cancer clinic who has breast cancer herself. More Photos »
For the nearly 90,000 patients who will go to the center in Houston this year, that mission cannot be fulfilled soon enough. They and their families arrive at the world’s largest freestanding cancer hospital from around the world, often leaving behind jobs and stashing children with relatives for months. Some rent apartments or stay in mobile home parks near the hospital.
They enter through a soaring lobby, with cheery aquariums and exuberant volunteer greeters eager to help in any way. They come looking for hope.
But there is no mistaking what this place is: the front line of the frustrating war on a still largely incurable disease.
Doctors are encouraged to try everything, and when insurers balk, they pick up the phone, repeatedly, hoping to persuade them to pay for what may be unconventional treatments.
The federal government gives more cancer research money to this hospital than to any other, and the hospital has an abundance of specialists in many forms of cancer, including rare ones. Medicare offers more generous reimbursement, and the hospital offers treatments that often go far beyond what can be offered at most other places.
“I tell young physicians who are starting out here that the big limitation is imagination,” said Dr. Martin Raber, an oncologist — and a cancer patient himself — at Anderson. “If you are good at what you do and you have great ideas, we will help you find the resources you need to make them happen.”
But like a modern version of the tuberculosis sanatorium in Thomas Mann’s “Magic Mountain,” Anderson is a world where the best that medicine has to offer is often far from enough. The odds are still grim, and while there are exhilarating recoveries, the exhausting, dispiriting road traveled by many patients comes into sharp relief.
They are patients like 35-year-old Mindy Lanoux of San Antonio, who has melanoma that has spread to her liver and lungs, her odds of surviving in the single digits. She has been to the hospital 16 times in nine months, spending a week there each time for treatments so debilitating she wanted to give up. But she keeps returning, smearing peppermint oil under her nose when she walks in the medical center’s door to hide the odor.
“The smell gets to me,” Ms. Lanoux said. “It smells like cleaning products and the sickness and the medicines. It takes your brave edge off.”
Then she and her father go to her room and start putting her things away. “We don’t talk,” Ms. Lanoux said. “There is no polite conversation. It is like an army setting up to do battle.”
Planet Cancer
With more than 17,000 employees and warrens of color-coded hallways so vast that even employees get lost, M. D. Anderson is its own parallel universe, where nothing matters but cancer. Patients sit in the lobbies and compare notes.
“Everyone in the waiting room talks about ‘How did you find yours?’ ” said June Toland, 71, of Harlingen, Tex., who is being treated for sarcoma, a cancer of connective tissue.
Every patient at Anderson has cancer. Every family member sitting anxiously in the lounges or lingering at a bedside or sleeping in a Murphy bed in a patient’s room has had the life-changing experience of being touched by cancer.
“It feels sometimes like the entire world has cancer,” said Cindy Davis, a nurse in the breast cancer clinic who has breast cancer herself.
Anderson is a quiet place. No loud pagers. The walls are decorated with vivid photographs of serene scenes, like water views. The muted colors in the hallways, soft cranberry and dull green, are meant to be soothing. There is a special room, Kim’s Place, for young people only, cancer patients and their friends ages 15 to 30, giving them a place to gather. There is a library and a cybercafe. It is a place meant to give hope.
Sometimes, as happened with Frances Anderson of Shreveport, La., that hope is realized. She discovered three years ago that she had a brain tumor, but it did not start in her brain. In fact, it is not clear where it started. After being told by a doctor elsewhere that she had four to seven months to live, she ended up at Dr. Raber’s clinic, one of the few that specialize in treating patients with cancer throughout their bodies but with no obvious source for the tumors.
At 66, wearing pressed jeans, her short blond hair carefully styled, Ms. Anderson has vision problems from the surgery to remove the brain tumor, and she gets tired. She still has cancer, but she exercises every day and is living with her disease, returning to Anderson every six months for checkups and scans.
Others are not so fortunate. One morning last month, Joe Maxwell, 52, sat in a chair next to his hospital bed, a compression bandage around his now-useless swollen left arm, a large bandage over his left shoulder. He was going home to sit on his deck in Kerrville, Tex., a four-hour drive. He had tried everything Anderson had to offer and decided that, with an estimated two weeks left, he would go home to die.
Mr. Maxwell came to Anderson in January after his doctor told him a bump on his shoulder was a rare tumor, Merkel cell carcinoma, and added, “If you have a rare tumor, you need to go where tumors are not rare.”
At Anderson, doctors tried everything they could think of — surgery, round after round of chemotherapy, a clinical trial of an experimental drug. Nothing worked. Finally, the doctors suggested yet another drug.
(Page 2 of 5)
“We spent a lot of time praying about it and just discussing it,” Mr. Maxwell said. “I wanted to go home; I was tired. They gave me a short amount of time and said, ‘If you want to go home, now is the time.’ ”
But leaving late last month was bittersweet. The doctors and nurses “have become our friends and our family,” his wife, Kathleen Maxwell, said. Anderson, she added, “has been our life for nine months.”
