The Complete Patient

Whatever happened with Greg Niewendorp’s resistance to the Michigan Department of Agriculture’s effort to test his 160 cows for bovine tuberculosis?

It turns out that the parties are pretty much where they were three months ago, when Niewendorp publicly challenged the MDA to press charges against him for refusing to go along with the agency's bovine TB test and, in the process, with the state’s first-in-the-nation requirement that all cattle be registered for the National Animal Identification System (NAIS). Niewendorp is still resisting, and the MDA says his farm remains under quarantine.

But interestingly, the standoff provides insights into the much ballyhooed case of the man who flew to Europe and back with a case of extensively drug resistant tuberculosis, known as XDR TB. The media and federal government have spent the last couple days playing up the dangers of a possible mass outbreak of a form of an ancient disease we can’t counter with antibiotics.

I called the MDA to learn about the agency’s response to Niewendorp, and was told by Bridget Patrick, a communications coordinator, that while the agency won’t comment on the specifics of a particular farm or farmer, the Niewendorp situation is “a stalemate.” In other words, the MDA still considers his farm to be under quarantine and to stay that way indefinitely.

In justifying the MDA’s requirement for testing animals in the northern part of Michigan’s lower peninsula for bovine TB, and monitoring all cattle electronically, she suggests that the situation is comparable to the current human TB case. “Ten years ago, it took us a minimum of six to eight weeks and as much as two years to track down all animals exposed to TB,” she said. Today, thanks to electronic records, “We find animals that have been infected within hours…The problem with not moving quickly is this disease can infect other (cattle) quickly…Bovine TB is a respiratory disease that is highly infectious—it can infect humans through raw milk and people who process the animals…The situation is comparable to what is happening now with TB” in the American traveler.

She suggested that Niewendorp was being something less than a good citizen for refusing to go along with the MDA’s TB testing and record-keeping program. “We have this covenant with our farmers…Everyone wants to get through this disease. It’s a joint effort with the producers.”

Niewendorp, for his part, remains defiant. He challenges the MDA to come after him, accusing the agency of “fraud” in suggesting to him last February that he was potentially at risk for a year in jail and a $50,000 fine for refusing to comply with the state, and then doing nothing. “You tell them to bring it on and they don’t bring it on, it’s fraud.”

He even questions whether his farm really is under quarantine. “I never signed their papers, so I don’t think I am.” In any event, he’s not been shipping animals into or out of his farm.

He scoffs at the MDA’s suggestion that he’s being a bad citizen for failing to help contain a contagious disease. “Bovine TB is not highly contagious. People inside the MDA have told me that.” Most of the animals that test positive for bovine TB actually have been exposed to avian TB, he says, which is much less of a problem.

He senses that the uproar over human TB is comparable to what's happening in Michigan. He argues that TB, whether in animals or humans, develops as a result of “stress”—malnutrition, bad living conditions, and poor immunity.

There seems to be debate in the scientific community about just how dangerous the human TB case really is, with scientists at both extremes, according to a New York Times article.

Somehow, the media and government upset have the feel of the hysteria that comes up periodically about raw milk: Another case of a “problem” our public officials thought was “solved” that just won't go away.

I suppose I shouldn't be surprised that there is so much behind the color differences between cow’s milk and goat’s milk (see the comments following yesterday’s post), One other item that stands out in reviewing the nutrient comparison Jean linked to: could the whiteness of goat’s milk have something to do with its high calcium content?

The discussion got me thinking about the fine points of eggs. I’ve become something of an egg aficionado over the last few years, since I’ve come to realize that there is a huge difference in egg quality, depending on where you obtain them (and as I've overcome my fear of eggs as dangerous because of their cholesterol). One of the first stops I make when traveling to our condo in New Hampshire is to stop at a nearby ranch-style house with a small sign outside, “Eggs, $2.00”. I’ve only met the owner, Clair, briefly a couple times, because she sells her eggs via the honor system—you take a package of a dozen from a cooler outside her front door and leave your money in the cooler.

The first time I met her, a year ago, she was apologizing because she frequently ran short of eggs; seems her chickens were getting old and their production had declined. She’s since rectified that problem, presumably with some spring chickens.

She has a small hen house out back where the chickens do their thing. I’d love to get a tour of the hen house and engage Clair in the fine points of her chickens’ egg production, since her eggs are the best I’ve ever had. The yolks are a deep orange, and stand up high when you fry them.

