MEDICAL TUESDAY . NET

NEWSLETTER

Community For Better Health Care

      Vol V, No 5, June 13, 2006

 

In This Issue:


1.      Featured Article: Shutting Down Alzheimer's by Michael S. Wolfe, Scientific American

2.      In the News: Are Business CEO's Overpaid? Just Check What Non-Profit CEOs Make By Phillip Reese and Todd Milbourn, Sacramento Bee

3.      International Medicine: How to Cut the UK's NHS Waiting Lists, Notebook by Mick Hume, The [London] Times Online

4.      Medicare: A Government Medical Bureaucracy (FDA) Versus Compounding Pharmacies

5.      Medical Gluttony: Gluttonous Behavior Is Still Prized

6.      Medical Myths: Doctors Always Know What's Best for the Patients

7.      Overheard in the Medical Staff Lounge: Is the Violent Death Rate in New Orleans Really Twice As High As Iraq?

8.      Voices of Medicine: Many Perversions of Peer Review Process by Philip R. Alper, M.D.

9.      Book/Movie Review: The Da Vinci Code by James J Murtagh, M.D.

10.  Hippocrates & His Kin: Caremark, and PBMs are Checking Mammograms? What's Next?

11.  Related Organizations: Restoring Accountability in HealthCare, Government and Society

* * * * *

The Annual World Health Care Congress, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case study data. The 3rd annual conference was held April 17–19, 2006, in Washington, DC. Watch these pages for reports on some of the more than 100 presentations given. Some of the regular attendees told me that the first Congress was approximately 90% pro-government medicine. This year it was 50 percent, indicating open forums such as these are critically important in sorting out the real issues. The 4th Annual World Health Congress has been scheduled for April 22-24, 2007 also in Washington, DC. The World Health Care Congress - Asia will be held in Singapore on September 14-16, 2006. The World Health Care Congress - Middle East will be held in Dubai, United Arab Emirates, in November 2006. World Health Care Congress - Europe 2007 will meet in Paris. For more information, visit www.WorldCongress.com. Or click on the link at the left.

* * * * *


 

1.      Featured Article: Shutting Down Alzheimer's

Shutting Down Alzheimer's, New research reveals strategies for blocking the molecular processes that lead to this memory-destroying disease, By Michael S. Wolfe in Scientific American

The human brain is a remarkably complex organic computer, taking in a wide variety of sensory experiences, processing and storing this information, and recalling and integrating selected bits at the right moments. The destruction caused by Alzheimer's disease has been likened to the erasure of a hard drive, beginning with the most recent files and working backward. An initial sign of the disease is often the failure to recall events of the past few days--a phone conversation with a friend, a repairman's visit to the house--while recollections from long ago remain intact. As the illness progresses, however, the old as well as the new memories gradually disappear until even loved ones are no longer recognized. The fear of Alzheimer's stems not so much from anticipated physical pain and suffering but rather from the inexorable loss of a lifetime of memories that make up a person's very identity.

Unfortunately, the computer analogy breaks down: one cannot simply reboot the human brain and reload the files and programs. The problem is that Alzheimer's does not only erase information; it destroys the very hardware of the brain, which is composed of more than 100 billion nerve cells (neurons), with 100 trillion connections among them. Most current medications for Alzheimer's take advantage of the fact that many of the neurons lost to the disease release a type of chemical communicator (or neurotransmitter) called acetylcholine. Because these medicines block an enzyme responsible for the normal decomposition of acetylcholine, they increase the levels of this otherwise depleted neurotransmitter. The result is stimulation of neurons and clearer thinking, but these drugs typically become ineffective within six months to a year because they cannot stop the relentless devastation of neurons. Another medication, called memantine, appears to slow the cognitive decline in patients with moderate to severe Alzheimer's by blocking excessive activity of a different neurotransmitter (glutamate), but investigators have not yet determined whether the drug's effects last more than a year.

More than a decade ago few people were optimistic about the prospects for defeating Alzheimer's. Scientists knew so little about the biology of the disease, and its origins and course were thought to be hopelessly complex. Recently, however, researchers have made tremendous progress toward understanding the molecular events that appear to trigger the illness, and they are now exploring a variety of strategies for slowing or halting these destructive processes. Perhaps one of these treatments, or a combination of them, could impede the degeneration of neurons enough to stop Alzheimer's disease in its tracks. Several candidate therapies are undergoing clinical trials and have yielded some promising preliminary results. More and more researchers are feeling hope--a word not usually associated with Alzheimer's.

