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Under Maryland Street, Ties to African Past
By JOHN NOBLE WILFORD, The New York Times, October 21, 2008
Over the years of exploring the old houses and streets of Annapolis, Md., archaeologists have uncovered a trove of artifacts of early American slave culture. Among them are humble remains connected with religious practices, which bear the stamp of the slaves’ West African heritage.
Early in the 18th century, as they were being baptized, African-Americans clung to “spirit practices” in rituals of healing and the invocation of ancestral and supernatural powers. Sometimes called black magic, these occult rites would persist in America in modified form, later, as voodoo and hoodoo.
University of Maryland archaeologists have discovered in Annapolis what they say is one of the earliest examples of traditional African religious artifacts in North America. It is a clay “bundle,” roughly the size and shape of a football, filled with about 300 pieces of metal and a stone axe, whose blade sticks out of the clay, pointing skyward.
The bundle, found in April and dated to 1700, appears to be a direct transplant of African religion into what is now the United States, said Mark P. Leone, a professor of anthropology at Maryland who directed the excavations. The materials and construction, he said, differed from the hoodoo caches his teams had previously found in Annapolis.
“The bundle is African in design, not African-American,” Dr. Leone said in an announcement of the discovery. “The people who made this used local materials. But their knowledge of the charms and the spirit world probably came with them directly from Africa.”
In interviews last week, Dr. Leone and scholars of West African culture said they could not yet determine the bundle’s association with a specific religion or ethnic group.
Frederick Lamp, curator of African art at the Yale University Art Gallery, who was not involved in the discovery, said there was “no reason to doubt” the bundle’s direct link to the long tradition of West African religious practices. “But bundles filled with materials seen to have extraordinary spiritual power were used by many different cultures in Africa,” he said.
Dr. Lamp noted that X-rays of the bundle’s contents revealed an abundance of lead shot, iron nails and copper pins. “Some of the pins were bent, indicating this was a purposeful part of a ritual,” he said.
Metal worked in fire was widely seen as having special power, Dr. Lamp added, “and combining these materials in compacted clay was believed to increase the power of these objects.” The practice, he said, is well documented to this day among the Mande groups, principally in what are now Sierra Leone, Guinea and Mali, and the Yoruba people of Nigeria and Benin.
Nor should the Kongo people be ruled out as a source of these religious practices, scholars said. This culture, living in lands around the Congo River and in Angola and Cabinda, was a major source of African-American slaves. Kongo bundles contain stones, shells and other items that are supposed to hold the spirits of the dead for the use of the living in a custom that underlies hoodoo.
The bundle’s most striking component, the stone axe, was especially intriguing. Dr. Lamp said this brought to mind the Yoruba and the Fon people of Benin, who considered the axe blade a symbol of Shango, their god of thunder and lightning.
Matthew D. Cochran, a doctoral student in anthropology at University College London, who uncovered the bundle, said it would probably prove to be associated with Yoruba practices related to Shango.
In the lands of coastal West Africa then, and in its rural areas still, these rituals and materials were used by community practitioners, whose role was akin to that of American Indian medicine men. They were not attached to any world religion, or any institution. But people went to them at small sanctuaries in the woods in time of grief and distress. The practitioners, with one of these bundles at hand, rallied spiritual forces to deal with personal crises.
The Annapolis bundle, presumably made by a recent African immigrant, was excavated four feet below Fleet Street, which is near the Maryland Capitol and the waterfront. The object is 10 inches high, 6 inches wide and 4 inches thick. It remains intact, though an outer wrapping, probably of leather or cloth, has decayed, leaving an impression on the clay surface. The bundle is to go on display this week at the African American Museum in Annapolis.
Mr. Cochran said that as he dug at the bottom of the trench, the object first appeared to be a flat stone embedded in sediment. Then he saw small bits of lead shot scattered about. As the archaeologists freed the lumpy mass, a corner cracked open, exposing the pins and nails inside.
“I had seen hoodoo materials from Annapolis,” Mr. Cochran said, “and my sense immediately was that we had something African and important, but it was unclear what it was.”
In the next week, the bundle was examined and X-rayed by experts under the direction of Dr. Leone. The bundle’s age, from the turn of the 18th century, or no later than 1720, was estimated from well-dated pottery shards found in the excavations. But how the object survived the centuries is a mystery, though its placement on what was then the street surface suggests to Dr. Leone a surprising aspect of the practices of slaves at the time.
In previous explorations, material remains of African-related religion were almost always found buried in backyards or hidden under hearths and in basement corners. Early African-Americans seemed to practice their spirit rituals in secret.
A close examination, Dr. Leone said, showed that the bundle was probably originally placed in the gutter alongside the street, in the open for all to see. At the time the street was paved with logs and sawdust and only later covered with modern surfaces, burying the bundle.
Dr. Leone said the bundle’s visibility suggested “an unexpected level of public toleration” of African religion in colonial Annapolis. Most of the artifacts indicating that the practices were conducted in secrecy came from 50 years later. According to articles in a newspaper of the period, white people in Annapolis engaged openly in magic and witchcraft, of the English variety.
