As British cattle began dying of a mysterious wasting disease in the late 80′s, the agriculture minister tried to reassure a nervous public that eating beef was safe. John Gummer posed for cameras with his 4-year-old daughter, Cordelia, each clutching a burger. When the girl refused to eat, Gummer took a bite of hers. “Delicious!” he proclaimed. By the time the European Union banned exports of British beef six years later, the cattle industry was devastated and several people in England had already died from a deadly, brain-wasting disease.
Flash forward to Wisconsin.
Chronic wasting disease (CWD), an illness strikingly similar to mad cow, is spreading to deer in the state, its first appearance east of the Mississippi. Many frightened hunters are sitting out the season, and demand for hunting licenses is down 22 percent.
To kick-start the deer season, hunter and Republican Gov. Scott McCallum, up for reelection this year, boasts that he’ll stalk his prey with bow and arrow. Not to be outdone, Ed Thompson, the Libertarian gubernatorial candidate (and brother of Tommy Thompson, secretary of the Department of Health and Human Services), stages a venison chow-down at a meat processing plant inside the disease hot zone. Thompson wolfs down two deer bratwursts with sauerkraut, smacks his lips, then commands: “Go ahead and hunt. Eat your venison.”
It couldn’t happen here — could it? The British experience demonstrated how critical it is to move fast to contain a health threat. So-called “new variant” Cruetzfeldt-Jakob disease (vCJD), a particularly brutal illness linked to mad cow that erodes brains and quickly drives its victims mad, has already claimed 130 lives. The first U.S. victim, a 22-year-old Florida woman born and raised in Britain, was identified last week.
It could happen here. Though scientists once almost uniformly scoffed at the idea that CWD posed any threat to domestic animals or humans, many are worried now. CWD prions — the family of mutant proteins that cause the disease — may have already claimed human lives in this country. There’s no physical evidence yet, but the rapid spread of the disease among elk and two different species of deer, its jump east across the Mississippi into dense populations of game and farm animals, and a rash of suspicious deaths among hunters are raising alarms.
Some health professionals and activists argue that not enough is being done to protect consumers, hunters, and the beef cattle and dairy cows that sometimes share pasture with infected game animals and were fed road-kill deer as recently as seven years ago.
The Wisconsin Department of Natural Resources, which relies on fees from hunting and fishing licenses, continues to reassure hunters there’s no evidence that humans can catch CWD from consuming venison. It cautions hunters to avoid obviously ill animals (though deer may be infected without showing symptoms), and to wear rubber gloves when butchering deer and avoid cutting into or consuming neurological tissue. Some hunters too squeamish to eat their kill are donating the venison to pantries for the homeless.
“My son and I went bull hunting this weekend,” boasted Tom Hauge, director of the Wisconsin DNR program on chronic wasting disease. “We had a perfectly grand time. We have always butchered our deer ourselves. I may very well be having venison for supper.”
But Judd Aiken, a CWD expert at the University of Wisconsin in Madison, believes no deer anywhere in Wisconsin should be consumed until sample carcass test results are in, which could take months. “The safest approach is not to consume venison where we know there’s CWD,” he said.
The spread of the disease to Wisconsin is particularly worrisome. Scientists and wildlife managers have viewed the Mississippi River as an effective barrier limiting the disease to the deer populations spread out across the Western plains. Wisconsin, with its huge deer population — nearly half a million were killed last year by hunters — is a potent breeding ground for infection.
Prion diseases are so awful and the proteins so unpredictable that scientists take extraordinary precautions against infection when studying them in the lab. Patrick Bosque, a neurologist at the University of Colorado in Denver, studied prions in hamsters and mice, which do not appear to be transmissible to people. Yet he routinely wore disposable gloves, shoe covers and a gown, and avoided carrying his lab notebook or other potentially contaminated material out of the lab. Whenever he conducted a procedure that might spray or splash prions, he worked in a special hood to shield his face and upper arms. “Then you’re going to tell me I’m going to eat deer?” Bosque asked. “I definitely would not eat deer I thought had been infected.”
Bosque believes no one knows enough about CWD — more commonly known as mad deer — to say that eating venison is safe. “If it was very transmissible, we’d know it,” he says. “But if it was somewhat transmissible, like BSE [bovine spongiform encephalopathy, or mad cow] in England, it would be hard to know.”
Creutzfeldt-Jakob is a rare, fatal illness often described as “fast Alzheimer’s” that occurs for no known reason in the population. It almost always occurs in the elderly.The first rash of cases in younger people was found in Britain and turned out to be a new variant of CJD, which was traced back to consumption of mad-cow beef. Variant CJD is similar to the “classic” illness, but often strikes younger people and tends to progress much more rapidly.
At least seven people age 66 or younger — all hunters or venison eaters — are known to have died of Creutzfeldt-Jakob in the U.S. in the last nine years. The total number will never be known because there’s no federal requirement that all cases be reported. Preliminary studies suggest, and some neurologists suspect, that CJD is more common than generally believed — it’s simply misdiagnosed as Alzheimer’s. That raises the obvious question: How many people would die of chronic wasting disease before a doctor called it?
