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THE UNFULFILLED PROMISE
Posted by Time for change in General Discussion (1/22-2007 thru 12/14/2010)
Sat Sep 12th 2009, 10:00 PM
If the lower rates of coronary intervention and medical treatment in women can be explained neither by differences in diagnostic findings nor age, that raises the possibility of a gender-based treatment bias on the part of physicians, which leads the
Heart disease is the leading cause of death in the United States in both men and women. It accounted for more than 652 thousand deaths in the United States in 2005, which was about 27% of total deaths that year. By far the largest sub-category of heart disease deaths is coronary heart disease, which is an obstruction of the arteries that supply the heart muscle with blood. When the obstruction of the coronary arteries is great enough, the amount of oxygen-carrying blood reaching the heart muscle (myocardium) is reduced, which can result in the death of heart muscle, which is known as a myocardial infarction – or a “heart attack” in common language. This situation usually requires aggressive treatment measures, consisting either of direct relief of the obstructed coronary artery or arteries (called percutaneous coronary intervention) or coronary artery bypass surgery, in addition to drug treatment.

It has long been known that men, on average, are Gender differences in Rx more aggressively treated for coronary heart disease (CHD) than are women. And it has also long been known that, although CHD is more common in men, it is more highly fatal in women. That has raised the question of WHY, if it is more fatal in women, is it treated more aggressively in men.

There has been no consensus on the answer to that question. One theory has been that the less aggressive treatment in women is do to the fact that women with CHD tend to be older and have more serious co-existing diseases than do men. Their older age and more serious co-existing diseases could and often do pose a barrier to aggressive treatment of their CHD. However, most studies that have analyzed this issue have found that treatment of men for CHD is, on average, still more aggressive than the treatment of women even after statistically controlling for age and co-existing disease. Those studies therefore showed that age and co-existing disease cannot fully explain the more aggressive treatment of CHD in men than in women.

The two other most prominent theories to explain the less aggressive treatment of CHD in women are: 1) Gender bias (of unknown reason) against women – meaning that doctors tend to give women insufficient treatment for CHD; or 2) More severe disease of the coronary arteries in men than in women – which could justify more aggressive treatment in men than in women.

In this post I’ll discuss a research study that I conducted at the Food and Drug Administration (FDA) to explore the second theory noted above – that men are treated for CHD more aggressively than women because they have more severe disease. This study was funded by the Office of Women’s Health at the FDA, whose main mission is to “Protect and advance the health of women through policy, science, and outreach”. It was the first large study that analyzed gender differences in treatment of CHD by comparing groups of men and women who had similar degrees of severity of coronary artery disease. I will present the results of this study at FDA conferences on September 25th and November 10th, and they will be published in the journal Clinical Cardiology.


FDA STUDY TO ASSESS GENDER DIFFERENCES IN THE TREATMENT OF MYOCARDIAL INFARCTION


Methods

The data for this study came from a registry (the acronym is CRUSADE) of coronary heart disease patients maintained at Duke University Medical Center. In collaboration with researchers from Duke University, we analyzed the records of 32,888 patients who were diagnosed with myocardial infarction and treated at 522 different clinical sites throughout the United States from 2001 through 2006.

Of the 32,888 patients who were included in our study, 18,448 received diagnostic cardiac catheterization. That is a procedure whereby a radio-opaque dye is injected into the coronary artery system, followed by X-rays to assess the degree of obstruction of the coronary arteries.

We divided the study population into four different categories of CHD severity: no significant obstruction; one coronary artery obstructed; two coronary arteries obstructed; and, three coronary arteries obstructed. We also divided the population into four different age groups. We then compared the percentage of men vs. women who were treated with either coronary artery bypass surgery or percutaneous coronary intervention within each of the groupings by age and number of obstructed coronary arteries. We did that so that we could be confident that all of our gender comparisons involved women and men with similar degrees of coronary artery obstruction and age.

We also made similar gender comparisons with regard to drug treatment for five different drugs that are commonly used to treat acute myocardial infarction.


Results

In 7 of the 16 age-CHD severity groups, men were characterized by a statistically higher frequency of coronary artery intervention than were women. There were no age-CHD groups in which women were characterized by a statistically higher frequency of coronary artery intervention than men.

As an example, consider men and women with obstruction of one coronary artery: In the less than 65-year age group, 86% of men were treated with coronary intervention, compared to 77% of women; in the 65-74-year age group, 82% of men were treated, compared to 74% of women; in the 75-84-year age group, 79% of men were treated, compared to 73% of women, and; in the 85-year and above age group, 73% of men were treated, compared to 70% of women.