The Amyloid Hypothesis
The two key features of the disease, first noted by German neurologist Alois Alzheimer 100 years ago, are plaques and tangles of proteins in the cerebral cortex and limbic system, which are responsible for higher brain functions. The plaques are deposits found outside the neurons and are composed primarily of a small protein called amyloid-beta, or A-beta. The tangles are located inside neurons and their branching projections (axons and dendrites) and are made of filaments of a protein called tau. The observation of these anomalies started a debate that lasted throughout most of the 20th century: Are the plaques and tangles responsible for the degeneration of brain neurons, or are they merely markers of where neuronal death has already occurred? In the past decade, the weight of evidence has shifted toward the amyloid-cascade hypothesis, which posits that both A-beta and tau are intimately involved in causing Alzheimer's disease, with A-beta providing the initial insult.

A-beta is a short peptide, or protein fragment, first isolated and characterized in 1984 by George G. Glenner and Cai'ne W. Wong, then at the
University of California, San Diego. This peptide is derived from a larger protein called the amyloid-beta precursor protein, or APP. Molecules of APP stick through the cellular membrane, with one part of the protein inside the cell and another part outside. Two protein-cutting enzymes, or proteases--beta-secretase and gamma-secretase--carve out A-beta from APP, a process that occurs normally in virtually all cells in the body. The reason why cells make A-beta is unclear, but current evidence suggests that the process is part of a signaling pathway.

A portion of the A-beta region of APP is inside the membrane itself, between its outer and inner layers. Because membranes are composed of water-repelling lipids, the regions of proteins that pass through membranes typically contain water-repelling amino acids. When A-beta is cut out of APP by beta- and gamma-secretase and released into the aqueous environment outside the membrane, the water-repelling regions of different A-beta molecules cling to one another, forming small soluble assemblies. In the early 1990s Peter T. Lansbury, Jr., now at Harvard Medical School, showed that at high enough concentrations, A-beta molecules in a test tube can assemble into fiberlike structures similar to those found in the plaques of Alzheimer's disease. The soluble assemblies as well as the fibers of A-beta are toxic to neurons cultured in petri dishes, and the former can interfere with processes critical to learning and memory in mice.

To read pages 2-5, (subscription required) go to

www.scientificamerican.com/article.cfm?chanID=sa006&colID=1&articleID=000555CD-DA5B-1448-97EC83414B7F0000.

* * * * *

2.      In the News: Are Business CEO's Overpaid? Just Check What Non-Profit CEOs Make

Watchdog report: Good works, great pay; Compensation on rise for top execs at nonprofits, By Phillip Reese and Todd Milbourn -- Bee Staff Writers, Published, Sunday, May 14, 2006

Charity jobs often come with meager salaries, but a review of nonprofit agencies around the region shows that, increasingly, is not always the case for the top bosses.

More than 200 employees of nonprofits in the Sacramento region earn more than $100,000 in salary and benefits. Thirty of those receive more than $200,000 - triple the number from 1999. Six make more than $300,000.

 

And, in what appears to be a first for the region, the chief executive officer of one nonprofit made more than $1 million in 2004 - and another reached that level through a one-time bonus - according to a Bee analysis of the latest federal tax records for the charity organizations.

 

Compensation for executives at the four-county region's 500 largest nonprofits is rising fast, too - even quicker than pay at for-profit companies. In the five years from 1999 to 2004, median salaries, benefits and expenses for the 100 best-paid rose about 42 percent. Adjusted for inflation, that was a 25 percent increase.

 

Those figures would have been even larger had they included nonprofit hospitals, CAL-ISO - which manages the power grid for most of the state - or Vision Service Plan - a massive health benefits organization based here with offices in 23 states - whose high salaries overshadow those of more traditional nonprofits.

 

Each nonprofit organization is unique, but some trends emerged in The Bee's analysis of individual cases:

* . . . Some spent more than 10 cents of every dollar raised to compensate one person - about twice the median compensation for the area's largest nonprofits. In an extreme example, about one of every four dollars raised in recent years by Community Dental Care, a dental service for low-income patients, went to its top executive, Gene Gowdey - more than $115,000 in 2004 - even during a period when revenue declined.

The public's role

The Sacramento region is home to thousands of nonprofits, most small and many without any highly paid staff. The issue of rising compensation centers on the area's larger nonprofits, the roughly 500 in the four-county area that generate more than $500,000 in annual revenue, often from government grants and fees for services, as well as from donations . . .

 

With all that in mind, several experts said, it's in the public's interest to ask whether publicly supported organizations need to pay someone six figures or more to run things efficiently . . .

To read the entire report, please go to

www.sacbee.com/content/business/finance/v-print/story/14255272p-15070633c.html.

About the writers: The Bee's Phillip Reese can be reached at preese@sacbee.com; Todd Milbourn can be reached at tmilbourn@sacbee.com.

* * * * *

3.      International Medicine: How to Cut the UK's NHS Waiting Lists

One way to cut waiting lists: don't treat people with the wrong views,

IT IS BAD enough that you can be refused medical treatment on the NHS for eating, drinking or smoking too much. Now it seems that you can be denied an operation for protesting too much in support of your religious or political beliefs.