“So both European and African spirit practices may have been more acceptable then,” Dr. Leone concluded. “That changed after 1750 with the growing influence of the Enlightenment.”
In Sour Economy, Some Scale Back on Medications
By STEPHANIE SAUL, The New York Times, October 22, 2008
For the first time in at least a decade, the nation’s consumers are trying to get by on fewer prescription drugs.
As people around the country respond to financial and economic hard times by juggling the cost of necessities like groceries and housing, drugs are sometimes having to wait.
“People are having to choose between gas, meals and medication,” said Dr. James King, the chairman of the American Academy of Family Physicians, a national professional group. He also runs his own family practice in rural Selmer, Tenn.
“I’ve seen patients today who said they stopped taking their Lipitor, their cholesterol-lowering medicine, because they can’t afford it,” Dr. King said one recent morning.
“I have patients who have stopped taking their osteoporosis medication.”
On Tuesday, the drug giant Pfizer, which makes Lipitor, the world’s top-selling prescription medicine, said United States sales of that drug were down 13 percent in the third quarter of this year.
Through August of this year, the number of all prescriptions dispensed in the United States was lower than in the first eight months of last year, according to a recent analysis of data from IMS Health, a research firm that tracks prescriptions.
Although other forces are also in play, like safety concerns over some previously popular drugs and the transition of some prescription medications to over-the-counter sales, many doctors and other experts say consumer belt-tightening is a big factor in the prescription downturn.
The trend, if it continues, could have potentially profound implications.
If enough people try to save money by forgoing drugs, controllable conditions could escalate into major medical problems. That could eventually raise the nation’s total health care bill and lower the nation’s standard of living.
Martin Schwarzenberger, a 56-year-old accounting manager for the Boys and Girls Clubs of Greater Kansas City, is stretching out his prescriptions. Mr. Schwarzenberger, who has Type 1 diabetes, is not cutting his insulin, but has started scrimping on a variety of other medications he takes, including Lipitor.
“Don’t tell my wife, but if I have 30 days’ worth of pills, I’ll usually stretch those out to 35 or 40 days,” he said. “You’re trying to keep a house over your head and use your money to pay all your bills.”
Although the overall decline in prescriptions in the IMS Health data was less than 1 percent, it was the first downturn after more than a decade of steady increases in prescriptions, as new drugs came on the market and the population aged.
From 1997 to 2007, the number of prescriptions filled had increased 72 percent, to 3.8 billion last year. In the same period, the average number of prescriptions filled by each person in this country increased from 8.9 a year in 1997 to 12.6 in 2007.
Dr. Timothy Anderson, a Sanford C. Bernstein & Company pharmaceutical analyst who analyzed the IMS data and first reported the prescription downturn last week, said the declining volume was “most likely tied to a worsening economic environment.”
In some cases, the cutbacks might not hurt, according to Gerard F. Anderson, a health policy expert at Johns Hopkins Bloomberg School of Public Health. “A lot of people think there there’s probably over-prescribing in the United States,” Mr. Anderson said.
But for other patients, he said, “the prescription drug is a lifesaver, and they really can’t afford to stop it.”
Dr. Thomas J. Weida, a family physician in Hershey, Pa., said one of his patients ended up in the hospital because he was unable to afford insulin.
Not everyone simply stops taking their drugs.
“They’ll split pills, take their pills every other day, do a lot of things without conferring with their doctors,” said Jack Hoadley, a health policy analyst at Georgetown University.
“We’ve had focus groups with various populations,” Mr. Hoadley said. “They’ll look at four or five prescriptions and say, ‘This is the one I can do without.’ They’re not going to stop their pain medication because they’ll feel bad if they don’t take that. They’ll stop their statin for cholesterol because they don’t feel any different whether they take that or not.”
Overall spending in the United States for prescription drugs is still the highest in the world, an estimated $286.5 billion last year. But that number makes up only about 10 percent of this country’s total health expenditures of $2.26 trillion.
Pharmaceutical companies have long been among those arguing that drugs are a cost-effective way to stave off other, higher medical costs.
The recent prescription cutbacks come even as the drug industry was already heading toward the “generic cliff,” as it is known — an approaching period when a number of blockbuster drugs are scheduled to lose patent protection. That will be 2011 for Lipitor.
Already, a migration to generic drugs means that 60 percent of prescriptions over all are filled by off-brand versions of drugs. But with money tight, even cheaper generic drugs may not always be affordable drugs.
Factors other than the economy that may also be at play in the prescription downturn include adverse publicity about some big-selling medications — like the cholesterol medications Zetia and Vytorin, marketed jointly by Merck and Schering-Plough. And sales of Zyrtec, a popular allergy medication, moved out of the prescription category earlier this year when Johnson & Johnson began selling it as an over-the-counter medication.
