“There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order.” - Niccolò Machiavelli, The Prince and The Discourses
Money in politics is making our nation sicker, threatening our national security, and ultimately destroying the very economic prosperity the “money in politics” seeks to achieve. It is undermining our capacity to care for our citizens and threatening our global economic competitiveness in invisible, insidious ways. The links, connections and patterns that promote obesity and chronic disease are clear, though. The economic and social impacts are evident. As health care consumes an increasingly large percentage of our federal budget, the negative impacts of money in politics have become too alarming too ignore, and never more obvious than in this election cycle of 2012.
It may seem odd to suggest that lobbying, and in particular Citizens United, the Supreme Court decision that personifies corporations and allows unlimited corporate campaign contributions through political action committees, threatens our nation’s health. But it does.
If money rules politics, then our nation is not protected from disease-causing Frankenfoods including soda and processed foods, or from unrestricted marketing of the lowest-quality, sugar-laden foods to our children. When money rules politics, our agricultural lands, soils and aquifers are depleted through oil-dependent industrial farming supported by billions in federal subsidies.
Depleting Nature’s and Human Capital
We are depleting nature’s capital — capital that once destroyed, cannot be reclaimed. One acre of arable land is lost to development every minute of every day. One pound of meat requires 2,000 gallons of waterand produces 58 times more greenhouse gases than 1 pound of potatoes. It takes 7,000 pounds of grain to produce 1,000 pounds of meat. Irrigation is depleting our Ogallala Aquifer on the Great Plains 1.3 trillion gallons faster than it can be replenished by rainfall. Three-quarters of our fresh water (only 5 percent of all the earth’s water) is used for agriculture, mostly to grow meat for human consumption.
If we all switched out one meat meal for a vegetarian meal each week, it would be the equivalent of takinghalf a million cars off the road. Driving a Hummer and being a vegetarian produces less greenhouse gases than driving a Prius and eating factory farmed meat. Yet when the USDA (United States Department of Agriculture) encouraged us to participate in “Meatless Mondays,” the National Cattleman’s Beef Association lobbied the government to retract their recommendation. And they did. Money in politics.
During health reform, I mentioned to Senator Harkin that all we wanted was for science to become policy. With a wry and somewhat sad smile he said, “That would be nice.”
Our energy policies support Orwellian “clean coal” that still discharges mercury, lead and particulate matter into our air, promoting heart disease, cancer and more, and our politically handicapped Environmental Protection Agency allows environmental policies that permit untested chemicals and toxins to permeate our lives. Should we worry when the average newborn has 287 known toxins in his or her umbilical cord blood that have been linked to neurodevelopment disorders such as attention deficit disorder and autism that now affects 1 in 6 of our nation’s children? What are the social and economic costs of that?
The reason we have these policies is not that they were encouraged and supported by citizens through a democratic process or grassroots movement. The policies are there for one reason — they were encouraged, shaped, lobbied for and even often ghostwritten by industries whose sole focus is profit, not public welfare.
Money in Health Care: Perverse Incentives
If money rules politics, then the most profitable medical therapies, not the best treatments, are researched and implemented. If hospitals and doctors are paid for volume and piecework, they produce more visits and procedures, but not better health. If hospitals suddenly cut cardiac bypasses and angioplasties in half by implementing proven intensive lifestyle therapies, they would go bankrupt. If Medicare refused to reimburse for cardiac bypasses or angioplasties proven to work in less than 5 percent of patients that receive them, and instead reimbursed for intensive lifestyle treatment programs for those with heart disease and diabetes, health care costs, as estimated by the Cleveland Clinic, would be reduced by almost one trillion dollars over the next 10 years. But since lifestyle treatment is not reimbursed it is not profitable, so it is not done.
At a recent medical innovation conference, I met with the head of Walgreen’s new Take Care Clinic and was impressed with their focus on education and service. But when I asked if he would implement a program that could be delivered through their clinics that could reduce prescription medication use by half, he was not interested. They want to appear to do the right thing, but not do it.
The head of health information technology from Partner’s Health Care, the Harvard group of hospitals, shared at a medical administrators meeting that the head of the Harvard health system rejected a proposal to connect two hospitals by a data line that would save 15 percent in labs costs by reducing redundant lab tests. They couldn’t afford a 15 percent reduction in lab billing.