Edward Atkinson, a 75-year-old anti-abortion activist, was jailed recently for 28 days for sending photographs of aborted foetuses [sic] to the Queen Elizabeth Hospital in King's Lynn, Norfolk. That draconian sentence was not deemed punishment enough: the hospital has banned Mr Atkinson from receiving the hip replacement operation he was expecting.

Mr Atkinson sounds like an unpleasant crank, and I am as much in favour [sic] of legalised [sic] abortion as he is against it. But his treatment (or the lack of it) is a scandal. This is about admitting a man to hospital, not electing him to Parliament. Even unhip old bigots need replacement hips.

Ruth May, the hospital's chief executive, claims that the ban is justified because the "offensive" publications he mailed caused "great distress" to her and her staff and thus contravened the NHS policy of "zero tolerance". Some may already feel that such policies make it seem as if a hospital's priority is to protect its staff against the patients, rather than protecting patients from illness. This case goes farther, equating the posting of offensive photos with punching a nurse on the nose.

Why on earth should hospitals be distressed by pictures of the sort of operations that they carry out? An aborted late-term foetus can certainly make a grisly spectacle, and there is no point trying to sanitise abortion. But neither need anybody be intimidated by the handful of zealots who like to wave around such bloody abortion porn.

In any case, that debate about abortion should have nothing to do with decisions about who gets hip replacements. Have hospital authorities been granted the power to turn away anybody who upsets them? It may come as a shock to delicate souls in the upper echelons of the NHS, but some elderly people can be cantankerous, obnoxious and express unfashionable opinions in an uninhibited way. So what? Should the NHS introduce a policy of euthanasia for offensive old gits?

We should take the principle of universal health care seriously, and insist that medical staff make decisions about treatment on clinical grounds alone. After all, so far as science can deduce, a member of the British National Party or an Islamic fundamentalist is the same as you or I under the surgeon's knife. Even loons who oppose animal experiments should be given the benefits of medical research that they would deny to others.

Many who normally shout about patients' rights have fallen silent over the case of Mr Atkinson. But you need not be anti-abortion to protest against the notion that only obedient individuals with healthy lifestyles deserve NHS treatment. Perhaps those who would put their own feelings ahead of others' needs should be advised that if you can't stand the patients, get out of the hospital.

THIS NEWSPAPER reports that local authorities are to be given powers to bar ice-cream vans from school gates. Many councils have already imposed strict controls on the ice-cream trade. These measures are justified in the name of the holy crusade against child obesity. Along with police threats to fine kids for playing football in the street, however, they look more like part of a war on childhood fun.

This is not just nostalgia talking. Children today are supposed to be world-weary cynics. Yet nothing excites my young daughters and their stampeding friends like the ice-cream van's traditional tuneless jingle. Educational experts pontificate about teaching "happiness" lessons in class, yet seem to want to stamp out the more sensual pleasures of being a kid. When selling ice-cream is treated as pushing an illicit substance, and Mr Whippy risks an ASBO, the warning bells should surely be jangling.

To read other timelines, please go to www.timesonline.co.uk/article/0,,8122-2176383,00.html.

Mick.Hume@spiked-online.com

Canadian Medicare does not give timely access to healthcare but only gives access to a waiting list.

* * * * *

4.      Medicare: The Medical Bureaucracy in Government Versus Compounding Pharmacies

Andrew Schlafly, Esq, Legal Counsel for the American Association of Physician and Surgeons reports:

"We just won another big victory against the FDA.  AAPS probably holds the record for helping win the most victories in the medical field against the often-invincible federal government!

 

"As recently described at our Board meeting in Chicago, we filed two amicus briefs against the FDA's attempt to regulate compounding pharmacies.  I see compounding pharmacies as crucial to expanding free enterprise in medicine.  The FDA was so concerned about our recent amicus filings in this case that it filed forceful opposition papers to our motion to file a brief, and then another submission against our brief itself.  But the judge allowed our filings and I think they made a big difference."

 

"The result of our work came in yesterday [May 25] at the hearing in Midland, Texas.  The federal judge ruled from the bench, "The Court finds that the compounding of ingredients to create a drug pursuant to a valid prescription from a health care provider does not create a new drug" which would be subject to the FDA's onerous new drug application process.  Accordingly, compounded drugs are fully legal and not subject to the requirements and prohibitions imposed on new drugs by the 1938 Food, Drug and Cosmetic Act.  A written order to make this ruling binding will be issued in late July."


The Editor-in-Chief of the JAAPS responds: "This is a really impressive win . . . In a way, an amicus brief is really an expression of free speech.  The fact that the government would so strongly oppose the filing of our amicus brief speaks volumes. 

"If I were a judge, I would wonder what it was the government didn't want me to hear in deciding the case.  Fortunately, this judge deferred to free speech, which allowed him to better assess both sides of the issue and render a fair decision."

