FEMA covered up cancer risks to Katrina victims

Documents obtained by Salon reveal FEMA officials ignored scientific advice about toxins in thousands of emergency trailers.

By Sheila Kaplan

FEMA covered up cancer risks to Katrina victims

Last summer, the Federal Emergency Management Agency was publicly shamed when lawmakers revealed the agency, to avoid lawsuits, put off testing trailers used to house Hurricane Katrina victims for formaldehyde, a toxic chemical. Now, documents obtained by Salon show that FEMA also pressured scientists to water down a report on the health risks of formaldehyde. FEMA officials instructed the scientists to omit any references to cancer or other long-term health risks from exposure to formaldehyde in FEMA trailers.

In a scathing letter sent today to Dr. Howard Frumkin, chief of the National Center for Environmental Health/Agency for Toxic Substances and Disease Registry, Reps. Brad Miller, chairman of the House Science and Technology Committee’s Subcommittee on Investigations and Oversight, and Nick Lampson, chairman of the Subcommittee on Energy and Environment, wrote, “you appear to have been complicit in giving FEMA precisely what they wanted … However what FEMA wanted and what you approved giving them was not the whole truth regarding formaldehyde. It was not based on ‘best science,’ nor did it provide ‘trusted health information’ to the Katrina survivors.” FEMA and ATSDR officials are expected to testify Tuesday before the House Committee on Homeland Security, which is also investigating the matter.

After Hurricane Katrina, FEMA placed tens of thousands of displaced families in travel trailers, more than 40,000 of which are still in use. Almost immediately, hundreds of families called FEMA to complain of illnesses, from breathing difficulties, bloody noses and rashes to more serious problems, and even deaths, possibly connected to high levels of formaldehyde gas permeating the trailers. Formaldehyde is a nearly colorless gas with a pungent, irritating odor even at low levels. It is used in many products and manufacturing procedures, notably as an adhesive in plywood used to make trailers. Health reports reveal that exposure to formaldehyde can impact fertility and the developing fetus, leading to spontaneous abortion or physical malformations.

In May 2006, FEMA asked ATSDR to compose a “health consultation” on the FEMA trailers. Dr. Christopher De Rosa, chief of toxicology for ATSDR, told FEMA that any report on health risks of exposure to formaldehyde would have to include information on the risk of cancer and other potential long-term problems. At that point, De Rosa was cut out of the loop. Internal ATSDR documents show that FEMA contacted two of De Rosa’s staffers, who then prepared the misleading consultation. When, nine months later, De Rosa learned ATSDR had omitted the key health information in its advisory, he drafted a letter to FEMA trial attorney Patrick Edward Preston.

“I am concerned that this health consultation is incomplete and perhaps misleading,” De Rosa wrote. “Formaldehyde is classified as ‘reasonably anticipated to be a human carcinogen.’ As such, there is no recognized ‘safe level’ of exposure. Thus, any level of exposure to formaldehyde may pose a cancer risk, regardless of duration. Failure to communicate this issue is possibly misleading, and a threat to public health.”

De Rosa also wrote to Frumkin, noting “FEMA’s initial contact came directly to me nine months ago on this issue.” “I reviewed the proposed statement and specified that they had neglected to address longer term risk including cancer.” After eight months of tense negotiations, a revised report included references to the potentially harmful effects of formaldehyde. But other health information, including the likelihood of other toxic gases, such as toluene, being present, was omitted, as was De Rosa’s insistence that ATSDR call for the government to take immediate action to end formaldehyde exposure to trailer residents and monitor them for long-term harmful effects. Records show that following his protests, De Rosa in October 2007 was “reassigned” out of his long-term post as director of ATSDR’s divison of toxicology and environmental medicine. De Rosa was not available for comment.

In their letter to Frumkin, the lawmakers wrote, “Yet, even after you were specifically told about the scientifically flawed and potentially misleading information in this report and apparently agreed that it should be amended, your agency did not revise this Health Consultation until seven months later in October 2007. Your lack of urgency in this matter is remarkable.” A call to Frumkin’s office was not returned.

In an equally contemptuous letter to Michael Chertoff, who, as head of Homeland Security, oversees FEMA, the lawmakers accused the agency of perverting ATSDR’s mission to provide independent health consultations. “Despite that mission, FEMA insisted that ATSDR produce a report that would meet FEMA’s legal and policy goals, not the public health issues of the residents — some of them ill — of those trailers. Incredibly, ATSDR obliged. As a result, ATSDR stands discredited … We have no confidence that the new testing protocols and sampling design agreed to by FEMA and ATSDR for the current testing are any more trustworthy than the previous one.”