Actually, my preferred way of eating eggs, and assessing their flavor and freshness, is to soft-boil them (remove them two minutes, 15 seconds after the water boils), slice off a small piece of the top, and eat them right out of the shell, sitting in an egg cup. (If you boil them too long, usually over two-and-a-half minutes, the yolks become too hard.) This is more European style, stemming from my parents’ German roots. (One thing I haven't gotten myself to do is eat eggs raw, even mixed with milk in a smoothie; when I researched the story of my aunt's experiences living with a group of children in southern France during the Holocaust, I learned that the adults in charge insisted that on the rare occasions when they obtained eggs, that the children eat them raw, supposedly to capture all the nutrients.)

A close runner up to Clair’s eggs are some I bought last week from Beth, the farmer I purchased my goat’s milk from. She has a neighbor with chickens, and those eggs were excellent—very delicate and tasty whites. They were also a combination of brown and white eggs, and widely varying sizes, and even some poop on a few of the eggs—which you never see at the supermarket.

Sometimes when I buy eggs at farmer’s markets, I’m disappointed. They don’t seem quite as fresh or the yolks as rich as they should be. Maybe they’re left sitting around too long.

I suspect that’s the big problem with eggs we buy at the grocery store. I once read where these eggs go through so many channels before getting to the store that they’re often weeks from having been laid. And, of course, if the chickens have been fed antibiotics and crammed together for months and months, the egg quality has to suffer--those pale yellow yolks are the result. And maybe that's also behind the occasional reports of salmonella in eggs that we see from time to time.

When I was visiting in Florida last month, I bought some of the organic eggs with the high omega 3 content at Whole Foods. They were okay…but just not the same as Clair’s eggs. Nothing new there, I suppose—being spoiled by the real thing.

Another thought on the effort by Standard Process to keep its products off the Internet: Sometimes it’s hustling entrepreneurial companies that force the old fogies to make business changes they’ve been resisting. The Japanese manufacturers did it to Detroit’s Big Three. Internet companies have done in all manner of industries ranging from travel to books to jewelry. As I pointed out in my BusinessWeek.com article about Standard Process, a Long Island company headed by entrepreneur Martin Meyer is fighting for the public’s right to buy Standard Process products online. He’s doing it for profit but also for principle—to fight what he sees as an effort by Standard Process to control prices.

Rather than stop using Standard Process products, as I previously suggested I would do, maybe the better approach is to buy it from a place like Meyer’s Total Health Discount Vitamins, Amazon, or any other such outlet.

A related issue is that raised anew by Dave Milano and Michael—of how the judgment and allegiance of health care providers is compromised when financial incentives beckon as an outcome of their medical recommendations. It’s one thing when auto sales people have sales incentives, but it doesn’t seem appropriate to health care providers. To explain it based on the fact that they are underpaid (as Michael does) would be similar to justifying teachers selling toys to their students because the teachers are underpaid. I don’t think it would go over too well (though many schools have earned money by having Coke machines in their halls).

***

I spent some time this past weekend trying to whittle down my pile of magazines and blog links. A couple of intriguing items I came across:

New research about health and disease in the 1800s. There’s a tendency to assume that today’s seemingly pervasive chronic illnesses weren’t as much a problem 150 years ago. Not necessarily so.

New research, based on an extensive study of the records of Civil War veterans suggests that men in the late 1800s actually suffered from more chronic conditions than most people do today. The research is described in a lengthy article in the University of Chicago Magazine (my alma mater).

Major causes appear to have been malnutrition and heavy-duty manual labor (and perhaps a lack of understanding about the importance of nutrition). One thing that strikes me is that the average number of chronic conditions may have declined in modern times, but the actual types of conditions appear to have changed. For example, diabetes is a fairly recent malady.

Speaking of chronic illnesses, here’s another take. A friend of mine who’s in the nutritional supplement business, Pat Sullivan, has made an intriguing discovery about his own challenges with chronic illness. After much searching and exploration among health care providers, and treatments of all kinds, he learned that a brain injury when he was a teenager may well have been the culprit. He’s described his search and treatment in an ongoing series of posts on his blog. (It’s written in a series of six installments; my link takes you to the first installment.)

Actually, his experience reminded me of a segment in Dr. Andrew Weil’s book, Spontaneous Healing, (which I discussed a few months ago) in which he describes the success of a holistic provider in treating patients with chronic conditions. This provider believed that many chronic conditions emanate from seemingly slight head injuries, or even from difficult births.

Finally, not necessarily apropos of anything, but I’ve noticed that the raw goat’s milk I’ve begun drinking is as pure a white as I’ve ever seen. It stands out because it contrasts with the cow’s milk, which is an off-white. The fat content of each isn’t all that different. Maybe it’s the breed of animal? Or the cream content in the cow’s milk?