In a highly publicized case, three Wisconsin hunters who attended wild-game feasts died of neurological diseases. Two had Creutzfeldt-Jakob, one turned out to have another rare neurological ailment, Pick’s disease. Tests are ongoing.
Another victim from Oklahoma died with a freezer full of venison. A 50-year-old Montana elk hunter died last summer; his brain tissue is now being analyzed at one of the world’s foremost prion labs, at the University of California in San Francisco. Test results are pending.
The Centers for Disease Control and Prevention did autopsies on three other deaths of people under the age of 31 — from Utah, Oklahoma and Maine — who died of CJD between 1997 and 2000. Two were hunters; a third was the daughter of a hunter. The agency concluded that there was “no strong evidence of a causal link” to mad deer because their brain tissue did not differ notably from carriers of standard CJD. Two did eat meat from animals killed in Wyoming and a third ate game processed at a plant that also butchered Colorado elk. Both states have infected deer, but the CDC could not find evidence of CWD infection in the specific areas linked to the victims. “According to our best evidence, their deaths were not linked to CWD,” says Dr. Ermias Belay, a CDC epidemiologist who tracks Creutzfeldt-Jakob cases. “But our findings were limited to those three cases. We must continue to investigate.”
The Medical Society of Milwaukee County, which is demanding strict new laws governing how deer are butchered in Wisconsin, did not find the CDC’s conclusion reassuring. The CDC’s determination was based, in part, “on the hypothesis that human CWD” here would look like the human cases linked to mad cow in Britain, said a statement by the medical society. Because a human version of CWD has not yet been identified, scientists don’t know exactly what to look for should they find a case. “In England, it took over 20 cases for scientists to definitively determine that transmission had occurred,” according to the society.
Given all that’s known — and still mysterious — about the disease, the organization earlier this month called on Wisconsin officials to “consider taking the same public-health precautions that the English imposed on the British beef industry,” on butchering and processing all deer carcasses. The organization called for a ban on any neurological deer tissue in sausage, and expressed concern about possible contamination of other meats by butchers carving deer. “Deer prions could survive standard cleaning procedures, imposing a potential risk to the beef, pork and chicken subsequently processed.”
“It would seem reasonable to take some steps now to decrease the potential risk of transmitting this disease,” said G. Richard Olds, chairman of medicine at the Medical College of Wisconsin and a member of the medical society’s public-health committee. “We’re only asking that instead of depending on the goodwill of people in a garage-and-basement industry, we have some assurances that they’re following these guidelines.”
Despite concerns, the CDC has not issued any warnings about consuming Wisconsin venison. “Why, and cause a panic?” Belay asked. “People have to make informed decisions for themselves,” he said. “No one is forcing those people to go into those areas to hunt.”
Chronic wasting disease was first identified in the 1960s in a mule deer at a wildlife research center in Ft. Collins, Colo. The illness was not recognized as a transmissible spongiform encephalopathy until the 1970s. For years, the disease remained confined to Colorado and Wyoming, first in research pens and zoological collections, then on the range.
Since 1996, the disease has moved relentlessly eastward: Montana, New Mexico, Nebraska, Kansas, Oklahoma, South Dakota, Saskatchewan, Alberta. In February, Wisconsin officials confirmed the first cases in that state, in three bucks shot near Mount Horeb, 25 miles west of Madison. Chronic wasting disease appears to be highly contagious among animals, much more than mad cow. A Nebraska ranch tested its herd after a deer fell ill and found half the animals had already been infected.
Besides mule deer, Rocky Mountain elk and white-tailed deer are susceptible. Sick animals typically waste away, stagger, behave erratically and drool excessively until they die. It’s not known how long animals are infected before they become symptomatic. The epidemic is already an environmental disaster, threatening not only wildlife but also tourism.
Many observers believe game farms played a key role in spreading the illness quickly over vast areas of the U.S. There is almost no government oversight of the thousands of deer and elk raised in game farms across the country. Wisconsin alone has more than 900 farms where deer and elk are raised and hunted, up from a handful 15 years ago. Farmers and ranchers trade deer and elk aggressively across state lines, raising the odds that an infectious outbreak will become an epidemic. One Colorado game farm shipped 400 exposed elk to more than a dozen states, including Wisconsin. Many states with no mad deer have recently banned the importation of live deer and elk. In August, California went a step further, restricting the importation of deer and elk killed by hunters. The measures are intended to protect herds, not public health. Consumer safeguards have been slower to come.
“We’re watching the total failure of any adequate preventive policy at the state or federal level,” says John Stauber, executive director of the Madison-based Center for Media and Democracy and coauthor of the book “Mad Cow U.S.A.” Stauber believes the government’s response to CWD is disturbingly similar to Britain’s failure to take quick action to stem mad cow. He believes officials’ reluctance to sound the alarm is influenced in part by economic considerations, like the $1 billion hunters pump annually into the Wisconsin economy.
The Department of Agriculture does not extensively test deer to determine the prevalence of CWD, nor require meat producers to test game to certify it’s infection free. This lack of controls doesn’t just affect hunters or those who eat venison. Millions of people who would never touch a venison steak consume deer in processed meat, such as sausage, or pop “glandulars,” nutritional supplements made from the adrenal glands of cows, deer and elk that purportedly do wonders for back and neck pain. And the soft antlers of young elk are marketed heavily and profitably to Asian communities as “velvet Viagra.”
