sunlight and you can see the occupation's already beginning to wear on people. >> we have another program at 6:00 so we have to end this session here but don't forget both authors will be here on either side of the table below and they will be signing books and michael can help you out. there is a vietnam -- world war ii men went to war on troopships, vietnam exhibit out front of graffiti left on the canvases during the vietnam war and you might find that of interest on the way out. thank you all for coming. [inaudible conversations]

[inaudible conversations] >> up next on booktv from the 2014 virginia festival of the book dr. otis brawley talks about how medicine is practiced in the u.s. and argues the rich are overtreated, the poor are undertreated and doctors, insurance companies and big pharma make money by taking the vantage of both groups. this is about an hour and 10 minutes. >> good evening. welcome to this nice event, thank you for coming. my name is rob richards, an oncologist and chair of the cancer committee. we have a lot of hospitals that make -- the speaker, dr. otis brawley, he wears many hats and

is currently a professor of human policy, oncology, medicine and epidemiology at emory university, the centers for disease control and prevention on breast cancer and young women. in addition he served as chief medical officer of the american cancer society and is responsible for promoting cancer prevention, early detection and quality treatment. he is an acknowledged the year in health transparency treatment, to live in disparity and quality cancer. he has received numerous awards including the key saint bernard parish for the public health service in the aftermath of hurricane katrina.

and about being sick in america and his thoughts on care today. join me in welcoming her doctor otis brawley. [applause] >> it is wonderful to be here. i want to say thank-you to the organizers of the virginia festival of the book. i want to thank the staff at martha jefferson hospital for sponsoring me, and dr. charlotte mcdaniel, wonderful emphasis for arranging to meet to be here to offer you today. a little bit about me i was born in detroit, michigan and had the fortune of attending jesuit high school, very good jesuit priest in still on me some thinking about ethics and social justice. i went on to go to medical school and actually applied many of those lessons as i practiced

medicine for 30 years. sorry about the feedback. one of the things, one of the jesuits told me early on, is that we should always remember what it is we know scientifically, what we don't know, and what we believe and we need to label them accordingly. when i went to medical school in reminded me doctors have an extremely bad habit of confusing what they believe with what they know and after 30 years of practice of medicine i have determined that is incredibly accurate. i trained as a medical oncologist and epidemiologists to look at outcomes, what things work, what things don't work in terms of treatment and overtime i realized there were tremendous disparities in medicine, there

were people who had incredibly bad outcomes because they did not get enough care but the big surprise there was a group of people who had bad outcomes because they had too much health care and the title of a book, "how we do harm," talking about those who don't get enough health care, the realization we could do better about the health care system if we were a little more rational in how we practice medicine. many politicians will talk about rationing of medicine. we need to be rational in our practice of medicine. that is a little bit different. at the same time, started looking at health care costs. we spent $2.7 trillion on health care in the united states in

2011. i don't know what to do to stop that. $2.7 trillion is an awful lot of money. with the $1.1 million on food that year, $2.7 trillion on health care. amounts to $8,100 for every man, woman and child in the united states. let's compare that to other countries. if american health care were an economy it would be the sixth largest economy in the world. we spent $2.7 trillion on health care in the united states and there was $2.6 trillion spent on everything in france in 2011, the sixth largest economy. we spent $800 for every man,

woman and child on health care, the second most expensive country in switzerland, $4,300 for every man, woman and child. at the same time we're spending this money on health care our outcomes are not very good. life expectancy overall, 56 and 26, when we look at white male life expectancy, we are four years different between the united states and canada. we like to bash the canadian health care system, canadian health care system is more than half the price of the american health care system on a per person basis. started realizing that the incredible cost of health care in the united states was actually depressing the economy of the united states significantly. if we were switzerland the second most expensive country in the world, if you were a company that employed 300 people. that company giving health care

to its employees the average cost of switzerland would be $10,000 a year for a family. the average cost in the united states for a family health care policy for an employer in 2011 was $1,800. just imagine you have savings employee and 300 people you might employee 306. and various small companies in the united states very quickly 7% rate% unemployment, 5% or 6% unemployment. health care is already, negatively affecting the united states. we have this incredible outcome that are not very good, we have outcomes that are not very good compared to other countries. suddenly underlying corruption in medicine is what we wrote about in the book.