-- Larry Huntoon, MD, PhD

 Government is not the solution to our problems, government is the problem.

- Ronald Reagan

 * * * * *

5.      Medical Gluttony: Gluttonous Behavior Is Still Prized

Joey Chestnut hopes to be the new face of speed eating -- first, he has some cramming to do by Justin Berton, Chronicle Staff Writer, Saturday, May 27, 2006.

Hot dogs one and two disappear into Joey Chestnut's mouth like a pair of flies going down a well. A flour-dusted bun gets tossed in afterward.

Hot dogs number three, four, five, six, seven, eight, nine ... 10, 11, 12 ... 13, 14, 15, 16, 17 ... 18, 19, 20 -- all of them. Gone.

Joey Chestnut is only halfway through his meal, and he's been at it for about four minutes.

It's Thursday night, and Chestnut's roommate, Nate Yates, 25, is hovering over Joey in their San Jose bachelor pad, helping the reigning American hot dog speed-eating champion train for the main event: Nathan's Famous Fourth of July International Hot Dog Eating Contest in Coney Island, N.Y.

"C'mon baby," Yates shouts at his roomie, whose cheeks are bursting with hot dog and sopping wet buns. "Put it down, put it down -- chew, chew, chew, chew."

At 23, Joey Chestnut is a rising, if humble, star in the world of competitive eating. Just last month, the "sport" earned a glut of attention after two books on the subject were released, along with a documentary and countless magazine articles. Most of the attention was lavished on the sport's more enigmatic personalities, namely Takeru Kobayashi, the skinny 32-year-old Japanese man who has won the Nathan's competition for the past five years.

Yet Chestnut, whose rise to prominence occurred in the past 15 months, has been largely ignored. He was an unknown until April 2005 when he beat 37-year-old American Sonya Thomas, the world's No. 2 ranked eater, at a fried asparagus contest in Stockton . . . 

In the past year Chestnut devoured world records for waffles (18.5 in 10 minutes), pork ribs (5.5 pounds in 12 minutes), grilled cheese sandwiches (32.5 in 10 minutes) and chicken wings -- 173 in 30 minutes, wiping out the previous record by 29 wings.

And on May 18, at a Nathan's qualifier in Las Vegas, Chestnut scarfed 50 dogs in 12 minutes, shattering the old record of 37.

"Joey Chestnut," marvels George Shea, president of the International Federation of Competitive Eating, "is clearly going to change the face of American competitive eating. He may become the greatest eater in America, if not the world."

To read the entire article about this unhealthy gluttonous behavior, please go to www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2006/05/27/DDGCHJ2JM21.DTL&type=printable. 

Can't we leave speeding performances to track, auto and horse racing events?

* * * * *

6.      Medical Myths: Doctors Always Know What's Best for the Patients

Buchwald can wait for heaven By DARLENE SUPERVILLE, Associated Press Writer Wednesday, May 24, 2006.   

A funny thing happened to humorist Art Buchwald on the way to his grave.

Nearly four months after refusing potentially life-extending treatment for his failing kidneys, Buchwald is alive against all expectations. He's planning to spend the summer at his house on Martha's Vineyard, Mass., writing his twice-weekly newspaper column, finishing a book about his experience and waiting for Carly Simon - once tapped to sing at his funeral - to serenade him while alive.

"I'm in a very good mood," Buchwald told The Associated Press in an interview Wednesday.

"I was happy when I made the decision not to have dialysis and now I'm happy that I made a decision to go to the Vineyard. I would say, on the basis of that, I'm a happy person."

Buchwald, 80, made plans to leave his hospice for the island July 1 after his doctor said he was unlikely to die right away. Experts say he's lived an improbably long time without properly functioning kidneys or dialysis.

And so heaven can wait, however much longer. So can his wished-for meetings in the hereafter with Hollywood bombshells Ava Gardner, Grace Kelly, Marilyn Monroe and Rita Hayworth, as well as Judas.

The man who thought he was done suddenly has a to-do list again. Among the items checked off: scrapping plans for his own funeral.

A week ago, Buchwald received a prosthesis to replace his right leg, which doctors amputated below the knee in January because of circulation problems.

"Everybody cheers when I use it and I cry," he said . . .

To read the entire article, please go to www.sacbee.com/24hour/entertainment/books/news/v-print/story/3295265p-12143125c.html.

Sometimes Patients Know What's Best for Them.