Speaking of raw milk, Jonathan asks in a comment on my posting concerning the wrapup of the Michigan Department of Agriculture case against Richard Hebron, why David Hochstetler received a warning letter from the FDA rather than Hebron. My understanding is that Hochstetler was making the deliveries, and was thus the one crossing state lines with the milk. As to the constitution, I'm not sure where it says individuals who are let off are entitled to compensation.

I have an uneasy feeling that I failed to communicate adequately on Thursday’s post why I’m so outraged by the behavior of Standard Process, along with that of Thorne Research and Designs for Health, in cutting off a Long Island wellness center from their products for re-sale. I’ve focused more on Standard Process because it appears to be carrying the “protect the channel” and anti-Internet banners the highest.

But I feel as if I’ve neglected the real message in this little spat. Without appreciating that, it’s easy, as Michael does in his comment, to suggest that manufacturers can protect the channel “through any legal means” as “their best (business) strategy”—no big deal, business is business.

But Michael in his aside about practitioners making money starts to touch on the real issue—of how selling supplements “has become a big part of many practitioners’ business model…” Linda Diane Feldt picks up the ball and runs with it in pointing out “the elephant in the living room” in the form of questionable ethics of practitioners selling supplements to patients. While ethics is an important issue here, my outrage has to do with these companies' attitudes toward their ultimate customers--us patients--before fully addressing larger issues like ethics.

Some personal background may shed further light on why I find the heavy-handed approaches of Standard Process and the others so offensive. I learned a lot about the nutritional supplement business as practiced by manufacturers and practitioners because I spent much of 2005--the year prior to launching this blog--working with a startup company that was testing a unique business concept: providing an online system for health-care practitioners to sell their nutritional supplements to patients. The idea was that patients would be able to obtain refills of supplements originally recommended and sold by practitioners without having to come in to the practitioner’s office or phone in or, most important, without being tempted to order over the Internet from Internet Discounter Inc. There would also be lots of information available about all supplements being recommended, so patients would know more about the supplements they were taking.

Practitioners were encouraged to offer discounts of 10-20% over their office prices as a way to stimulate the online business. Whatever practitioners gave up in discounts, we thought, they would more than make up in increased volume from more loyal patients. We eventually tested the concept with four practitioners, and eventually had about 150 of their patients using the online system.

Most supplement manufacturers we discussed it with agreed at least not to fight us on it, since the online system was password-protected, meaning that only practitioner patients would have access to make purchases. We never discussed it directly with Standard Process executives for the simple reason that a Standard Process sales rep warned us it would never fly with the company. He said he liked the idea and would try to convince executives of its merit, but he warned that the odds were long. Practitioners who carried Standard Process products also told us they couldn’t imagine the company going along with such a system, since the company resisted all forms of discounting, and discounting was an inherent part of Internet commerce. Presumably, if practitioners discounted their prices to patients, the next step would be for practitioners to demand that Standard Process discount its prices to them.

Many practitioners resisted the discounting as well. They couldn’t get past the fact that they weren’t making as much on each order as when they sold directly from their offices. They had the same mindset as Standard Process, Thorne Research, and Designs for Health.

And what about the 150-plus patients who were using our system through the four practitioners testing our system? When we surveyed them, they were nearly unanimous in saying they loved being able to purchase their practitioners’ supplements online—for the convenience, the cost savings, and having their records easily available to them.

So when Michael says he is “agnostic” about the whole thing, I suspect he is looking at it as a practitioner, rather than as a patient. Patients are accustomed to buying pretty much everything at discount online.

It all comes back to what seems to be an outmoded idea in our health care system: the importance of providing for the patient’s interests first and foremost. It’s really not such a revolutionary idea, since businesses in nearly all industries other than health care successfully focus on “customer satisfaction” every day.

By November 2005, I pushed this startup venture to give up on its experiment. I thought it could succeed in spite of resistance from Standard Process and many practitioners, but I was more concerned about some internal problems in the venture, combined with higher-than-expected costs to finance a full rollout. When the venture discontinued operations at the end of that month, many patients were quite disappointed.

A month later, in December 2005, Standard Process came out with its written notice to all its practitioners prohibiting ALL online sales, even from password-protected systems, and threatened to terminate them as re-sellers if they were caught providing products over the Internet. I’ll never know if our little test venture prompted Standard Process to go public with its objections, but I suspect it played at least some role.

There are simple reasons why most things are cheaper online: it costs sellers much less to fill online orders than to fill orders from an office or store. You don’t need as much real estate, you don’t need sales people standing around, you don’t need cashiers, and it’s extremely easy to handle re-orders. So you pass on the savings to buyers. That is why so many of us order everything from books to shoes online.

