Fermentation: 1971-1973

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medical        *
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The past 4-5 days have been miserable with lots of deep aches and pains together with numbness of the hands and feet. Trying to do without steroids and analgesics was a mistake. I've decided to use what I need to feel acceptable quality of life. Without the medication I was too sick to write much. Today is a much better day.

Fermentation:  1971 -- 1973

I have also been stuck in my narrative in the years from 1971 until 1975. When I think  back, I see myself circling around in a dog's bed, trying to find the perfect resting place, round and round, trying to find a way to convey this portion of my life. Thankfully, in 1971 I realized that I was not mature enough or committed enough to settle into a medical practice. I wanted my nights and weekends to be as free as possible for partying, visiting, living.

When viewed in the context of my childhood religion, the practice of medicine is very much like a vocation to the priesthood. While medicine may not demand celibacy, it does demand that one keep abreast of the field and to generally put the service of patients above the best interest of family. Medical practice appeared too consuming early in my profession and I was still trying to find work that would involve technology. Medicine is my religion. I think it represents one of our best features as a species.

Meeting Charles Eby
In my medical school class, there were fewer than 10 women. One of them, Barbara Eby, was a strikingly confident woman whose goal was ob-gyn from day 1.  My wife Sally and I moved to Laurel, Maryland sometime in 1967 right around the time of Kristin's birth. Barbara lived there also and gave me rides to and from school on occasion. Barbara was married to a physicist, Charles, who was doing economic analysis for a Washington think-tank. Shortly before graduation from medical school, Barbara said that she and Charles wanted to try pot--would I come. I was separated from Sally and dating Molly. Barbara and I set up a time to get together on a Saturday to see the movie, Monterey Pop. The marijuana was great. The movie was even better and we were back at the Eby apartment hanging out.

Suddenly there was a loud knock at the door. All of us were very high. Charles got up and went to the door and returned and in loud, conspiratorial whisper exclaimed: "He says he is the mail man." After a brief consultation among us, we decided that it was very likely that the chap at the door was in fact the mail man and that we should honor the knock and see what he wanted. Charles did so and returned to the living room with a large box from his mother. He opened and it contained our dessert, a variety of brownies, cookies, and california nuts.

Would this possibly be the coincidence to convince me of divine providence? How likely is it that one would receive such goodies from Mom in the mail on the day that one first tries pot?

I wouldn't see Charles for more than a year thereafter. I remember Barbara coming to visit me at South Baltimore Hospital a few months later and telling me that she had decided to leave her marriage. She felt that she and Charles were just too different and that she had to make a break. Although we had commuted together for many hours, I had never been her confidant and I was surprised (but glad!) that she had told me what was happening. I don't think we have ever shared a secret since. When Charles died, I thought it was important to let her know. She did attend the service and have the opportunity to share stories with Charles' ex-wife and other lovers.

Charles was the intellectual friend of my life. He was a gigantic IQ--totally dwarfed mine-- who entered Harvard early as this high school genius from Santa Ana, California. In addition to formidable brain power, Charles came from a family of Mennonite carpenters. He was an exquisite craftsman. To see his wordwork could bring tears to your eyes. While I was trying to make corduroy pants with a sewing machine in 1972, Charles was making silk shirts for his girlfriend. While at Harvard, he had worked for BF Skinner constructing various types of learning machines.

He had a difficult time finishing certain things, particularly after he had absorbed the value of the project and was left with the task of explaining it to others. He dropped his master's thesis at George Washington University in the early 70's. When he did training at Rand Corporation medical in the 80's he again had a hard time getting the final paperwork done. He was a perfectionist and hated being responsible for something that did not measure up in his own life.

Charles became interested in health care delivery while he was working for Resource Management Corporation in Bethesda, Md. This was a small "think tank" that lived on doing various evaluations for parts of the poverty program. It also developed an inhouse market reasearch group. I thought Charles' work on the evaluation of a transportation system in rural Appalachia was excellent.