underlying corruption involves not just greed. there's a problem with a lot of folks who make money and the doctors, the hospital's, the drug companies, even the patients that are part of this underlying corruption. it is not just greed, the corruption of lack of respect for what we know. it is a mind-set problem. confusing what we believe with what we know. let me give you some examples. in 1903, dr. hall said told us how to do a mastectomy, breast cancer surgery, removing the breast for breast cancer and he described going all the way down

to the ribs and up to the third level of nymph no. a mastectomy in 1903 was unable to raise her arm higher than this for the rest of her life and always had swelling. we did the halsted mastectomy into the 1980s. in the 1930s and 40s doctors were saying we have to do this to the iran operation? and the loss academic careers because they questioned the halsted mastectomy. the halsted mastectomy was an inappropriate operation and has been dead for 20 years. quite honestly, bernie fisher from pittsburgh and another physician from milan, did a series of clinical trials with

difficulty in the 1960s and '70s -- 70s, removal of the entire breast, incredibly morbid procedure, you could just remove the outer breast further on the show, just remove the cancer and radiation the breast and all equipment in terms of outcomes. the halsted mastectomy and most other things might be relevant operation, the halsted mastectomy was too much of an operation and we did it in the united states for 40 additional years and we criticize anybody who questioned if what we were doing was the right thing. numerous examples of this. i will stick with breast cancer for a second. in the early 1980s a couple of doctors from boston and doctors from boston tend to be very

smart, said the way to deal with breast cancer is to give high doses of chemotherapy and noted with high doses of chemotherapy the tumor shrank. if we gave even higher doses of chemotherapy to women who had surgery to remove all known cancer would probably still have cancer left in their body, maybe we could cure the of breast cancer. what problem was the bone marrow was an innocent bystander that was obliterated with this high dose of chemotherapy but so they came up with a procedure called bone marrow transplant where you could take a woman's bone marrow, store it in a freezer, give her the high dose of chemotherapy. when her chemotherapy cleared her system, give her her bone marrow back. it seemed to be the right thing to do theoretically. these doctors believed it was right. we in the united states started

doing it like crazy. in the 1980s and 1990s women would sue their insurance companies for bone marrow transplants with breast cancer and the insurance companies didn't want to pay for it for one reason. is very expensive and two reasons, there was no scientific study to show it was beneficial. there was opinion that it was beneficial. ten stake in legislatures passed laws and said insurances must pay for this procedure. most of them still have it on the books and is quite interesting. in 1999, 19 years after they started the bone marrow transplant in the united states, three studies were ultimately published. these studies were very difficult to do, especially the one in the united states. who would go into a trial to see a bone marrow transplant actually worked when everybody knows bone marrow transplant

works? these three studies, one from the united states and two from europe, published back to back-to-back in the new england journal showed that bone marrow transplant was more harmful than standard care and within three months of the publication of these three articles, 210 bone marrow transplant centers in the united states for breast cancer all closed. 65,000 american women had been transplanted in the 1990s. all of this was done and this industry had been created without a clinical trial to actually show bone marrow transplant for breast cancer saved lives. let's go closer to something that happened even today. i actually was talking to a

patient, wonderful man who lives in ohio who called me up because of my concerns about prostate cancer screening. his story was that his wife encouraged him to go to this screening being offered by the local hospital and he went to the screening that was held in a mall. he got a letter a week later saying his test was -- suggested he go to this particular doctor and this particular doctor had all these men have had gone the same letter in his office and this doctor ultimately after a couple weeks had done a biopsy and determine if this guy had prostate cancer. it appeared to be localized to the prostate and this fellow started really freaking out because he was diagnosed with prostate cancer. didn't really like this doctor

so he started shopping for another doctor, another young doctor in the same town was now using this robotic machine. one of the things, it is new, it must be better. so he ended out getting his prostate surgically removed like this machine by young fellow but his psa state elevated. it never went to zero. he has no prostate. his psa should be zero so he started worrying about this and kept worrying, they reassured him, kept worrying, finally went to radiation oncologist and convinced this oncologist to radiate his pelvis. we call it a shotgun radiation to the pelvis where you radiate the entire pelvis and hope we