Unlike animals in Britain, deer and elk in the wild aren’t feasting on each other’s brains, where the prions are known to thrive. The disease may be spread through casual contact. Prions are shed in feces, saliva and urine. The fact is, no one knows exactly how the disease is transmitted.
A growing group of activists — including old-line consumer advocates such as Consumers Union, disenchanted hunters, and a community of people who have lost loved ones to Creutzfeldt-Jakob — blame in part the growing use of supplemental feeding by deer farmers who want to induce the growth of big antlers to increase game animals’ value as trophies. Food supplements often contain rendered byproduct, or animal waste, the stuff that proved disastrous in England, where sheep with scrapie — another prion disease — were ground up and fed to cows.
There is a popular notion in the U.S. that feed is strictly regulated to prevent a mad cow-type epidemic. The Food and Drug Administration implemented regulations in 1997 but the rules are not as strict as the public assumes they are. They ban the use of feed containing proteins derived from mammalian tissue, and require that such feed be labeled: “Do Not Feed to Ruminants — cattle, deer, elk and other animals with multiple stomach chambers.” Legally, cows and deer can be ground up and fed to non-ruminants, such as pigs, horses or pet poodles. “You can feed cattle to pigs, then grind up the pigs and feed them to cattle,” said Michael Hansen, research associate at Consumers Union. The regulations exempt plate waste and bovine blood products; spray-dried cow plasma is used widely as a milk substitute for weaned young cattle. The FDA called the new regulation a “firewall” against mad cow. “We called it a white picket fence,” said Hansen. “We are still feeding mammal protein to food animals. If any of that protein is contaminated, the disease will spread.”
“We frankly are astounded that the FDA would permit TSE-positive material to be used for any purpose,” said a statement from Consumer’s Union issued at the time. “The decision flies in the face of recommendations from the World Health Organization … that “no part or product of any animal which has shown signs of a TSE should enter any food chain (human or animal).”
Enforcement also has gaps. A September 2000 report (#RCED-00-255) by the General Accounting Office found that 10 percent of rendering facilities weren’t properly labeling the feed, and claimed not to know they were supposed to. The GAO investigated 9,000 renderers. A closer examination of 2,000 renderers handling ruminant bone meal found that 28 percent did not include the FDA warning on labels. Last January, a follow-up report (#GAO-02-183) by the GAO found that the FDA’s data on inspections was “severely flawed.” The agency “has not acted promptly to force firms to keep prohibited proteins out of cattle feed and to label feed that cannot be fed to cattle.” The GAO also pointed out that the U.S. feed ban is “more permissive” than other countries’.
Because nobody knows how long it takes for an infected deer to become sick, nobody can say when Wisconsin’s herds were exposed to chronic wasting disease, so pre-1997 feeding practices are also worrisome. Stauber, who lives in Wisconsin and has followed chronic wasting developments closely, says that in the 1980s through the mid-’90s, cattle, sheep and deer were rendered and fed by the tons as meat and bone meal to cattle, sheep and deer. In 1995, for instance, 26,488 deer were scraped off roads and delivered to renderers, according to a state Department of Natural Resources report on road kill.
While the laws remain lax, disturbing scientific evidence continues to build. Bosque’s prion research, conducted at UCSF, calls into question the idea that eating possibly infected meat is safe as long as the brain, nerves and tonsils are avoided. Bosque and his colleagues detected prions at fairly high levels in the muscle of mice. “We recommended that other animals be looked at,” he said.
The study was published in March in the prestigious Proceedings of the National Academy of Sciences. So far, wildlife officials in many states have ignored it. Pam Swift, a veterinarian at the California Department of Fish and Game, recently said eating Wisconsin deer was perfectly safe if it was butchered properly and the brain, spinal column and tonsils were discarded. “Prions are not known to be present in the muscle,” she said.
There are other open questions. Can an animal that appears healthy be a “silent carrier” of the illness? A study published last November in the Journal of Virology suggests yes. The researchers, at the federal government’s Rocky Mountain Laboratories in Hamilton, Mont., reported that infected but apparently healthy mice transmitted prions not only to other mice but also to hamsters, which then fell ill.
Strong evidence suggests that prions do not readily spread from one species to another. But it can happen. Scrapie never jumped to humans. But mad cow did. Researchers at the Rocky Mountain Labs found evidence that human (and cattle) proteins are slightly susceptible to deer prions. The work involved technical molecular experiments: Essentially, infectious prions from deer and elk were mixed with proteins from deer, cow, humans. The study, published in the EMBO (European Molecular Biology Organization) Journal in 2000, found that the exposure changed the human and cattle proteins in ways that suggested they’d been infected.
Earlier this month the Senate passed legislation introduced by Sens. Russ Feingold and Herb Kohl to require the U.S. Department of Agriculture to develop an efficient program for the inspection and certification of federal, state and private labs to conduct deer and elk tests for CWD. “The U.S. Department of Agriculture has really dropped the ball in providing the necessary resources and assistance to assure that Wisconsin hunters have the information they deserve,” the senators said in a statement.