Perverse economic incentives drive policy and medical decisions, not the best interests of the patients, and certainly not better health outcomes. Violation of public trust, the sacred covenant between our elected leaders and our people, results from money in politics. What ever happened to government by the people, for the people and of the people? My friend, lawyer and environmental advocate Robert F. Kennedy, Jr., calls our political system a “corporate kleptocracy.” Communism, he says, is when the government runs business; and fascism is when business runs government.
Our nation’s health and economy are close to entering an irrevocable downward spiral. It is difficult for most of us to grasp the immensity of the politically sanctioned economic forces at work that threaten our health. This quiet, dangerous set of forces in play in American society fuel the explosive and uncontrolled growth of disease in America.
Accounting for Sustainability: The True Cost of Money in Politics
The basic fact is that one-third of our economy profits from making people sick and fat. The food industry sells products scientifically proven to kill more people than cigarettes, while our health care industry profits from providing more volume of care focused on medication and procedures, not better health.
Certain facts are clear. Lifestyle-induced chronic disease is on the rise, and accounts for nearly 80 percent of our health care costs. Nearly 70 percent of our population is overweight or obese. Almost 1 in 4 teenagers have pre-diabetes or Type 2 diabetes, up from only 9 percent in 2000 and almost zero in 1960. Most chronic disease is best prevented and even treated with lifestyle medicine and a systems approach to disease. By 2042, 100 percent of our federal budget will be needed to pay for Medicare and Medicaid. Today, 1 in 3 Medicare dollars is spent on Type 2 diabetes. This is unsustainable.
The true cost of our food and agriculture, energy, education, environmental policies on our health are not even measured in the equation. Our government subsidizes the production of low-cost high-fructose corn syrup and trans fats from soybeans (used to make soda and French fries), but we don’t do an accurate cost accounting of the health, environmental and energy impact of producing those crops in the way we do, or the health impact on the children and adults who consume those products.
Prince Charles gave a speech at the Future of Food conference at Georgetown University in 2011. He describes a new kind of cost accounting, “accounting for sustainability” that expands our accounting processes to include the interconnected impact of financial, health, environmental and social impact on long-term “profits.”
Unless we do a true cost accounting for social, environmental, and health sustainability, I fear that simply addressing health care reform with the new Affordable Care Act — an effort that righted many wrongs in health care, but without addressing the systems-wide issues across all sectors of society that affect the health of our nation and health care costs — will fail.
Supporting Innovations to Create Health
For example, areas outside the direct domain of health care — intellectual property laws, for instance — could encourage private industry to develop products and services that promote health and wellness rather than generate profit from sickness and obesity.
Education policies must support transformation of schools as incubators of health rather than disease. (How can we feed our children for learning and thriving when so many school kitchens have only deep fat fryers and microwave ovens?)
Government agencies and departments with domains that impact health, such as the Departments of Agriculture, Health and Human Services, Environmental Protection Agency, Transportation, Education, Defense, and the Centers for Medicare and Medicaid Services (CMS), etc, must be coordinated to create a culture of health and wellness.
I have no doubt that when applied well, the personalized systems-medicine approach based on functional medicine is a scalable model for medical practice, education, and research. It can dramatically improve outcomes while reducing costs, providing a real solution to our health care crisis, which I have described in previous blogs.
Creating the incentives to build this approach and delivering it through integrated health care teams — including health educators/coaches driven by the operating system of functional medicine — has to be part of the solution.
There is also an urgent need to mobilize the power of social networks and communities, for peer-supported health programs, health champions and community health workers can help us cope with another growing problem: the serious deficit of general-practice doctors available to care for all the sick. If we in health care can’t cure the patient, perhaps the community can.
People helping people, armed with the right information on how to create health, can disrupt health care, improve outcomes and reduce costs. This is how we got Saddleback Church to have 15,000 people lose over 250,000 pounds in 10 months — people helping people in community based programs like The Daniel Plan.
Ending Industry Influence in Science and Medicine
Even if we get everything else right in health care reform — such as payment reform, universal access, electronic records (currently conceived of as simply transferring the 19th- and early 20th-century medical records system to the computer, rather than facilitation of a fundamentally new way to practice medicine based on whole-systems analysis), reduction of medical errors, malpractice reform — none of our efforts will matter unless we address the true drivers of cost and chronic disease. And among the biggest drivers of all are the complex, industry-driven government policies that promote obesity, disease, and agricultural and environmental degradation.
