Death by Medicine: Part II

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We have added, cumulatively, figures from 13 references of annual iatrogenic deaths. However, there is invariably some degree of overlap and double counting that can occur in gathering non-finite statistics.

Death numbers don't come with names and birth dates to prevent duplication On the other hand, there are many missing statistics. As we will show, only about 5 to 20% of iatrogenic incidents are even recorded.16,24,25,33,34 And, our outpatient iatrogenic statistics112 only include drug-related events and not surgical cases, diagnostic errors, or therapeutic mishaps.

We have also been conservative in our inclusion of statistics that were not reported in peer review journals or by government institutions. For example, on July 23, 2002, The Chicago Tribune analyzed records from patient databases, court cases, 5,810 hospitals, as well as 75 federal and state agencies and found 103,000 cases of death due to hospital infections, 75% of which were preventable.152 We do not include this figure but report the lower Weinstein figure of 88,000.9 Another figure that we withheld, for lack of proper peer review was The National Committee for Quality Assurance, September 2003 report which found that at least 57,000 people die annually from lack of proper care for commons diseases such as high blood pressure, diabetes, or heart disease.153

Overlapping of statistics in Death by Medicine may occur with the Institute of Medicine (IOM) paper that designates "medical error" as including drugs, surgery, and unnecessary procedures.6 Since we have also included other statistics on adverse drug reactions, surgery and, unnecessary procedures, perhaps a much as 50% of the IOM number could be redundant. However, even taking away half the 98,000 IOM number still leaves us with iatrogenic events as the number one killer at 738,000 annual deaths.

MEDICAL AND SURGICAL PROCEDURES

It is instructive to know the mortality rate associated with different medical and surgical procedures. Even though we must sign release forms when we undergo any procedure, many of us are in denial about the true risks involved. We seem to hold a collective impression that since medical and surgical procedures are so commonplace, they are both necessary and safe. Unfortunately, partaking in allopathic medicine itself is one of the highest causes of death as well as the most expensive way to die.

Shouldn?t the daily death rate of iatrogenesis in hospitals, out of hospitals, in nursing homes, and psychiatric residences be reported like the pollen count or the smog index? Let?s stop hiding the truth from ourselves. It?s only when we focus on the problem and ask the right questions that we can hope to find solutions.

Perhaps the words ?health care? give us the illusion that medicine is about health. Allopathic medicine is not a purveyor of healthcare but of disease-care. Studying the mortality figures in the Healthcare Cost and Utilization Project (HCUP) within the U.S. government?s Agency for Healthcare Research and Quality, we found many points of interest.13 The HCUP computer program that calculates the annual mortality statistics for all U.S. hospital discharges is only as good as the codes that are put into the system.

In an e-mail correspondence with HCUP, we were told that the mortality rates that were indicated in tables and charts for each procedure were not necessarily due to the procedure but only indicated that someone who received that procedure died either from their original disease or from the procedure.

Therefore there is no way of knowing exactly how many people died from a particular procedure. There are also no codes for adverse drug side effects, none for surgical mishap, and none for medical error. Until there are codes for medical error, statistics of those people who are dying from various types of medical error will be buried in the general statistics. There is a code for ?poisoning & toxic effects of drugs? and a code for ?complications of treatment.?

However, the mortality figures registered in these categories are very low and don?t compare with what we know from studies such as the JAMA 1998 study1 that said there were an average of 106,000 prescription medication deaths per year.

WHY AREN?T MEDICAL AND SURGICAL PROCEDURES STUDIED?

In 1978, the U.S. Office of Technology Assessment (OTA) reported that, ?Only 10 percent to 20 percent of all procedures currently used in medical practice have been shown to be efficacious by controlled trial."83 In 1995, the OTA compared medical technology in eight countries (Australia, Canada, France, Germany, Netherlands, Sweden, United Kingdom, and the United States) and again noted that few medical procedures in the United States had been subjected to clinical trial. It also reported that infant mortality was high and life expectancy was low compared to other developed countries.84

Although almost 10 years old, much of what was said in this report holds true today. The report lays the blame for the high cost of medicine squarely at the feet of the medical free-enterprise system and the fact that there is no national health care policy. It describes the failure of government attempts to control health care costs due to market incentive and profit motive in the financing and organization of health care including private insurance, hospital system, physician services, and drug and medical device industries.