He died 10 days later, early in the morning of Oct. 8.
Even those who finish their treatments and live cancer-free are forever changed by the experience.
Mrs. Toland learned that lesson from her son, George Toland. Twenty-four years ago, when he was 21, he was a sarcoma patient at Anderson. One day he looked at his mother and said, “My life will never be the same.”
His mother tried to reassure him, telling him that he would be fine, that he would go on to a perfectly normal life.
But he demurred, saying, “You know, Mother, it’s a loss of innocence.”
Mrs. Toland knew he was right.
She told him: “Most people lose their innocence in little doses as they go through life. You lost yours all at once.”
Battling the Odds
Donald Berry, a statistician who is head of the division of quantitative sciences at Anderson, says part of his role at the cancer center is to provide a reality check.
Yes, it is true, as doctors and nurses there repeatedly say, that treatment has improved. Anti-nausea drugs have all but eliminated the constant vomiting that once accompanied chemotherapy. New drugs are attacking genes that go awry in cancer. Most cancer patients come and go over a period of years, for checkups, scans, treatment if the cancer is still there. In between they go on with their lives.
But there is still little that can be done for most of those whose cancer has spread. And, Dr. Berry said, “that is a fact that doctors at M. D. Anderson can have a hard time facing, understandably so.”
Dr. Russell Harris, an associate professor of medicine at the University of North Carolina and a member of a board that evaluates cancer therapies for the National Institutes of Health, said the temptation at major cancer centers like Anderson was to try treatment after treatment.
“Everyone is totally immersed in the idea that death is the enemy,” Dr. Harris said. Such a no-holds-barred stance, he added, is spurring a growing debate in the cancer community.
“There is a lot of concern within the oncology community right now, and appropriately so, that people don’t completely understand what they are getting into,” Dr. Harris said.
An aggressive — and expensive — course of treatment can place a huge burden on patients. Ms. Lanoux knows that all too well. She came hoping for a cure for her advanced melanoma, but got her first dose of reality the day she walked into the main lobby.
She saw patients in wheelchairs, their heads sunken on their chests. She saw patients who had lost their hair, patients wearing sky-blue masks to protect them from infections. And there were the children. She had to avert her eyes. “I still can’t look at the kids,” Ms. Lanoux said.
“I think we were all trying to be very brave,” she said. “But it was like walking into a coffin.”
Ms. Lanoux, a small blond English teacher, lives in San Antonio with her husband, also a teacher, a 19-month-old daughter, an 8-year-old daughter and a 12-year-old son. The day she arrived at Anderson, Feb. 9, was the beginning of a difficult journey at the cancer center. She has been coming about every three weeks since, staying for a week at a time.
Her problems began in August 2008 on the way to a beach vacation. She started coughing. Her doctor was not concerned, telling her he thought she had acid reflux because she had had it when she was pregnant. He gave her Nexium. She returned in November at a friend’s urging, and her doctor prescribed cough drops and steroids. But she kept coughing.
Finally, in January, when she still could not catch her breath, her doctor ordered a chest X-ray to see if she had bronchitis. The next week, she returned to learn the result. Her husband wanted to go with her, but she told him not to bother, it was probably just bronchitis.
The doctor “came in and said, ‘This is the part I hate most about being a doctor,’ ” Ms. Lanoux recalled. There was a spot on her lung. A CT scan also revealed spots on her liver. And a biopsy of the spots on her liver revealed what it was. Melanoma. It had spread from an initial lesion — no one could ever find where it started — and was now threatening her life.
Ms. Lanoux’s doctor in San Antonio told her to go to Anderson. “She very honestly told me, ‘I don’t want to try treating you,’ ” Ms. Lanoux said.
“I think I was in denial until last month,” she said. “I had a 10 percent chance to survive five years, and I was going to do it.”
She has tried everything. Immunological therapy with side effects so severe it has to be administered in the intensive care unit. It did not work. Then she started biochemotherapy — a combination of three chemotherapy drugs and two immune system hormones to stimulate her body to attack her tumors. It is a controversial treatment, said her doctor, Patrick Hwu, but some patients had lasting remissions.
(Page 3 of 5)
Not Ms. Lanoux. At least not yet. On a recent sunny fall afternoon, she lay in her hospital bed on the 10th floor, wearing striped pajamas, blinking away tears as she told her story. She had just finished her sixth biochemotherapy treatment. Once again, she said, the therapy had made her feel “barely human.”
The effects hit her hard after the second treatment.
“I got home and ordered a wheelchair, a shower seat, a walker,” she said. “I am 35 years old and I have a wheelchair, a shower seat, a walker.” Just a few years ago she had run a marathon.
“My husband was helping me take a shower,” Ms. Lanoux said. “Of course it was awful. You’re cold, you can’t get enough water on you. I told him I don’t want to do this again. Call Dr. Hwu. I’m not going back.”
But she relented. Now Dr. Hwu wants her to try an experimental drug that takes the brakes off the immune system and might allow her body to destroy her cancer.
