[inaudible conversations] up next on booktv from the 2014 virginia festival of the book dr. Otis brawley talks about how medicine is practiced in the u. S. And argues the rich are overtreated, the poor are undertreated and doctors, Insurance Companies and big pharma make money by taking the vantage of both groups. This is about an hour and 10 minutes. Good evening. Welcome to this nice event, thank you for coming. My name is rob richards, an oncologist and chair of the cancer committee. We have a lot of hospitals that make the speaker, dr. Otis brawley, he wears many hats and is currently a professor of human policy, oncology, medicine and epidemiology at emory university, the centers for Disease Control and prevention on Breast Cancer and young women. In addition he served as chief medical officer of the American Cancer Society and is responsible for promoting cancer prevention, Early Detection and quality treatment. He is an acknowledged the year in Health Transparency treatment, to live in disparity and quality cancer. He has received numerous awards including the key Saint Bernard parish for the Public Health service in the aftermath of hurricane katrina. And about being sick in america and his thoughts on care today. Join me in welcoming her doctor otis brawley. [applause] it is wonderful to be here. I want to say thankyou to the organizers of the virginia festival of the book. I want to thank the staff at Martha Jefferson hospital for sponsoring me, and dr. Charlotte mcdaniel, wonderful emphasis for arranging to meet to be here to offer you today. A little bit about me i was born in detroit, michigan and had the fortune of attending jesuit high school, very good jesuit priest in still on me some thinking about ethics and social justice. I went on to go to medical school and actually applied many of those lessons as i practiced medicine for 30 years. Sorry about the feedback. One of the things, one of the jesuits told me early on, is that we should always remember what it is we know scientifically, what we dont know, and what we believe and we need to label them accordingly. When i went to medical school in reminded me doctors have an extremely bad habit of confusing what they believe with what they know and after 30 years of practice of medicine i have determined that is incredibly accurate. I trained as a medical oncologist and epidemiologists to look at outcomes, what things work, what things dont work in terms of treatment and overtime i realized there were tremendous disparities in medicine, there were people who had incredibly bad outcomes because they did not get enough care but the big surprise there was a group of people who had bad outcomes because they had too much health care and the title of a book, how we do harm, talking about those who dont get enough health care, the realization we could do better about the Health Care System if we were a little more rational in how we practice medicine. Many politicians will talk about rationing of medicine. We need to be rational in our practice of medicine. That is a little bit different. At the same time, started looking at health care costs. We spent 2. 7 trillion on health care in the United States in 2011. I dont know what to do to stop that. 2. 7 trillion is an awful lot of money. With the 1. 1 million on food that year, 2. 7 trillion on health care. Amounts to 8,100 for every man, woman and child in the United States. Lets compare that to other countries. If American Health care were an economy it would be the sixth largest economy in the world. We spent 2. 7 trillion on health care in the United States and there was 2. 6 trillion spent on everything in france in 2011, the sixth largest economy. We spent 800 for every man, woman and child on health care, the second most expensive country in switzerland, 4,300 for every man, woman and child. At the same time were spending this money on health care our outcomes are not very good. Life expectancy overall, 56 and 26, when we look at white male life expectancy, we are four years different between the United States and canada. We like to bash the canadian Health Care System, canadian Health Care System is more than half the price of the american Health Care System on a per person basis. Started realizing that the incredible cost of health care in the United States was actually depressing the economy of the United States significantly. If we were switzerland the second most expensive country in the world, if you were a company that employed 300 people. That Company Giving health care to its employees the average cost of switzerland would be 10,000 a year for a family. The average cost in the United States for a Family Health care policy for an employer in 2011 was 1,800. Just imagine you have savings employee and 300 people you might employee 306. And various Small Companies in the United States very quickly 7 rate unemployment, 5 or 6 unemployment. Health care is already, negatively affecting the United States. We have this incredible outcome that are not very good, we have