In the fall of 1970, I had contacted Charles and we started hanging out together. Once having tried Marijuana, he had changed his life. He grew some dope. He stopped wearing suits, let his hair grow, bearded up, and started tie-dyeing tee shirts. He was getting into the scene. Charles also worked with a number of economists who had migrated to D.C. from Rice University. They lived in a commune in Northwest Washington, and they made occasional appearances in our social life.

My consulting job with Bruce Waxman lasted through the first 6 months of 1971. I was given interesting work and was sent out to look at ongoing projects using my "physician's eye." This allowed me to visualize much of the new technology of the time. I also became friends with Bruce. As I was hired, he was in the process of moving from Rockville, Md. to a large home in Harpers Ferry WV. I recall helping him move his furniture one Saturday and having a conversation about relationships. I told him that  my relationship with Molly had become the most important thing in my life. The loss of my first marriage and the restrictions on seeing my child, Kristin, had made me realize that relationship had to take priority.

My first trip west was to the Rand Corporation in 1971 to visit a mathematician who was doing early graphics work. At the time there were no "graphics" cards which make such easy work of graphical functions. To utilize a million dollar computer in 1971 to display a scatter graph of a few thousand data points required that all other programming operations be shut down to free up enough computing power to handle the display and its manipulation. We take the use of icons and graphic driven interfaces as the norm since the 1980s but this type of interaction with the user was a radical departure from prior methods of communication between human and machine. The fellow at Rand was demonstrating this capability.

I was also given a look at the DARPA (Defense Advanced Research Projects Agency) net on that same visit. This was the forerunner of the internet. The attempt was to design a network that could sustain a nulear attack with the loss of many nodes while still guaranteeing that an intended communication would still occur.

To get some notion of the speed of data transmission circa 1970, watch the film Bullitt. There is a scene where Bullitt is awaiting a fascimile (fax) transmission from Chicago. It seems to take hours. Compare that speed with the email available on your smart phone. Light years difference. The advantage of high speed data for medicine would be the delivery of medical records. In 1970, there were no CT scans in routine use. Who would have anticipated the current volume of traffic in medical imaging?

I was the second physician on staff at the Technology Branch in 1971. The senior person was Charles "Chuck"  Post, M.D. He was a well-trained, doctor on his way to an eye residency. When I met him, he was handling several grants and contracts for Dr. Waxman and also working as an emergency room physician. I think we provided a good mix of skills for the Branch. I was more interested in the nitty-gritty technical aspects while Chuck was intrigued with the overall picture. For example, Waxman wanted to demonstrate to the Mental Health Administration that the MUMPS computer language  used by projects in Boston could be applied in other areas. The mental health people were working on a self-administered questionnaire. Waxman assigned me to learn the MUMPS language to the extent necessary to write the computer program that permitted the interaction and the scoring of the questionnaire.

Over those six months, there was a steady stream of well-known computer experts, mathematicians, and physicians who visited Waxman. He was generous in allowing staff members to sit in on many of those. The one I found the most interesting was Julian Bigelow who had worked with John Von Neumann and may have actually built the first digital computer.
http://en.wikipedia.org/wiki/Julian_Bigelow

At the end of six months, I realized that a Ph.D. in computer science was unlikely to be terribly useful in medical computing.  In the meanwhile, out of the blue, I received an offer from Baltimore to become the medical director of the first outpatient opiate detoxification program in the state. Dr. Waxman was paying me about $19,000 per year. The Maryland offer was $25,000 a year with a $4000 bonus. The practical difference was the ability to immediately buy the color TV I wanted. I took the money.

The other advantage of a job in addiction was the opportunity to read extensively in the field. I was addicted to cigarettes and committed to regular use of alcohol and social pot smoking. What was the relationship among all of these phenomenon? Andrew Weil had just published a book called the Natural Mind which pointed out that there seemed to be a general desire on the part of humans to experience altered states of consciousness. I had also read the Ford foundation report revealing the dog chases tail aspects of our national drug policies. While in medical school in 1967, I read jealously of the happenings in Haight-Asbury. Perhaps I was hoping to catch-up and get paid to boot.