Diane M. Conmy, the director of market insights for IMS Health, said the drop in prescriptions might also be partly related to the higher out-of-pocket drug co-payments that insurers are asking consumers to pay.
“Some consumers are making decisions based on the fact that they are bearing more of the cost of medicines than they have in the past,” Ms. Conmy said.
The average co-payment for drugs on insurers’ “preferred” lists rose to $25 in 2007, from $15 in 2000, according to the Kaiser Family Foundation, a nonprofit health care research organization. And, of course, lots of people have no drug insurance at all. That includes the estimated 47 million people in the United States with no form of health coverage, but it is also true for some people who have medical insurance that does not include drug coverage — a number for which no good data may exist.
For older Americans, the addition of Medicare drug coverage in 2006 through the Part D program has meant that 90 percent of Medicare-age people now have drug insurance. And in the early going, Part D had helped stimulate growth in the nation’s overall number of prescriptions, as patients who previously had no coverage flocked to Part D.
But a potential coverage gap in each recipient’s benefit each year — the so-called Part D doughnut hole — means that many Medicare patients are without coverage for part of the year.
The recent IMS Health figures reveal that prescription volume declined in June, in July and again in August, mirroring studies from last year suggesting that prescription use begins dropping at about the time more Medicare beneficiaries begin entering the doughnut hole.
Under this year’s rules, the doughnut hole opens when a patient’s total drug costs have reached $2,510, which counts the portion paid by Medicare as well as the patient’s own out-of-pocket deductibles and co-payments.
The beneficiary must then absorb 100 percent of the costs for the next $3,216, until total drug costs for the year have reached $5,726, when Medicare coverage resumes.
Gloria Wofford, 76, of Pittsburgh, said she recently stopped taking Provigil, prescribed for her problem of falling asleep during the day, because she could no longer afford it after she entered the Medicare doughnut hole.
Her Provigil had been costing $1,695 every three months. “I have no idea who could do it,” she said. “There’s no way I could handle that.”
Without the medication, Ms. Wofford said, she falls asleep while sitting at her computer during the day but then cannot sleep during the night. Because she feels she has no choice, Ms. Wofford is paying out of pocket to continue taking an expensive diabetes medication that costs more than $500 every three months.
For some other people, the boundaries of when and where to cut back are less distinct.
Lori Stewart of Champaign, Ill., is trying to decide whether to discontinue her mother’s Alzheimer’s medications, which seem to have only marginal benefit.
“The medication is $182 a month,” said Ms. Stewart, who recently wrote about the dilemma on her personal blog.
“It’s been a very agonizing decision for me. It is literally one-fifth of her income.”
Basics: The Wonders of Blood
By NATALIE ANGIER, The New York Times, October 21, 2008
You’re born with a little over a pint of it, by adulthood you’re up to four or five quarts, and if at any point you suddenly shed more than a third of your share, you must either get a transfusion or prepare to meet your mortician.
Human cultures have long recognized that blood is essential to life and have ascribed to it a vast array of magical powers and metaphorical subroutines. Blood poultices and blood beverages were said to cure blindness, headaches, gout, goiter, worms and gray hair. The Bible mentions blood more than 400 times, William Shakespeare close to 700. It’s “all in the blood,” your temperament, your fate. Are you a blue-blooded Mesopotamian princess or a red-blooded American male?
Yet to scientists who study blood, even the most extravagant blood lore pales in comparison to the biochemical, evolutionary and engineering marvels of the genuine article.
The fluid tissue we call blood not only feeds us and cleans us, delivering fresh oxygen and other nutrients to all 100 trillion cells of the body and flushing out carbon dioxide, ammonia and other metabolic trash. It not only houses the immune system that defends us against the world.
Our blood is the foundation of our very existence as multicellular animals, said Andrew Schafer, a professor at Weill Cornell Medical College and the outgoing president of the American Society of Hematology. Blood is the one tissue that comes into contact with every other tissue of the body, and it is through blood that our disparate parts communicate, through blood that our organs cooperate. Without a circulatory system, there would be no internal civilization, no means of ensuring orderly devotion to the common cause that is us.
“It’s an enormous communications network,” Dr. Schafer said — the original cellphone system, if you will, 100 trillion users strong.
Blood can also be thought of as a private ocean, a recapitulation of what life was like for all the years we spent drifting as microscopic, single-celled organisms, “taking up nutrients from sea water and then eliminating waste products back into sea water,” Dr. Schafer said. Not only is blood mostly water, but the watery portion of blood, the plasma, has a concentration of salt and other ions that is remarkably similar to sea water.
Of course, we can’t rely on wind and weather to keep our hidden seas salubriously churned and aerated, so we have evolved an active respirator and pumping mechanism, the lungs and heart. Our eight pints of blood circulate through the powerhouse duet maybe 60 times an hour, absorbing recently inhaled oxygen from the honeycombed fabric of the lungs and proceeding into the thickly muscled heart, which then shoots the enriched fluid outward.