Whereas we may want to expand health-care, expansion of disease-care is the goal of free enterprise. ?Health Care Technology and Its Assessment in Eight Countries? is also the last report prepared by the OTA, which was shut down in 1995. It?s also, perhaps, the last honest, in-depth look at modern medicine. Because of the importance of this 60-page report, we enclose a summary in the Appendix.

SURGICAL ERRORS FINALLY REPORTED

Just hours before completion of this paper, statistics on surgical-related deaths became available. An October 8, 2003 JAMA study from the U.S. government?s Agency for Healthcare Research and Quality (AHRQ) documented 32,000 mostly surgery-related deaths costing $9 billion and accounting for 2.4 million extra days in the hospital in 2000.85 In a press release accompanying the JAMA study, the AHRQ director, Carolyn M. Clancy, M.D., admitted, ?This study gives us the first direct evidence that medical injuries pose a real threat to the American public and increase the costs of health care.? 86

Hospital administrative data from 20 percent of the nation?s hospitals were analyzed for eighteen different surgical complications including postoperative infections, foreign objects left in wounds, surgical wounds reopening, and post-operative bleeding. In the same press release the study?s authors said that, ?The findings greatly underestimate the problem, since many other complications happen that are not listed in hospital administrative data.? They also felt that, "The message here is that medical injuries can have a devastating impact on the health care system. We need more research to identify why these injuries occur and find ways to prevent them from happening."

One of the authors, Dr. Zhan said that improved medical practices, including an emphasis on better hand-washing, might help reduce the morbidity and mortality rates. An accompanying JAMA editorial by health-risk researcher Dr. Saul Weingart of Harvard?s Beth Israel Deaconess Medical Center said, ?Given their staggering magnitude, these estimates are clearly sobering.?87

UNNECESSARY X-RAYS

When X-rays were discovered, no one knew the long-term effects of ionizing radiation. In the 1950s monthly fluoroscopic exams at the doctor?s office were routine. You could even walk into most shoe stores and see your foot bones; looking at bones was an amusing novelty. We still don?t know the ultimate outcome of our initial escapade with X-rays.

It was common practice to use X-rays in pregnant women to measure the size of the pelvis, and make a diagnosis of twins. Finally, a study of 700,000 children born between 1947 and 1964 was conducted in 37 major maternity hospitals. The children of mothers who had received pelvic X-rays during pregnancy were compared with the children of mothers who had not been X-rayed. Cancer mortality was 40 percent higher among the children with X-rayed mothers.88

In present-day medicine, coronary angiography combines an invasive surgical procedure of snaking a tube through a blood vessel in the groin up to the heart. To get any useful information during the angiography procedure X-rays are taken almost continuously with minimum dosage ranges between 460 and 1,580 mrem. The minimum radiation from a routine chest X-ray is 2 mrem. X-ray radiation accumulates in the body and it is well-known that ionizing radiation used in X-ray procedures causes gene mutation. We can only obtain guesstimates as to its impact on health from this high level of radiation. Experts manage to obscure the real effects in statistical jargon such as, ?The risk for lifetime fatal cancer due to radiation exposure is estimated to be four in 1 million per 1,000 mrem.?89

However, Dr. John Gofman, who has been studying the effects of radiation on human health for 45 years, is prepared to tell us exactly what diagnostic X-rays are doing to our health. Dr. Gofman has a PhD in nuclear and physical chemistry and is a medical doctor. He worked on the Manhattan nuclear project, discovered uranium-2323, was the first person to isolate plutonium, and since 1960, he?s been studying the effects of radiation on human health.

With five scientifically documented books totaling over 2,800 pages, Dr. Gofman provides strong evidence that medical technology, specifically X-rays, CT scans, mammography, and fluoroscopy, are a contributing factor to 75 percent of new cancers.

His 699-page report, updated in 2000, ?Radiation from Medical Procedures in the Pathogenesis of Cancer and Ischemic Heart Disease: Dose-Response Studies with Physicians per 100,000 Population to here?90 shows that as the number of physicians increases in a geographical area with an increase in the number of X-ray diagnostic tests, there is an associated increase in the rate of cancer and ischemic heart disease. Dr. Gofman elaborates that it?s not X-rays alone that cause the damage but a combination of health risk factors including: poor diet, smoking, abortions, and the use of birth control pills. Dr. Gofman predicts that 100 million premature deaths over the next decade will be the result of ionizing radiation.