hit some cancer. when the fellow called me, all of this had been done. he had one for school and one for your and where he had all kinds of radiation damage to his palace and was in and out of a hospital all the time with urinary sepsis, urinary tract infections that actually led the bacteria in his blood. he asked me why was i against plastic screening? i explained to him by wasn't against prostate cancer screening. i am concerned about prostate cancer screening, i am concerned about how it is being promoted and concerned about whether it saves lives but everybody is saying it saves lives. i went on to explain about an experience i had in 1998 after i attended the white house

ceremony, very moving ceremony where president clinton apologized for the fact that the u.s. government had lied to 600 putin in tuskegee, alabama in something called the tuskegee syphilis study. two weeks later i went to a cancer center, very famous cancer center in the united states and since i worked for the federal government at the time, they bring out the dog and pony show to talk about how great their research is. i was sitting next to their marketing guy, started talking to him, just want to let you guys know, marketing people are evil. be very careful. he started explaining to me there business plan for prostate cancer screening. and announce prostate cancer is going to be free and getting at

a certain moral in 6 weeks but it is predictable how much increased business, and the hospital cares about their man. it is predictable how much increase in business hospital is going to get in their chest pain center. they know how much brief publicity they are going to get and if we announce the free screening we get the equivalent of this much of what we pay, how much we paid to the local newspaper in publicity. then he explained to me that they had done this for several years now and it was all in the business plan. if they go to this small, 155 will have abnormal screening. 155 will have insurance their hospital doesn't take, god bless them, that will help their

competitors. 145 are going to come to them to be evaluated for their prostate cancer. about $3,000 per person for the evaluation and 145, 45 are going to have prostate cancer. you know the percentage that we are going to get radiation feeds, the percentage that we get external beam radiation even explain he liked external beam radiation because the fees for that were $80,000. it got better. he explained to me that if we screen 1,000 guys and diagnose 45 with prostate cancer this is the proportion of guys with urinary incontinence to the point diapers don't do it for them so if they screen 1,000 guys this is how many artificial

sphincters, he had the apology and explained to me there was a new drug called viagra, how many female press >> that were going to implant in men upset about the importance caused by prostate cancer. he is stopping me, i am a smart guy, if you scream thousand guys how many lives are you going to save? he was a complete and utter fool, don't you know there was never a study to show this saves lives, it was all about making money. that is when i realized we have a huge ethics problem in the united states. the first study ever published to suggest this actually saves

lives, in 2011, for every 200 men treated for prostate cancer you prevent death and caused death and the other 190 have all the side effects of the treatment. you may get better as you get further out in terms of the follow-up but at 11 years those are the numbers. that is by the way the good study that shows that it actually might work. studies out there suggest that it doesn't. so i started worrying about this low level of corruption in medicine where we are interested in making money and stop asking questions. that hit doctors pretty hard with three examples. let me talk about the drug companies. their is this company called asters and poinrazeneca .

and i name names. they added four year patent on exclusivity. they were making billions of dollars on the sale of prozac. they came up with the project. they call it operation shark fed. was the manhattan project to find the next multibillion-dollar drug and looked at numerous different things and finally came up with -- difficult to talk to a non science audience but i will try it. prilosec is a large 3-dimensional molecule and the

chemist actually talks about this molecule being 3-dimensional and there is a mirror image called isomers. they're left and a nice summers and right-handed isomers. the left-handed i summers possesses acid. the right-handed isomer, your kidneys do a wonderful thing, urinate it away. it is inert. what they did was they found a chemical step separating left versus right and created a new skills and went out and did a series of clinical trials for the fda that actually did what my 13-year-old daughter would have predicted. they showed that a bill with the active ingredient was equivalent to prilsec and got it fda approved. they went to at the same time the u.s. patent office and got

this bill with the active ingredient patented for 18 years. then they went to the marketing guys. .. nexium you see, is on the market

because it's in multiple trials shown to be equivalent to prilosec. nexium cost $6 a pill at the cvs down the street. generic prilosec costs 20 cents a pill. one of the 10 most prescribed drugs in the united states is actually on the market because it has been shown to be equivalent to something that costs 124th of what it costs. but we in the united states just keep taking it and people who swear it's better than the old standard, but it's the same thing. by the way, the european union, they decided not to give a patent. they said we gave this patina of him he gave it to prilosec so this is a uniquely american problem. it's one of the reasons why we spend $2.7 trillion on health