Oxygen allocation is the task of the red blood cells, which hematology researchers refer to with a mix of affection and awe. “Red cells have enormous capabilities,” said Stanley Schrier of Stanford University’s School of Medicine. They give up so much to make room for their hemoglobin, the proteins that can latch onto oxygen and that give blood its brilliant grenadine sheen. Alone among body cells, red cells at maturity jettison their nucleus and DNA to accommodate their cargo.
And oh how roughly they are treated. A red cell at rest looks like a plump bialy and measures about 8 microns, or .0003 inches, across. Yet to reach every far-flung, oxygen-hungry customer, the cells must squeeze through capillaries less than half their width, which they accomplish by squashing down into threads that then crawl in single file along the capillary wall, pulling themselves forward, Dr. Schrier said, like tank treads gripping the road.
Blood is also a genius, able to sustain two contradictory states without going mad. To ceaselessly shuttle along the body’s 60,000 miles of arteries, veins and capillaries, blood must be fluid, our trusty souvenir sea.
Yet even though we constantly replace components of our blood, directing the aged and the battered to the spleen and liver — the “graveyards for blood cells,” Dr. Schafer said — and replenishing them with fresh blood cells forged in the bone marrow, the turnover cycle is gradual and we can’t afford to lose everything in one big gush wrought by a predator’s gash. Blood, then, departs from sea water, or, for that matter, from breast milk, another prized body fluid, in one outstanding way: it is always poised to clot, to relinquish liquidity and assume solidity.
In deciding whether to flow or clot, blood takes its cues from its surroundings. As blood glides through the bulk of its tubular circuitry, the comparatively heavy red cells are driven toward the center of the swirl, said James N. George, a hematologist at the University of Oklahoma Health Sciences Center, while two other, lighter characters are pushed out to the periphery: the white blood cells that operate as immune warriors, and the platelets, tiny cells that have been called the Band-Aids of the body. Their marginalization is no accident. “They’re surveillance cells,” Dr. George said. “It’s almost like they’re scouting for trouble.”
White blood cells look for signs of invasive microbes, while platelets scan for leaks. As long as the platelets detect the Teflon-like surface of unbroken endothelium, the tissue with which blood vessels are lined, they keep moving.
But even the tiniest cut or gap in the smooth vessel wall will expose some of the fibrous strands beneath, and the platelets are primed to instantly detect the imperfection. A passing platelet will stick to the raggedy strand and change shape, from round to octopoid, which in turn attracts other platelets, forming a little clump. “If the cut is small, that’s all you need,” Dr. George said. If not, the next phase of flood control begins. Signals from the platelets arouse the blood’s clotting factors, free-floating proteins that can cross-link together into bigger, better Band-Aids.
“Platelets and clotting factors,” Dr. Schrier said. “It’s a marriage made in heaven.”
Up to a point. Just as our immune cells can go awry and begin attacking our own body tissue, so an overzealous clot response can have dire consequences. Should a clot happen to cut off blood flow to a vital organ like the heart or brain, the only one playing the harp will be you.
Mountain Climbing Bad for the Brain
Tanya Parker-Pope, The New York Times, October 20, 2008
If you’ve ever fantasized about scaling Mount Everest, think again. A new study of professional mountain climbers shows that high-altitude climbing causes a subtle loss of brain cells and motor function.
Italian researchers used magnetic resonance imaging to look at the brains of nine world-class mountain climbers who had at least 10 years of experience, including expeditions to Mount Everest and K2. The climbers ranged in age from 31 to 52, with an average age of just under 38, and were used to climbing to altitudes of at least 4,000 meters (two-and-a-half miles, or over 13,000 feet) several times a year.
The scientists, who published their findings in the October issue of the European Journal of Neurology, compared the climbers’ M.R.I. brain scans with 19 age- and sex-matched healthy control subjects. A number of neuropsychological tests were also carried out to assess the climbers’ cognitive abilities, including memory and motor functions.
On scans, the climbers showed a reduction in both white and gray matter in various parts of the brain. Overall, the researchers found that the cognitive abilities that were most likely to be affected were the climbers’ executive function and memory.
Six of the nine climbers had lower than average scores on the Digit Symbol test, which measures executive functions. Three out of nine scored lower than average on memory tests, while four scored below average on a visual-motor function test. The study authors noted that the results “are most likely to be due to progressive, subtle brain insults caused by repeated high-altitude exposure.”
Other studies have shown links between brain problems and repeated exposure to extreme conditions. The British Journal of Sports Medicine reported in 2004 that scuba diving may have long-term negative effects on the brain, particularly when performed in extreme conditions, such as cold water, more than 100 dives per year, and diving below 40 meters.
And last year, researchers at New York University noted that high-altitude illness is a growing concern in sports medicine given the increasing popularity of extreme sports like high-altitude mountaineering, skiing and snowboarding. The report noted that about 20 percent of tourists to Colorado report acute mountain sickness, and complications arising from sports activities at high altitudes, such as the potentially fatal conditions of pulmonary and cerebral edema, are on the rise.