In his book, ?Preventing Breast Cancer,? Dr. Gofman says that breast cancer is the leading cause of death among American women between the ages of 44 and 55. Because breast tissue is highly radiation-sensitive, mammograms can cause cancer. The danger can be heightened by a woman?s genetic makeup, pre-existing benign breast disease, artificial menopause, obesity, and hormonal imbalance.91

Even X-rays for back pain can lead someone into crippling surgery. Dr. Sarno, a well-known New York orthopedic surgeon, found that X-rays don?t always tell the truth. In his books he cites studies on normal people without a trace of back pain that have spinal abnormalities on X-ray. Other studies have shown that some people with back pain have normal spines on X-ray. So, Dr. Sarno says there is not necessarily any association between back pain and spinal X-ray abnormality.92 However, if a person happens to have back pain and an incidental abnormality on X-ray, they may be treated surgically, sometimes with no change in back pain, or worsening of back pain, or even permanent disability.

In addition, doctors often order X-rays as protection against malpractice claims to give the impression that they are leaving no stone unturned. It appears that doctors are putting their own fears before the interests of their patients.

UNNECESSARY HOSPITALIZATION

Summary:

8.9 million (8,925,033) people were hospitalized unnecessarily in 2001.4

In a study of inappropriate hospitalization 1,132 medical records were reviewed by two doctors. Twenty-three percent of all admissions were inappropriate and an additional 17 percent could have been handled in ambulatory out-patient clinics. Thirty-four percent of all hospital days were also inappropriate and could have been avoided.93 The rate of inappropriate admissions in 1990 was 23.5 percent.94 In 1999, another study confirmed the figure of 24 percent inappropriate admissions indicating a consistent pattern from 1986 to 1999,95 showing steady reporting of approximately 24 percent inappropriate admissions each year.

Putting these figures into present-day terms using the HCUP database, the total number of patient discharges from hospitals in the U.S. in 2001 was 37,187,641.13 The above data indicate that 24 percent of those hospitalizations need never have occurred. It further means that 8,925,033 people were exposed to unnecessary medical intervention in hospitals and therefore represent almost 9 million potential iatrogenic episodes.4

WOMEN?S EXPERIENCE IN MEDICINE

Briefly, we will look at the medical iatrogenesis of women in particular. Dr. Martin Charcot (1825-1893) was world-renowned, the most celebrated doctor of his time. He practiced in the Paris hospital La Salpetriere. He became an expert in hysteria diagnosing an average of 10 hysterical women each day, transforming them into ? ?iatrogenic monsters,? turning simple ?neurosis? into hysteria.96 The number of women diagnosed with hysteria and hospitalized rose from one percent in 1841 to 17 percent in 1883.

Hysteria is derived from the Latin ?hystera,? meaning uterus. Dr. Adriane Fugh-Berman stated very clearly in her paper that there is a tradition in U.S. medicine of excessive medical and surgical interventions on women. Only 100 years ago male doctors decided that female psychological imbalance originated in the uterus. When surgery to remove the uterus was perfected it became the ?cure? for mental instability, effecting a physical and psychological castration. Dr. Fugh-Berman noted that U.S. doctors eventually disabused themselves of that notion but have continued to treat women very differently than they treat men.97 She cites the following:

• Thousands of prophylactic mastectomies are performed annually.
• One-third of U.S. women have had a hysterectomy before menopause.
• Women are prescribed drugs more frequently than are men.
• Women are given potent drugs for disease prevention, which results in disease substitution due to side effects.
• Fetal monitoring is unsupported by studies and not recommended by the CDC.98 It confines women to a hospital bed and may result in higher incidence of cesarean section.99
• Normal processes such as menopause and childbirth have been heavily medicalized.
• Synthetic hormone replacement therapy (HRT) does not prevent heart disease or dementia. It does increase the risk of breast cancer, heart disease, stroke, and gall bladder attack.100

We would add that as many as one-third of postmenopausal women use HRT.101,102 These numbers are important in light of the much-publicized Women?s Health Initiative Study, which was forced to stop before its completion because of a higher death rate in the synthetic estrogen-progestin (HRT) group.103