* * * * *

7.      Overheard in the Medical Staff Lounge: Is the Violent Death Rate in New Orleans Really Twice As High As Iraq?

Dr Dave: Quoted the Best of the Web Today - May 18, 2006 By JAMES TARANTO

How Does Iraq Rate? In her New York Sun column, Alicia Colon cites some interesting figures about Iraq, offered by Rep. Steve King of Iowa:

 

According to Mr. King, the violent death rate in Iraq is 25.71 per 100,000. That may sound high, but not when you compare it to places like Colombia (61.7), South Africa (49.6), Jamaica (32.4), and Venezuela (31.6). How about the violent death rates in American cities? New Orleans before Hurricane Katrina was 53.1. FBI statistics for 2004-05 have Washington at 45.9, Baltimore at 37.7, and Atlanta at 34.9.

Dr Sam was even more upset today than last month as he was continuing his battle with Medicare or perhaps with his billing clerk. Since there were no Medicare payments for eight weeks, his billing clerk stated she had sent out paper claims for the last eight weeks while she tried to research the Medicare lack of response. She then reminded Dr Sam that Medicare would not process these claims for four weeks. Medicare had arbitrarily inserted the four-week delay for paper claims as an effort to encourage electronic claims and discourage paper claims.

Dr Sam had tried to intercept this mailing of claims but the clerk had already deposited them into the mailbox the previous day. He almost fired her on the spot, but then realized it might take an extra month or two to replace her and then a month or two for the learning curve in a new job. This could make a pending desperate event even worse. Oh, for the joys of a government largess and then being a slave to the government. Dr Sam made the decision to leave Medicare. He felt that it would take a year or possibly two to make the transition since so many of his friends had experienced retaliatory legal action when they left Medicare. It was critical that all the "I's" were dotted and all the "T's" were crossed.


Dr Rosen was surveying an article in the SF Chronicle about the crises in Government Education, formerly known as Public Education.  Nanette Asimov and Heather Knight, www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2006/05/28/MNG4GJ3R251.DTL&type=printable, reported:

"This should be a good time for San Francisco's public schools. Test scores are rising, the district has earned national praise, and voters have approved a measure that will add millions of dollars to the school budget each year.

"Instead, the schools are at a crisis point, and the main cause is beyond their control: High housing prices are spurring many families to leave the city.

"As a result, enrollment is declining, schools are closing, and officials are concerned the turmoil will reinforce negative perceptions that have helped give San Francisco the state's highest percentage of children in private schools, 29 percent."

Dr Rosen pointed out the fallacy of all government programs. The disconnect between the paragraphs above is that if all those families leaving SF stayed and placed their children in private schools, the percentage would be much greater.  Or the converse, the exodus of children had nothing to do with the high housing prices as the cause of the alleged crises.

We should brace ourselves for the same thing with government medicine. Since school taxes should be in abundance with 29 percent of the students not requiring government (formerly known as public) educational moneys euphemistically called resources, the school districts should be happy with the huge surplus in moneys. But they don't see it that way. They want to control all of education so that there is no alternative to their ineptness. Hats off to the 29 percent of parents that still pay those onerous school taxes and also pay tuition. He also pointed out that there are many private and parochial schools that charged a tuition equal to about half the tax dollars the government (formerly known as public) schools required to teach each student.

Dr Rosen feels that government medicine is deteriorating in quality in the same manner as government education. The worst doctors, just like the worst teachers, get paid the same in a government-funded program as the best. As government health care continues its descent to mediocrity, Medicare recipients will have to begin obtaining health insurance to make sure that they get quality health care even though they are paying onerous Medicare taxes. Just like responsible parents pay tuition without educational tax relief.

To read further about SF unaffordable housing, please go to www.ncpa.org/newdpd/dpdarticle.php?article_id=3396.

* * * * *

8.      Voices of Medicine: Many Perversions of Peer Review Process by Philip R. Alper, M.D.

San Mateo County Medical Association Bulletin www.smcma.org/Bulletin/BulletinIssues/

Death and complications conferences during training introduced me to peer review. At Mt. Sinai Hospital, in New York City, attending physicians would travel from neighboring states to attend. The questioning was often brutal, but the aim was to improve patient care. It was done with almost religious fervor and in perfect safety.

The first variation on the theme that I encountered occurred years ago, when a rogue anesthesiologist tied the hospital medical staff up in knots as they sought to restrict his privileges for cause. The legalities dragged on for years and put the reviewers at personal risk due to accusations of malice and violation of antitrust laws. This was hardly a sordid quirk. The pages of Medical Economics Magazine regularly describe similar cases.

From such humble beginnings, peer review has gone on to extend, for better or worse, into almost every aspect of medical care. In the process, it has become perverted by misuse. The original purpose of peer review was the protection of patients and enhancement of the quality of care. Its scrupulous implementation has served as the basis for public trust and trust among colleagues. Honesty and fairness are assumed.

That is the ideal. Where peer review has taken a severe turn for the worse, in my opinion, is in the co-opting of the peer review process by numerous parties -- government, insurers, hospitals, and even medical journals, to name just a few -- to serve ulterior purposes. Medicare employs peer review with dual motives -- no doubt to seek the best care for the dollars it pays out, but also to serve as a moral basis to enforce dubious fraud and abuse laws that leave physicians in a perpetual state of debilitating uncertainty. Although this is difficult to explain to nonphysicians, it is intuitively understood by anyone practicing medicine today.