FEMA spokesman James McIntyre acknowledged that the agency did not call for data on long-term effects. In a statement, he wrote: “This agency has and continues to take responsible steps to address formaldehyde in its direct housing units. FEMA has been proactive in reviewing the situation, has recommended a wide range of actions to travel trailer residents that reduce health risks, and has been working with experts to better understand the health environment and to investigate additional short and long-term solutions. The health and safety of residents has been and continues to be our primary concern.”

In April 2006, the Sierra Club discovered high levels of formaldehyde in the trailers, spurring federal testing. Says Sierra Club spokesman Oliver Bernstein today: “At this point, all we can do is wonder whether FEMA is taking this seriously. Nobody should be living in housing that will make people sick. There are still tens of thousand of people, mostly along the Gulf Coast, still being exposed. It’s another example of politics trumping science.”

Dr. Heidi Sinclair, medical director of the Children’s Health Project, affiliated with Louisiana State University, was frustrated by the eight-month delay in making the correct information available. “If people had known about the possible long-term consequences, perhaps more of them would have made an effort to find more appropriate housing for the families that have been stuck in these FEMA travel trailers for two and a half years,” she said. “As people moved out, there hasn’t been a system set up to track people. If you are worried about the long-term possible consequences, it would have been nice, before people moved out, to create a database to track the long-term health of families that stayed there for an extended period of time. It’s going to be much harder now to track people down.”

: Sheila Kaplan is an investigative reporter and television producer who divides her time between Washington, D.C. and Los Altos, Calif. More Sheila Kaplan

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Illuminating the history of medicine

A lush new chronicle of health-related art tracks centuries of scientific gains

SLIDE SHOW

By Emma Mustich

Spike Walker, "Quinidine Crystals," 2006. Polarised light micrograph. (Credit: Spike Walker, Wellcome Images, London)

View the slide show

Topics:Art, Medicine, Health, Books

Sir Henry Solomon Wellcome died in 1936, but his curiosity about human understandings of “the preservation of health and life” — carried forward in the 21st century by the Wellcome Trust — is supremely infectious.

Open “The Art of Medicine: Over 2,000 Years of Images and Imagination” (University of Chicago Press, out now), which spotlights works from London’s Wellcome Collection, and you’ll find illuminations from late medieval medical manuals; 18th-century anatomical waxworks with removable organs; leaves from hand-colored plant and herb guides; early-20th-century lithographs advertising gout remedies; astonishing close-ups of implanting human embryos; and much, much more. The collection is so wide-ranging and diverse as to defy a pithy explanation — but taken as a whole, it’s transfixing.

Emma Shackleton, one of the book’s co-authors, answered a few of my questions over email; the accompanying slide show offers a whirlwind tour of the past few hundred years of medical imagery.

Roughly how many of the images featured in the book do you think were originally conceived by their creators as “art”? How much of the material was intended simply to be instructional?

For the historic works, we often do not know what the creators’ original intentions were. In making the images, they each would have been working within their own stylistic and cultural traditions. So, for example, anatomical representations made in Persia and Asia would have been created in line with particular traditions, in contrast to those of, say, 15th-century Europe, where the artists of “The Apocalypse” would have drawn on existing images in order to create the Organ Man [slide 1], and his accompanying anatomical figures.

There are many images in this gallery that do instruct and inform, yet, even where this is their primary role, they were often made by highly skilled artists and were valued for their artistic qualities too. In the 16th century, for example, Charles Estienne wrote of the aesthetic pleasure to be gained from studying the human anatomy, while Andreas Vesalius commissioned the engravings of his revolutionary book, “On the Fabric of the Human Body,” to be made in the great artistic center of Venice. Their work was appreciated not only by practitioners, but by lay people, too.

However, art relating to medicine has been made for many audiences, and it is the breadth of these perspectives that we were keen to explore and bring together to offer a compelling journey into the landscape of medicine. Some objects and images played a role within spiritual ritual or religious practice; others were made as artifacts intended to protect health or cure disease, as caricatures, as narrative paintings or as contemplative pieces that reflect on personal experiences or medical developments.

Do scientists and doctors today go to the same efforts as their forebears to make graphics, charts, tools and records aesthetically pleasing? How have values changed in this regard?