But the drug has not been approved by the Food and Drug Administration and is not available. Dr. Hwu knows it can have serious side effects and may not help Ms. Lanoux. But some who took the drug defied the odds, living for years. Maybe Ms. Lanoux could be one of those survivors, Dr. Hwu thinks.
And how about surgery, he asked her last month. “You can live with half a lung,” he said. But she probably would have to have her entire lung removed, he learned. And a surgeon would also have to take out the tumors on her liver. It may not be feasible, Dr. Hwu said, but, he added, “It’s definitely something I’m thinking about.”
Dr. Hwu struggles with the grim statistics — 8 percent of patients like Ms. Lanoux survive five years. The median survival rate is one year.
“It’s hard to see most patients die,” Dr. Hwu said. “You look at patients and see yourself and your family. We have to keep focusing on making these treatments better.”
On Wednesday, Ms. Lanoux was admitted for her eighth cycle of biochemotherapy. Dr. Hwu was worried.
“I don’t think her body will tolerate many more cycles,” he said. Already he has had to reduce the doses of some of the drugs and eliminate others.
In the meantime, he makes calls nearly every day, trying to get the experimental drug for Ms. Lanoux.
“We’re on the front lines,” he said. “We need armor.”
“I need this drug, and I need to be able to offer it to her.”
A View From Both Sides
As a breast cancer nurse, Cindy Davis thought she knew what her patients were going through. Until she went through it herself.
The first time she had a mammogram, it found cancer. She was 43. But after a lumpectomy, radiation and hormonal treatment with the drug tamoxifen, she was cancer free. The statistics were with her. She had every reason to think the cancer would not come back.
And that helped because she had taken a nursing job in the breast cancer clinic at Anderson, working with many patients pretty much like her — their cancer had been caught early, they would be fine.
Then, last April, nine years after the diagnosis, her cancer came back in a pelvic bone.
“You never think it is going to happen to you,” Mrs. Davis said. “I look at the risk factors, and I have none of them. It’s like, ‘Wait — I did everything right.’ ”
“I did the denial thing, 100 percent,” she said. “And I was angry. No, no, it can’t be that. And I was in shock — you’ve got to be kidding.”
As a nurse, she knew all too well there is no cure for breast cancer that has spread beyond the breast. Two-thirds with advanced disease are dead within five years.
“When you know what I know, it’s very scary,” Mrs. Davis said.
Her chemotherapy began a few days after she learned that her cancer had spread.
“I was scared; I was very scared,” Mrs. Davis said. “I know all the possible things that can go wrong.”
To her surprise, it was uneventful. Three weeks later, she and her husband went on a cruise. Just before it was over, her hair fell out.
I got out of the shower and started combing my hair and it was coming out,” she said. “I started crying. Everyone says, ‘It’s just hair. It will grow back.’ But as women, that’s a big thing to us.”
Articles in this series examine the struggle to defeat cancer.
Devastated, she got a wig and, feeling very self-conscious, went back to work. She has been working ever since, taking most of the week off after each chemotherapy treatment to recover from nausea and overwhelming fatigue. So far she has had 17 treatments, with more to come.
She is a nurse by day in the fifth-floor breast cancer clinic, and a patient in the evening, going to the eighth floor for chemotherapy. There she sees many of the women who were in the clinic earlier.
“It’s like a club,” Mrs. Davis said. The women talk about side effects — mouth sores and damage to the nerves of their feet — and the nausea and the anticipatory nausea.
“I have patients who say, ‘I just see a hospital gown and I feel nauseated,’ ” Mrs. Davis said. “I didn’t understand it before.”
She also asks patients for help, turning to those who learned they had advanced breast cancer two, three, four years ago.
“I say, ‘How do you do it?’ ” Mrs. Davis said. “They say they pray a lot and they just do it. They get through it one day at a time.”
Working at Anderson while being a patient there means cancer is always on her mind.
“You are around it all the time,” she said. “It’s just so hard to shut it off when you go home. Now I find myself thinking more and more about patients. I pray for them, and they hug me and say they are praying for me.”
She ran into a patient’s mother recently. The patient, a young woman, had advanced breast cancer and was terrified. Mrs. Davis told her she had advanced breast cancer, too, and she would help. “I am your nurse,” she told the young woman.
The mother came up to Mrs. Davis and said: “You have no idea how you have impacted this family. You gave my daughter hope that she could get through this.”
An Opponent That Won’t Quit
Dr. Raber used to think he understood when his patients told him that their appetite was good or that they were feeling more energetic.
But now, a cancer patient himself, he talks to patients in a very different way.
In the old days, if a patient said she had a good appetite, he would interpret that to mean her appetite was the same as his. Now he asks different questions.
“What did you have for lunch?”
“Crackers and soup.”
“What did you have for dinner?”
“Crackers and soup.”
“What did you have for breakfast?”
“I don’t eat breakfast.”
“Patients who say their appetite is fine often are saying it is better than it was,” Dr. Raber said. “They are not saying it is anything like the appetite of a healthy person.”