The arguments about protecting patients from “self medicating,” and the supplement companies against liability suits, are empty arguments, rationalizations, as the argument of “protection” often is. The fact is that federal law classifies supplements as food products, separate from prescription drugs. (Standard Process plays up the fact that most of its products are made from real food.) If Standard Process and the others were really so concerned about patients injuring themselves from using the wrong supplements, then these companies would favor some of the legislative initiatives that come up periodically about making supplements available only by prescription. But no, they lobby against that. For a simple reason: They would lose their “channel,” since the supplements would then be available via Walgreens and online pharmacies in Canada, among other places. That would really cut into margins. Talk about playing both sides of the fence.

The real story is that Standard Process, Thorne Research, Designs for Health, and a few others don’t want to risk using the Internet to improve the patient experience because the patient isn’t a high priority to them. They only want to maximize profits for themselves and their “channel” by avoiding any and all discounting.  I can say this with confidence because no company in today’s highly competitive business environment takes the highly unusual step of arbitrarily cutting off lucrative long-term customers unless it is feeling terribly threatened or wants to set an example to the mass of other customers.

Standard Process, in particular, has managed to establish something approaching cult status with practitioners. They love the company’s products. And they love the money they make from its products. Standard Process is counting on this loyalty as it sacrifices colleagues it suspects of bucking the no-discount system.

Of course, the problem of serving one’s own financial interests at the expense of patients isn’t unique to practitioners who sell nutritional supplements. It’s part and parcel of the entire health care system, whether it’s insurance companies, Big Pharma, hospitals, or doctors. Health care is well over a $1 trillion annual business, so there’s a lot of money to divvy up. And I haven’t even begun to address the ethics issues Linda raises.

Patients? Who the hell are they?

I am definitely becoming tempted to try making cheese. I have a recipe for cottage cheese I’ve wanted to try for a while. I think I’m a little intimidated by the cheese-making process, since I’ve never done it before, and it involves some utensils and techniques I'm not familiar with. (Some of the discussion on my Wednesday post sounds a little foreign to me.) I'm finally getting comfortable making kefir, and enjoy it (the making and the kefir), so it's probably time to move on to something new.  

Beth Corbett, the goat farm owner, suggested New England Cheesemaking as a place to get instruction for doing it myself, which a couple of people refer to.  My search for raw milk, and now the cheese place, is certainly helping me with my Massachusetts geography. I keep hearing of towns I never knew existed. New England Cheesemaking is in Ashfield, which turns out to be the northwest corner of Massachusetts, a good two hours from Boston. (I was interested in possibly taking one of their courses.) But maybe that's another bonus of buying direct and learning new food-making skills--getting in touch with rural areas I didn't know much about.

The only thing that concerns me about New England Cheesemaking comes in its FAQ—while they understandably warn against using ultrapasteurized milk for making cheese, because the calcium has been rendered unsuitable, they also make a strange statement about raw milk:

“Raw cow's milk works quite well as long as you have complete faith in its purity (if you would gladly drink it).
Be very careful here. The milk needs to come from tested animals and be kept as clean as possible. That means from the milking to the cheese vat. Also it should not be stored for longer than 24 hrs ... 36 max.”

It’s the part about the short storage time (added to the alarmist tone), suggesting you should dispose of the milk if you don’t use it nearly immediately. As many have noted here, raw milk can often be kept for two weeks or longer, and then used for kefir (and I presume cheese).

Anyway, Linda Diane Feldt’s recipe sounds like it’s about my speed at this point, so I may give it a shot.

***

Our country is greatly influenced by what movie actors and actresses do or say or want. Most of the time, their influence is channeled toward fashion or failed marriages. But every once in a while, a celebrity comes up with something positive, and last evening on “Nightline” was one of those times.

Actor Paul Newman was featured in a segment promoting buying organic food directly from farmers. Newman has backed a restaurant in Connecticut that specializes in serving locally grown produce and meat. The ABC interviewer was obviously ga-ga over Newman, and let him go on and on about how his daughter influenced him to realize the importance of locally-based food.

What was even more amazing to me was that the segment aired his chef explaining why it's so beneficial to buy meat direct from farmers--that most cattle are sick, and barely survive because of the widespread use of antibiotics. Take a look, it’s pretty interesting--about 8-10 minutes. The buy-direct movement just got a big boost.

Actually, Newman is pretty impressive, especially for a celebrity. His “Newman’s Own” products have raised about $250 million for charity, and that’s just part of what he’s accomplished in dedicating his post-acting life to helping the needy. The only thing I didn't get is that he makes product available to McDonald's, to raise $4 million a year. I'm not sure it's worth being in bed with the king of fast food.