care, almost twice what anybody else spends. another problem was for politicians. this is a drug that stimulates red blood cells. we used to give it to people who were anemic. it was fda approved for anemia due to chemotherapy. and gm tried to encourage doctors to think outside the box and give it to people who would need it for other reasons. they actually did a series of clinical trials to promote it for that. also to promote giving a erythropoitin. you have to understand bundling we in medical college make money

by buying our chemotherapy wholesale and selling it at retail. and we make money on chemotherapy marco. while the cost of chemotherapy is actually the cost that we can charge the patient is actually set by governmental influences but the cost that we pay the company is determined by the company. bundling is the concept that was wal-marwal-mar t would call volume discounting. if i were in a four person ecology practice in the big city like atlanta or d.c. and our practice views a little bit of erythropoitin what we gave for erythropoietin and what we paid for erythropoietin we broke even but if we used a lot of

erythropoietin there were four person practices that made for quarters of a million dollars in profit in any given year off of giving a lot of erythropoietin so even if you are a reasonable doctor in the back of your mind he kept thinking cannot justify giving this person this drug? will their insurance pay for it? they are separate questions by the way. will the insurance pay for it and can i justify it but we will merge them. you see those studies that ammo general is doing to try to encourage people to think outside the box actually showed erythropoietin stimulated tumor growth. this drug was a miracle grow for cancer and we were giving it to cancer patients. in 2009 the food and drug administration put tremendous limitations on the use of erythropoietin and cancer patients. it is a drug that has a

legitimate use in some cancer patients but it was being tremendously overused prior to the fda black boxing and putting limitations on it. we have other problems going on in medicine today. lung cancer screening with low-dose spiral ct promoted by every hospital. the issue there is it actually does save lives when it's done in very high-quality and done on people at high-risk for lung cancer. high-risk for lung cancer is a person in their 50s who smoked a pac of cigarettes a day for at least 30 years. unfortunately there are some hospitals that have decided you know, we could make a lot of money off of this so they are recommending lung cancer screening. st. jo's hospital in atlanta actually has an advertisement on their web site. did you know that women in their 40s can get lung cancer even

if they didn't smoke? they are actually recommending that women in their 40s who have lived in urban an urban area for more than 10 years, and pay them $99 to take the screening. one of the things you need to know about lung cancer screening is a quarter of the people who get lung cancer screening either 40-year-old non-smoking women or 60 rolled men who packed -- smoked a pac or 30 years at least a quarter of them will have an abnormal screen and they can charge their insurance companies to find out why the screen was abnormal. the study that shows the that lung cancer screening saves lives shows that for people at high-risk who are over the pages 508 saves 5.4 lives for every one life lost due to medical interventions caused by the screening. that study actually even showed that the people who are at higher risk for lung cancer the benefit is even greater by

people who are at very low risk for lung cancer could benefit to risk ratio starts going down. so what i'm telling you is non-smoking people in their 40s are still have a very high-risk of being harmed but a lower risk of ever benefiting compared to the heavy smokers who are in their 60's and 70's. but hospitals are doing this. these are all part of the problem. it's a combination of greed, combination of ignorance. some people have said that the problem with doctors and people in medicine -- it's not just doctors. by the way i should bash the lawyers as well. lawyers are part of the problem as well. some of the solutions to these problems are, we need to focus on what does the science say? we need to actually support doing some of the scientific studies and once the scientific studies are actually done we

need to listen to them. the other thing of course is remember when i was talking about the halstead mastectomy. we had all these doctors who actually criticized any doctor who asked the question is this appropriate and do we need to investigate it? when you look back over the history of medicine we right now are overdoing it in c-sections. we are overdoing it in his tract of maize. those of us with a little gray hair can remember we had an epidemic of tonsillectomies in the 1960s and 70's. we had too many -- and if it epidemic of putting tubes in kids ears. we had an epidemic of coronary artery bypass grafts carotid endarterectomy's. we in medicine to get in these these trends are we ever do things. people actually think it's better to consume than to harm. yet there is still this group of people who don't get what they need.