Wisconsin officials are still scrambling to contain the damage to wildlife and the state’s reputation as a hunter’s paradise. Wildlife authorities have mapped an eradication zone of roughly 400 square miles where as many as 25,000 deer will be killed and incinerated. But last summer a ranch-raised deer outside that zone, in central Wisconsin, tested positive, diminishing the likelihood that the slaughter will end the problem, Judd Aiken said. Authorities now plan to test 500 deer in every county beyond the zone to determine the prevalence of infection. To ease fears among hunters and consumers, the state has also launched a system of color-coded metal tags — red for deer killed in the eradication zone, blue for deer killed just beyond, and silver for the rest — so meat processors know where the deer come from.
In some communities, local officials urge worried hunters to get the meat tested before consumption, and several entrepreneurs are trying to market test kits. But although the current testing technology is valuable for measuring the prevalence of infection in a herd, it is not sensitive enough to reliably determine the safety of a single carcass. “It’s possible for CWD to be present in levels that aren’t detectable,” Hauge said.
Meanwhile, hunters continue to sort through the often contradictory signals from officials, and health activists worry about the potential time bomb ticking in the herds of infected game. Says Stauber: “We should learn from mad cow in Britain. That was absolutely botched in the early 1990s by the public-health community. I believe we have a really dangerous situation here. And it’s been botched from the beginning.”
Back in the ’80s, before I was ready to settle down with husband or child, I got pregnant. I went to my OB-GYN to talk about abortion.
I’d known and trusted this doctor for years. He’d always listened attentively and answered my questions with kindness and respect. That’s what I expected now. Instead, he looked stricken. “Abortion?” he asked, almost choking on the word. “But you’d make such a great pregnant lady!”
Considering the hassle and outrageous harassment that women often confront when they seek abortions, a dumb, hurtful comment from a doctor should seem like no big deal. But that moment sticks in my mind more vividly than the memory of the vacuum aspiration that eventually ended the pregnancy. The message was unmistakable: Yes, abortion is legal; yes, it is one of the most common surgeries performed on women. But it is a procedure beyond the bounds, interest and dignity of the medical establishment.
Two decades later, medical schools and doctor training programs are finally taking important steps to bring abortion into the mainstream of medicine — where it belongs. After years of simply ignoring the procedure and conveniently sidestepping controversy, a growing number of training programs are now requiring obstetrician-gynecologists to learn how to do abortions. This slow, steady, quiet shift got a dramatic boost this spring, when New York became the first city to mandate abortion training for OB-GYN residents at its public hospitals.
The move to incorporate abortion into standard medical education is one of the most significant developments in decades in the debate over a woman’s right to choose. By teaching medical students about abortions, and by requiring newly minted M.D.’s to get hands-on experience, educators are giving the procedure the same legitimacy as any other medical treatment — for the first time since Roe vs. Wade.
“If abortion is part of a clerkship, it’s not going to be seen as a dirty procedure that has no educational value for students,” said Mindy Sobota, a fourth-year student at the New York University School of Medicine.
Abortion-rights groups such as Medical Students for Choice and the National Abortion and Reproductive Rights Action League have pressed educators for years to add abortion to the medical-school curriculum. The effort has gained urgency as abortion providers — actively stalked and threatened with death — have packed up and abortion clinics have shut. Eighty-six percent of U.S. counties, and one-third of U.S. cities — Sioux City, Iowa; Grand Forks, N.D.; Erie, Penn.; and Joplin, Mo., among them — had no identifiable abortion provider in 1996, according to the most recent survey by the Alan Guttmacher Institute in New York.
While it is possible to blame antiabortion violence for the diminishing access to abortion, the medical establishment bears some responsibility. When medical schools and training programs fail to teach medical students how to do abortions, very few doctors perform them.
Though it was never part of most OB-GYN curricula, abortion training began to surge after 1973, when women suddenly flocked to hospitals for a newly legal procedure that almost no M.D. had been taught to perform. But by the late 1970s — despite the demand — only about one-quarter of OB-GYN residency programs routinely included abortion training. The number of programs to carry the training diminished further when abortions were less frequently performed in hospitals, the doctor’s traditional training ground.
By the mid-1990s, a mere 7 percent of abortions were performed in hospitals, down from 81 percent in 1973. Women were going to clinics, like those operated by Planned Parenthood, for the procedure. The shift made sense medically and economically — at least in the years before 1982, when clinics largely operated in peace. Early abortions are technically simple and patients tend to be healthy. Hospital operating rooms are set up and staffed for complicated surgery on the desperately ill. Outpatient abortions proved to be safer, quicker and cheaper — so successful, in fact, that they precipitated the wholesale shift of elective surgery to outpatient centers.
But the rise of abortion clinics had an unintended consequence: It eroded abortion education. As abortions slipped off the hospital operating-room schedule, they also were dropped as a training requirement for young physicians. “They get trained to do things that happen in hospitals,” said Felicia Stewart, co-director of the Center for Reproductive Health Research and Policy at the University of California, San Francisco. “It’s not easy to get trained to do things that don’t happen in hospitals.”