There is a strong tradition of the sciences and art being intertwined, and this continues. The artist Annie Cavanagh has said of the work she creates with microscopist David McCarthy [slide 9]: “It makes an idea concrete or solid, whereas interpretation of literature can go many ways.” Perhaps their extraordinary micrographs highlight one of the major changes in the visual images that are created today.

In the hands of scientists and practitioners like Annie Cavanagh and David McCarthy, we now have remarkable insights at a microscopic level into the body (so we can gain, say, a view of a blood vessel rupturing or neurons in the brain), of the appearance and actions of viruses and diseases, and the structure of medication. Such images can instruct and inform, yet they also give an aesthetic pleasure and reward the curiosity of a lay viewer.

What do you think is the single most powerful thing the collection says about the progress of medicine over the course of the periods it covers? What’s the most powerful thing it says about the progress of art?

It is interesting that you ask about progress. For me, the most powerful message the collection came to say was one about continuity. This eclectic collection does span major developments in medicine, diverse art practices and many perspectives from different cultures. Yet at the heart of it is the human body, and while we are each individuals across time and location, personally and within our cultures we have had to find ways to understand our bodies and ourselves in sickness and health. So, for me, at the core is a message about the human condition — and that is a thread connecting the past, present and future.

Do you have a single favorite image (or a favorite section) from the book? Is there something in particular you think readers might be surprised by?

I hope you don’t mind if I choose a favorite quality. It is that the images allow us to go on fascinating journeys to explore many strands of medicine across time and place, be they anatomy, medical or surgical practice, disease or medication. Follow the trail of herbal medicine, for example, and the images take us from 15th-century Europe to Japan and 19th-century Tibet, or explore astrology in medicine, and we can see visions of its practice across Europe, in Persia, Asia and Mexico.

View the slide show

: Emma Mustich is an assistant editor at Salon. Follow her on Twitter: @emustich. More Emma Mustich

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Komen for the Cure sells out women, again

The pink-ribbon charity, with a Sarah Palin ally as senior policy director, turns its back on Planned Parenthood

By Mary Elizabeth Williams

Karen Handel and Sarah Palin in August, 2010. (Credit: AP/John Bazemore)

Topics:Breast cancer, Health, Planned Parenthood, Cancer

First, the good: Since its founding 30 years ago, Susan G. Komen for the Cure has put over a billion dollars toward research, screening and awareness in the name of eradicating breast cancer. It’s certainly no coincidence that in that same span of time, breast cancer rates have declined sharply, and what was once a devastating diagnosis is now, for many, a treatable condition.

Yet when the news broke Tuesday that Komen was ending its funding for Planned Parenthood breast cancer screenings and services, the organization’s eagerness to throw Planned Parenthood – and the women who depend upon it – under the bus wasn’t surprising. It’s actually thoroughly unshocking for this venerated organization to pull such a crass, insensitive move.

The very name Susan Komen — with its direct association with a real woman, and founder Nancy G. Brinker’s promise to fight the disease that claimed her sister — is heart-tugging. Today, everyone who knows a woman likely has a breast cancer story – and with it, a Komen-flavored story about donning a pink T-shirt and running in a Race for the Cure, or shopping in October for pink-themed “Girls Just Want to Have Fun” notepads to help raise “awareness.” Along the way, Komen has become the McDonald’s of cancer — an easy-to-remember brand with a logo that demands little thought or effort from the consumer. Write a check, buy a ribbon, voila! You get to feel like you’re curing cancer.

It’s not that Komen is some questionable, Wyclef Jean-esque mess. It gets high marks from both the Better Business Bureau and Charity Navigator. Yet this is an organization that has repeatedly come under fire for its extravagant promotion of itself as an organization dedicated to a “cure,” when only a small portion of its expenses go to, you know, curing cancer. Komen itself cops to portioning just 24 percent of its funds to research – and 20 percent to fundraising and administration. For an organization with reported revenues of nearly $350 million, that’s still a lot of money for research. It’s an awful lot for itself, too.

Yet Komen remains pretty damn territorial around that whole “cure” thing. In a 2010 story for the Huffington Post, writer Laura Bassett pointed out that, according to Komen’s own financial records, it spends almost “a million dollars a year in donor funds” aggressively going after other organizations that dare to use the phrase “for the cure” – including small charities like Kites for a Cure, Par for the Cure, Surfing for a Cure, Cupcakes for a Cure, and even a dog-sledding event called Mush for the Cure. Let me just give you that number again. A million bucks a year. Robert Smith, better watch your back.