Addiction:
The literature on the treatment of opiate addiction prior to 1965 was very discouraging. For years, the United States Public Health Service had run programs in Lexington, Kentucky to study addiction to morphine, opium, and heroin but all attempts at intervention had failed. The idea of the addiction was broken into two components, a physical part, and a psychological part.

Opiates, like morphine and heroin, have a number of physical effects on the body. These include pain relief, a sense of well-being, and constipation. Within a few days of regular use, a physical dependence can be demonstrated. For example, many people who are given narcotics for several days after a surgery will have some withdrawal when the drug is stopped. This may include yawning, sweating, runny nose, loose bowel movements, etc. There may just be a sense of a "let down." Most people take these symptoms in stride and ignore them as being a "cold." So, physical dependence is not necessarily interpreted as suffering. All this changes with the addict who is acutely aware of the withdrawal syndrome and who will go to great lengths to prevent it. The "psychological" dependence has a physical basis as well that ties into brain receptors and the overall neural reward pathways. These connections were unknown 50 years ago.

It is estimated that the "typical" intravenous heroin addict will self-inject 2-4 times a day. This keeps him busy. He must ensure that he has a supply. If there is no money for a supply, he must "hustle" and raise the necessary money within a few hours. An addict can be a very busy man.

Methadone was first synthesized in Germany in 1937 and became widely available as a cough suppressant and pain reliever in the U.S. in 1947. Methadone has an extremely long "half-life." It takes many hours for the body to rid itself of the drug. During the 1960s it was discovered that Methadone in large enough doses, could relieve the craving for heroin in addicts. Furthermore, pre-loading with methadone prevented  euphoria if heroin was used. This meant that addicts who were hustling to find a fix two to four times a day, could use methadone to relieve craving. As a result the heroin addict could be relieved of the need to spend his entire day in the search for the next fix.

In New York in 1962, Dole and Nyswander developed a model for the treatment of opiate addiction that was termed "methadone maintenance." In addition to dosing strategies for methadone, there was an important rehabilitation component that began to address the addict's shattered social structure. In this model, recovering addicts became a pool of recruits for further extension and growth of the program. The recovering addict became the best possible teacher.

So, by 1971 there was good data demonstrating that daily methadone was a useful treatment for many with chronic opiate addiction. Although often criticized as the "substitution of one drug for another," a cursory look at the successes of the methadone users revealed the possibility for the addict to begin to make adjustments and to join a more normal social order, to think about getting a job, to begin taking on responsibility for family, etc. Methadone addiction could be much different. The opiate addiction itself could be managed with a fraction of the time previously spent in seeking the next fix.

Also in 1971, Methadone was a legally available drug by prescription anywhere in the United States. But the government was about to step in by making a distinction between using a drug like Methadone for pain and suffering, as opposed to using a drug in the long-term to continue an addiction. With this line of thinking, the Federal government would label methadone maintenance "experimental" in some way, not a routine use of a drug. Of course "experiments" have to be monitored and the government began to build the machinery to permit it to do so. The Feds were going to control this.

It is during this era where Thomas Moore, M.D. saw a niche for himself in Washington, D.C. Moore opened a clinic totally devoted to the dispensing of methadone. I did see parts of the operation at one time but 4 decades ago. These are my recollections.

In the Moore clinic, Methadone was kept in liquid form in large containers, similar in size to the large water jugs that are used in office water supplies. The container has a spout for delivery of the methadone into smaller bottles. This was the delivery method--via water cooler.

A clinic visit at Dr. Moore's was either $15 or $30 depending on the amount of liquid methadone you intended to purchase. There were armed guards at the water coolers and the cashier's space. There was generally a long line outside of his office that just kept moving through all day. There were estimates that his yearly office visit counts were in the hundreds of thousands and Dr. Moore's take home at several million a year.