one of the papers that i'm most proud of right -- writing and also one of the papers i most ashamed of. it shows that in the united states if you have staged two colorectal cancer with insurance the chances of five-year survival, your chances of being alive in five years or 90%. if you have stage i colon cancer without insurance your chances of being alive in five years or 80%. you are better off having more dance colon cancer with insurance than the less dangerous cancer without health insurance. this is unique to the united states. other issues we have shown are seven to 8% of the black women who live in middle georgia were diagnosed with breast cancer get

no treatment in the first year of diagnosis. they have enough access to care that they can actually be diagnosed with the disease but they get no access to care. we have all of these disparities of people who are not getting care yet we have all these people who are being harmed because they are getting rational care. again i come back to the theme. we need not talk about rational health care. we need to talk about rational use of -- use of health care. we need to talk about the fact that there are people who are wasting resources and hurting other people and themselves by wasting those resources. i'm going to end by saying the definition of a professional is someone who puts the welfare of their patients or their clients above their own welfare. the definition of a professional is someone who actually does the right thing by looking at what the science is or what the

science says and by trying to explain to their patients and their peers or other doctors with the science actually says. the solution out of this health care morass is to actually be much more allegiant to the science, to actually listen to what the science says, to actually respect the science and to support the science. i'm going to stop at that point and if you have any questions i'll be happy to try to answer. thank you. [applause] do we have a traveling microphone? go ahead i will repeat it sir. >> can you talk about the difficulties that we seem to have the medical profession where the foxes paying to figure

out what the right way to get into the henhouse is and putting it under a patina of scientific study. >> the question is about -- he started out with an important point. it's important to respect the science when the science is unbiased. you are asking about biases in the science. there are huge rises in science and we need to manage those biases. that's an ethical problem. to me the greatest problem is not a financial conflict. the greatest conflict is an emotional conflict of interest. especially right now the two arguments going on, one in radiology having to do with lead cancer screening and the other in radiology having to do with breast cancer screening. some of the proponents have to be radiologiradiologi st to make money doing those tests.

those folks ,-com,-com ma i've looked into their eyes. i thought think those folks are motivated by wanting to make money. i think those folks just believe in what they do so much that they become biased. it's an emotional conflict of interest. we have to be able to somehow manage conflict of interest. financial conflict of interest is easier to handle because you can pretty much force people to disclose financial conflicts of interest. disclosure of emotional conflict of interest is way more difficult. yes, sir? >> your figures are right on target about the prilosec when they need a new one. $6 a pill because i would describe --

prescribed to eliminate the. [inaudible] the next time the doctor came in he said why did we just have you eliminate red wine and no food after 6:00 p.m. and between them i don't have acid reflux. and knott. >> in the united states there is a unique thing about our culture that everybody wants a pill. you have obviously run counter to that vulture but everybody needs a pill for this problem has actually gotten us into a lot of trouble.

>> a related question and maybe a broader question do you see anything in the affordable care act that -- and if you could write your own what would you add? >> yeah. i always wonder how long before someone will ask that. by the way, thank you for that term obamacare. the affordable care act is really reform of how we pay for health care. what we really need to do is transform how we view and how we consume health

if i were to write a health care transformation bill i would stress a lot having to do with the education in grade school

about diet and exercise. i would stress everybody would get hurt. the insurance has come out really well in the affordable care act because they stay in business. by the way the most profitable business in the united states last year was energy and the second most profitable with health insurance. those guys had 20% profits last year. how many people had 20% return on their 401(k)? [laughter] if i were to write a health care bill some people are not going to be able to get some of this excessive care that they have been wanting. health insurances are not going to be able to profit as much. doctors are probably not going to pay as much for our hospitals but i would suspect i would be run out of united states on a rail if you had my health care

bill. people would not tolerate it. yes maam. >> i was in mandala couple of weeks ago. and knott. [inaudible] >> that's a much longer conversation than we have time for. i will tell you one of my concerns about the mammography conversation that i'm hearing right now and most organizations including american cancer society recommends screening beginning at the age of 40. they don't talk about high-quality enough. they don't talk about the limitations of mammography or not and it's my personal belief

that most people think screening is actually better than it is. it's not to say that it shouldn't be done. as to say it's not as good as many people think it is. one of the problems with people thinking it's better than it actually is is the supports for the research to find something better to have eroded because people think it's so good. it's a huge problem to the extent that -- i deal with bioengineers at georgia tech and emory and those young people, graduate students are not going into mammography or breast cancer. they are going into some other disease because it's all been done in breast cancer. >> there are several complaints. and knott looking as an observer

i think people who are in this, they need to learn more about their own bodies and learn about what is good for them and what is not good for them to be better consumers of the system. >> i would agree with you. i would point out the breast cancer bone marrow transplant where women were suing their insurances since forcing state legislatures to pass laws to say paper pay for this. this thing that we have no science to support raid. >> another thing that i wanted to talk about was -- and knott.