By JOHN NOBLE WILFORD, The New York Times, October 21, 2008
Over the years of exploring the old houses and streets of Annapolis, Md., archaeologists have uncovered a trove of artifacts of early American slave culture. Among them are humble remains connected with religious practices, which bear the stamp of the slaves’ West African heritage.
Early in the 18th century, as they were being baptized, African-Americans clung to “spirit practices” in rituals of healing and the invocation of ancestral and supernatural powers. Sometimes called black magic, these occult rites would persist in America in modified form, later, as voodoo and hoodoo.
University of Maryland archaeologists have discovered in Annapolis what they say is one of the earliest examples of traditional African religious artifacts in North America. It is a clay “bundle,” roughly the size and shape of a football, filled with about 300 pieces of metal and a stone axe, whose blade sticks out of the clay, pointing skyward.
The bundle, found in April and dated to 1700, appears to be a direct transplant of African religion into what is now the United States, said Mark P. Leone, a professor of anthropology at Maryland who directed the excavations. The materials and construction, he said, differed from the hoodoo caches his teams had previously found in Annapolis.
“The bundle is African in design, not African-American,” Dr. Leone said in an announcement of the discovery. “The people who made this used local materials. But their knowledge of the charms and the spirit world probably came with them directly from Africa.”
In interviews last week, Dr. Leone and scholars of West African culture said they could not yet determine the bundle’s association with a specific religion or ethnic group.
Frederick Lamp, curator of African art at the Yale University Art Gallery, who was not involved in the discovery, said there was “no reason to doubt” the bundle’s direct link to the long tradition of West African religious practices. “But bundles filled with materials seen to have extraordinary spiritual power were used by many different cultures in Africa,” he said.
Dr. Lamp noted that X-rays of the bundle’s contents revealed an abundance of lead shot, iron nails and copper pins. “Some of the pins were bent, indicating this was a purposeful part of a ritual,” he said.
Metal worked in fire was widely seen as having special power, Dr. Lamp added, “and combining these materials in compacted clay was believed to increase the power of these objects.” The practice, he said, is well documented to this day among the Mande groups, principally in what are now Sierra Leone, Guinea and Mali, and the Yoruba people of Nigeria and Benin.
Nor should the Kongo people be ruled out as a source of these religious practices, scholars said. This culture, living in lands around the Congo River and in Angola and Cabinda, was a major source of African-American slaves. Kongo bundles contain stones, shells and other items that are supposed to hold the spirits of the dead for the use of the living in a custom that underlies hoodoo.
The bundle’s most striking component, the stone axe, was especially intriguing. Dr. Lamp said this brought to mind the Yoruba and the Fon people of Benin, who considered the axe blade a symbol of Shango, their god of thunder and lightning.
Matthew D. Cochran, a doctoral student in anthropology at University College London, who uncovered the bundle, said it would probably prove to be associated with Yoruba practices related to Shango.
In the lands of coastal West Africa then, and in its rural areas still, these rituals and materials were used by community practitioners, whose role was akin to that of American Indian medicine men. They were not attached to any world religion, or any institution. But people went to them at small sanctuaries in the woods in time of grief and distress. The practitioners, with one of these bundles at hand, rallied spiritual forces to deal with personal crises.
The Annapolis bundle, presumably made by a recent African immigrant, was excavated four feet below Fleet Street, which is near the Maryland Capitol and the waterfront. The object is 10 inches high, 6 inches wide and 4 inches thick. It remains intact, though an outer wrapping, probably of leather or cloth, has decayed, leaving an impression on the clay surface. The bundle is to go on display this week at the African American Museum in Annapolis.
Mr. Cochran said that as he dug at the bottom of the trench, the object first appeared to be a flat stone embedded in sediment. Then he saw small bits of lead shot scattered about. As the archaeologists freed the lumpy mass, a corner cracked open, exposing the pins and nails inside.
“I had seen hoodoo materials from Annapolis,” Mr. Cochran said, “and my sense immediately was that we had something African and important, but it was unclear what it was.”
In the next week, the bundle was examined and X-rayed by experts under the direction of Dr. Leone. The bundle’s age, from the turn of the 18th century, or no later than 1720, was estimated from well-dated pottery shards found in the excavations. But how the object survived the centuries is a mystery, though its placement on what was then the street surface suggests to Dr. Leone a surprising aspect of the practices of slaves at the time.
In previous explorations, material remains of African-related religion were almost always found buried in backyards or hidden under hearths and in basement corners. Early African-Americans seemed to practice their spirit rituals in secret.
A close examination, Dr. Leone said, showed that the bundle was probably originally placed in the gutter alongside the street, in the open for all to see. At the time the street was paved with logs and sawdust and only later covered with modern surfaces, burying the bundle.
Dr. Leone said the bundle’s visibility suggested “an unexpected level of public toleration” of African religion in colonial Annapolis. Most of the artifacts indicating that the practices were conducted in secrecy came from 50 years later. According to articles in a newspaper of the period, white people in Annapolis engaged openly in magic and witchcraft, of the English variety.