outcomes that are not very good compared to other countries. Suddenly underlying corruption in medicine is what we wrote about in the book. Underlying corruption involves not just greed. Theres a problem with a lot of folks who make money and the doctors, the hospitals, the Drug Companies, even the patients that are part of this underlying corruption. It is not just greed, the corruption of lack of respect for what we know. It is a mindset problem. Confusing what we believe with what we know. Let me give you some examples. In 1903, dr. Hall said told us how to do a mastectomy, Breast Cancer surgery, removing the breast for Breast Cancer and he described going all the way down to the ribs and up to the third level of nymph no. A mastectomy in 1903 was unable to raise her arm higher than this for the rest of her life and always had swelling. We did the halsted mastectomy into the 1980s. In the 1930s and 40s doctors were saying we have to do this to the iran operation . And the loss academic careers because they questioned the halsted mastectomy. The halsted mastectomy was an inappropriate operation and has been dead for 20 years. Quite honestly, Bernie Fisher from pittsburgh and another physician from milan, did a series of Clinical Trials with difficulty in the 1960s and 70s 70s, removal of the entire breast, incredibly morbid procedure, you could just remove the outer breast further on the show, just remove the cancer and radiation the breast and all equipment in terms of outcomes. The halsted mastectomy and most other things might be relevant operation, the halsted mastectomy was too much of an operation and we did it in the United States for 40 additional years and we criticize anybody who questioned if what we were doing was the right thing. Numerous examples of this. I will stick with Breast Cancer for a second. In the early 1980s a couple of doctors from boston and doctors from boston tend to be very smart, said the way to deal with Breast Cancer is to give high doses of chemotherapy and noted with high doses of chemotherapy the tumor shrank. If we gave even higher doses of chemotherapy to women who had surgery to remove all known cancer would probably still have cancer left in their body, maybe we could cure the of Breast Cancer. What problem was the bone marrow was an innocent bystander that was obliterated with this high dose of chemotherapy but so they came up with a procedure called bone Marrow Transplant where you could take a womans bone marrow, store it in a freezer, give her the high dose of chemotherapy. When her chemotherapy cleared her system, give her her bone marrow back. It seemed to be the right thing to do theoretically. These doctors believed it was right. We in the United States started doing it like crazy. In the 1980s and 1990s women would sue their Insurance Companies for bone Marrow Transplants with Breast Cancer and the Insurance Companies didnt want to pay for it for one reason. Is very expensive and two reasons, there was no Scientific Study to show it was beneficial. There was opinion that it was beneficial. Ten stake in legislatures passed laws and said insurances must pay for this procedure. Most of them still have it on the books and is quite interesting. In 1999, 19 years after they started the bone Marrow Transplant in the United States, three studies were ultimately published. These studies were very difficult to do, especially the one in the United States. Who would go into a trial to see a bone Marrow Transplant actually worked when Everybody Knows bone Marrow Transplant works . These three studies, one from the United States and two from europe, published back to backtoback in the new england journal showed that bone Marrow Transplant was more harmful than standard care and within three months of the publication of these three articles, 210 bone Marrow Transplant centers in the United States for Breast Cancer all closed. 65,000 american women had been transplanted in the 1990s. All of this was done and this industry had been created without a Clinical Trial to actually show bone Marrow Transplant for Breast Cancer saved lives. Lets go closer to something that happened even today. I actually was talking to a patient, wonderful man who lives in ohio who called me up because of my concerns about Prostate Cancer screening. His story was that his wife encouraged him to go to this screening being offered by the local hospital and he went to the screening that was held in a mall. He got a letter a week later saying his test was suggested he go to this particular doctor and this particular doctor had all these men have had gone the same letter in his office and this doctor ultimately after a couple weeks had done a biopsy and determine if this guy had Prostate Cancer. It appeared to be localized to the prostate and this fellow started really freaking out because he was diagnosed with Prostate Cancer. Didnt really like this doctor so he started shopping for another doctor, another young doctor in the same town was now using this robotic machine. One of