This is a national security issue that threatens our standing in the world. As President Obama stated, “Fixing health care is no longer only a moral imperative, but a fiscal imperative.”
But opponents will not go quietly into the night. As reported in The New York Times, there is an insidious presence of pharma and industry in medical education, research, and practice — a presence that prevents the best evidence on lifestyle medicine from becoming the standard of care.
Concern about this dynamic is what led Harvard medical students to petition for their right to an education free of pharma bias, and to ask for limits on consulting and payments by pharma to faculty members (one of whom had 47 industry affiliations, and many of whom received tens to hundreds of thousands of dollars in payments).1
A recent JAMA review that examined the basis for clinical practice guidelines for evidence-based medicine (EBM) found that only 11 percent of guidelines are based on firm clinical evidence (level of evidence A); most are based on “expert” opinion (level of evidence C).2 Of guidelines with good evidence (level A), only 19 percent are Class I recommendations (general agreement among experts that treatment is useful or effective). These clinical practice guidelines considered “best evidence” are heavily influenced by what we have done (driven by pharma), not what we should do (based on evidence for systems medicine).
Medical device and pharma industries routinely pay consulting fees and payments to physicians who promote their products, often without evidence of benefit or for off-label uses. Eli Lilly and Company (Indianapolis, Ind.) paid $1.4 billion in 2009 to settle criminal charges that it illegally marketed Zyprexa, an anti-psychotic drug; and Pfizer (New York, N.Y.) set aside $2.3 billion in fines for illegally marketing Bextra.3
Dr. Peter Green, the world’s expert on gluten, found in a study of 10 million subscribers to CIGNA (Philadelphia, Penn.) that correctly diagnosing celiac disease would result in a 30 percent reduction in health care costs by decreasing utilization (oral communication, March 2009), yet this is not advanced because there is no pharma marketing for testing or treatment of gluten intolerance, something that affects 3 million to 10 million Americans, only 1 percent of whom are diagnosed.
The corruption of our political process by money has many unintended consequences, only a few of which are catalogued above. Money in politics has corrupted virtually all the systems and institutions upon which our collective health depends. That’s why what we need now is nothing less than a revolution in the way our country thinks about health to include, as Prince Charles implores, “accounting for sustainability” — sustainability for our health, our environment, our communities, our economy and our nation, all of which are at risk today.
Certain ideas, while radical, seem obvious to me if we are to create real change and avert disaster. Horse-and-buggy makers gave way to the automobile, and eight-track manufacturers gave way to the iPod.
While some industries will fade, others that promote health and wellness will flourish. These are the changes that will shift our system from sick care to health care. A coordinated effort at the White House level is necessary to successfully create a culture of health and wellness and transform our health care system. That is the task of our next president.
Creating Health: Getting Money Out of Politics
The following are a few strategies that could have the biggest impact on cost and outcomes.
Send letters and e-messages to your elected representatives, encouraging them to support the following health initiatives:
Reclaim Food Policy
- Eliminate unhealthy foods from all schools, child-care and health care facilities, and all government institutions. The government must establish rigorous standards for school nutrition consistent with current science (through the USDA). Similarly, we need to create nutrition programs for other public and government-run institutions.
- Support lobby reform. We must change campaign finance laws so that corporate political donations from entities like big food, big farming, and big pharma can no longer control the political process. Reverse Citizens United.
- Subsidize the production of fruits and vegetables. Change the Farm Bill. Agricultural policies should support public health and encourage the production of fruits and vegetables, not commodity products like corn and soy. Eighty percent of government subsidies presently go to soy and corn that are used to create much of the junk food we consume. We need to rethink subsidies and provide more for smaller farmers and a broader array of fruits and vegetables.
- Incentivize supermarkets to open in poor communities. Poverty and obesity go hand in hand. One reason is the food deserts we see around the nation. Poor people have a right to high-quality food, too. We need to create ways to provide it for them.
- Build the real cost of industrial food into the price. Include its impact on health care costs and lost productivity.