The boldness of Moore's operation shook up the local governments. Addicts were coming to Moore from Maryland, Virginia, West Virginia, Delaware, and D.C. For many of these patients, Moore was providing a necessary service (my cousin was one of them). No one in D.C. had access to a Dole-Nyswander program which was still being evaluated in New York. However, thousands of D.C. addicts had the opportunity to legally purchase methadone in sufficient quantity to eliminate the multiple daily withdrawal effects of heroin. In addition, the methadone blocked the euphoria of heroin, making it a "waste" to use it if you wanted to get high from heroin.

While the methadone user is still "addicted" to a substance, he has a tool which can enable him to work, to function, to reintegrate into society in some manner.

Maryland was interested in bringing methadone maintenance to the city of Baltimore in particular. However, methadone maintenance meant ongoing addiction to methadone for the patient. It was essential that the state provide an initial opportunity for the addict to detoxify from heroin and to move on in a drug-free manner. Otherwise the state might incur liability for having caused the addiction de novo.

 In 1971 a state grant was awarded to Bon Secours Hospital in West Baltimore for the creation of a detoxification unit. I was the first medical director of that program, later renamed the West End Drug Abuse Program. I busted my butt for several weeks and got the program from ground zero to a point where it could begin to operate.

It was an interesting job if short-lived job. I had the opportunity to travel to New York on a few occasions for eye-opening education into the ugly world of drug addiction. However, the grant process in Maryland included the formation of a "community board of directors," and broke down along racial lines, 40% of the catchment area was white and 60% black. Most board members had businesses in the area or visible social connections.

Board members were often interested in having the program rent space from them or employ friends and family. The board met weekly on Friday mornings. Not much was said to me until the program actually began to function and to move patients through. At this point it had achieved viability and then squabbling became quite intense over various leadership positions in the program. I recall going to three straight board meetings and using a librium capsule beforehand to reduce my anxiety.

Sometime in November, I decided to leave the rancor and resigned, giving them two weeks notice. Board members couldn't believe that I would resign without having another job. I went home and opened up a sewing machine and began to make trousers for the next few weeks. I never did get the zippers right--all of my pants had buttons instead. I only showed up at the drug program to perform necessary tasks.

What happened next was very surprising. While sitting alone at home running that sewing machine, I began receiving phone calls from all over Baltimore. Suddenly I went from unemployed to having five part-time jobs, including a part-time job at the West End Drug Abuse Program that required about 10 hours of work a week and paid almost 1/2 of my previous salary. I also had work at the Towson County Jail, North Charles General Hospital, Sheppard Pratt Hospital, Loch Raven Veteran's Administration Hospital, and the University of Maryland Department of Psychiatry. For the next seven months, I worked seven days a week and went from one assignment to another. I saved the money. In June, Molly and I set out for an extended vacation to the Canadian Rockies and Vancouver Island. I recall months of sunshine and catching up with several years work of reading.

In the meanwhile,  the Federal Drug Enforcement people decided to close down Dr. Moore in the fall of 1972. This created a disaster. Thousands of addicts being maintained outside of the system by Dr. Moore were now without a source of drug. The state of Maryland responded by creating short-term detoxification programs in Baltimore. Addicts were offered help in tapering off from Methadone over three weeks. However, long-term methadone users may need 6 months or more to achieve a comfortable detoxification. Furthermore, many of Moore's patients were practicing a form of methadone maintenance in a successful manner. These were the real victims.

In January 1973, I returned to work--this time as an employee of the Public Health Service. Since leaving 18 months before, the organization had accumulated a number of very bright young physicians. Probably our most famous resident was Robert Brook, M.D. While a Robert Wood Johnson clinical scholar at Hopkins, he had written the definitive work about assessment of the quality of medical services. I recall a conversation one morning with a young Arthur Barsky, M.D. concerning the generation of false positive results from comprehensive laboratory screening. Being that values outside of 2 standard deviations were classified as abnormal, any given person had a 50% chance of having an abnormal lab value when 15 or more individual laboratory tests were administered at the same sitting.