Komen has also, in its relentless pursuit of ubiquity and corporate sponsorship, aligned itself with more dubious product placement than a “Jersey Shore” marathon. It has a whole online store encouraging visitors to “purchase with purpose to end breast cancer forever,” where you can buy “silicone bling watches” and “Passionately Pink” ribbon-shaped cake pans. And because you’ll have to root around for the numbers, you can spend extravagantly on candles and “spirit gloves” without knowing that merely “at least 25 percent of the retail sales price … will go to Komen to help support … research and community programs.” Twenty-five percent of that $4.95 dog leash? Why, that’s more than a whole dollar!

Komen also famously outsources its merchandising. It’s teamed up with the likes of KFC for “Buckets for the Cure” – because nothing says you care about women’s health like a big vat of fried chicken. Komen has additionally sold a pink-hued “Promise Me” perfume that contains several toxins – including galaxolide, a synthetic musk that critics claim is a hormone disruptor. Komen has promised to reformulate the scent this year, but as Uneasy Pink calculated last spring, that’s still a lot of questionable chemicals to buy when roughly only 3 percent of the purchase price will go to Komen’s oft-invoked “cure” anyway.

And what of Komen’s latest, most potentially damaging stunt with Planned Parenthood? Komen says the move is just about “newly adopted criteria barring grants to organizations that are under investigation by local, state or federal authorities.” You know what else is pretty “new” around Komen? Its senior vice president of public policy, Karen Handel. During the Sarah Palin-endorsed, Tea Party favorite’s 2010 campaign for governor of Georgia, Handel declared, “I do not support the mission of Planned Parenthood,” making clear that she “strongly supports” laws prohibiting “the use of taxpayer funds for abortions or abortion-related services.” She did, however, emphasize that she “strongly support(s) the noble work of crisis-pregnancy centers.” If you were one of the world’s biggest charities and were looking to hire someone who had women’s welfare as her greatest imperative, would you go for someone who’d send them to a place that offers breast cancer screenings – as well as ovarian cancer screenings and HPV tests? Or someone who prefers a bunch of right-to-life fanatics pretending to be a medical facility? If you picked the former, you’re smarter than Komen for the Cure.

That Komen has raised staggering amounts of money is undeniable. There’s also pretty compelling evidence that it has done so in some pretty boneheaded ways. So given its track record, it’s fair to ask what happens now to the 11 percent of the Komen budget that goes to screening. Does it get funneled toward more glitter bracelets and “Promise Bears”? And what happens to the women who depend upon Planned Parenthood to tell them whether or not they have breast cancer? What becomes of mothers and daughters and wives and friends who believed that Komen’s commitment to “the cure” meant something more than protecting its catchphrase? It’s worth noting that while breast cancer rates are dipping, an October report from the American Cancer Society warned that they are declining more slowly among low-income women, and that “Poor women are now at greater risk for breast cancer death because of less access to screening and better treatments. This continued disparity is impeding real progress against breast cancer.” You know who loses when Komen backs away from Planned Parenthood? Probably not those nice, pink-clad ladies who attend Susan Komen wine-tasting events.

Women’s healthcare is not about lace-trimmed scarves and bottles of perfume. It’s sure as hell not about some feel-good, lip-service version of what my colleague Rebecca Traister calls “infantilizing Pepto-ed advocacy.” It’s not even — for anyone still stupid enough to think Planned Parenthood is some giant fetus-killing complex — about abortion. It’s about screening. It’s about treatment. It’s just that simple. The further away an organization gets from that mission, the more women suffer. It’s just that simple too. And you don’t make good on a “promise” to your dead sister by selling out women who need you most.

: Mary Elizabeth Williams is a staff writer for Salon and the author of "Gimme Shelter: My Three Years Searching for the American Dream." Follow her on Twitter: @embeedub. More Mary Elizabeth Williams

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L.A.’s porn mistake

As an actress who's worked with and without condoms, I can tell you: Mandatory enforcement is misguided

By Lorelei Lee

Lorelei Lee

Topics:Pornography, Sex, Health

Yesterday, in a widely anticipated vote, the Los Angeles City Council passed an ordinance requiring condoms to be used in all permitted adult films shot within their city limits. This move may be well intentioned, but having worked as a performer and director in the adult film industry for the last decade, I see this as an ineffectual move that might be bad news for the performers it ostensibly protects.