- Tax sugar. We do it for cigarettes and alcohol, which helps pay for prevention and treatment programs. Sugar is at least as addictive, if not more. Scientists suggest a penny-an-ounce tax on sugar-sweetened beverages. This would reduce sugar consumption, obesity, health care costs, and provide revenue to support programs for the prevention and treatment of obesity.
- Create a public health advertising campaign that makes being healthy cool and sexy, that is supported by celebrities and sports icons, and that exposes the subversive practices of big food, big farming and big pharma that propagate disease and suffering for millions. Focus on kids, teenagers and adults, using the best advertising techniques that speak to the emotional needs and feelings of the consumer. Use industry’s best weapons against them, like the successful campaign against teen smoking Rage Against the Haze.
Reclaim Public Airwaves
- Restrict all media marketing of fast food, junk food, and processed food to children.Food marketing directed at children should be banned (through the Federal Trade Commission). This has been done in over 50 countries across the globe, including Australia, the United Kingdom, the Netherlands, and Sweden. We should follow suit.
- Regulate marketing of liquid calories (especially to children). Food-industry marketing practices brainwash children to believe that choosing their products will provide instant happiness and fun. Do they know something we don’t, or are they simply acting on sound evidence that having a 2-year-old ask for brand-name junk food before he or she can complete a full sentence might not be good for people or society? One billion cans of Coca-Cola are consumed every day around the world; we have taken the bait. In communities without health care, education, running water, or enough food, there is Coke!
- The Food and Drug Administration should also restrict unproven health claims on labels. Foods with health claims on the label are often the least healthy. Adding a little fiber to a sugary cereal doesn’t make it healthy. Will Vitaminwater (made by Coca-Cola) or Gatorade (made by Pepsi) and made cool by Kobe Bryant and Lebron James make our kids super athletes, or just super fat? Is there a reason that over 50 countries ban processed food advertising to children?
Reclaim Our Schools
- Help reinvent school lunch programs starting with the Healthy, Hunger-Free Kids Act of 2010, which provides extra money for schools that comply with federal nutrition standards, removes junk food from schools by applying nutrition standards to all foods sold in schools (including vending machines in hallways where most kids get their breakfast of soda and chips) and supports access to fresh produce through farm-to-school networks, the creation of school gardens, and the use of local foods. It doesn’t solve the void in education for self-care and nutrition, but is a beginning.
- Support schools as safe zones where there is access only to foods that support and create health and optimal brain functioning.
- Support changes in zoning laws that prevent fast food and junk food outlets from being next to schools.
- Build school gardens and teach children about the origins of food and experience the sensory delight of real, garden-fresh fruits and vegetables.
- Support integration of self-care and nutrition curriculum into school K-12.
- Bring back basic cooking skills to schools as part of a curriculum that includes essential life tools.
Reclaim Health Care Reform
- Support real health care reform that not only changes insurance regulation, but also changes the type of medicine we do (lifestyle medicine) and changes how we deliver health care (in small groups, in communities and in health care organizations); and pay for quality, not quantity of care. During the health reform process in Washington, D.C., a group of three doctors (Dean Ornish, Michael Roizen and myself) were asked what organization we represented. We replied simply that we didn’t represent anyone except the patients or anything but the science. They accepted it, but looked perplexed. No wonder. During health reform, the pharmaceutical industry had three lobbyists for every member of Congress and spent over $600,000 a day to make sure their needs were represented in the legislation.
- Provide demonstration projects in community health centers to provide inexpensive, nutritious meals (including takeout), recreational facilities, counseling/education (e.g., cooking classes), and health care based on systems/lifestyle/functional medicine at one location.
- Impose limits on pharmaceutical and unhealthful food advertising. More than $30 billion is spent on marketing junk and fast food to consumers, including $13 billion targeted at children, and more than $30 billion is spent by pharma on marketing drugs to physicians (about $30,000 annually per physician). Direct-to-consumer drug advertising also drives prescribing practices based on induced preferences rather than science.
- Empower the National Prevention, Health Promotion and Public Health Council as an ongoing vehicle for coordination of strategy and policy. Focus specifically on developing policies and programs for lifestyle-based chronic disease prevention and management, integrative health care practices and health promotion.