the things, it is new, it must be better. So he ended out getting his prostate surgically removed like this machine by young fellow but his psa state elevated. It never went to zero. He has no prostate. His psa should be zero so he started worrying about this and kept worrying, they reassured him, kept worrying, finally went to radiation oncologist and convinced this oncologist to radiate his pelvis. We call it a shotgun radiation to the pelvis where you radiate the entire pelvis and hope we hit some cancer. When the fellow called me, all of this had been done. He had one for school and one for your and where he had all kinds of radiation damage to his palace and was in and out of a hospital all the time with urinary sepsis, urinary Tract Infections that actually led the bacteria in his blood. He asked me why was i against plastic screening . I explained to him by wasnt against Prostate Cancer screening. I am concerned about Prostate Cancer screening, i am concerned about how it is being promoted and concerned about whether it saves lives but everybody is saying it saves lives. I went on to explain about an experience i had in 1998 after i attended the white house ceremony, very moving ceremony where president clinton apologized for the fact that the u. S. Government had lied to 600 putin in tuskegee, alabama in something called the Tuskegee Syphilis study. Two weeks later i went to a Cancer Center, very famous Cancer Center in the United States and since i worked for the federal government at the time, they bring out the dog and pony show to talk about how great their research is. I was sitting next to their marketing guy, started talking to him, just want to let you guys know, marketing people are evil. Be very careful. He started explaining to me there Business Plan for Prostate Cancer screening. And announce Prostate Cancer is going to be free and getting at a certain moral in 6 weeks but it is predictable how much increased business, and the hospital cares about their man. It is predictable how much increase in Business Hospital is going to get in their chest pain center. They know how much brief publicity they are going to get and if we announce the free screening we get the equivalent of this much of what we pay, how much we paid to the local newspaper in publicity. Then he explained to me that they had done this for several years now and it was all in the Business Plan. If they go to this small, 155 will have abnormal screening. 155 will have insurance their hospital doesnt take, god bless them, that will help their competitors. 145 are going to come to them to be evaluated for their Prostate Cancer. About 3,000 per person for the evaluation and 145, 45 are going to have Prostate Cancer. You know the percentage that we are going to get radiation feeds, the percentage that we get external beam radiation even explain he liked external beam radiation because the fees for that were 80,000. It got better. He explained to me that if we screen 1,000 guys and diagnose 45 with Prostate Cancer this is the proportion of guys with urinary incontinence to the point diapers dont do it for them so if they screen 1,000 guys this is how many artificial sphincters, he had the apology and explained to me there was a new drug called viagra, how many female press that were going to implant in men upset about the importance caused by Prostate Cancer. He is stopping me, i am a smart guy, if you scream thousand guys how many lives are you going to save . He was a complete and utter fool, dont you know there was never a study to show this saves lives, it was all about making money. That is when i realized we have a huge ethics problem in the United States. The first study ever published to suggest this actually saves lives, in 2011, for every 200 men treated for Prostate Cancer you prevent death and caused death and the other 190 have all the side effects of the treatment. You may get better as you get further out in terms of the followup but at 11 years those are the numbers. That is by the way the good study that shows that it actually might work. Studies out there suggest that it doesnt. So i started worrying about this low level of corruption in medicine where we are interested in making money and stop asking questions. That hit doctors pretty hard with three examples. Let me talk about the Drug Companies. Their is this Company Called asters and poinrazeneca. And i name names. They added four year patent on exclusivity. They were making billions of dollars on the sale of prozac. They came up with the project. They call it operation shark fed. Was the Manhattan Project to find the next multibilliondollar drug and looked at numerous Different Things and finally came up with difficult to talk to a non science audience but i will try it. Prilosec is a large 3dimensional molecule and the chemist actually talks about this molecule being 3dimensional and there is a mirror image called isomers. Theyre left and a nice summers and righthanded isomers. The lefthanded i summers possesses acid. The righthan