“So both European and African spirit practices may have been more acceptable then,” Dr. Leone concluded. “That changed after 1750 with the growing influence of the Enlightenment.”
In Sour Economy, Some Scale Back on Medications
By STEPHANIE SAUL, The New York Times, October 22, 2008
For the first time in at least a decade, the nation’s consumers are trying to get by on fewer prescription drugs.
As people around the country respond to financial and economic hard times by juggling the cost of necessities like groceries and housing, drugs are sometimes having to wait.
“People are having to choose between gas, meals and medication,” said Dr. James King, the chairman of the American Academy of Family Physicians, a national professional group. He also runs his own family practice in rural Selmer, Tenn.
“I’ve seen patients today who said they stopped taking their Lipitor, their cholesterol-lowering medicine, because they can’t afford it,” Dr. King said one recent morning.
“I have patients who have stopped taking their osteoporosis medication.”
On Tuesday, the drug giant Pfizer, which makes Lipitor, the world’s top-selling prescription medicine, said United States sales of that drug were down 13 percent in the third quarter of this year.
Through August of this year, the number of all prescriptions dispensed in the United States was lower than in the first eight months of last year, according to a recent analysis of data from IMS Health, a research firm that tracks prescriptions.
Although other forces are also in play, like safety concerns over some previously popular drugs and the transition of some prescription medications to over-the-counter sales, many doctors and other experts say consumer belt-tightening is a big factor in the prescription downturn.
The trend, if it continues, could have potentially profound implications.
If enough people try to save money by forgoing drugs, controllable conditions could escalate into major medical problems. That could eventually raise the nation’s total health care bill and lower the nation’s standard of living.
Martin Schwarzenberger, a 56-year-old accounting manager for the Boys and Girls Clubs of Greater Kansas City, is stretching out his prescriptions. Mr. Schwarzenberger, who has Type 1 diabetes, is not cutting his insulin, but has started scrimping on a variety of other medications he takes, including Lipitor.
“Don’t tell my wife, but if I have 30 days’ worth of pills, I’ll usually stretch those out to 35 or 40 days,” he said. “You’re trying to keep a house over your head and use your money to pay all your bills.”
Although the overall decline in prescriptions in the IMS Health data was less than 1 percent, it was the first downturn after more than a decade of steady increases in prescriptions, as new drugs came on the market and the population aged.
From 1997 to 2007, the number of prescriptions filled had increased 72 percent, to 3.8 billion last year. In the same period, the average number of prescriptions filled by each person in this country increased from 8.9 a year in 1997 to 12.6 in 2007.
Dr. Timothy Anderson, a Sanford C. Bernstein & Company pharmaceutical analyst who analyzed the IMS data and first reported the prescription downturn last week, said the declining volume was “most likely tied to a worsening economic environment.”
In some cases, the cutbacks might not hurt, according to Gerard F. Anderson, a health policy expert at Johns Hopkins Bloomberg School of Public Health. “A lot of people think there there’s probably over-prescribing in the United States,” Mr. Anderson said.
But for other patients, he said, “the prescription drug is a lifesaver, and they really can’t afford to stop it.”
Dr. Thomas J. Weida, a family physician in Hershey, Pa., said one of his patients ended up in the hospital because he was unable to afford insulin.
Not everyone simply stops taking their drugs.
“They’ll split pills, take their pills every other day, do a lot of things without conferring with their doctors,” said Jack Hoadley, a health policy analyst at Georgetown University.
“We’ve had focus groups with various populations,” Mr. Hoadley said. “They’ll look at four or five prescriptions and say, ‘This is the one I can do without.’ They’re not going to stop their pain medication because they’ll feel bad if they don’t take that. They’ll stop their statin for cholesterol because they don’t feel any different whether they take that or not.”
Overall spending in the United States for prescription drugs is still the highest in the world, an estimated $286.5 billion last year. But that number makes up only about 10 percent of this country’s total health expenditures of $2.26 trillion.
Pharmaceutical companies have long been among those arguing that drugs are a cost-effective way to stave off other, higher medical costs.
The recent prescription cutbacks come even as the drug industry was already heading toward the “generic cliff,” as it is known — an approaching period when a number of blockbuster drugs are scheduled to lose patent protection. That will be 2011 for Lipitor.
Already, a migration to generic drugs means that 60 percent of prescriptions over all are filled by off-brand versions of drugs. But with money tight, even cheaper generic drugs may not always be affordable drugs.
Factors other than the economy that may also be at play in the prescription downturn include adverse publicity about some big-selling medications — like the cholesterol medications Zetia and Vytorin, marketed jointly by Merck and Schering-Plough. And sales of Zyrtec, a popular allergy medication, moved out of the prescription category earlier this year when Johnson & Johnson began selling it as an over-the-counter medication.