There were doctoral level economists trying to model the provision of health services as the product of a "medical assembly line," and there were a number of psychologists who obtained posts as career level bureaucrats.

Within the Technology Branch, two new physicians had arrived, Peter Walton and William Glenn both of whom were superbly trained phyicians with strong computer skills. Throughout 1973  the parade of glitterati continued through Dr. Waxman's office, people like Joshua Lederberg and Norbert Wiener and Bill Lear.

I was assigned projects in Boston and met with Anthony Kamaroff, M.D. who was working on algorithm development at the Lincoln Lab at MIT. My closest associates in Boston were Warner Slack, M.D., the father of the automated medical history, and Howard Bleich, M.D. who wrote what I thought was a watershed computer program,  the most useful and complex interactive medical program for managing Acid-Base and Fluid Balance. Both of them were very much interested in what was happening with Watergate and I routinely took them the Washington Post when I travelled to Boston. They were both kind to me and offered me a medical residency at Beth Israel. I laugh to think that I could have been there when the "House of God" was being written.

In my own reading, I became increasingly interested in the "Diseases of Medical Progress." We had reached a point where the ability to deliver services exceeded the ability to provide on the spot information about the services being delivered. We knew that there were large numbers of medication errors occurring in hospitals and a patient admitted to a hospital was more likely than not to receive ten or more medications in the first 72 hours. Little was being done about it.

A general dictum for medical practice is "Primum non nocere." -- in the first place, do no harm. Our medical system had progressed quite a way beyond that.

The Study Section
Within the NIH were a number of "study sections," panels of ouside scientists with an interest and expertise in a particular area of medical research and practice. The study section model had migrated to the National Center for Health Services Research (NCHSRD). I was most familiar with the Technology Study Section, which was grouped around Dr. Waxman's office.

Within the study section were 15--30 "principal investigators," scientists who had demonstrated pioneering work in the area. When a proposal for a new research project was submitted to the NCHSRD, it would be assigned to a particular study section dependent upon the content of the proposal. Generally this meant that copies of the proposal were sent to three random names in the study section. These members were expected to critique the materials and to report findings to the next general meeting of the study section which got together every few months.

In this way, proposals were evaluated by "peers" who were not government employees. It was believed that this was a reasonable way of keeping the government out of the nitty-gritty parts of medical research grants.

Given this system, it was possible for the study section to come to logger heads with the inside NIH scientists who might view these requests for grants in an entirely different fashion. This potential for friction could be alleviated by a parallel "contract" process wherein the NIH employee decided that a particular piece of scientific work needed to be done, drew that work up in the form of a contract, and put the job up for competitive bidding. Dr. Waxman was very much prone to using the contract mechanism which reduced the total money available for the study section to use for grants.

The study section members saw the contracts as depleting the basic supply of funds. The bureaucrats saw the contracts as the only way of getting certain kinds of work done.

In my mind the study section is likely to be corrupted over time. Many members already receive grants from the section. In order to continue to receive grants, other peers have to agree that the research continues to merit funding. If I want peers to vote for my project, maybe it is a good idea if I vote for theirs.

The NASA Takeover at Health Services and Mental Health Administration


In retrospect we see the 1960's NASA effort for moon landing as having had a positive effect on the United States Economy to the point where investment in government research is touted as one of the ways of growing ourselves out of the current economic distress.

However, the economic benefits in terms of the microcomputer revolution were not apparent in 1973. For all intents and purposes, the Kennedy moon program had cost several billions of dollars without evidence of long-term benefit. The American public would have considered the space program an economic waste if you had polled them in 1972.

As parts of the space program were dismantled, top brass were funnelled into other areas of government, including the office where I worked--the National Center for Health Services Research. There, these refugees from space concocted a plan to attempt to polish up NASA's image by demonstrating new technology to solve a medical problem.

 SPACE PROGRAM = GOOD MEDICINE.