But much further back, at the source, where we obtain the very knowledge we need to remain at the state of the medical art, we have reason for misgivings. Medical journals, including the very best of them, have come under attack recently for bias that includes commercial and political motivation. The lead editorial in the Wall Street Journal (11-16-05) is titled, "New England Journal of Politics." It condemns the credibility conferred by the status of a "peer-reviewed journal" to advance a variety of left-leaning political agendas.

I find this criticism credible. Shortly after I was appointed a Visiting Scholar at Stanford's Hoover Institution, I arranged an even-handed study of the impact of managed care on physicians in San Mateo County under the joint sponsorship of our Medical Association and Stanford Medical School. My most senior Stanford colleague on the paper we wrote refused to let me cite my Hoover affiliation in the manuscript we submitted to the major journals. "It would mean certain death for acceptance," this very savvy medical academic advised. (Actually, in the only analysis ever done, rather than showing the presumed "right-leaning bias," Hoover's voting pattern in a presidential election exactly replicated the national average.)

It's a given that money, fame, and power tend to corrupt. That applies most obviously to fraudulent scientists, particularly in stem cell research. The process is more complex in the current case of the Cleveland Clinic, where conflict of interest has been taken to new heights. It involves the promotion of a controversial surgical technique to treat atrial fibrillation, the patented instrument needed to perform it, stock investments by the institution in a company set up to sell it and partly owned by its inventor, who, in turn, became the chief executive of the Clinic.

More subtle is the case of Arnold Relman, M.D., former editor of the NEJM, and the scion of the Massachusetts school of utopians who aim to entirely demonetize medicine. I was raised in the era in which we were taught to "never consider money; just do what's right." Though desirable as policy, the notion struck me as unrealistic as a policy prescription, but I didn't dare argue then.

Dr. Relman is still beating the drum for yesterday's ideas -- essentially, socialized medicine with medical academic control at its core -- all emanating from Boston, where managed care has treated medical institutions (if not physicians) far more kindly than elsewhere in the country, and from Harvard, the beneficiary of the world's largest university financial endowment (by far) . . .

Coming closer to home and to our everyday lives, hospital medical staff actions constitute the form of peer review that is most familiar to us. There is a long history of argument over legitimate indications for various surgical procedures, usually with fairly wide latitude for differences of opinion. In years past, self-promotion was considered anathema. I thought it a bit strange when internationally renowned physicians in our community were treated locally as nobody special. But those were the days when advertising was not supposed to be used to seek professional advantage.

How far we have come! Now, our own hospitals promote individual physicians, procedures, and equipment with the undisguised goal of revenue enhancement. Continuing controversies over the safety of minimally invasive procedures, whether orthopaedic or cardiac, are glossed over. As the radio and television ads are broadcast, issues of visibility and credit make the difficult job of assessing professional excellence even harder. I am told that surgical departments were given monthly status reports detailing their relative place as revenue-generators for the hospital until at least one department rebelled. As one physician put it, "It's as if the indications and outcomes weren't even relevant." . . .

Intraprofessionally, orthopaedists are unhappy that primary physicians can vote on requiring other specialties to take night call at annual staff meetings when many primary physicians no longer admit patients to the hospital. Indeed, why do such physicians maintain privileges and what do those privileges signify? Perhaps it's because hospital staff privileges are required by PPOs for accrediting primary physicians into their networks. And since primary physicians refer lucrative cases to the hospital, there is little incentive for anyone to make waves. On the other hand, nobody seems to much care that the burdens of implementing the costly clinical guidelines mandated by pay-for-performance programs fall almost exclusively on primary physicians.

A word about insurers. Every one of them is developing surveillance programs to assess physician performance and "increase compliance." Meticulously detailed literature sources and recognized clinical guidelines based on the peer-review process mix the science and the money in such inscrutable ways that they are difficult to argue against. Blue Shield of California has gone to the head of the class with its "Relative Efficiency Scores (RES)" that rate individual physicians on a "Resource Utilization Grid." The scores aggregate the physician's use of resources (a euphemism for cost) in treating selected diagnoses. Clinical outcomes are not relevant…

To summarize: peer review has been compromised in many ways -- by politicization, introduction of other agendas, hidden financial considerations, and misuse of the "peer-reviewed" imprimatur to promote dubious practices. Consequently, this process that all doctors could automatically subscribe to in the past, now needs to be re-validated.

Dr. Alper has a practice in internal medicine and endocrinology in Burlingame, [California.]

To read Dr. Alper's entire article, or to read other articles on Peer Review, please go to www.smcma.org/Bulletin/BulletinIssues/Feb06issue/FeaturedArticlesFeb06.html.