[inaudible] >> let me say that i may disagree with you a little bit there, just a little bit. as i talk to young medical students i have been to almost every medical school in the country believe it or not over the last 20 years. i see a difference and the younger medical student and younger doctors. somewhere in their mid-30 as doctors are below an age somewhere in the mid-30s you have got many more who have got masters degrees in public health in addition to having gone to medical school. many of them, actually i think have gone to medical school for the right reasons.

now i worry that these excess pills will cause them to change that many of them have gone to medical school for the right reasons. i am in my mid-50s and my generation a lot more people went to medical school because it was a pathway to a great living. among the younger guys and gals and that's another thing. there are a lot of gals in medical school now. there are more women in medical school today than there are men. in the mid-1980s when i graduated we are running 25 to 30% female and 10 years prior to me they were running 5% female. maybe the increase in the number of women has made us more scientific and interest in doing the right thing. i'm not sure but i actually have a lot more hope for the younger people than i do for my own generation. i just hope my generation doesn't run it for the

generation behind us. but you and i agree that $60,000 a year from for medical school is outrageous. people graduating 200, $250,000 in debt. of course i was 43 years old when i finish paying off the university of chicago. >> virginia is one of the states that didn't pass medicaid expansion. >> medicaid expansion is a program that is part of the affordable care act and it is paid for by the federal government. in the first several years with a very small co-payment afterwards and it allows the state to actually enroll all people who are under a certain

level i think 1.5 times under the poverty level, don't hold me to those numbers, enroll in medicaid which is a state-supported health insurance the key here is the affordable care act, the federal government would pay for this and ultimately when the states and up having to pay which would be several years down the road it would actually cost them less than what they are paying for now. so this would be a net savings to the state if they expand medicaid. unfortunately unfortunately governors who are from particular political party have decided they are contented thing having to do with the affordable care act and they are not going to expand medicaid in their state and what they are going to do is they're going to create a

new level of impoverished disenfranchised people who are not going to have access to health care and their access to health care is actually going to be worse than it was in the old system. they are going to increase the disparity and ironically when i talk about disparities also going to affect poor white americans more. there are more poor white americans and there are poor black or hispanic americans. when we talk about disparity people frequently think of race. i think of socioeconomics. >> be sure with look writings or studies talk about --. >> use the microphone. >> is your book or studies or writings talk about the role of medical records and forcing the

use of electronic go -- it electronic medical records. >> i personally have not written much about the electronic medical record. the electronic medical record in my view can be a good thing but it can also be a bad thing if it is used wrongly. one aspect of the electronic medical record that i like is there's a lot of our describing practices as physicians where we prescribe drugs that are contraindicated with other drugs create electronic medical record can figure that out. the other problem that i worry about with the electronic medical record is as i see patients it's always easy to hit those three keys that have my standard i have seen the patient, graywith with the resident said without my ever thinking. when i have to write things out

i actually force myself to think by writing. now i have to force myself to think the for a hit those three keys that magically signed a record. so i am worried about the electronic medical record but i think it could be a good thing. [inaudible] >> i am a reserve officer in united states public health service. i was actually active duty when i was at the institute of health from 1988 through 2001 that became a reservist. i went back onto active duty after six months and ran a couple of urgent care centers in southern louisiana plaquemines st. bernard cameron and even new orleans. we were based in st. bernard parish so i became very close to the folks.

see what do you do specifically medicine wise? >> what the i do specifically medicine wise? if you know what i do academically you want me doing general internal medicine. i was in charge urging care centers in the centers that i was that in st. bernard for example saw about 142150 people every day ,-com,-com ma seven days a week. these were folks coming in with anything you can imagine from colds to migraines to chest pain to i fell off the roof while i was trying to fix fix it after e hurricane, to nail injuries and saw injuries and everything you can imagine. basically after hurricane -- it was a great experience for someone who's interested in health disparities.

the hospital in st. bernard parish was one large hospital. they had 130 doctors and four months after the hurricane, four of the 130 doctors had come back so this was an area that had very little health care resources moving back into it. we from the public health service with civilian volunteers went in and provided that health care until they could reestablish their own health care system again. >> i would like to suggest a correction. i would like to suggest a correction. ..