In their wisdom, the top brass had decided that a Satellite-delivered, automated medical record system was exactly what the Papago Indians needed for 20th century medical care.

Peter Walton and I went to the "kick-off" of the program high up in the Parklawn building in Rockville. We could identify the NASA types by their crew cut and flat top haircuts. There were high tech models of rockets and capsules on display about the room. There were many pretty women as well. I think we had some cake and ice cream and then left to talk about this public relations campaign.

Pete and I had read extensively about the Papago Indians. It is a large reservation with people scattered over more than 4 thousand square miles. It is a desert and seldom rains. There are no oases. There is no year round running water.

Instead, various natural cisterns fill with water during the rainy season and are used by the community as a water supply for much of the rest of the year. These are standing, open sources of water and they become contaminated--the origin of the diarrheal illness. 5% of newborns die.

http://en.wikipedia.org/wiki/Tohono_O'odham

The following is a study of the health of Papago Indian Children done in the 1960s.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2031817/pdf/pubhealthreporig01060-0017.pdf

Page 1051 outlines the 5% neonatal mortality for the tribe. This was 4 times the rate for the U.S. population at large in 1970.

Page 1058 continues

Infectious diseases, especially diarrhea and pneumonia, present the greatest health problem
of Papago children during the neonatal period and through the first year. It is unlikely that
these children have a peculiar susceptibility to these disorders (23).
However, the impact of infectious disease is certainly affected by cultural and environmental factors. During the hot summer months, diarrhea becomes a serious problem as the opportunity for transmission of infective agents increases. Because the Papago frequently do not have refrigerators it is impossible to keep artificial formulas sterile. Water is hauled considerable distances in unsanitary containers and is stored in open vats and pots.
The infant is the one most seriously affected by diarrhea and, too often, the parents do not
get him to the hospital until the infection is considerably advanced. Although treatment
with intravenous fluids is usually successful, it has been suggested that such febrile illnesses
associated with extreme dehydration may cause irreversible changes in perceptual and mental
abilities. Hospitalization for diarrhea is usually prolonged (an average of 16.7 days), since staff
physicians have learned that recurrences are frequent if the child is returned to the home
environment before he has completely recovered and shown a significant weight gain.
Breast feeding and closer medical supervision would greatly reduce the morbidity from diarrhea. Unfortunately, breast feeding frequently is not possible with Papago mothers. Children are often placed in the care of babysitters or grandparents while the mother is working or otherwise occupied. The long distances which separate most villages make intensified medical
supervision difficult. The possibility remains that an intensive program especially aimed at reducing mortality and morbidity resulting from diarrhea might well be an entering wedge toward controlling the health problems of the Papago.


Of course the experiment with Satellite delivered medical records proceeded on the Papago reservation. Washington saw utility in the Papago geography and was able to look past the dying children. Rather than address the need for clean water, the lessons from the 19th century, an electronic medical record system met the propaganda needs of the time.

I also began to realize that our institutions were rising up to begin to control medical services, we saw the Federal re-regulation of methadone for the treatment of opiate addiction.  In order to do so, institutions needed physicians on the payroll to lend an air of "legitimacy." Often we are there to provide window dressing and cover for political agendas. The National Center For Health Services Research had demonstrated its real concern for Papago Indians in choosing to ignore the most basic health need while utilizing the tribe in a public relations campaign that served the purpose of the administraton.  And no one was responsible. Or were they? Who else could be responsible than the physicians being used to mask the decision-making process.

I began to look at some of the other things around the office. One of my projects was at the Leahy Clinic in Boston. This was world-famous as a diagnostic center, much as the Mayo Clinic. A patient could schedule an appointment there and see any number of specialists and leave a few days later with a much better understanding of the particular health concern. This was a very rich medical business.

Somehow the Leahy Clinic had received a grant to best determine the scheduling of a new patient based upon a telephone interview. The problem is that a patient calls for an appointment, perhaps complaining of stomach pain. How does the receptionist know which physician to start the patient with? That is the essence of the issue that Leahy Clinic wanted to study at government expense for two years. It would not be cheap. An operations research professor would run this study.