Similar findings (i.e. greater frequency of treatment in men than women) were found for four of the five drug treatment categories that we analyzed.


The meaning of these findings

These findings go a long way towards showing that the reason for more aggressive treatment of CHD in men than in women is not due to a greater severity of CHD in men than in women, since we compared men and women with similar numbers of obstructed coronary arteries against each other. This study doesn’t completely rule out a greater severity of CHD in men than in women as the explanation for their more aggressive treatment. It is possible, for example, that men with a given number of obstructed coronary arteries had more obstruction of their arteries than women with the same number of obstructed coronary arteries (That data was not collected in this study). But then, if more severely diseased coronary arteries explained the greater frequency of coronary artery intervention in men compared to women, then what would explain the more frequent use of drug treatment in men than in women? In summary, these results go a long way towards ruling out greater severity of coronary artery disease in men as an explanation for their receiving more aggressive treatment than women.


GENDER-BASED TREATMENT BIAS?

In the conclusion to our soon to be published journal article we address the possibility of gender-based treatment bias, by asking the key question:

If the lower rates of coronary intervention and medical treatment in women can be explained neither by differences in diagnostic findings nor age, that raises the possibility of a gender-based treatment bias on the part of physicians, which leads them to consider CHD less seriously in women than in men... That is a very serious matter, given that the prognosis of CHD is generally worse in women than in men and that their worse prognosis is possibly explained at least in part by less aggressive treatment in women.

There are other possible explanations for the gender differences in treatment. For example it is possible that physicians treat women less aggressively for this disease because women prefer to be treated less aggressively. I’m not saying that’s likely, but it does seem possible, and as far as I know that possibility has never been extensively analyzed. And, there could be other explanations that most of us haven’t thought of.


WHY would physicians have a treatment bias against women?

One explanation that might explain a physician treatment bias against women with respect to CHD is the simple fact that CHD is more common in men than in women. But based on the results of this study, that explanation doesn’t seem very likely, since women still receive less frequent treatment of CHD even when they’ve been diagnosed with it by angiography.

After giving the matter much thought, it seems reasonably possible to me that the explanation involves socio-economic status and insurance coverage. Women on average make less money than men, and they’re likely to have worse insurance coverage. A study by Charlotte Muller showed that:

Women use more family and personal funds and rely more on Medicaid; men have more and better coverage by private insurance and are more likely to be covered by Veterans Administration programs and by Workers’ Compensation. Women, paying more expenses out of pocket than men, are more likely to have unmet health care needs.

A relative lack of insurance coverage is undoubtedly translated into less medical care. With regard to Muller’s studies:

It is interesting to note that when men and women are given routine examinations for the same conditions, men tend to receive more tests; perhaps this indicates that men’s complaints are often taken more seriously than women’s.

Yes, it could indicate that men’s complaints are often taken more seriously than women’s. But it could also be explained by less insurance coverage – or by a combination of these two reasons.

A much smaller study that I participated on using funds from the Office of Women’s Health at the FDA suggested that black patients are less aggressively treated for CHD than white patients. It is possible that a relative lack of health insurance coverage partly explains the differences in CHD treatment by both gender and race.

Our next step, if I can get permission to continue with this research, will be to examine how socioeconomic status in general, and different kinds of insurance coverage in particular affect differences in CHD treatment by race and by gender.
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The Unfulfilled Promise
The Unfulfilled Promise of the American Dream: The Widening Gap between the Reality of the United States and its Highest Ideals




Time for change


Notwithstanding the lofty sentiments and purpose of the U.S. Declaration of Independence, the reality of the United States of America did not then – and never has – lived up to its ideal. Our nation remains today a long way from fulfilling the promise implied by those ideals. Yet, our Declaration was a great start, and it has long shone as a beacon of hope for people all over the world.

Throughout our history, while many have striven to close the gap between our highest ideals and the reality of our nation, others have focused on the accumulation of private wealth and power, at the expense of everyone else. In recent decades the latter have gained much ground, leading to increasing imperialism abroad and deteriorating democracy at home, characterized by routine (and legal) bribery of our public officials, the fusion of government and private corporate interests (corporatocracy), a corrupt election system largely in the hands of private corporations, a corporate controlled communications media, and the widespread acceptance of Executive Branch secrecy, routinely justified with little if any questioning, by the magic words “national security”. All of this is rapidly turning our country from the democracy proclaimed at our founding into a plutocracy (government by the wealthy and for the wealthy). The result is the most obscene wealth gap our country has ever known, the highest imprisonment rate in the world, rampant militarism, routine flaunting of international law, the least efficient health care system in the developed world, a pending environmental catastrophe that threatens to destroy the life sustaining forces of our planet, and myriad other problems that threaten to destroy our nation and tyrannize our people.