According to the ordinance, adult film production companies will pay an additional fee with their permit applications to cover an as-of-yet undetermined method of enforcement. Currently, condoms are used in the mainstream gay adult film industry (which includes only gay male films), while the heterosexual industry (which includes both lesbian and straight films) has used mandatory STI testing as a health and safety precaution since the early 2000s. Until May of 2011, the Adult Industry Medical Center, founded by retired performer Dr. Sharon Mitchell, ran the nationwide STI testing service and database that certified heterosexual performers as STI-free previous to their working on any production.

The ordinance comes in response to a campaign spearheaded by Michael Weinstein, head of the San Francisco-based nonprofit AIDS Healthcare Foundation. In the last few years, Weinstein, alongside similarly agenda-driven Shelley Lubben of the Pink Cross Foundation, has aggressively campaigned to mandate the use of condoms in heterosexual adult films, enlisting half a dozen adult performers, boycotting the Marriott Hotel chain for carrying condom-less porn, suing the L.A. Department of Public Health, and staging protests throughout Los Angeles at industry events and at AIM headquarters. Weinstein called AIM a “fig leaf” over the adult industry and backed the lawsuit that led to the organization’s financial insolvency and shutdown last year, which left a vacuum in health and safety protections in the industry. Weinstein seemed to hope that leaving performers without any kind of health protection would force legislators to mandate condom use. If the city of Los Angeles had not passed the ordinance this week Weinstein had a backup plan: Using AHF funds, he had collected 70,889 signatures to put the condom-mandate question to Los Angeles voters in June, a move that would have cost L.A. $4.4 million.

Among performers I know, there is a mix of opinions as to whether they mind actually using condoms on set themselves – a different question than the one of a legislated condom mandate. Some, like Nina Hartley, who is also a sex educator and has training as a nurse, are strongly opposed to using condoms at work, believing that they may actually increase likelihood of STI transmission. Personally, I’m not opposed to using condoms during my shoots – in fact, I already do. I became a condom-only performer in 2010, after eight years of working non-condom. But during my time as a non-condom performer, I never once contracted an STI on set that condoms would have prevented, and truthfully, I’m not sure that condoms actually keep me safer than testing alone. Further, I would never want to work on a set that required condoms in lieu of STI testing. The company I’ve worked for since 2010 is a fetish company, and as such, there is less emphasis on penetration in most of the scenes I shoot – meaning that I worry less about what Nina Hartley oh-so-glamorously calls “friction burn.” AIM founder Sharon Mitchell was also not opposed to condom use in porn; in fact, she may have given Weinstein the idea of targeting the Marriott.

What Mitchell was opposed to, and what I and every other performer I can think of is opposed to, is regulating a condom mandate through city or state government. The most basic reason is that ordinances like the one passed this week will not have the effect of increasing condom usage in straight porn. The adult film industry has only been legal for roughly 30 years. It is still looked down on by many civilians as a shameful business, and the workings of the industry are still, in many ways, shrouded to outsiders – which is a good or bad thing depending on whom you talk to. Many of the people attracted to this industry are still those who don’t care a lot about public opinion or about obeying authorities. In the case of a condom mandate tied to permits, many producers will simply shoot in Los Angeles without a permit. Others will move production outside of the city – to places like Las Vegas, San Francisco or Miami, where some companies are already established. With that in mind, I do have to wonder if moving porn outside of L.A. may be closer to what the City Council is actually after.

What performers like Hartley and I are equally opposed to is being condescended to by hypocritical zealots like Weinstein and Lubben who are obviously motivated by a concern for something other than our health and safety. Who have, in fact, shown a “blatant disregard” for the health and safety of industry workers by making it more difficult for us to use the protections we already have in place when their actions led to the closure of AIM. We’re also opposed to the squandering of AHF resources – resources that could be effectively used to help prevent and treat HIV and AIDS – on a political campaign against an industry whose health and safety regulations are already working. In the decade since AIM began the program of mandatory testing, six performers have tested positive for HIV, and only three of those have shown to be from on-set transmissions. That’s three transmissions during the course of filming tens (or perhaps hundreds) of thousands of scenes. There are no real statistics as to how this compares to transmission rates in the general population. Rather than concrete evidence, Weinstein has used references to AIDS as a scare tactic, leading those who have been affected by the disease, like City Councilman Bill Rosendahl, to believe that a condom mandate would actually have some effect on HIV transmission rates. Condoms, even when used “consistently and correctly,” do not have a 100 percent success rate. Although numbers vary, one study showed condoms to be only 80 percent effective against HIV transmission in couples of different sero-statuses (in which one partner is HIV positive and the other negative). I have a hard time believing that condom mandate, if it is even possible to enforce, is likely to have a higher success rate than testing.