The same goes for energy level.
“When I came home from the hospital when I had been really, really sick, I was able to walk down the stairs once a day and up the stairs once a day. After I had been home for a couple of weeks, I could walk up and down maybe twice. If a doctor had asked how was my energy level, I would say, ‘Great, much better,’ ” Dr. Raber said. “The doctor would assume it was the same energy level as his.”
Dr. Raber’s journey as a cancer patient began in 1996, when he was 48 and physician-in-chief at Anderson. “I was at the top of my game,” he said.
A routine exam showed abnormalities in liver function tests. He thought it was nothing, waited six weeks, and had the test again.
The results were still abnormal. His internist suggested a CT scan, but neither Dr. Raber nor his doctor was concerned.
While Dr. Raber was on the table, the radiologist came in and said, “You have a problem.” There was a mass near his liver.
“This is serious,” he thought. “I figured, ‘This is early November. I could be dead by Christmas.’ ”
His doctor scheduled a biopsy for later that day.
That afternoon, after the biopsy, the pathologist told Dr. Raber he thought it was melanoma.
“I said to myself, melanoma. I could be dead by Thanksgiving,” Dr. Raber said.
It turned out to be lymphoma, a tumor of the lymphoid cells of the immune system, which is easier to treat and even cure than liver cancer or melanoma.
But treatment, with chemotherapy and radiation, made it impossible for Dr. Raber to work full time. At best, he could manage a few hours a day. He was ill, he was tired, and, he said, “My brain was scrambled.”
He stepped down as physician-in-chief. He no longer saw patients.
Two years later the cancer was back, in the same place. Once again he had aggressive chemotherapy and radiation. Two years after that, his kidneys failed. He spent time in the intensive care unit.
He did not work for a year, spending most of his time on the sofa. His lower body filled with fluid. His 32-inch waist ballooned to 52 inches. His size 9 ½ foot became a 12. All he could wear was a sweatsuit and slippers.
Finally, he went back to work for an hour, two or three times a week. And he went back not as an administrator but as a doctor and a teacher, “an earlier iteration of myself.”
In February, he got another cancer, melanoma.
By now he has gotten used to living with cancer.
“It just becomes your life,” Dr. Raber said. “You come in, you have tests, you go home, you do your thing, you come back again for treatment.
“I tell patients, ‘It used to be that you had cancer, you got treated, you died or you were cured,’ ” he said. “Now, for most of us, it’s a chronic illness. It’s not a question of being psyched up: I will have this surgery and then I will be cured. The disease comes back.”
He works part time, seeing patients on Tuesday and Thursday mornings and spending a day a week working at a clinic in the county hospital.
“A common question people would ask is ‘Are you a better doctor since you’ve been sick?’ ” Dr. Raber said. “My first answer is that I thought I was a good doctor before. I was worried about being a worse doctor. Having lived through these biopsies and all these tests, would I be hesitant to order all these things patients need because I had experienced them and knew they were not pleasant?
“Then I realized I am not better, but I am a different doctor,” he said. “I talk to patients differently. I understand more of what their situation might be.
“My life was very different than it was before that day in the CT scanner,” Dr. Raber said. “It’s not the life I thought I would have. But my life is still really good.
“My son is fond of saying, ‘It is what it is.’ That’s true. This is my life. I enjoy it a lot. It works out well for me.”
As for winning the war on cancer, Dr. Raber, on the front lines, has his own thoughts. “We are making a lot of progress,” he noted.
But “are we there yet?” he asked.
“Not even close.”
Comment
My Mom died of lung cancer, after beating breast cancer with a mastectomy 15 years before. She went thru four courses of chemo, lost her hair, and it wasnt a pretty sight to see. She was very brave throughout the entire process and I admire the courage it takes to face death head-on. She was pretty spiritual and I think that helped her because she knew she was going to a better place. Hospice nurses that deal with cancer every day are less likely to burn out if they have the same spiritual outlook. I found that to be true in my unpublished Masters paper thesis. My results indicated they were more depressed than hospital nurses, but less burned out. The premise of the paper was that burnout and depression are two faces of the same entity, and it was generally true, but not as clearly cut as that, especially in hospice nurses. Hospice nurses were emotionally spent, the first stage of burnout, but overall didnt allow themselves to emotionally withdraw from their patients, which is what happens in the second stage of burnout. the third stage is a sense that one is not doing as good a job as they used to do. There was a little of that in hospice nurses but not much. Hospital nurses fit the progressive burnout theory much better than hospice nurses. Hospice nurses were more depressed than hospital nurse overall and reported a significant lack of support from their supervisors, in that the hospice nurses felt they gave a lot more support to others, at home and at work, than they received.
Scott Dalton for The New York Times
Virginia Montes heading for treatment at M. D. Anderson Cancer Center, where 90,000 patients will be seen this year. More Photos >
GINA KOLATA
Published: October 24, 2009
HOUSTON — M. D. Anderson Cancer Center has a mission statement, and everyone who works there, from the president to the cleaning crews, can state it like a catechism: to “eliminate cancer in Texas, the nation and the world.”