My new book, The Unfulfilled Promise of the American Dream – The Widening Gap between the Reality of the United States and its Highest Ideals, explores the roots and consequences of the demise of our democracy, and why most Americans have been unable to understand this process or even become aware of it. A good understanding of why and how we have deviated so greatly from the ideals of our nation is the first and necessary step towards getting back on the right track and revitalizing our society.

The book is currently being sold in electronic PDF format and can be purchased at http://www.unfulfilledpromise.com/Buy-the-... for $3.99. It will also soon be available in Amazon Kindle format. DU members who cannot afford to buy the book but would like to read it can pm me with your e-mail address, and I will send you a free PDF copy.

I’ve previously posted on DU a slightly earlier version of the introduction to the book, which is also posted at my site. Here is the Table of Contents, followed by a brief description of the three parts of the book:


TABLE OF CONTENTS

Introduction
Acknowledgements
Prologue – What is Wrong with the United States of America?

Part I – Root Causes of the Impending Demise of American Democracy
Chapter 1 – Legalized Bribery
Chapter 2 – Human Psychological Factors
Chapter 3 – Corporatocracy
Chapter 4 – Corporate Control of Media
Chapter 5 – Corrupt Election System
Chapter 6 – Government Secrecy
Chapter 7 – American Exceptionalism

Part II – A Sampling of Imperialist Actions
Chapter 8 – Slavery and its Legacy
Chapter 9 – Early U.S. Imperialism
Chapter 10 – U.S. Imperialism in Cold War
Chapter 11 – Iraq War and Occupation
Chapter 12 – Afghanistan War

Part III – Consequences
Chapter 13 – Election of George W. Bush
Chapter 14 – War and Imperialism
Chapter 15 – Class Warfare
Chapter 16 – Predator Financial Class
Chapter 17 – Shock Therapy
Chapter 18 – Contempt for Int. Law
Chapter 19 – The “War on Drugs”
Chapter 20 – Climate Change
Chapter 21 – “War on Terror”
Chapter 22 – Health Care
Chapter 23 – Unaccountable government
Chapter 24 – Response to 9/11 Attacks
Epilogue


PART I – Root Causes of the Impending Demise of American Democracy

It is somewhat difficult to separate the causes of our problems from their consequences, since they combine to form a long chain of cause leading to consequence, leading to more consequences, etcetera. Nevertheless, it seems worth while to identify the root causes of our problems, those that occur early in the chain and lead to so many of the tragic consequences we see today. The only chance we have of reversing the demise of our democracy is through addressing and attacking its root causes.

At the top of the list is the systematic bribery of public officials by the powerful corporations (Chapter 1) whom our government is charged with regulating in the public interest. Instead of calling it bribery, we call it “campaign contributions”, but what we call it isn’t as important as what it is. It is hard to fathom how democracy can survive when such a practice is legal and condoned.

Working in tandem with our system of legalized bribery is the nature of the people who inhabit our country. That is not to say that Americans are inherently substantially different than any other people. Human beings are imperfect, and that is probably a major reason why in a world where civilization began more than five millennia ago, the oldest written national framework of government in the world today – the Constitution of the United States of America – is only a little more than two and a quarter centuries old. Chapter 2 explores the roles of basic human needs, authoritarianism, psychological defense mechanisms used to prevent us from perceiving reality as it is rather than as we’d like it to be, and corrupted ideologies in causing us to passively accept the accumulation of power in the hands of ambitious and ruthless individuals who care about little else than expanding their own wealth and power.

When bribery of public officials is tolerated as an inevitable aspect of public life, government inevitably grows close to the wealthy interests that shower it with money in return for legislative and other favors. A malevolent symbiosis grows between the state and corporate power, resulting in rule by an oligarchy that is highly detrimental to the lives of ordinary people (Chapter 3). Using their accumulated wealth and power to manipulate our legislative process, the oligarchy grabs for more and more control of the communications media (Chapter 4) that are used to control the information available to and shape the attitudes of our nation’s people, in pursuit of their own narrow interests.