Cesarean Section

In 1983, 809,000 cesarean sections (21 percent of live births) were performed, making it the most common obstetric and gynecologic (OB/GYN) surgical procedure. The second most common OB/GYN operation was hysterectomy (673,000), and diagnostic dilation and curettage of the uterus (632,000) was third. In 1983, OB/GYN operations represented 23 percent of all surgery completed in this country.104

In 2001, Cesarean section is still the most common OB/GYN surgical procedure. Approximately 4 million births occur annually, with a 24 percent C-Section rate, i.e., 960,000 operations. In the Netherlands only eight percent of babies are delivered by Cesarean section. Assuming human babies are similar in the United States and in the Netherlands, we are performing 640,000 unnecessary C-Sections in the United States with its three to four times higher mortality and 20 times greater morbidity than vaginal delivery.105

The cesarean section rate was only 4.5 percent in the United States in 1965. By 1986 it had climbed to 24.1 percent. The author states that obviously an ?uncontrolled pandemic of medically unnecessary cesarean births is occurring.?106 VanHam reported a cesarean section postpartum hemorrhage rate of seven percent, a hematoma formation rate of 3.5 percent, a urinary tract infection rate of three percent, and a combined postoperative morbidity rate of 35.7 percent in a high-risk population undergoing cesarean section.107

NEVER ENOUGH STUDIES

Scientists used the excuse that there were never enough studies revealing the dangers of DDT and other dangerous pesticides to ban them. They also used this excuse around the issue of tobacco, claiming that more studies were needed before they could be certain that tobacco really caused lung cancer. Even the American Medical Association (AMA) was complicit in suppressing results of tobacco research. In 1964, the Surgeon General's report condemned smoking, however the AMA refused to endorse it. What was their reason? They needed more research. Actually what they really wanted was more money and they got it from a consortium of tobacco companies who paid the AMA $18 million over the next nine years, during which the AMA said nothing about the dangers of smoking.108

The Journal of the American Medical Association (JAMA), "after careful consideration of the extent to which cigarettes were used by physicians in practice," began accepting tobacco advertisements and money in 1933. State journals such as the New York State Journal of Medicine also began to run Chesterfield ads claiming that cigarettes are, "Just as pure as the water you drink ? and practically untouched by human hands."

In 1948, JAMA argued "more can be said in behalf of smoking as a form of escape from tension than against it ? there does not seem to be any preponderance of evidence that would indicate the abolition of the use of tobacco as a substance contrary to the public health."109 Today, scientists continue to use the excuse that they need more studies before they will lend their support to restrict the inordinate use of drugs.

OVERVIEW OF STATISTICAL TABLES AND FIGURES

Adverse Drug Reactions

The Lazarou study1 was based on statistical analysis of 33 million U.S. hospital admissions in 1994. Hospital records for prescribed medications were analyzed. The number of serious injuries due to prescribed drugs was 2.2 million; 2.1 percent of in-patients experienced a serious adverse drug reaction; 4.7 percent of all hospital admissions were due to a serious adverse drug reaction; and fatal adverse drug reactions occurred in 0.19 percent of in-patients and 0.13 percent of admissions. The authors concluded that a projected 106,000 deaths occur annually due to adverse drug reactions.

We used a cost analysis from a 2000 study in which the increase in hospitalization costs per patient suffering an adverse drug reaction was $5,483. Therefore, costs for the Lazarou study?s 2.2 million patients with serious drug reactions amounted $12 billion.1,49

Serious adverse drug reactions commonly emerge after Food and Drug Administration approval. The safety of new agents cannot be known with certainty until a drug has been on the market for many years.110

Bedsores

Over 1 million people develop bedsores in U.S. hospitals every year. It?s a tremendous burden to patients and family, and a $55 billion dollar health care burden.7 Bedsores are preventable with proper nursing care. It is true that 50 percent of those affected are in a vulnerable age group of over 70. In the elderly bedsores carry a four-fold increase in the rate of death.

The mortality rate in hospitals for patients with bedsores is between 23 percent and 37 percent.8 Even if we just take the 50 percent of people over 70 with bedsores and the lowest mortality at 23 percent, that gives us a death rate due to bedsores of 115,000. Critics will say that it was the disease or advanced age that killed the patient, not the bedsore, but our argument is that an early death, by denying proper care, deserves to be counted. It is only after counting these unnecessary deaths that we can then turn our attention to fixing the problem.