Weinstein has remarked that the L.A. attorney’s office is trying to “thwart” voters’ will, but what stake do Los Angeles voters have in this matter? I’ve heard too many times the claim that the adult industry is acting irresponsibly by portraying barrier-free sex when – as the argument goes – people of all ages are getting their information about sex from pornography. But the overwhelming majority of porn is fiction, and the world it portrays is one of fantasy. I have to believe that most people who encounter porn know this. We don’t generally expect other forms of entertainment to be responsible for disseminating health and safety information. If pornography is in some capacity replacing sex education for people in this country, then mandating condom use is a ludicrously indirect way of addressing that problem.

Industry workers and civilians alike may recognize the implications that government regulation in this arena could have for free speech and privacy, a position articulated by law professor David Groshoff in the Huffington Post earlier this month.

Of course, another reason that performers oppose a condom mandate is that porn with condoms doesn’t sell as well as porn without condoms, and that leads directly to fewer jobs. After four performers tested positive for HIV in 2004, many of the big L.A. studios tried making condom-only films. All but a few lost enough money that they went back to shooting non-condom. In the last five years, porn sales have been deeply reduced by Internet pirating and the proliferation of “amateur porn.” There are fewer scenes being shot in the valley, and performers are working significantly less. No one wants to lose more work. If consumers really want to see adult productions use condoms, then voting for a condom mandate is not the way to make it happen. The only effective way to make condoms standard in adult productions is for consumers to vote with their wallets, by actually buying porn in which condoms are used.

: Lorelei Lee is a writer, and porn performer and director More Lorelei Lee

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The real key to good health

Don't fear resolutions or dread the January fitness crunch. Just make yourself one simple promise in 2012

By Mary Elizabeth Williams

(Credit: Shannon Stapleton / Reuters)

Topics:Health, Obesity

January sucks. Every magazine cover is festooned with the image of a celebrity in a bikini, promising you the secrets of a BETTER BODY for the new year. Your friends are all going on juice fasts. And the answer to “Feel like going for a bike ride today?” is “Maybe sometime when it’s not 11 degrees out.”

So here’s a crazy idea. This time, let’s not use the beginning of the year as an excuse to hate on our bodies. Let’s not swear to get a tinier butt by Memorial Day, or even Labor Day. No 21-day “action plans.” No master cleanse. Nothing, in fact, that sounds like an enema from a dominatrix. Instead, let’s do something radical. Let’s do something small.

In just the time it takes to realize that “Work It” is the worst thing that ever happened to television, you could change your life. Thirty minutes a day. That’s the minimum amount of physical activity the CDC recommends to stay fit. Yet approximately 30 percent of Americans get no weekly activity at all. Zero. Not even candy-ass pastimes like gardening. And many more of us aren’t exactly wearing out the gym membership cards. Right now, the only thing moving at a fast pace in our country is the obesity rate – 30 percent and climbing.

In an already over-saturated life full of work and family and errands and commuting, it’s often grueling to find 30 minutes to do anything at all. There are days when carving out a window of opportunity to grab a shower feels like a big deal. But I promise, a half-hour is not a lot of time. Treated seriously and honored consistently, it’ll do a lot more for your health and well-being than that spinning class across town you go to once a month. And don’t you deserve as much loving attention as you’d give your car or your iPad?

Here’s what you need. Sneakers. A mix of cardio and strength training. An understanding that you can’t fool your body by not making an effort. A casual saunter on the treadmill while tweeting isn’t going to do jack. You know that lady in the Apple Siri ad, the one who wants to be reminded to call Chris while she’s going for a run? Yeah, don’t be her. No talking on the phone. No checking the weather. And no excuses. Thirty minutes to put in real work, whatever work feels like for your fitness level. (Here’s the inevitable reminder that this isn’t medical advice, and you should talk to your doctor about a plan that’s realistic for you.) Here’s the payoff. Research says that you can build bone density and ease the symptoms of arthritis, high blood pressure and even depression. If this stuff came in a pill, it’d be hotter than Viagra and Effexor put together.