The Front Line
Articles in this series examine the struggle to defeat cancer.
Scott Dalton for The New York Times
“It feels sometimes like the entire world has cancer,” said Cindy Davis, a nurse in Anderson's breast cancer clinic who has breast cancer herself. More Photos »
For the nearly 90,000 patients who will go to the center in Houston this year, that mission cannot be fulfilled soon enough. They and their families arrive at the world’s largest freestanding cancer hospital from around the world, often leaving behind jobs and stashing children with relatives for months. Some rent apartments or stay in mobile home parks near the hospital.
They enter through a soaring lobby, with cheery aquariums and exuberant volunteer greeters eager to help in any way. They come looking for hope.
But there is no mistaking what this place is: the front line of the frustrating war on a still largely incurable disease.
Doctors are encouraged to try everything, and when insurers balk, they pick up the phone, repeatedly, hoping to persuade them to pay for what may be unconventional treatments.
The federal government gives more cancer research money to this hospital than to any other, and the hospital has an abundance of specialists in many forms of cancer, including rare ones. Medicare offers more generous reimbursement, and the hospital offers treatments that often go far beyond what can be offered at most other places.
“I tell young physicians who are starting out here that the big limitation is imagination,” said Dr. Martin Raber, an oncologist — and a cancer patient himself — at Anderson. “If you are good at what you do and you have great ideas, we will help you find the resources you need to make them happen.”
But like a modern version of the tuberculosis sanatorium in Thomas Mann’s “Magic Mountain,” Anderson is a world where the best that medicine has to offer is often far from enough. The odds are still grim, and while there are exhilarating recoveries, the exhausting, dispiriting road traveled by many patients comes into sharp relief.
They are patients like 35-year-old Mindy Lanoux of San Antonio, who has melanoma that has spread to her liver and lungs, her odds of surviving in the single digits. She has been to the hospital 16 times in nine months, spending a week there each time for treatments so debilitating she wanted to give up. But she keeps returning, smearing peppermint oil under her nose when she walks in the medical center’s door to hide the odor.
“The smell gets to me,” Ms. Lanoux said. “It smells like cleaning products and the sickness and the medicines. It takes your brave edge off.”
Then she and her father go to her room and start putting her things away. “We don’t talk,” Ms. Lanoux said. “There is no polite conversation. It is like an army setting up to do battle.”
Planet Cancer
With more than 17,000 employees and warrens of color-coded hallways so vast that even employees get lost, M. D. Anderson is its own parallel universe, where nothing matters but cancer. Patients sit in the lobbies and compare notes.
“Everyone in the waiting room talks about ‘How did you find yours?’ ” said June Toland, 71, of Harlingen, Tex., who is being treated for sarcoma, a cancer of connective tissue.
Every patient at Anderson has cancer. Every family member sitting anxiously in the lounges or lingering at a bedside or sleeping in a Murphy bed in a patient’s room has had the life-changing experience of being touched by cancer.
“It feels sometimes like the entire world has cancer,” said Cindy Davis, a nurse in the breast cancer clinic who has breast cancer herself.
Anderson is a quiet place. No loud pagers. The walls are decorated with vivid photographs of serene scenes, like water views. The muted colors in the hallways, soft cranberry and dull green, are meant to be soothing. There is a special room, Kim’s Place, for young people only, cancer patients and their friends ages 15 to 30, giving them a place to gather. There is a library and a cybercafe. It is a place meant to give hope.
Sometimes, as happened with Frances Anderson of Shreveport, La., that hope is realized. She discovered three years ago that she had a brain tumor, but it did not start in her brain. In fact, it is not clear where it started. After being told by a doctor elsewhere that she had four to seven months to live, she ended up at Dr. Raber’s clinic, one of the few that specialize in treating patients with cancer throughout their bodies but with no obvious source for the tumors.
At 66, wearing pressed jeans, her short blond hair carefully styled, Ms. Anderson has vision problems from the surgery to remove the brain tumor, and she gets tired. She still has cancer, but she exercises every day and is living with her disease, returning to Anderson every six months for checkups and scans.
Others are not so fortunate. One morning last month, Joe Maxwell, 52, sat in a chair next to his hospital bed, a compression bandage around his now-useless swollen left arm, a large bandage over his left shoulder. He was going home to sit on his deck in Kerrville, Tex., a four-hour drive. He had tried everything Anderson had to offer and decided that, with an estimated two weeks left, he would go home to die.
Mr. Maxwell came to Anderson in January after his doctor told him a bump on his shoulder was a rare tumor, Merkel cell carcinoma, and added, “If you have a rare tumor, you need to go where tumors are not rare.”
At Anderson, doctors tried everything they could think of — surgery, round after round of chemotherapy, a clinical trial of an experimental drug. Nothing worked. Finally, the doctors suggested yet another drug.