The project was assigned to me. I noted that the Leahy Clinic did not accept Medicaid--no poor people need apply. I wondered why the federal government would want to fund such a flush organization when the data would exclude a significant portion of the population. Then I started looking at the numbers and the so-called models being generated for handling phone calls. It turned out that for about $100,000 in 1973 money, the principal scientist had developed  a set of questions that gave the patient a 60% chance of being scheduled with the appropriate doctor on the first visit. However, if one just used the high school graduate operators who normally answered the phone, one could get to the right doctor 59% of the time. There was no real difference. It was smoke and mirrors.


There is an interesting statement about the effectiveness of 1 on 1 medical care, that is the kind of care you get from a personal physician. The statement goes something like this: "It was not until about 1907 that one could visit a doctor and have greater than 50% chance of being better off rather than worse off.

When we think about improvements in life expectancy, we have to remember that the big, initial jumps occurred with attention to sanitation. By guaranteeing safe water supplies, we eliminate cholera. By controlling mosquitoes, we reduce yellow fever. By careful attention to cleanliness in our food chain, we can control salmonella and typhoid fever. By eliminating lice, we control typhus.

These public health measures are designed to prevent the occurrence of illness in the first place. This means that we will be unable to identify the particular individuals whose lives will be spared. In addition to cleanining up food and water supplies and safely treating garbage and waste, the knowledge of infectious diseases permitted the development of vaccines for smallpox, then polio, rubella, measles, mumps, influenza, etc. Again, we don't know which of us are here because the immunization prevented us from acquiring a fatal illness.

In addition to public health measures, there are treatments for individuals as well. The ability to demonstrate the effectiveness of such individual treatments has become more difficult. As an example, take the operation "appendectomy" for the acute appendix. Once introduced, there was no doubt of the benefit derived. Instead of hundreds or thousands of deaths annually, few people die from a ruptured appendix today. The benefits are so dramatic that further study is not warranted.

However, today we are in a situation where doctors offer patients treatments where benefit is hard to prove, for example, the use of antidepressant drugs in mild cases of depression. Here, a sugar pill looks very similar in effect to an expensive antidepressant.

We have gone from an age of big differences with effects so obvious that scientific study of proof seems superfluous to an era when scientific study of effectiveness is absolutely necessary before making statements about various treatments.

We Move To West Virginia


Molly and I had returned from an extended vacation in 1972 and moved into Charles Eby's house for the next few months while I started my second cycle of employment at the National Center for Health Services Research. House prices around D.C. had inflated and passed us by. Charles was doing consulting work in Chicago and he had a small contract with one of the health agencies to review literature. He could't get around to it himself, and he asked me to do it. In addition, I obtained some work doing insurance physicals to keep some money coming in for incidentals while I awaited the Feds to complete the paperwork for my position.

Charles and I were together every weekend. We were passionate about the need to better understand the variables underlying the medical process. We read and discussed the literature. We were able to free associate and to drop any need for one upsmanship. It was one of the most stimulating times of my life.

In the spring of 1973, Bruce Waxman told me that there was an interesting house for sale near his place in Harper's Ferry. Molly and I took a look and loved it.

It was an A-frame on two acres overlooking a lake. During the winter, you could see the Shenandoah through the bare trees. There were many fallen trees available for firewood, and there was a swimming lake in the summer. Although it was an hour from Rockville, it was the most delightful place for spending weekends.

Soon after, Molly took a job in Rockville as well, so we were together during the two hours of commuting each day. Kristin came every other weekend and our family life settled down into a routine for the next three years.

I still had not found a comfortable place within medicine, but with my new interest in iatrogenic illness, I took a shot at writing a medication guide for consumers. I believed that there was enough information available to make it worthwhile to warn people about certain very common side-effects and drug interactions.

Eric and Kris building a fire Harpers Ferry 1973