Like a lot of people, I spend most of my days on my butt. Yet I have a beautiful heartbeat. When I see my doctor for my weekly health monitoring, he smiles appreciatively as he presses the stethoscope to my sternum, praising my “slow, steady, runner’s rate.” And last summer, shortly before my lung surgery, the respiratory technician was similarly complimentary. “Look at that pulmonary function,” he said encouragingly as I puffed into a tube. “I can always spot the yoga people.”

Now here’s what you need to know about me. I was always chosen last in gym class. I can’t open a jar of pickles without assistance. I don’t train for marathons. I will never be on the cover of a magazine, Valerie Bertinelli-style, flaunting my abs. I have a body that’s over 40 and has birthed two children, and looks it. And many days, I don’t want to get out of bed. But I put in three and a half hours of exercise a week – mostly running, mixed with the use of a pair of five-pound dumbbells and a yoga app on my phone. I breathe hard. I stretch muscles. I resist gravity. Then I’m back on my butt, possibly holding a beer. That’s it.

Good health should not be reserved for the perky sporty types. Screw the jocks. Almost everybody, of every age and fitness level, can afford a half-hour a day. You can. Why am I telling you this? Because when the surgeon had to cut some cancer out of my lung last August, I was pretty happy I could breathe unassisted afterward. And because I hope that if you’re ever in a similar situation, you are likewise prepared.

This year, it’s not about fitting into those jeans that linger accusatorily in the back of the closet. It’s not about the scale. It’s about getting in touch with what we humans were meant to do – move around. It’s about taking the stairs. It’s about being able to play with your kids. It’s about those sweet, sweet endorphins. And it’s about knowing that though we’re all different, we’re all capable of greater wellness. Is it hard sometimes? Does it get boring at times, day in and day out? Sure. Is it achievable, and is it worth it? Always. But don’t listen to me. Listen to my beautiful heartbeat. Now get out there and thump along. And tell me about your progress — I’ll be right alongside, cheering you on.

: Mary Elizabeth Williams is a staff writer for Salon and the author of "Gimme Shelter: My Three Years Searching for the American Dream." Follow her on Twitter: @embeedub. More Mary Elizabeth Williams

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Why doctors can’t say no

Often it's easier to just say yes. But there are ways to say no that are better for both physician and patient

By Rahul K. Parikh

Conrad Murray (Credit: Reuters/Salon)

Topics:PopRX, Michael Jackson, Health

Doctors routinely meet with patients who make requests for specific medicines, tests and referrals to specialists. In this era of the Internet, consumer-driven healthcare and direct-to-consumer drug marketing, this is no surprise. And while an informed patient is a good thing, what may surprise you is just how hard it is for doctors to say no when a patient makes a specific request for something he or she doesn’t really need.

Right now, Dr. Conrad Murray sits in jail because he couldn’t say no to Michael Jackson when Propofol came up in conversation between them. But even doctors who aren’t tempted by an enormous monthly retainer and access to one of the world’s biggest celebrities are challenged by the word “no.”

American medicine is a business — but a weird one. In any other sector of our economy, businesses are determined to give their customers what they want, however they want it. But in medicine, the “have it your way” mind-set doesn’t always jive. First, physicians have a duty to avoid doing harm. The choice of a drug or test based solely on a patient’s request can undermine that. Second, as everybody knows, we spend a big slice of our GDP on healthcare. Since the person who has control over expensive tests and the prescription pad is your doctor, there’s ever-increasing scrutiny to be responsible stewards of healthcare dollars.

All these factors come to life in the exam room. Case in point: I periodically get requests from parents to prescribe cough medicine for their child that contains codeine. Besides the codeine, the drug contains alcohol, naturally leading to a better night’s sleep for child and, hence, the exhausted parent. But there’s no evidence that this cough medicine helps the child get better any faster, and it may even be dangerous. Should I prescribe it or not? The evidence says no, but to say that can lead to a confrontation with an angry parent. Though cough medicines aren’t expensive, if it’s hard to say no to something that simple, it’s even harder when the stakes are higher — an unneeded new drug, a CT scan, a referral to America’s top cardiologist.

The phenomenon of how requests impact the patient-doctor relationship has been studied extensively by Dr. Richard Kravitz at the University of California at Davis. Kravitz’s research has shown that somewhere between 10 and 25 percent of patients bring a specific request to their doctor (the high end of that range is between a patient and his or her primary care doctor). Here are some of his sober conclusions: Patients who do not have their requests met rate their physician lower, are less likely to adhere to their doctor’s recommendations, and use more healthcare resources than those who do get their request.