(Page 2 of 5)
“We spent a lot of time praying about it and just discussing it,” Mr. Maxwell said. “I wanted to go home; I was tired. They gave me a short amount of time and said, ‘If you want to go home, now is the time.’ ”
But leaving late last month was bittersweet. The doctors and nurses “have become our friends and our family,” his wife, Kathleen Maxwell, said. Anderson, she added, “has been our life for nine months.”
He died 10 days later, early in the morning of Oct. 8.
Even those who finish their treatments and live cancer-free are forever changed by the experience.
Mrs. Toland learned that lesson from her son, George Toland. Twenty-four years ago, when he was 21, he was a sarcoma patient at Anderson. One day he looked at his mother and said, “My life will never be the same.”
His mother tried to reassure him, telling him that he would be fine, that he would go on to a perfectly normal life.
But he demurred, saying, “You know, Mother, it’s a loss of innocence.”
Mrs. Toland knew he was right.
She told him: “Most people lose their innocence in little doses as they go through life. You lost yours all at once.”
Battling the Odds
Donald Berry, a statistician who is head of the division of quantitative sciences at Anderson, says part of his role at the cancer center is to provide a reality check.
Yes, it is true, as doctors and nurses there repeatedly say, that treatment has improved. Anti-nausea drugs have all but eliminated the constant vomiting that once accompanied chemotherapy. New drugs are attacking genes that go awry in cancer. Most cancer patients come and go over a period of years, for checkups, scans, treatment if the cancer is still there. In between they go on with their lives.
But there is still little that can be done for most of those whose cancer has spread. And, Dr. Berry said, “that is a fact that doctors at M. D. Anderson can have a hard time facing, understandably so.”
Dr. Russell Harris, an associate professor of medicine at the University of North Carolina and a member of a board that evaluates cancer therapies for the National Institutes of Health, said the temptation at major cancer centers like Anderson was to try treatment after treatment.
“Everyone is totally immersed in the idea that death is the enemy,” Dr. Harris said. Such a no-holds-barred stance, he added, is spurring a growing debate in the cancer community.
“There is a lot of concern within the oncology community right now, and appropriately so, that people don’t completely understand what they are getting into,” Dr. Harris said.
An aggressive — and expensive — course of treatment can place a huge burden on patients. Ms. Lanoux knows that all too well. She came hoping for a cure for her advanced melanoma, but got her first dose of reality the day she walked into the main lobby.
She saw patients in wheelchairs, their heads sunken on their chests. She saw patients who had lost their hair, patients wearing sky-blue masks to protect them from infections. And there were the children. She had to avert her eyes. “I still can’t look at the kids,” Ms. Lanoux said.
“I think we were all trying to be very brave,” she said. “But it was like walking into a coffin.”
Ms. Lanoux, a small blond English teacher, lives in San Antonio with her husband, also a teacher, a 19-month-old daughter, an 8-year-old daughter and a 12-year-old son. The day she arrived at Anderson, Feb. 9, was the beginning of a difficult journey at the cancer center. She has been coming about every three weeks since, staying for a week at a time.
Her problems began in August 2008 on the way to a beach vacation. She started coughing. Her doctor was not concerned, telling her he thought she had acid reflux because she had had it when she was pregnant. He gave her Nexium. She returned in November at a friend’s urging, and her doctor prescribed cough drops and steroids. But she kept coughing.
Finally, in January, when she still could not catch her breath, her doctor ordered a chest X-ray to see if she had bronchitis. The next week, she returned to learn the result. Her husband wanted to go with her, but she told him not to bother, it was probably just bronchitis.
The doctor “came in and said, ‘This is the part I hate most about being a doctor,’ ” Ms. Lanoux recalled. There was a spot on her lung. A CT scan also revealed spots on her liver. And a biopsy of the spots on her liver revealed what it was. Melanoma. It had spread from an initial lesion — no one could ever find where it started — and was now threatening her life.
Ms. Lanoux’s doctor in San Antonio told her to go to Anderson. “She very honestly told me, ‘I don’t want to try treating you,’ ” Ms. Lanoux said.
“I think I was in denial until last month,” she said. “I had a 10 percent chance to survive five years, and I was going to do it.”
She has tried everything. Immunological therapy with side effects so severe it has to be administered in the intensive care unit. It did not work. Then she started biochemotherapy — a combination of three chemotherapy drugs and two immune system hormones to stimulate her body to attack her tumors. It is a controversial treatment, said her doctor, Patrick Hwu, but some patients had lasting remissions.
(Page 3 of 5)
Not Ms. Lanoux. At least not yet. On a recent sunny fall afternoon, she lay in her hospital bed on the 10th floor, wearing striped pajamas, blinking away tears as she told her story. She had just finished her sixth biochemotherapy treatment. Once again, she said, the therapy had made her feel “barely human.”
The effects hit her hard after the second treatment.
“I got home and ordered a wheelchair, a shower seat, a walker,” she said. “I am 35 years old and I have a wheelchair, a shower seat, a walker.” Just a few years ago she had run a marathon.