- Support the creation a health corps for America to train 1 million community health workers and health champions in communities around the country by 2020. Through the act of “accompaniment” — getting healthy together — we can create a double revolution: Change the medicine we do (focus on lifestyle medicine that addresses the causes of chronic illness) and change how we do medicine (in small groups that help people create positive social and behavioral change). This new workforce of community health workers would “accompany” and support individuals in making better food and lifestyle choices and cleaning up their homes, workplaces, schools, faith-based organizations and their environment.
Reclaim Medical Education
- Mandate nutrition and lifestyle medicine training in medical schools and residency programs. Consider this: All of the major drivers of disease and health care costs are lifestyle — and therefore preventable — factors. If these factors were addressed, we could eliminate 90 percent of heart disease and diabetes, yet only 1 in 4 medical schools have a nutrition course, and only 28 percent of schools meet the minimum 25 hours of nutrition education recommended by the Institute of Medicine. And most of those nutrition hours are about nutritional deficiencies disease like scurvy and rickets. If we were successful in reducing heart disease by half or reducing diabetes (along with its complications) by 80 percent, hospitals would go bankrupt, pharma would see their profits plummet, and many physicians would be looking for another line of work.
- Support and develop a modular scalable nutrition curriculum to address lack of supply of adequate experts (scale existing programs such as the Institute for Functional Medicine).
- Provide reimbursement for lifestyle treatment of chronic disease. Despite reviews of the science by major organizations, and support of nearly all the major medical societies who joined in publishing a review of the scientific evidence for lifestyle medicine both for the prevention andtreatment of chronic disease, this approach is still not part of medical training or medical practice.
- Develop more funding for nutritional science. Congress should mandate greater funding of nutritional science, and examine and test innovative treatment models that work. Guidance for dietary policy should be placed with an independent scientific group such as the Institute of Medicine, instead of the politically and corporately influenced U.S. Department of Agriculture, which now tells us what to eat. They advised a low-fat diet food pyramid with at least eight to 11 servings of bread, rice, pasta and cereal a day in the 1980s that coincided with the rapid increase in obesity and diabetes. It was lethal to mix politics and health recommendations.
- End irresponsible relationships between medicine and industry. Public health organizations like the American Heart Association and the American Dietetic Association should avoid partnerships, endorsements, or financial ties with industry that compromises their independence and credibility. Coca-Cola sponsoring events at the American Dietetic Association, or the American Heart Association promoting chocolate sugary cereals as heart-healthy because they have a few grains of whole wheat — is this credible?
It’s worth noting that these strategies span multiple industries, systems and domains. We are currently experiencing a perfect storm where economic, scientific and moral imperatives are all colliding, and increasingly they are aligning around one very powerful, integrated solution. This provides an opportunity for us as a nation to do well by doing good — through fundamentally changing the way we think about health, money and politics, illuminating the often invisible forces that are putting our health and our nation at risk.
To solve this will require the collective imagination, intention, focus and action by health care providers, consumers, and industry and policymakers. It will also require campaign finance reform and reversal of the Citizens United decision that puts too much money into politics, money whose first interest is not public welfare but profit. There is no place for that in our nation’s government.
In the words of the ancient Jewish sage, Rabbi Hillel, “If I am not for myself, then who will be for me? And if I am only for myself, then what am I? And if not now, when?”
Go to www.takebackourhealth.org to learn how to take back our health, take money out of politics and join how we can and must get healthy together. Share your ideas and stories of how we can take back our health.
1. Snyderman R, Langheier J. Prospective health care: the second transformation of medicine. Genome Biol. 2006;7(2):104.
2. Wilson D. Harvard Medical School in ethics quandary. The New York Times. March 2, 2009. Availablehere. Accessed March 9, 2009.
3. Tricoci P, Allen JM, Kramer JM, Califf RM, Smith SC Jr. Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA. 2009;301(8):831-841.
4. Harris G. Crackdown on doctors who take kickbacks. The New York Times. March 3, 2009. Available at:
5.http://www.nytimes.com/2009/03/04/health/policy/04doctors.html?_r=1&ref=health. Accessed March 9, 2009.
6. Adams KM, Kohlmeier M, Zeisel SH. Nutrition education in U.S. medical schools: latest update of a national survey. Acad Med. 2010 Sep;85(9):1537-42.
Mark Hyman, MD is family physician, a four-time New York Times bestselling author, and an international leader in his field.
Reposted from http://drhyman.com/blog