By the early ’90s, only 12 percent of OB-GYN training programs routinely included abortion. A resident determined to master abortion techniques could volunteer at a clinic in her spare time — after putting in 100 hours a week in the hospital. Not surprisingly, few bothered.
The paucity of training had a logical effect: Most OB-GYNs in practice today completed their education without so much as a half-hour lecture on terminating a pregnancy. As a practical matter, the omission is staggering, considering that roughly half the women in the U.S. will undergo an abortion in their lifetime. The corresponding political impact is palpable: The lapse has effectively and insidiously pushed abortion to the margins of healthcare.
“The message was, at best, that [abortion] isn’t worthy of your time. At worst, it’s that [abortion] is bad,” said David Toub, a board-certified OB-GYN in Pennsylvania. “Ultimately that really harms women.”
With a majority of doctors unable to terminate a pregnancy, women eventually lost all choice in abortion providers. These days, it’s a big clinic or nothing. The scarcity of these clinics means that women typically must wait to get a clinic appointment, a serious problem given that the risk of complications doubles with every two weeks an abortion is delayed. Moreover, women outside big cities, especially in the South, the Midwest and the Rockies, must travel far to find a clinic where doctors perform abortions. And those clinics are no longer able to operate peacefully, as they did through the ’70s. Patients must often dodge hostile protesters — a cruel warm-up to a procedure that is rarely easy, regardless of the circumstances.
“The unspoken message is very powerful that abortion is so completely out of the norm that you have to drive 500 miles and bring cash,” Stewart said. “The reality is, we’re making women feel like they’re on the run. They have to be ashamed and hide what they’re doing. It undermines women’s self-worth, I think, to feel like they have to go through a clandestine experience.”
As abortion has been relegated to the periphery of medicine, the right to choose abortion has come under threat. Abortion clinics are not only highly visible targets for antiabortion groups but also outposts of controversy easily — or conveniently — ignored by anyone who isn’t a patient, a provider or a protester. Certainly the medical profession hasn’t provoked the violence against abortion doctors and their patients. But would the attacks have gotten so vicious if abortions were performed under the same roof as tonsillectomies or cardiac stress tests? Polls show that Americans largely support legal abortion. Might they have become fed up with antiabortion harassment long ago if the protests took place outside community hospitals or popular HMOs?
For a while, some medical experts predicted that abortion drugs such as mifepristone would at last shift early abortion from clinics into doctors’ offices. But so far few doctors prescribe the drugs — nearly all prescriptions are written at abortion clinics. The oft-cited explanation is that the Food and Drug Administration imposed conditions on the use of mifepristone that many private doctors cannot meet. But it was unrealistic to expect that OB-GYNs who had never learned the first thing about abortion would rush to try the latest technique for ending a pregnancy.
“What was very disheartening to me as a physician wasn’t so much the potential threat from the general public opposed to [abortion], who are very militant in some cases,” said Toub, who has worked in abortion clinics and performed the procedure in his private practice. “What bothered me more was the attitude of my own colleagues. They couldn’t even use the word ‘abortion.’ They’d use all sort of euphemisms: VIP — voluntary interruption of pregnancy. TAB — therapeutic abortion.”
Such attitudes and ignorance have infuriated abortion-rights and women’s health groups. But it was the dwindling supply of abortion doctors that triggered efforts to require training. Activists lobbied on several fronts — individual hospitals, accreditation bodies, medical school administrators. Many medical educators, too, recognized that abortion care — once the model for minor surgery — had been shoved, dangerously, to the fringe.
“Abortion is as common as a hernia repair,” said Carolyn Westhoff, professor of public health and obstetrics and gynecology at Columbia University. “What are we going to do — have one hernia surgeon in each state that does repairs? It’s absurd. Abortion is an everyday piece of women’s health. [Doctors] should have a clue about something so common.”
In January 1996, the Accreditation Council for Graduate Medical Education, the private body that establishes educational standards for thousands of residency programs in all specialties, called on OB-GYN programs to require abortion training. The decision capped an enormous controversy — letters, debates, articles in the professional literature, all flowed freely — with pro-choice activists, women’s health groups and some educators on one side, and antiabortion organizations and Catholic and other religiously affiliated hospitals on the other. The council stopped short of imposing a blanket mandate. “No program or resident with a religious or moral objection will be required to provide training in, or to perform, induced abortions,” the council said.
By granting individual physicians and training centers the right to opt out, the accreditation council recognized that choice lay at the heart of the abortion issue — and subtly reinforced the marginality of abortion. Nowhere else in medical training may doctors decline to serve a patient because they don’t personally approve of the necessary treatment.
“I did not get much pleasure doing a below-the-knee amputation when I was an intern,” Toub said. “Its not a procedure you feel good about afterward. But I’m very glad I had the opportunity to receive the training. It adds to your pool of knowledge.”
Law students, even those heading for careers in patents or divorces, must study criminal procedure whether or not they “object” to crime. Imagine if a group of hospitals refused to teach residents how to do C-sections because some influential donors considered them largely unnecessary.