“My husband was helping me take a shower,” Ms. Lanoux said. “Of course it was awful. You’re cold, you can’t get enough water on you. I told him I don’t want to do this again. Call Dr. Hwu. I’m not going back.”
But she relented. Now Dr. Hwu wants her to try an experimental drug that takes the brakes off the immune system and might allow her body to destroy her cancer.
But the drug has not been approved by the Food and Drug Administration and is not available. Dr. Hwu knows it can have serious side effects and may not help Ms. Lanoux. But some who took the drug defied the odds, living for years. Maybe Ms. Lanoux could be one of those survivors, Dr. Hwu thinks.
And how about surgery, he asked her last month. “You can live with half a lung,” he said. But she probably would have to have her entire lung removed, he learned. And a surgeon would also have to take out the tumors on her liver. It may not be feasible, Dr. Hwu said, but, he added, “It’s definitely something I’m thinking about.”
Dr. Hwu struggles with the grim statistics — 8 percent of patients like Ms. Lanoux survive five years. The median survival rate is one year.
“It’s hard to see most patients die,” Dr. Hwu said. “You look at patients and see yourself and your family. We have to keep focusing on making these treatments better.”
On Wednesday, Ms. Lanoux was admitted for her eighth cycle of biochemotherapy. Dr. Hwu was worried.
“I don’t think her body will tolerate many more cycles,” he said. Already he has had to reduce the doses of some of the drugs and eliminate others.
In the meantime, he makes calls nearly every day, trying to get the experimental drug for Ms. Lanoux.
“We’re on the front lines,” he said. “We need armor.”
“I need this drug, and I need to be able to offer it to her.”
A View From Both Sides
As a breast cancer nurse, Cindy Davis thought she knew what her patients were going through. Until she went through it herself.
The first time she had a mammogram, it found cancer. She was 43. But after a lumpectomy, radiation and hormonal treatment with the drug tamoxifen, she was cancer free. The statistics were with her. She had every reason to think the cancer would not come back.
And that helped because she had taken a nursing job in the breast cancer clinic at Anderson, working with many patients pretty much like her — their cancer had been caught early, they would be fine.
Then, last April, nine years after the diagnosis, her cancer came back in a pelvic bone.
“You never think it is going to happen to you,” Mrs. Davis said. “I look at the risk factors, and I have none of them. It’s like, ‘Wait — I did everything right.’ ”
“I did the denial thing, 100 percent,” she said. “And I was angry. No, no, it can’t be that. And I was in shock — you’ve got to be kidding.”
As a nurse, she knew all too well there is no cure for breast cancer that has spread beyond the breast. Two-thirds with advanced disease are dead within five years.
“When you know what I know, it’s very scary,” Mrs. Davis said.
Her chemotherapy began a few days after she learned that her cancer had spread.
“I was scared; I was very scared,” Mrs. Davis said. “I know all the possible things that can go wrong.”
To her surprise, it was uneventful. Three weeks later, she and her husband went on a cruise. Just before it was over, her hair fell out.
I got out of the shower and started combing my hair and it was coming out,” she said. “I started crying. Everyone says, ‘It’s just hair. It will grow back.’ But as women, that’s a big thing to us.”
Articles in this series examine the struggle to defeat cancer.
Devastated, she got a wig and, feeling very self-conscious, went back to work. She has been working ever since, taking most of the week off after each chemotherapy treatment to recover from nausea and overwhelming fatigue. So far she has had 17 treatments, with more to come.
She is a nurse by day in the fifth-floor breast cancer clinic, and a patient in the evening, going to the eighth floor for chemotherapy. There she sees many of the women who were in the clinic earlier.
“It’s like a club,” Mrs. Davis said. The women talk about side effects — mouth sores and damage to the nerves of their feet — and the nausea and the anticipatory nausea.
“I have patients who say, ‘I just see a hospital gown and I feel nauseated,’ ” Mrs. Davis said. “I didn’t understand it before.”
She also asks patients for help, turning to those who learned they had advanced breast cancer two, three, four years ago.
“I say, ‘How do you do it?’ ” Mrs. Davis said. “They say they pray a lot and they just do it. They get through it one day at a time.”
Working at Anderson while being a patient there means cancer is always on her mind.
“You are around it all the time,” she said. “It’s just so hard to shut it off when you go home. Now I find myself thinking more and more about patients. I pray for them, and they hug me and say they are praying for me.”
She ran into a patient’s mother recently. The patient, a young woman, had advanced breast cancer and was terrified. Mrs. Davis told her she had advanced breast cancer, too, and she would help. “I am your nurse,” she told the young woman.
The mother came up to Mrs. Davis and said: “You have no idea how you have impacted this family. You gave my daughter hope that she could get through this.”
An Opponent That Won’t Quit
Dr. Raber used to think he understood when his patients told him that their appetite was good or that they were feeling more energetic.
But now, a cancer patient himself, he talks to patients in a very different way.
In the old days, if a patient said she had a good appetite, he would interpret that to mean her appetite was the same as his. Now he asks different questions.