Malnutrition in Nursing Homes

The General Accounting Office (GAO), a special investigative branch of Congress, gave citations to 20 percent of the nation's 17,000 nursing homes for violations between July 2000 and January 2002. Many violations involved serious physical injury and death.111

A report from the Coalition for Nursing Home Reform states that at least one-third of the nation?s 1.6 million nursing home residents may suffer from malnutrition and dehydration, which hastens their death. The report calls for adequate nursing staff to help feed patients who aren?t able to manage a food tray by themselves.11 It is difficult to place a mortality rate on malnutrition and dehydration. This Coalition report states that malnourished residents, compared with well-nourished hospitalized nursing home residents, have a five-fold increase in mortality when they are admitted to hospital. So, if we take one-third of the 1.6 million nursing home residents who are malnourished and multiply that by a mortality rate of 20 percent,8,14 we find 108,800 premature deaths due to malnutrition in nursing homes.

Nosocomial Infections

The rate of nosocomial infections per 1,000 patient days has increased 36 percent - from 7.2 in 1975 to 9.8 in 1995. Reports from more than 270 U.S. hospitals showed that the nosocomial infection rate itself had remained stable over the previous 20 years with approximately five to six hospital-acquired infections occurring per 100 admissions, which is a rate of 5-6 percent. However, because of progressively shorter inpatient stays and the increasing number of admissions, the actual number of infections increased.

It is estimated that in 1995, nosocomial infections cost $4.5 billion and contributed to more than 88,000 deaths - one death every 6 minutes.9 The 2003 incidence of nosocomial mortality is quite probably higher than in 1995 because of the tremendous increase in antibiotic-resistant organisms. Morbidity and Mortality Report found that nosocomial infections cost $5 billion annually in 1999.10 This is a $0.5 billion increase in four years. The present cost of nosocomial infections might now be in the order of $5.5 billion.

Outpatient Iatrogenesis

Dr. Barbara Starfield in a 2000 JAMA paper presents us with well-documented facts that are both shocking and unassailable.12

• The U.S. ranks twelfth out of 13 countries in a total of 16 health indicators. Japan, Sweden, and Canada were first, second, and third.
• More than 40 million people have no health insurance.
• 20 percent to 30 percent of patients receive contraindicated care.

Dr. Starfield warns that one cause of medical mistakes is the overuse of technology, which may create a "cascade effect" leading to more treatment. She urges the use of ICD (International Classification of Diseases) codes that have designations called: "Drugs, Medicinal, and Biological Substances Causing Adverse Effects in Therapeutic Use" and "Complications of Surgical and Medical Care" to help doctors quantify and recognize the magnitude of the medical error problem. Starfield says that, at present, deaths actually due to medical error are likely to be coded according to some other cause of death.

She concludes that against the backdrop of our abysmal health report card compared to the rest of the Westernized countries, we should recognize that the harmful effects of health care interventions account for a substantial proportion of our excess deaths.

Starfield cites Weingart?s 2000 article, ?Epidemiology of Medical Error? on outpatient iatrogenesis. And Weingart, in turn, cites several authors and provides statistics showing that between 4 percent to 18 percent of consecutive patients in outpatient settings suffer an iatrogenic event leading to:112

116 million extra physician visits
77 million extra prescriptions
17 million emergency department visits
8 million hospitalizations
3 million long-term admissions
199,000 additional deaths
$77 billion in extra costs

Unnecessary Surgeries

There are 12,000 deaths per year from unnecessary surgeries. However, results from the few studies that have measured unnecessary surgery directly indicate that for some highly controversial operations, the fraction that are unwarranted could be as high as 30 percent.74

IT?S A GLOBAL ISSUE

A survey published in the Journal of Health Affairs pointed out that between 18 percent and 28 percent of people who were recently ill had suffered from a medical or drug error in the previous two years. The study surveyed 750 recently-ill adults in five different countries. The breakdown by country showed 18 percent of those in Britain, 25 percent in Canada, 23 percent in Australia, 23 percent in New Zealand, and the highest number was in the U.S. at 28 percent.113