Even with this important loophole, the accreditation council’s abortion-training standard had a dramatic effect. Reliable statistics are hard to come by, but according to various estimates, 35 percent to 40 percent of OB-GYN residency programs now include abortion training — roughly triple the percentage in 1992. The University of California at San Francisco, which continued to rotate OB-GYN residents through its outpatient abortion service even at the national low point of training, launched a program three years ago to promote abortion education around the country. The Kenneth J. Ryan Residency Training Program helps teaching hospitals set up abortion clinics where residents do five- to 10-week stints. Fifteen clinics have opened under the program, and 20 more are in the works, said Uta Landy, the program’s director.
But until this summer, the expansion of medical training to include abortion happened one hospital at a time, without much public notice. The new training mandate at New York City hospitals, issued by Mayor Michael Bloomberg, was a breakthrough. It was the first time a city government required abortion training in publicly funded hospitals. And its installation has already sparked talk among proponents of abortion training for medical students in California of promoting legislation to require abortion training at public teaching hospitals throughout that state.
New York is also one of the largest training grounds for doctors — one in seven U.S. doctors does a residency in a city-owned hospital there. This year, more than 150 OB-GYN residents will work in eight New York public hospitals. If any training program can help to replenish the ranks of abortion providers, it is New York’s.
Finally, the city is a media nerve center, so the announcement got a lot of press. Unfortunately, the crush of publicity created the impression that New York’s abortion-training mandate was novel– instead of a new twist in a longtime trend. There were other distortions in the coverage, the most dangerous being the idea that doctors would now be forced to perform abortions no matter what their moral or religious objections. That is not the case. Nonetheless, a headline in the conservative Washington Times blared: “N.Y. hospitals to deny choice on abortion training.”
Choice, of course, is what’s at stake — a doctor’s choice to learn how to perform abortions, and a woman’s choice to have one. Certainly, it makes no sense to force doctors to end pregnancies, just as it makes no sense to force women to carry pregnancies to term. But is it asking too much to expect all OB-GYNs to understand the basics of such a common procedure? Is it asking too much to require them to know how to handle post-abortion complications?
More than 1 million women in the U.S. will seek abortions this year. Many will turn first to an OB-GYN. It is not too much to hope that these doctors will offer options and wise counsel, instead of conjuring some rosy image of a great pregnant lady and then dishing out guilt. Patients, no matter what ails them, want professionalism, not patronization.
African-American infants are more than twice as likely as whites to die before turning 1. The average life expectancy for black men is 66, eight years shorter than for white men. Blacks of all ages suffer higher rates of illness and death from just about every major disease, including diabetes, heart disease, AIDS and a variety of cancers.
And the numbers for treatment are just as bad. Inferior care occurs at every step in the system: prenatal checkups, routine care, therapy for life-threatening illnesses, mental health treatment, pain control before death. African-Americans are less likely to undergo heart bypass, angioplasty, kidney dialysis, transplants and other expensive procedures. They get less aggressive treatment for cancer, and they’re slower to get the latest drugs for HIV. And in the rare instances when blacks get more aggressive care, it is not necessarily a good thing: They are, for example, more likely to have leg amputations for diabetes instead of sophisticated, conservative limb-saving treatment.
There are no surprises in these data, documented most recently in a congressionally mandated report, by the prestigious National Academies’ Institute of Medicine, titled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” The most exhaustive analysis ever published on the subject, the institute’s 586-page review of just about every study that has appeared in a medical journal reaches some stark conclusions: Disparities in care and treatment for all racial and ethnic minorities are pervasive, harmful to patients, and overwhelmingly not their fault.
The Bush administration finally addressed the issues in the institute’s call to action — part of a chorus that has droned on for years — with a gesture that has some health experts reeling. The plan, announced by Tommy Thompson, secretary of Health and Human Services, is “Take a Loved One to the Doctor Day,” scheduled for Sept. 24 , 2002. Thompson, with cosponsor ABC Radio Networks, is encouraging communities to offer health fairs, screenings and other “wellness” events where participants can be weighed, poked, tested, examined, questioned and counseled. One day to make up for a whole lifetime without ongoing, comprehensive care.
“It’s comedy,” says Dr. Thomas LaVeist, associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health. “Or it would be comedy if this weren’t such a serious problem. It’s very depressing, actually.”
“Take a Loved One to the Doctor Day” is a crusade that essentially pins the problem of healthcare disparities on the patients, as if they were somehow responsible for a healthcare system that often gives them second-rate care or shuts them out altogether. By preaching the virtues of checkups and offering redemption to minorities identified as medical slackers, Thompson ignores the roots of healthcare inequities — poverty, institutional racism, lack of funding, and the shortage of services in minority communities — and shifts the blame to the victims. He also sidesteps the very sticky matters of bias in the largely white medical profession, and the failure of HHS to enforce civil rights in healthcare.
“It is disconcerting that the leadership of the Department of Health and Human Services would come up with a solution that is so far off the mark,” LaVeist adds. “It really displays a staggering misunderstanding and lack of understanding of the problem.”
It is particularly hard to explain such a lack of understanding in the wake of the Institute of Medicine report, published in March, just weeks before the announcement of “Take a Loved One to the Doctor Day.” In addition to spelling out, in impressive detail, the nature, extent and impact of disparities of medical treatment, the study also pinpoints the causes, placing heavy responsibility on doctors, hospitals, insurance companies, lawmakers and government regulators.