The Hidden Meaning: "Clinical outcomes are not relevant" means quality of care is not relevant.

* * * * *

9.      Book/Movie Review: The Da Vinci Code: Does History Matter? By James J Murtagh, M.D.

Warning: Movie spoiler alert. If you have not seen Da Vinci Code, consider seeing the film before reading further. However, since almost every person on the planet knows the plot of Da Vinci, this spoiler alert may not be necessary.

In my beginning is my end -TS Eliot

Is it easier to believe in the historical divinity of Mary Magdalene than the historical Jesus Christ? Does it matter?

After all, Tom Hanks says, "the only thing that really matters is what you believe yourself." The film's heroine thinks for a minute, considers whether she might be Christ's sole living descendant, puts her foot in the water, then realizes, no, she can't walk on water. Drat, history got in the way.

History is more than bunk. Myth is important, but not all myths can be equally true. Truth, to be true, must be verifiable, or at least, there must be, in the phrase of Karl Popper, falsifiable.

Religious claims are indisputably most difficult. But two completely different sorts of religious truths exist: first, historical claims, and second, value claims. We cannot prove values, which are ultimately a matter of faith.

But historical claims can be verified or falsified. "Did King Solomon build a temple?" or "Did Mohammed raise an army?" or "Does the earth go around the sun?"

Apologetics (both Christian and non-Christian) have wrestled with the search for a historical Christ for centuries. C.S. Lewis described in "Mere Christianity" what he called "the trilemma": "Jesus claimed to be the Son of God. It follows that he was either a liar, a madman, or the Son of God."

Bertrand Russell examined the trilemma and decided he was an atheist. Pascal considered roughly the trilemma and decided to wager to believe. But all realized that the historical existence of a divine Christ is historical claim that is either true or false.  But Dan Brown seems to put more credence in the divinity of Mary Magdalene than in the divinity of Christ.

What kind of paradox is this? Who would ever have heard of Magdalene if she had not been the follower of Christ?  More to the point, if Magdalene was a goddess, and Christ was not god, how could Magdalene find that Christ had left his tomb, and why would she proclaim he had risen? Was the goddess Magdalene defrauding humanity? Was she starting a false religion? Brown is asking us to believe and not to believe at the same time.

Some of my Christian friends have told me the Da Vinci code has strengthened their religious faith. What! The Da Vinci code postulates Christians have worshipped the wrong deity for 2,000 years. Essentially, Brown is claiming that traditional Christianity is a fraud, roughly equivalent to a form of devil worship.

You can understand how this has some people's blood boiling. After all, a simple cartoon of another religious figure almost started a war recently. So, both the religious and non-religious may have a stake in the controversy.

The end of King Arthur's grail quest, and all other grail quests from Indiana Jones to T.S. Eliot was the womb of Magdalene? Tosh.

It should be clear to atheists, Christians, and every one else that if Magdalene were a goddess, she would not have been so easily fooled. The goddess could not allow Christians to persecute her true following. Why would a goddess reveal herself only to a small Priory of Sion? Shouldn't salvation be for everyone, not just a few Gnostics?

Even conspiracy theorists ought to be suspicious of this conspiracy.

Don't get me wrong. I loved Brown's book. The places, the paintings, the ideas are magnificent and fascinating. Brown loves to stir up a hornet's nest, and I love hornet's nests. I love the debate and the dispute..

But Brown should have also paid attention to the fundamentals of logic. There is such a thing as verifiable or falsifiable truth . . .

To read this entire review, click on The Da Vinci Code at www.delmeyer.net/CinematicOpEdReviews.htm.

* * * * *

10.  Hippocrates & His Kin: Caremark, The Pharmacy Benefit Manager, Sent A Letter That A Patient Has Not Had A Mammogram In A Year!

Caremark as well as the other pharmacy benefit managers (PBMs) send a ton of paper to each office telling doctors how to practice. Usually they are offering alternatives to the prescriptions we write. As we heard in section 2 of our last issue, the CEO of Caremark sold $185 million of stock last November. The CEOs of the PBMs are some of our wealthiest CEOs. Each letter they send to doctors has a disclaimer stating that since Caremark doesn't have the entire medical chart, there may be other issues of which they may not be aware. How did they get my patient's x-ray file?

If a pharmacy knows so much about what an x-ray facility does with my patients, they must have an unbelievable sleuthing network. We should have the CIA hire Caremark to keep tabs on all the terrorists. The $185 million the CEO made in November may be cheaper.

[Actually, it is probably HIPAA which allows almost everyone access to a patient's medical record without disclosure to the patient except doctors and hospitals who really need them. Stalin, Hitler, Mussolini, Saddam and others would have drooled with access to such private information in their totalitarian police state?]