HEALTH INSURANCE

A recent finding by the Institute of Medicine is that the 41 million Americans without health insurance have consistently worse clinical outcomes than those who are insured, and are at increased risk for dying prematurely.114

Insurance Fraud

When doctors bill for services they do not render, advise unnecessary tests, or screen everyone for a rare condition, they are committing insurance fraud. The U.S. General Accounting Office (GAO) gave a 1998 figure of $12 billion lost to fraudulent or unnecessary claims, and reclaimed $480 million in judgments in that year. In 2001, the federal government won or negotiated more than $1.7 billion in judgments, settlements, and administrative impositions in health care fraud cases and proceedings.115

WAREHOUSING OUR ELDERS

It is only fitting that we end this report with acknowledgement of our elders. The moral and ethical fiber of society can be judged by the way it treats its weakest and most vulnerable members. Some cultures honor and respect the wisdom of their elders, keeping them at home--the better to continue participation in their community. However, American nursing homes, where millions of our elders die, represent the pinnacle of social isolation and medical abuse.

Important Statistics about Nursing Homes

1. In America, at any one time, approximately 1.6 million elderly are confined to nursing homes. By 2050 that number could be 6.6 million.11,116

2. A total of 20 percent of all deaths from all causes occur in nursing homes.117

3. Hip fractures are the single greatest reason for nursing home admissions.118 Nursing homes represent a reservoir for drug-resistant organisms due to overuse of antibiotics.119

Congressman Waxman reminded us that ?as a society we will be judged by how we treat the elderly" when he presented a report that he sponsored, "Abuse of Residents is a Major Problem in U.S. Nursing Homes," on July 30, 2001. The report uncovered that one-third--5,283 of the nations? 17,000 nursing homes--were cited for an abuse violation in the two-year period studied, January 1999 to January 2001.116 Waxman stated that ?the people who cared for us, deserve better." He also made it very clear that this was only the tip of the iceberg and there is much more abuse occurring that we don?t know about or ignore.116a

The major findings of "Abuse of Residents is a Major Problem in U.S. Nursing Homes," were:

• Over 30 percent of nursing homes in the United States were cited for abuses, totaling more than 9,000 abuse violations.
• 10 percent of nursing homes had violations that caused actual physical harm to residents, or worse.
• Over 40 percent, or 3,800, abuse violations were only discovered after a formal complaint was filed, usually by concerned family members.
• Many verbal abuse violations were found.
• Occasions of sexual abuse.
• Incidents of physical abuse causing numerous injuries such as fractured femur, hip, elbow, wrist, and other injuries.

Dangerously understaffed nursing homes lead to neglect, abuse, overuse of medications, and physical restraints. An exhaustive study of nurse-to-patient ratios in nursing homes was mandated by Congress in 1990. The study was finally begun in 1998 and took four years to complete.120 Commenting on the study, a spokesperson for The National Citizens? Coalition for Nursing Home Reform said, ?They compiled two reports of three volumes each thoroughly documenting the number of hours of care residents must receive from nurses and nursing assistants to avoid painful, even dangerous, conditions such as bedsores and infections. Yet it took the Department of Health and Human Services and Secretary Tommy Thompson only four months to dismiss the report as ?insufficient.??121

Bedsores occur three times more commonly in nursing homes than in acute care or veterans? hospitals.122 But we know that bedsores can be prevented with proper nursing care. It shouldn?t take four years for someone to find out that proper care of bedsores requires proper staffing. In spite of such urgent need in nursing homes where additional staff could solve so many problems, we hear the familiar refrain ?not enough research?--one that merely buys time for those in charge and relegates another smoldering crisis to the back burner.

Since many nursing home patients suffer from chronic debilitating conditions, their assumed cause of death is often unquestioned by physicians. Some studies show that as many as 50 percent of deaths due to restraints, falls, suicide, homicide, and choking in nursing homes may be covered up.123,124 It is quite possible that many nursing home deaths are attributed, instead, to heart disease, which, until our report, was the number one cause of death. In fact, researchers have found that heart disease may be over-represented in the general population as a cause of death on death certificates by 7.9 percent to 24.3 percent. In the elderly the over-reporting of heart disease as a cause of death is as much as two-fold.125

When elucidating iatrogenesis in nursing homes, some critics have asked, ?To what extent did these elderly people already have life-threatening diseases that led to their premature deaths anyway?? Our response is that if a loved one dies one day, one week, one year, a decade, or two decades prematurely, thanks to some medical misadventure, that is still a premature, iatrogenic death. In a legalistic sense perhaps more weight is placed on the loss of many potential years compared to an additional few weeks, but this attitude is not justified in an ethical or moral sense.

