American College of Physicians: Internal Medicine — Doctors for Adults ®

Monday, November 5, 2012

Sowing smaller government, reaping salmonella

For the entire span of my career in medicine and public health, the U.S. FDA has been under-funded to do the job everyone expects it to do. I have heard this from colleagues in the agency my entire career, and have heard it directly from no fewer than two former FDA commissioners, one of whom is a friend.

The agency is supposed to review every medication that comes through the developmental pipeline and make sure the good ones are promptly approved, and the bad ones just as reliably rejected. It's a big job, considering the scope of the modern pharmaceutical industry, and mistakes in either direction can cost lives, but we expect the FDA to do it.

We also expect the FDA to monitor and safeguard our food supply. They are not entirely alone in this endeavor, of course; they have allies in other government agencies, such as the USDA and the EPA. But let's stick with FDA, understanding that this is in part preferentially about the job the FDA does, and in part about government agencies for which FDA serves as a good illustration.

No one notices when food outbreaks don't happen, but nobody much cares for outbreaks of food-borne illness that do. When they occur, as they do with disconcerting regularity, there is at first a degree of worry, perhaps fear, and in the case of outbreaks that are really big and bad, maybe even some panic. There are foodborne pathogens, from salmonella, to E. coli 0157H7, to C. botulinum, and others, that can be, and at times are, deadly. Foodborne infections can kill us. They can kill someone we love.

We all know this, but we can't really run from it, not without foreswearing eating altogether. We have to eat, and so we take our chances. We count on the FDA to shift those chances in our favor.

And when they don't, when outbreaks happen, we tend, both individually and collectively, to segue from fear to outrage as the threat dies down. How could this have happened? Who's to blame?

We are to blame. Because, as noted, the FDA has never had the person-power required to inspect the food supply with the rigor required to forestall such outbreaks more reliably than they do. And nobody else steps in to pick up the slack.

We should note that inspections do happen, of course, and save many of us from the outbreaks they prevent. But there are too few inspectors, too few inspections, and too many of us eating too much food from all over the country and world. The malady is far bigger than the remedy, and so we reap exactly what we sow.

FDA funding is, of course, not the only reason for so many foodborne infections. The kinds of food we eat, and our processing of them, are also relevant here. But that's not today's topic. For more on that subject, I recommend to you Six Arguments for a Greener Diet by my friends at the Center for Science in the Public Interest.

For today, let's stick with the perennially under-funded, under-staffed FDA, and mull over those foodborne infections in the context of political strife, and frequent calls for "smaller" government.

"Smaller government" makes a swell sound bite, because it sounds like standing up against waste, inefficiency, and the quagmire of bureaucracy. But in the course of political harangues where sound bites prevail, details tend to be omitted, and it's often hard to tell exactly who is apt to get bitten.

Smaller government doesn't just mean containing bureaucracy run amok. Nor does it seem to mean cutting the size of Congress in half, or laying off Supreme Court judges, although I frankly think good arguments could be made for both of those. It means fewer police, fewer teachers and fewer firehouses. We all know that government does jobs no one else does, such as building and maintaining interstate highways and bridges. Smaller government means less of that.

It means a smaller corps of engineers to maintain levees, a smaller national guard to respond to crises in our communities. It means turning employed people who earn money and pay taxes into unemployed people who compound our economic woes. But I'll leave such minor concerns to the politicians, and stick to my day job. In my world of medicine and public health, it means more salmonella.

Government does jobs nobody else does. Food inspection is an example.

Now, consider the food inspector who is unemployed instead of doing her job because "smaller government or bust" is in fashion. She is out of work, and so her family is struggling. They are not spending money, and so the things they might have bought go unsold. If there are many like her, and there are, companies take a hit. The economy languishes. You get the idea.

But never mind her, let's worry about the inspectors left on the job, and their need to do twice as much in too little time. And then, let's worry about ourselves!

That unemployed inspector is not on the job, so contaminated food at some farm or factory goes uninspected. Salmonella breezes by on a conveyor belt, unobserved, and finds its way into some product you take home to your family, or I to mine. We get sick, we writhe and suffer, we miss work. We incur medical bills. Maybe we get better, maybe not. Either way, it's a bad time, and a bad deal for all concerned.

Nobody likes waste, inefficiency, or bureaucracy. Nobody likes earmark boondoggles or pork-barrel politics. And I suspect all reasonable people would agree that government should be no bigger than it needs to be to do what it needs to do. Honestly, you can believe in a social safety net AND not like to see your tax money wasted on basket-weaving. But those of us in public health know that government hires real people to do real jobs, and often jobs nobody else will do if government doesn't do them. Like safeguarding our food supply.

So here's to ever smaller government, which sounds really terrific, until it's you, or someone you love, who winds up with salmonella.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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