Diane M. Conmy, the director of market insights for IMS Health, said the drop in prescriptions might also be partly related to the higher out-of-pocket drug co-payments that insurers are asking consumers to pay.
“Some consumers are making decisions based on the fact that they are bearing more of the cost of medicines than they have in the past,” Ms. Conmy said.
The average co-payment for drugs on insurers’ “preferred” lists rose to $25 in 2007, from $15 in 2000, according to the Kaiser Family Foundation, a nonprofit health care research organization. And, of course, lots of people have no drug insurance at all. That includes the estimated 47 million people in the United States with no form of health coverage, but it is also true for some people who have medical insurance that does not include drug coverage — a number for which no good data may exist.
For older Americans, the addition of Medicare drug coverage in 2006 through the Part D program has meant that 90 percent of Medicare-age people now have drug insurance. And in the early going, Part D had helped stimulate growth in the nation’s overall number of prescriptions, as patients who previously had no coverage flocked to Part D.
But a potential coverage gap in each recipient’s benefit each year — the so-called Part D doughnut hole — means that many Medicare patients are without coverage for part of the year.
The recent IMS Health figures reveal that prescription volume declined in June, in July and again in August, mirroring studies from last year suggesting that prescription use begins dropping at about the time more Medicare beneficiaries begin entering the doughnut hole.
Under this year’s rules, the doughnut hole opens when a patient’s total drug costs have reached $2,510, which counts the portion paid by Medicare as well as the patient’s own out-of-pocket deductibles and co-payments.
The beneficiary must then absorb 100 percent of the costs for the next $3,216, until total drug costs for the year have reached $5,726, when Medicare coverage resumes.
Gloria Wofford, 76, of Pittsburgh, said she recently stopped taking Provigil, prescribed for her problem of falling asleep during the day, because she could no longer afford it after she entered the Medicare doughnut hole.
Her Provigil had been costing $1,695 every three months. “I have no idea who could do it,” she said. “There’s no way I could handle that.”
Without the medication, Ms. Wofford said, she falls asleep while sitting at her computer during the day but then cannot sleep during the night. Because she feels she has no choice, Ms. Wofford is paying out of pocket to continue taking an expensive diabetes medication that costs more than $500 every three months.
For some other people, the boundaries of when and where to cut back are less distinct.
Lori Stewart of Champaign, Ill., is trying to decide whether to discontinue her mother’s Alzheimer’s medications, which seem to have only marginal benefit.
“The medication is $182 a month,” said Ms. Stewart, who recently wrote about the dilemma on her personal blog.
“It’s been a very agonizing decision for me. It is literally one-fifth of her income.”
Basics: The Wonders of Blood
By NATALIE ANGIER, The New York Times, October 21, 2008
You’re born with a little over a pint of it, by adulthood you’re up to four or five quarts, and if at any point you suddenly shed more than a third of your share, you must either get a transfusion or prepare to meet your mortician.
Human cultures have long recognized that blood is essential to life and have ascribed to it a vast array of magical powers and metaphorical subroutines. Blood poultices and blood beverages were said to cure blindness, headaches, gout, goiter, worms and gray hair. The Bible mentions blood more than 400 times, William Shakespeare close to 700. It’s “all in the blood,” your temperament, your fate. Are you a blue-blooded Mesopotamian princess or a red-blooded American male?
Yet to scientists who study blood, even the most extravagant blood lore pales in comparison to the biochemical, evolutionary and engineering marvels of the genuine article.
The fluid tissue we call blood not only feeds us and cleans us, delivering fresh oxygen and other nutrients to all 100 trillion cells of the body and flushing out carbon dioxide, ammonia and other metabolic trash. It not only houses the immune system that defends us against the world.
Our blood is the foundation of our very existence as multicellular animals, said Andrew Schafer, a professor at Weill Cornell Medical College and the outgoing president of the American Society of Hematology. Blood is the one tissue that comes into contact with every other tissue of the body, and it is through blood that our disparate parts communicate, through blood that our organs cooperate. Without a circulatory system, there would be no internal civilization, no means of ensuring orderly devotion to the common cause that is us.
“It’s an enormous communications network,” Dr. Schafer said — the original cellphone system, if you will, 100 trillion users strong.
Blood can also be thought of as a private ocean, a recapitulation of what life was like for all the years we spent drifting as microscopic, single-celled organisms, “taking up nutrients from sea water and then eliminating waste products back into sea water,” Dr. Schafer said. Not only is blood mostly water, but the watery portion of blood, the plasma, has a concentration of salt and other ions that is remarkably similar to sea water.
Of course, we can’t rely on wind and weather to keep our hidden seas salubriously churned and aerated, so we have evolved an active respirator and pumping mechanism, the lungs and heart. Our eight pints of blood circulate through the powerhouse duet maybe 60 times an hour, absorbing recently inhaled oxygen from the honeycombed fabric of the lungs and proceeding into the thickly muscled heart, which then shoots the enriched fluid outward.