The fact that there are very few statistics on malnutrition in acute-care hospitals and nursing homes shows the lack of concern in this area. A survey of the literature turns up very few American studies. Those that do appear are foreign studies in Italy, Spain, and Brazil. However, there is one very revealing American study conducted over a 14-month period that evaluated 837 patients in a 100-bed sub-acute-care hospital for their nutritional status. Only eight percent of the patients were found to be well nourished.

Almost one-third (29 percent) were malnourished and almost two-thirds (63 percent) were at risk of malnutrition. The consequences of this state of deficiency were that 25 percent of the malnourished patients required readmission to an acute-care hospital compared to 11 percent of the well-nourished patients. The authors concluded that malnutrition reached epidemic proportions in patients admitted to this sub-acute-care facility.126

Many studies conclude that physical restraints are an underreported and preventable cause of death. Whereas administrators say they must use restraints to prevent falls, in fact, they cause more injury and death because people naturally fight against such imprisonment. Studies show that compared to no restraints, the use of restraints carries a higher mortality rate and economic burden.127-129 Studies found that physical restraints, including bedrails, are the cause of at least one in every 1,000 nursing-home deaths.130-132

However, deaths caused by malnutrition, dehydration, and physical restraints are rarely recorded on death certificates. Several studies reveal that nearly half of the listed causes of death on death certificates for older persons with chronic or multi-system disease are inaccurate.133 Even though 1-in-5 people die in nursing homes, the autopsy rate is only 0.8 percent.134 Thus, we have no way of knowing the true causes of death.

Over-medicating Seniors

The CDC may be focused on reducing the number of prescriptions for children but a 2003 study finds over-medication of our elderly population. Dr. Robert Epstein, chief medical officer of Medco Health Solutions Inc. (a unit of Merck & Co.), conducted the study on drug trends.135 He found that seniors are going to multiple physicians and getting multiple prescriptions and using multiple pharmacies. Medco oversees drug-benefit plans for more than 60 million Americans, including 6.3 million senior citizens who received more than 160 million prescriptions. According to the study, the average senior receives 25 prescriptions annually.

In those 6.3 million seniors, a total of 7.9 million medication alerts were triggered: less than one-half that number, 3.4 million, were detected in 1999. About 2.2 million of those alerts indicated excessive dosages unsuitable for senior citizens, and about 2.4 million alerts indicated clinically inappropriate drugs for the elderly. Reuters interviewed Kasey Thompson, director of the Center on Patient Safety at the American Society of Health System Pharmacists, who said, ?There are serious and systemic problems with poor continuity of care in the United States.? He says this study shows ?the tip of the iceberg? of a national problem.

According to Drug Benefit Trends, the average number of prescriptions dispensed per non-Medicare HMO member per year rose 5.6 percent from 1999 to 2000--from 7.1 to 7.5 prescriptions. The average number dispensed for Medicare members increased 5.5 percent--from 18.1 to 19.1 prescriptions.136 The number of prescriptions in 2000 was 2.98 billion, with an average per person prescription amount of 10.4 annually.137

In a study of 818 residents of residential care facilities for the elderly, 94 percent were receiving at least one medication at the time of the interview. The average intake of medications was five per resident; the authors noted that many of these drugs were given without a documented diagnosis justifying their use.138

Unfortunately, seniors, and groups like the American Association for Retired Persons (AARP), appear to be dependent on prescription drugs and are demanding that coverage for drugs be a basic right.139 They have accepted the overriding assumption from allopathic medicine that aging and dying in America must be accompanied by drugs in nursing homes and eventual hospitalization with tubes coming out of every orifice.