In their analysis of the health gap, institute researchers first identify barriers to care, the most significant being (no surprise here) money. Blacks are twice as likely as whites (and Hispanics are three times as likely) to have no health insurance, a situation that more or less guarantees that a patient will get no treatment until he or she turns up seriously ill in the emergency room.
But access is not the only cause, or even the major cause, of inequities. The institute report found that even when minorities do get care, it tends to be inferior. In a statement typical of the report’s dry and unblinking language, the researchers write: “Racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as patients’ insurance status and income, are controlled.”
In other words, simply getting minorities into the examination room is not the answer. Because once they are there, the odds are good that the treatment they get will be compromised by the bias of the doctor. There isn’t a nook or cranny of the medical system, according to the report, in which minority patients are not treated differently, by which, according to the data, the researchers mean — emphatically — worse.
What has been fairly obvious for years is that disparate treatment stems in part from Medicaid, the public health insurance program. There was a time, long past, when a Medicaid card worked more or less like a Blue Cross card: It got patients into many private doctors’ offices. Not anymore. Funding cuts and ever tighter restrictions (on doctors and patients) have largely turned Medicaid into a separate, unequal system for the poor. Minorities, of course, are not alone in this boat, but they are disproportionately stuck there.
But Medicaid is not the whole story. According to the Institute of Medicine, even when minority patients have decent insurance, a solid income, a college degree — in other words, even when things are the same as for typical white patients except race or ethnicity — treatment is different. Why? The report puts much of the blame on prejudice and stereotyping by doctors, a startling and courageous assertion when you consider that scores of researchers have documented disparities for more than a decade, and almost nobody has dared to talk about this in a forthright way until now.
The chapter title, cautious to the point of parody, is “Assessing Potential Sources of Racial and Ethnic Disparities in Care: The Clinical Encounter.” It is no polemic on racism but, like the rest of the report, a sober, dense review of the relevant research. Most of it involves experiments and surveys aimed at teasing out physician attitudes and judgments and measuring their influence on what should be straightforward medical decisions.
In one well-known study, doctors watched videotaped vignettes of patients (really actors) with symptoms of coronary artery disease. Each video featured a different patient — a white man, a black woman and so forth — but the complaints were the same. According to the study, doctors were much less likely to propose cardiac catherization for blacks and women than for whites and men.
Does such bias persist even among minority doctors? In another study, medical students — whites and minorities — watched vignettes of patients complaining of chest pain. Overall, the students were more likely to provide a “definite” diagnosis of angina for white male patients than for black female patients. But when asked to rate the patients’ overall health, the doctors split according to their own race, ethnicity and gender. White students, and male students, tended to assess the black female patients as having worse general health and a lower quality of life than the white male patients — even though both patient groups presented the same basic information. Minority and women students tended to rate all patients the same on this score.
Studies like these have sparked hot debate in the scientific literature. On the surface, these are arcane arguments over methods: Should the investigators use odds ratios or risk ratios to calculate a patient’s chances of getting a specialist referral? But it’s no great stretch to assume that something deeper fuels the fire of these controversies. Doctors don’t take kindly to allegations of bias. Who does? Nevertheless, the institute pulls no punches.
“Although it is reasonable to assume that the vast majority of health care providers find prejudice morally abhorrent, several studies show that even well-meaning people who are not overtly biased or prejudiced typically demonstrate unconscious negative racial attitudes and stereotypes,” says the press release on the report.
The pressures of medical practice probably exacerbate these impulses. A doctor spends just minutes with each patient, often patients he barely knows, and must make ever more complex decisions. “If physicians are having trouble making a diagnosis because the symptoms are not clear-cut, they are trained to place greater emphasis on prior expectations about the patient’s condition based on age, gender, socioeconomic status, race or ethnicity,” the press release said.
Of course, the patient brings baggage, too. Minorities are more likely than whites to say they mistrust doctors and nurses. (Hardly suprising in light of this research.) Suspicion does not make for an optimal doctor-patient dynamic, and it can be frustrating and insulting to a doctor who is working hard to help a seriously ill patient and likely to lose money on the effort. But as the institute notes, the doctor “is the more powerful actor” in this relationship and should bear more of the load for making sure that all patients are treated the same.
The report’s first recommendation for reducing disparities is to increase awareness among the general public, doctors, insurance companies, policymakers. It’s the flip side of the HHS strategy of targeting African-Americans exclusively. And it makes far more sense. Two recent polls show that a significant majority of Americans believe that blacks get the same quality of healthcare as whites. Minorities apparently know that’s not true. A survey released in March by the Commonwealth Fund in New York found that blacks (and Hispanics and Asian-Americans) are more likely than whites to report difficulty communicating with doctors, to feel they are treated with disrespect when they get healthcare, and to believe they would receive better treatment if they were a different race or ethnicity.
The Institute of Medicine also recommends the elimination of two-tier healthcare: People on Medicaid should get the same services, and the same protections, as privately insured patients. (The institute noted that Congress fussed mightily last year over legislation to safeguard the rights of people in private HMOs, but not Medicaid managed care. The report said any patient’s rights bill must extend to people in public programs.)