Physicians who encounter the patient with a request report those visits to be stressful and unsatisfying as well. But if you’re wondering who wins, Kravitz suggests it’s the patient, though just slightly. He and his team looked at how doctors responded to patients’ requests for an antidepressant medication. Fifty-six percent of the time, patients got the drug they wanted.

Why is it so hard for doctors to say no? To be honest, it’s often just easier to say yes. Usually, we’re behind schedule, with a waiting room full of impatient customers, and we have a desk full of phone messages to return and charts to finish. To take even a few extra minutes and open the conversation — even a confrontation — about a request is time and energy we don’t want to expend. So we put pen to paper, rip the script off the pad and hand it to them as we rush out the door.

The other thing is that nobody really teaches us how to say no. It seems ridiculous, but neither Kravitz nor I could remember an instance during medical school or residency when we were coached about how to manage inappropriate requests from patients. Many of us probably figure out ways to parry the patient over time, but not without inflicting some damage. Back to the example of cough medicine requests for kids: I remember earlier in my career when, on a very stressful day, I walked into a room with a teenage girl and her mother. The mother directly asked for a codeine-containing cough syrup. I knew better, and I wasn’t about to let this parent have it. “No. Look,” I bluntly replied, “it only works because it contains alcohol. Why don’t you just go out and give her a glass of Scotch.” It was not my best moment doctoring. I’ve taken a long and bumpy road since to get better at managing patient requests. These days, I’m more likely to explain the issue, decline the request, ofter an alternative, apologize for any inconvenience, and make sure they know they can always seek a second opinion.

Kravitz’s research, in fact, does reveal that there are ways to say no that are better for both doctor and patient. In Kravitz’s aforementioned study where patients requested an antidepressant, he was able to categorize how doctors handled patient requests. The most successful method is for the doctor to exercise a little curiosity and delve deeper. It’s not surprising, for example, to find out that a patient who comes in with headaches wanting an MRI had a friend or relative who died of a brain tumor, or one with a cough who wants an antibiotic who knew someone hospitalized with pneumonia. If both patient and doctor can get to the root of the request, they can, in many cases, discuss it and figure out a third way.

The second way doctors in the study managed patient requests was to try to order some tests. While it can be a successful strategy to look for “objective data” to help reassure a patient, it isn’t always cheap or safe. Labs and X-rays don’t cost much individually, but the volumes of them that doctors order add up fast. Unnecessary tests beget more unnecessary tests. For example, if I order blood work for a patient who I don’t really think needs it, and one of the numbers — one that has nothing to with why I ordered the test — comes back slightly off, I’m stuck having to call the patient and tell them to repeat the test, even if the child is completely fine now. All of us have had a test or radiology result we ordered just to satisfy a patient come back to bite us like this.

Kravitz and I both agreed that “patient-centered care” or “shared decision-making” are euphemisms for negotiation. And perhaps, like other professionals, we in medicine ought to focus more on negotiation tactics (Kravitz’s last paper is called “Getting to ‘No,’” a riff on the famous business book about negotiation called “Getting to ‘Yes’). This may sound coldly corporate to the average patient who has ever wanted something from their doctor, but it’s a reality we need to address. In pediatrics, where limiting the overuse of antibiotics is a priority, it’s recommended that doctors not prescribe drugs in most cases of middle-ear infections. Instead, since evidence suggests most ear infections get better on their own pretty quickly, we can treat a child’s pain with over-the-counter drugs like ibuprofen. But just in case things don’t get better, we often keep an antibiotic prescription ready for the child for the parent to fill. Doctors call it a “safety-net prescription,” but MBAs know it as a contingency — a common negotiating tactic to satisfy both parties during a negotiation.

Finally, for doctors who are still entrenched in the belief that patients shouldn’t be asking for anything, or for patients who are too timid to speak up, Kravitz has some interesting findings: In cases where the patient had a specific request but didn’t make it because they were uncomfortable, pressed for time, or because the doctor’s bedside manner didn’t afford the chance, that patient left less satisfied. Doctors, too, rated the visit where something was left unsaid as more difficult.

The lesson here is that it’s best for the doctor and the patient to get everything out in the open, and for a healthcare system that affords the right amount of access and time — especially in primary care — to make that to happen.

Rahul K. Parikh is a physician and writer in the San Francisco Bay Area. He wrote the Vital Signs column on Salon in 2008-2009. His pop culture-medical column, PopRx, runs on alternate Mondays.

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