For a man with such respectable bona fides—University of Chicago medical school graduate, trained in oncology at the National Cancer Institute, Emory professor, and currently chief medical officer at the American Cancer Society—Dr. Otis Brawley sure knows how to piss people off. Since long before October, when he spoke out to the New York Times Magazine, he’s been accused of prosecuting an irrational “vendetta” against use of the prostate-specific antigen (PSA) test to screen apparently healthy men for prostate cancer. Some critics say he’s killing men by steering them away from this test, which in the best cases leads to lifesaving treatment but in worse cases leaves men impotent and incontinent after treatment for growths that posed no danger.
Brawley is no stranger to controversy. He jokes that he’s the “Forrest Gump of medicine” because he has been in the thick of historic medical advances and debates for thirty years. Mere fortune made Gump a war hero and a shrimp tycoon. But it wasn’t luck that joined Brawley with the team that pioneered the first effective AIDS drugs, or with Surgeon General David Satcher in the battle against health disparities, or with President Clinton in apologizing for the infamous Tuskegee experiment.
In 2002 Brawley became chief of oncology and hematology at Grady Hospital. Though no longer in a leadership position at Grady, Brawley still practices there. His experiences at Grady partly inspired his new book, "How We Do Harm: A Doctor Breaks Ranks About Being Sick in America" (with Paul Goldberg, St. Martin’s Press). In what he calls “a guided tour through the back rooms of American medicine,” Brawley not only takes on the unfolding catastrophe of U.S. healthcare, but also hits closer to home with chilling stories about irresponsible doctors here in Atlanta, such as some who dispense inappropriate, even life-threatening chemo. To accompany the following excerpt, veteran health and medical journalist Patricia Thomas talked with Brawley about his new book.
In your book, you say that instead of having a healthcare “system,” we Americans live in a fragmented universe where famine and gluttony exist side by side. What do you mean? Cervical cancer is a good example of famine and gluttony. Ten years ago, most organizations that issue screening guidelines started saying that women who had two or three normal Pap smears in a row, and who were in a stable relationship, could go to every three years for Pap smears. And many doctors and many middle-class and upper-class women were outraged. They wanted their annual test. Every year about 4,290 women die from cervical cancer. The majority of them have never had a Pap smear, ever. And of those who have, the overwhelming majority had not had one within ten years of their diagnosis. The women who died never got the services they needed. Then you’ve got all the folks who are upset because we say they should be tested every three years instead of every year.
How does practicing at Grady affect your view of what’s happening in healthcare? I see a lot of people who suffer with undiagnosed chronic disease. These are folks who need healthcare and for one reason or another can’t get it. Sometimes they aren’t sophisticated enough to get into the system, or sometimes healthcare is just not available.
You’ve been thinking about the problems of American medicine for years. Why did you do this book now? I actually think we need to transform how we think of healthcare. Most of it is about responding to illness, not about preventing illness in the first place. Last year healthcare costs were 17.5 percent of our gross domestic product. That’s one and a half times the amount in the next most expensive country. On a per capita basis, it’s approaching $8,000 per person. When organizations like the American Cancer Society or the American Heart Association go to hire a clerk who makes $25,000 per year, we have to think about the fact that healthcare coverage for them—if they have a family of four—is upwards of $16,000 per year. If healthcare costs keep growing at the present rate, they’ll be 25 percent of our GDP by 2025. Healthcare is choking our economy.
But don’t some people believe that all this money buys us the best healthcare in the world? When we look at outcomes, such as life expectancy, we rank fiftieth. We have very high infant mortality rates. Even if you look at white male life expectancy in the U.S., it’s lower than places like Canada, whose healthcare system we criticize. We have tremendously more CT and MRI scanners than Canada per capita. People in the United States may not live longer than people in Canada, but we sure as hell do a better job taking pictures of them. We do not get what we pay for out of our healthcare system.
If you were the healthcare czar, what would you do to make healthcare better? We need to change how we reimburse for care. We need to reimburse doctors to coach patients about leading a healthy life. We pay doctors tremendously for sticking things into people and cutting on them, and instead we need to reimburse for teaching patients. [We should teach] kids about healthy eating and physical fitness habits starting in third grade. I don’t see health promotion happening in the United States. Some hospitals have gyms, and we need more of that. Hospitals should be advertising more about nutrition and cooking classes and less about diagnosing your disease early.
Last October you were featured in a New York Times Magazine article about the PSA screening controversy called “Can Cancer Ever Be Ignored?” Why aren’t you convinced that PSA testing saves lives? According to epidemiologic studies, many of these things we find in the early stages are never destined to grow or metastasize and cause harm. Some are; some aren’t. It’s a shame when a man is screened for prostate cancer and not told that his cigarette smoking is more likely to kill him than prostate cancer. I believe men should be told truthfully what the potential benefits are and what the potential risks are. They need to be allowed to make an informed decision.
How do you feel when you are denounced as an enemy of men by patient advocates or even your fellow physicians? Quite honestly, criticism doesn’t scare me very much.