>> [inaudible] >> yes the national institutes of health where i worked 14 years and

loved, the largest funder of medical records in the world. and the budget and for a long time now id has gone down over the last 12 years there is less money now than 12 years ago. we're finding now about and not 10% of the grant of something that merits being funded. when i was young investigator about with 30 or 35%. now people who are my age can compete but those who are in their thirties just are not in a laboratory or a setting they are unable to get funded because they

don't have the reputation. i am very concerned there is no whole host of people who very well may have discovered a cure for cancer or better treatments for higher retention or a whole host of those now in their thirties deciding to go into private practice for with ph.d. say go work at wall street for the investment houses for drug companies and we are losing a generation of young scientists to would be incredibly productive to provide new treatment in new skiers. -- cures. >>

[inaudible] >> you are very close to right. osteoporosis are real diseases. but the problem is those of bastille pina especially really ought to adjust say do nothing. my new favorite phrase by the way is low t. [laughter] but there are the manmade diseases that have been created for treatment where the issue should be walk

around the block everyday. as opposed to taking a drug that causes all kinds of reflux problems that you are correct. other examples of diseases that we have created you may throw tomatoes at me, but we've made osteoporosis a diseased that every woman should take post menopausal hormones that was through the forties and then in the early '90s there was a clinical trial to figure out if we should do the post menopausal hormones. everybody said why are you wasting this money? by 2003 everybody was quiet when the study showed the post menopausal hormones

were causing 5% of the breast cancer in the united states. that is another example of an inappropriate treatment of a legitimate problem with the discomforts of menopause >> [inaudible] >> the first problem i cannot tell you about i don't know about the maker baidu know there is controversy. but i can tell you we have had problems especially with certain acids to treat

osteoporosis. the problems that actually result in people to get the drugs end up getting dental procedures lydgate necrosis of the job as a result of surgery combined with the acid. some of the gap -- the others, acid is another drug set was developed interestingly got the first fda approval because it was very good to prevent hairline fractures of his spine for those who had metastatic cancer. when you hear that, it sounds important but with the randomized study of people with cancer who got the acid or nothing they

noted less hairline fractures from those who got the acid but what they didn't know those who got the hairline fractures didn't know that they had them except somebody had of x-rays to say they had one so they prevented something that was a symptomatic. there is a rule about these. they do not bother you. [laughter] >> [inaudible] >> that is a great follow question to your example. lot over the last 30 years of medicine we have or the threshold for everything. when i was a medical student

of blood sugar less than 140 was normal. when i was the resident less than 120 was normal. one day around 2,000 in all my cancer patients had abnormal blood sugars because the lab had moved normal down at 100. the same with blood pressure where the normals have guided lower ian flow were to the point if you have a blood pressure you are abnormal. [laughter] that is almost an exaggeration. [laughter] the assignments for this is not solid. 80 percent of men over 60

ought to be honest that an accord big to the american heart association i am for it about this. some of the guidelines the staten guidelines published a couple of months ago everybody on the committee takes money from a drug company. how can you trust? the institute of medicine by the way to publish guidelines how to make trust for the guidelines. we need to start falling those. you can get a pd f. >> [inaudible]

>> number one and we'd elected officials who can ask questions and understand. i literally had to explain a congresswoman and a congressional hearing and the mortality is dying from cancer.

she may be great with foreign affairs but with health care does not doing very well. many elected officials get donations from these people in sweden much clearer understanding where they get their money. i had a run in with a black congressman from brooklyn and one of the lobbyists had to whisper in my year in and explain he is the number one part taker of money and because of all the tobacco farmers. [laughter] >> you really have to know where these people are taking their money. sometimes you have people who have personal

experiences and bob dole would be upset if i told you about prostate cancer screenings because he is convinced a screening saved his life. that is the emotional conflict of interest. but it may have. he'd probably says i am clearly a democrat right now but where people get their money is important. the one thing i have learned. next to be smart enough to understand i.m. heavily controlled. i will talk to after. thank you very much. [applause] [inaudible conversations]