Oxygen allocation is the task of the red blood cells, which hematology researchers refer to with a mix of affection and awe. “Red cells have enormous capabilities,” said Stanley Schrier of Stanford University’s School of Medicine. They give up so much to make room for their hemoglobin, the proteins that can latch onto oxygen and that give blood its brilliant grenadine sheen. Alone among body cells, red cells at maturity jettison their nucleus and DNA to accommodate their cargo.
And oh how roughly they are treated. A red cell at rest looks like a plump bialy and measures about 8 microns, or .0003 inches, across. Yet to reach every far-flung, oxygen-hungry customer, the cells must squeeze through capillaries less than half their width, which they accomplish by squashing down into threads that then crawl in single file along the capillary wall, pulling themselves forward, Dr. Schrier said, like tank treads gripping the road.
Blood is also a genius, able to sustain two contradictory states without going mad. To ceaselessly shuttle along the body’s 60,000 miles of arteries, veins and capillaries, blood must be fluid, our trusty souvenir sea.
Yet even though we constantly replace components of our blood, directing the aged and the battered to the spleen and liver — the “graveyards for blood cells,” Dr. Schafer said — and replenishing them with fresh blood cells forged in the bone marrow, the turnover cycle is gradual and we can’t afford to lose everything in one big gush wrought by a predator’s gash. Blood, then, departs from sea water, or, for that matter, from breast milk, another prized body fluid, in one outstanding way: it is always poised to clot, to relinquish liquidity and assume solidity.
In deciding whether to flow or clot, blood takes its cues from its surroundings. As blood glides through the bulk of its tubular circuitry, the comparatively heavy red cells are driven toward the center of the swirl, said James N. George, a hematologist at the University of Oklahoma Health Sciences Center, while two other, lighter characters are pushed out to the periphery: the white blood cells that operate as immune warriors, and the platelets, tiny cells that have been called the Band-Aids of the body. Their marginalization is no accident. “They’re surveillance cells,” Dr. George said. “It’s almost like they’re scouting for trouble.”
White blood cells look for signs of invasive microbes, while platelets scan for leaks. As long as the platelets detect the Teflon-like surface of unbroken endothelium, the tissue with which blood vessels are lined, they keep moving.
But even the tiniest cut or gap in the smooth vessel wall will expose some of the fibrous strands beneath, and the platelets are primed to instantly detect the imperfection. A passing platelet will stick to the raggedy strand and change shape, from round to octopoid, which in turn attracts other platelets, forming a little clump. “If the cut is small, that’s all you need,” Dr. George said. If not, the next phase of flood control begins. Signals from the platelets arouse the blood’s clotting factors, free-floating proteins that can cross-link together into bigger, better Band-Aids.
“Platelets and clotting factors,” Dr. Schrier said. “It’s a marriage made in heaven.”
Up to a point. Just as our immune cells can go awry and begin attacking our own body tissue, so an overzealous clot response can have dire consequences. Should a clot happen to cut off blood flow to a vital organ like the heart or brain, the only one playing the harp will be you.
Mountain Climbing Bad for the Brain
Tanya Parker-Pope, The New York Times, October 20, 2008
If you’ve ever fantasized about scaling Mount Everest, think again. A new study of professional mountain climbers shows that high-altitude climbing causes a subtle loss of brain cells and motor function.
Italian researchers used magnetic resonance imaging to look at the brains of nine world-class mountain climbers who had at least 10 years of experience, including expeditions to Mount Everest and K2. The climbers ranged in age from 31 to 52, with an average age of just under 38, and were used to climbing to altitudes of at least 4,000 meters (two-and-a-half miles, or over 13,000 feet) several times a year.
The scientists, who published their findings in the October issue of the European Journal of Neurology, compared the climbers’ M.R.I. brain scans with 19 age- and sex-matched healthy control subjects. A number of neuropsychological tests were also carried out to assess the climbers’ cognitive abilities, including memory and motor functions.
On scans, the climbers showed a reduction in both white and gray matter in various parts of the brain. Overall, the researchers found that the cognitive abilities that were most likely to be affected were the climbers’ executive function and memory.
Six of the nine climbers had lower than average scores on the Digit Symbol test, which measures executive functions. Three out of nine scored lower than average on memory tests, while four scored below average on a visual-motor function test. The study authors noted that the results “are most likely to be due to progressive, subtle brain insults caused by repeated high-altitude exposure.”
Other studies have shown links between brain problems and repeated exposure to extreme conditions. The British Journal of Sports Medicine reported in 2004 that scuba diving may have long-term negative effects on the brain, particularly when performed in extreme conditions, such as cold water, more than 100 dives per year, and diving below 40 meters.
And last year, researchers at New York University noted that high-altitude illness is a growing concern in sports medicine given the increasing popularity of extreme sports like high-altitude mountaineering, skiing and snowboarding. The report noted that about 20 percent of tourists to Colorado report acute mountain sickness, and complications arising from sports activities at high altitudes, such as the potentially fatal conditions of pulmonary and cerebral edema, are on the rise.
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