The report also urges Medicaid to bring stability to doctor-patient relationships. These have been trampled by budget cuts and other changes in the program. The institute devotes considerable ink to the importance of consistent, ongoing medical care. Against that backdrop, a one-shot go-to-the-doctor day seems not only misguided but also counterproductive.
In its meatiest recommendation, the report calls for aggressive civil rights enforcement in healthcare. The HHS Office for Civil Rights “has long abandoned proactive, investigative strategies,” the report said. Although complaints have increased in recent years, the enforcement budget in fiscal year 2000 was 60 percent of the 1981 funding, adjusted for inflation.
Under Bill Clinton the Department of Health and Human Services pledged to narrow the medical divide by 2010. Inside the giant federal health bureaucracy, some momentum continued after the White House changed hands. Every institute of the National Institutes of Health, for instance, has a mandate to develop a plan for addressing disparities in its programs. In July, the HHS Office of Minority Health will hold a “national leadership summit to eliminate racial and ethnic disparities.”
But some minority health advocates worry that the Bush administration, distracted by high-profile issues like the threat of biological terrorism, will not give disparities priority in the agenda. And there’s no doubt it will take pressure, and a moral imperative, to move an entrenched medical establishment and to provoke broad concern about an outrageous situation that the public has tolerated too long.
If nothing else, “Take a Loved One to the Doctor Day” by itself provides ample evidence that the alarms raised by the report might be muffled.
“People can take charge of their health, and participating in Take a Loved One to the Doctor Day can be a positive first step,” Thompson said at an April 18 press conference. “Prevention and early detection of potential health problems are essential, and there are steps within our reach that we can all take to better protect ourselves and our families.”
It is always tempting, and valid to a point, to pin responsibility on patients. Personal behavior is important in healthcare. If you smoke cigarettes, never see a dentist, eat crap, do drugs, live like a sloth, blow off your prescriptions, you put yourself at risk.
But in the context of the health gap, Thompson’s message is weirdly patronizing, all the more so because his “Day” is a twist on the ever popular Take Our Daughters to Work Day. Is the subtext here that blacks, like 8-year-olds, must be led by the parental hand and shown what’s good for them?
Even if that message was unintended — and to be fair, let’s assume it was — it’s a Band-Aid for what should be recognized as a public health emergency. More than a decade ago, researchers at Columbia University reported that black men in Harlem had a shorter life expectancy than men in Bangladesh. The day after Thompson announced Take a Loved One to the Doctor Day, the U.S. Centers for Disease Control and Prevention reported that in some cities the black-white differences in infant mortality are even more glaring than national statistics suggest.
In Pittsburgh and Tampa, black babies are three times as likely as white babies to die before the age of 1; in San Diego, nearly four times as likely; in San Francisco, nearly five times. Hauling your sister to a health fair in September will not save black infants anymore than trotting your daughter (and now your son) through your cubicle in April will obliterate pay gaps for women.
Nevertheless, some major black organizations and influential minority health advocates have signed up as “partners” in Sept. 24. The list includes Rainbow/Push Coalition, 100 Black Men of America, Congress of National Black Churches, National Black Womens Health Project, and the National Medical Association, the nations largest organization of African American physicians.
“It’s always a positive step to get people to seek medical care,” says Ruth Perot, executive director of the Summit Health Institute for Research and Education, a Washington, D.C., nonprofit that promotes health equity.
Perot, a passionate voice on minority health, takes a broad, deep view of the problems and remedies. Why did she endorse Sept. 24? She said she hoped it would encourage people not only to go to doctors but also to “very assertively seek the kind of care to which they’re entitled.”
But if assertiveness is the goal, why not urge people to make appointments for themselves? Didn’t the pitch, Take a Loved One, send an opposite message, about patient helplessness, passivity or sheer irresponsibility?
“Im trying to be charitable.” Perot says. “Im trying to acknowledge some blooming blossoms where I see them.”
It should come as no shock that the blossoms are mostly window dressing. Big, costly improvements in Medicaid were never on the Bush agenda. Neither is more money or more muscle to crack down on civil rights violations, in healthcare or anywhere else.
And the notion that it is each black person’s job to close the health gap fits neatly with the famous Bush ethic of personal responsibility. Across the board, from drug abuse to poverty to failing schools, the burden of solving societal problems is shifting from the government to the shoulders of the people who suffer most — or their “loved ones.”
Conveniently, Thompson’s crusade also appears to mesh nicely with current public sentiment. Folksy campaigns are the name of the game in medical causes. AIDS has red ribbons and movie stars. Breast cancer has pink ribbons and teddy bears. ALS has navy pinstripe ribbons inspired by Lou Gehrigs Yankee uniform. Diabetes has gray ribbons to depict the despair of the disease and the hope, the “silver lining,” that a cure will be found. The American Cancer Society has daffodils.
Now African Americans have Sept. 24, a finger-wagging day of obligation meant to placate poor and poorly served patients with health fairs. America still isn’t a country where healthcare is colorblind, but it is the land of equal-opportunity kitsch.