Since the 1980s an orchestrated campaign has been underway to demonize “big government”, thereby paving the way for private corporate control over more and more functions that were previously deemed intrinsic functions of government. Among those functions is the running of public elections (Chapter 5) – the function that symbolizes democracy perhaps more than any other single function. Consequently, the purging of selected registered voters from our computerized voter rolls has become a routine recurring event throughout much of our country, and without a doubt determined the results of the 2000 – and probably 2004 as well – presidential election. Just as bad, more and more of the counting of votes in our public elections have been turned over to private corporations, which count our votes using electronic machines using secret software to produce vote counts that cannot be verified by anyone.

Bribery, the fusion of government and private interest, fake and biased news, and corrupt elections are not things that government and its corporate allies want us to know about. Consequently, they construct walls of secrecy (Chapter 6) to keep us from obtaining information that sheds light on their activities. The perfect phrase for facilitating this is “national security”. When our government tells us that the “national security” requires that certain things be kept secret from us, the understanding is that to question such a pronouncement is unpatriotic, and to actually attempt to obtain the “secret” information may be treasonous.

But indefinitely maintaining secrets from the American people can be very difficult, because at least some people want to know what their government is up to. So in addition to the formal mechanisms of secrecy, informal mechanisms are constructed (Chapter 7) to keep vital information away from us. One of the primary methods for doing this is to make certain sensitive subjects taboo – that is, to create the widespread belief that discussion of these topics is so outside the bounds of acceptable human discourse that anyone who discusses them should be shunned by society, or worse. The most common issue that falls into this category is any discussion that sheds light on the disparity between American ideals and the reality of life in our country today.


PART II – A Sampling of Imperialist Actions in U.S. History

Notwithstanding the fact that our founding document says that “all men are created equal” and speaks of the inalienable rights of humankind, the United States has throughout its history partaken of massive exploitation of other peoples.

It is estimated that at the time of our birth, 18% of our population was black slaves. In our expansion westwards during the late 18th and 19th centuries, we decimated the original inhabitants of our continent, and often treated them with great cruelty. In 1846 we manufactured an excuse for war with our neighbor Mexico, in which we continued to expand our country westwards and southwards. In 1893 we began our overseas imperialism with the conquest of Hawaii. Our overseas expansion was greatly accelerated in 1898 with our participation in the Spanish-American War, which led to our conquest of Cuba, Puerto Rico, and the Philippines. With our arrival at world superpower status at the end of World War II, we began the Cold War, which led to and served as a rationalization for covert and/or direct military actions against myriad foreign nations over the next 46 years. With the September 11, 2001 attacks on our country, we declared a perpetual “War on Terror”, which served and continues to serve as an excuse to invade and occupy Iraq and Afghanistan, nations that posed no threat to us. We do not know when or if this perpetual war will ever end. We don’t know how many additional imperial conquests it will lead to.

Most Americans don’t think much about all this. Many of these actions are done in secrecy, and the American people don’t find out about them until many years later – or we never find out about them at all. Those that we do know about are spun into the most favorable light, to make them seem benign or even noble.

But these actions come at great costs: in the lives of our soldiers; in the ruined lives of the peoples of the victim countries; in trillions of dollars cost to our people and their future generations; in our international reputation; in anti-American hatred leading to terrorism; and, to our democracy itself. For how can a nation claim to believe in the inalienable rights of humankind specified in its founding document, while making a mockery of that belief in the way it treats other peoples? For that reason alone it is worth while to take a brief look at our long history of imperialist actions.


PART III – Consequences

In the Prologue I give a brief account of what I see as some of the worst and tragic consequences of the root causes that I discuss in Part I – to enable the reader to see where this book is heading. When elections of our public officials are for sale to the highest bidder… when our public officials are so addicted to the “campaign contributions” of their wealthiest constituents that they develop a symbiotic relationship with them… when our communications media are owned and controlled by an oligarchy of wealthy elites… when our citizenry lack the ability to differentiate propaganda from reality… when we allow machines provided by private corporations to count our votes using secret electronic software… then we should expect that the consequences will not be pretty or comfortable for the vast majority of our citizens.

In Part III, I explore those consequences in much greater detail, in the hope that the reader will agree with me that these are very serious problems, and that they must be successfully addressed if our country is ever to fulfill the promise of its ideals, or even make progress in that direction. When enough Americans recognize our problems as problems, stripped of the gloss and spin put on them by our oligarchy, they will rise up and do something about them. Until then there will be no progress, and we are very likely to head in the direction of all the former empires of our planet, ending in chaos, widespread catastrophe, suffering, and ignominy.

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