Instead of choosing between drugs and a diet-lifestyle change, seniors are given the choiceless option of either high-cost patented drugs or low-cost generic drugs. Drug companies are attempting to keep the most expensive drugs on the shelves and to suppress access to generic drugs, in spite of stiff fines of hundreds of millions of dollars from the government.140,141 In 2001 some of the world's biggest drug companies, including Roche, were fined a record ?523 million ($871 million) for conspiring to increase the price of vitamins.142

We would urge AARP, especially, to become more involved in prevention of disease and not to rely so heavily on drugs. At present, the AARP recommendations for diet and nutrition assume that seniors are getting all the nutrition they need in an average diet. At most, they suggest extra calcium and a multiple vitamin/mineral supplement.143 This is not enough, and in our next report we will show how to live a healthier life without unnecessary medical intervention.

We would like to send the same message to the Hemlock Society, which offers euthanasia options to chronically ill people, especially those in severe pain. What if some of these chronic diseases are really lifestyle diseases caused by deficiency of essential nutrients, lack of care, inappropriate medication, or lack of love? This question is extremely important to consider when you are depressed or in pain. We must look to healing those conditions before offering up our lives.

Let?s also look at the irony of under use of proper pain medication for patients that really need it. For example, in one particular study pain management was evaluated in a group of 13,625 cancer patients, aged 65 or over, living in nursing homes. Overall, almost 30 percent, or 4,003 patients, reported pain. However, more than 25 percent received absolutely no pain relief medication; 16 percent received a World Health Organization (WHO) level-one drug (mild analgesic); 32 percent a WHO level-two drug (moderate analgesic); and only 26 percent received adequate pain relieving morphine. The authors concluded that older patients and minority patients were more likely to have their pain untreated.144

The time has come to set a standard for caring for the vulnerable among us--a standard that goes beyond making sure they are housed and fed, and not openly abused. We must stop looking the other way and we, as a society, must take responsibility for the way in which we deal with those who are unable to care for themselves.

WHAT REMAINS TO BE UNCOVERED

• Our ongoing research will continue to quantify the morbidity, mortality, and financial loss due to:
• X-ray exposures: mammography, fluoroscopy, CT scans.
• Overuse of antibiotics in all conditions.
• Drugs that are carcinogenic: hormone replacement therapy (*see below), immunosuppressive drugs, prescription drugs.
• Cancer chemotherapy: If it doesn?t extend life, is it shortening life?70
• Surgery and unnecessary surgery: Cesarean section, radical mastectomy, preventive mastectomy, radical hysterectomy, prostatectomy, cholecystectomies, cosmetic surgery, arthroscopy, etc.
• Discredited medical procedures and therapies.
• Unproven medical therapies.
• Outpatient surgery.
• Doctors themselves: when doctors go on strike, it appears the mortality rate goes down.

*Part of our ongoing research will be to quantify the mortality and morbidity caused by hormone replacement therapy (HRT) since the mid-1940s. In December 2000, a government scientific advisory panel recommended that synthetic estrogen be added to the nation's list of cancer-causing agents. HRT, either synthetic estrogen alone or combined with synthetic progesterone, is used by an estimated 13.5 million to 16 million women in the United States.145

The aborted Women?s Health Initiative Study (WHI) of 2002 showed that women taking synthetic estrogen combined with synthetic progesterone have a higher incidence of ovarian cancer, breast cancer, stroke, and heart disease and little evidence of osteoporosis reduction or prevention of dementia. WHI researchers, who usually never give recommendations, other than demanding more studies, are advising doctors to be very cautious about prescribing HRT to their patients.100,146-150

Results of the ?Million Women Study? on HRT and breast cancer in the U.K were published in the Lancet, August 2003. Lead author, Professor Valerie Beral, director of the Cancer Research UK Epidemiology Unit, is very open about the damage HRT has caused. She said, "We estimate that over the past decade, use of HRT by UK women aged 50 to 64 has resulted in an extra 20,000 breast cancers, oestrogen-progestagen (combination) therapy accounting for 15,000 of these.?151 However, we were not able to find the statistics on breast cancer, stroke, uterine cancer, or heart disease due to HRT used by American women. The population of America is roughly six times that of the U.K. Therefore, it is possible that 120,000 cases of breast cancer have been caused by HRT in the past decade.

CONCLUSION

When the number one killer in a society is the health care system, then that system has no excuse except to address its own urgent shortcomings. It?s a failed system in need of immediate attention. What we have outlined in this paper are insupportable aspects of our contemporary medical system that need to be changed--beginning at its very foundations.