“What did you have for lunch?”
“Crackers and soup.”
“What did you have for dinner?”
“Crackers and soup.”
“What did you have for breakfast?”
“I don’t eat breakfast.”
“Patients who say their appetite is fine often are saying it is better than it was,” Dr. Raber said. “They are not saying it is anything like the appetite of a healthy person.”
The same goes for energy level.
“When I came home from the hospital when I had been really, really sick, I was able to walk down the stairs once a day and up the stairs once a day. After I had been home for a couple of weeks, I could walk up and down maybe twice. If a doctor had asked how was my energy level, I would say, ‘Great, much better,’ ” Dr. Raber said. “The doctor would assume it was the same energy level as his.”
Dr. Raber’s journey as a cancer patient began in 1996, when he was 48 and physician-in-chief at Anderson. “I was at the top of my game,” he said.
A routine exam showed abnormalities in liver function tests. He thought it was nothing, waited six weeks, and had the test again.
The results were still abnormal. His internist suggested a CT scan, but neither Dr. Raber nor his doctor was concerned.
While Dr. Raber was on the table, the radiologist came in and said, “You have a problem.” There was a mass near his liver.
“This is serious,” he thought. “I figured, ‘This is early November. I could be dead by Christmas.’ ”
His doctor scheduled a biopsy for later that day.
That afternoon, after the biopsy, the pathologist told Dr. Raber he thought it was melanoma.
“I said to myself, melanoma. I could be dead by Thanksgiving,” Dr. Raber said.
It turned out to be lymphoma, a tumor of the lymphoid cells of the immune system, which is easier to treat and even cure than liver cancer or melanoma.
But treatment, with chemotherapy and radiation, made it impossible for Dr. Raber to work full time. At best, he could manage a few hours a day. He was ill, he was tired, and, he said, “My brain was scrambled.”
He stepped down as physician-in-chief. He no longer saw patients.
Two years later the cancer was back, in the same place. Once again he had aggressive chemotherapy and radiation. Two years after that, his kidneys failed. He spent time in the intensive care unit.
He did not work for a year, spending most of his time on the sofa. His lower body filled with fluid. His 32-inch waist ballooned to 52 inches. His size 9 ½ foot became a 12. All he could wear was a sweatsuit and slippers.
Finally, he went back to work for an hour, two or three times a week. And he went back not as an administrator but as a doctor and a teacher, “an earlier iteration of myself.”
In February, he got another cancer, melanoma.
By now he has gotten used to living with cancer.
“It just becomes your life,” Dr. Raber said. “You come in, you have tests, you go home, you do your thing, you come back again for treatment.
“I tell patients, ‘It used to be that you had cancer, you got treated, you died or you were cured,’ ” he said. “Now, for most of us, it’s a chronic illness. It’s not a question of being psyched up: I will have this surgery and then I will be cured. The disease comes back.”
He works part time, seeing patients on Tuesday and Thursday mornings and spending a day a week working at a clinic in the county hospital.
“A common question people would ask is ‘Are you a better doctor since you’ve been sick?’ ” Dr. Raber said. “My first answer is that I thought I was a good doctor before. I was worried about being a worse doctor. Having lived through these biopsies and all these tests, would I be hesitant to order all these things patients need because I had experienced them and knew they were not pleasant?
“Then I realized I am not better, but I am a different doctor,” he said. “I talk to patients differently. I understand more of what their situation might be.
“My life was very different than it was before that day in the CT scanner,” Dr. Raber said. “It’s not the life I thought I would have. But my life is still really good.
“My son is fond of saying, ‘It is what it is.’ That’s true. This is my life. I enjoy it a lot. It works out well for me.”
As for winning the war on cancer, Dr. Raber, on the front lines, has his own thoughts. “We are making a lot of progress,” he noted.
But “are we there yet?” he asked.
“Not even close.”
Comment
My Mom died of lung cancer, after beating breast cancer with a mastectomy 15 years before. She went thru four courses of chemo, lost her hair, and it wasnt a pretty sight to see. She was very brave throughout the entire process and I admire the courage it takes to face death head-on. She was pretty spiritual and I think that helped her because she knew she was going to a better place. Hospice nurses that deal with cancer every day are less likely to burn out if they have the same spiritual outlook. I found that to be true in my unpublished Masters paper thesis. My results indicated they were more depressed than hospital nurses, but less burned out. The premise of the paper was that burnout and depression are two faces of the same entity, and it was generally true, but not as clearly cut as that, especially in hospice nurses. Hospice nurses were emotionally spent, the first stage of burnout, but overall didnt allow themselves to emotionally withdraw from their patients, which is what happens in the second stage of burnout. the third stage is a sense that one is not doing as good a job as they used to do. There was a little of that in hospice nurses but not much. Hospital nurses fit the progressive burnout theory much better than hospice nurses. Hospice nurses were more depressed than hospital nurse overall and reported a significant lack of support from their supervisors, in that the hospice nurses felt they gave a lot more support to others, at home and at work, than they received.
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