California Senator, Diane Feinstein, and her mega-millionaire husband, Dick Blum just purchased an abode for $16.5 million near Presidio and San Francisco's most posh residences. Sounds like the United States Senate, frequently known as the Rich Man's Club, also has some well-healed lady members sitting on the left side of the aisle.


How fathers teach their sons to kill. At the Century theatre, I took a stroll through the arcade gallery to see what the attractions were. It was amazing to find men with such determination to kill the "bad guys" on the screen. What really tore at my heart was a father teaching his son to "kill the bad guys" on the screen. The child was practically turning inside out saying to his father pleadingly, "Daddy, I don't want to kill those guys." The father told him to act like a man and do it. The boy was now really squirming.  I told the son, "Good boy. I wouldn't want to either." The father started to make a fist and I just leaned forward a few inches to stand by my assertion and he then took the boys hands and left. Personal responsibility will always be more effective than all the laws that Feinstein and her cohorts can possibly dream up to prevent such behavior. With most new laws running into hundreds of pages, it may take an attorney a hundred hours at $300 an hour to sort out a lawsuit and another set of attorneys that much time to defend a lawsuit. And in the process, no one wins and behavior doesn't change. Since lawsuits cannot occur with a law, can't we just put a moratorium on new laws for a decade or so?


How parents teach their children to steal. At a church picnic, the two families at the next park table were preparing their cookout. The lady, as she was laying out the blanket for the children to sit on, mentioned that they had obtained the blanket at a company outing. The children, having gotten out of Sunday School a short time earlier, looked at their parents and at each other. They obviously had not missed this immoral turpitude. As my mother remarked after a similar incident, "Your actions speak so loudly that I can't hear what you're saying."

* * * * *

11.  Organizations Restoring Accountability in HealthCare, Government and Society:


 

•                      The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave and Devon M. Herrick wrote Lives at Risk which we reviewed in MedicalTuesday issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports. To scan this weeks health issues, go to www.ncpa.org/newdpd/index.php.

•                      Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may subscribe at www.pacificresearch.org/pub/hpp/index.html or access their health page at www.pacificresearch.org/centers/hcs/index.html. Be sure to read Sally C Pipes' Second Opinion on the Uninsured at www.pacificresearch.org/press/opd/2006/opd_06-05-08sp.html.

•                      The Mercatus Center at George Mason University (www.mercatus.org) is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government. This week, be sure to read how Insurance Mandates subsidize addiction at www.mercatus.org/Publications/pubID.1547/pub_detail.asp.

•                      The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page.  Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. www.nahu.org/publications/hiu/index.htm. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business. Be sure to review the current articles listed on their table of contents at hiu.nahu.org/paper.asp?paper=1. To see my recent column, go to http://hiu.nahu.org/article.asp?article=1386.

•                      The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at www.galen.org. The Galen report on Health Systems Abroad focuses on our Northern Neighbors this month at www.galen.org/healthabroad.asp?docID=893.

•                      Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). To read the initial series of his newsletter, Consumers Power Reports, go to www.chcchoices.org/publications.html. To join, go to www.chcchoices.org/join.html. Be sure to read Greg's latest paper "100 Years of Market Distortion" in the current issue of Fresh Thinking on Health Policy at www.chcchoices.org/publications/Market%20Distortions.PDF.

•                      The Heartland Institute, www.heartland.org, publishes the Health Care News. A number of email subscriptions are available at www.heartland.org/Article.cfm?artID=10481  To read about a Free Market Health Care Proposal in Illinois, go to www.heartland.org/Article.cfm?artId=19012.

•                      The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Richard M Ebeling, PhD, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. To read about the Universal Preschool, which is on the California Ballot, please go to www.fee.org/in_brief/default.asp?id=510. Don't miss the parting comment: Great idea. Let them do to preschool what they've done to elementary and secondary schools.

•                      The Council for Affordable Health Insurance, Dr. Merrill Matthews, director, www.cahi.org/index.asp, was founded by Greg Scandlen in 1991, when he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care - and may even make things worse." Dr Matthews testimony in Washington, DC, can be read at www.cahi.org/cahi_contents/newsroom/article.asp?id=794.

•                      The Health Policy Fact Checkers is a great resource to check the facts for accuracy in reporting and can be accessed from the preceding CAHI site or directly at www.factcheckers.org/. This week, read the Daily Medical Follies: "Woeful Tales from the World of Nationalized Health Care" at www.factcheckers.org/showArticleSection.php?section=follies.  

•                      The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter at http://www.i2i.org/main/page.php?page_id=9. Gorman, a teacher, will give you a review in her newsletters about what's happening in teaching (Brain Care) as well as what's happening in Health Care which can be found at www.i2i.org/main/article.php?article_id=1285. But what's really fun is to access the home page and watch that meter which shows how fast Colorado politicians can spend money. You might also tell your friends about it.

•                      Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at www.quebecoislibre.org/apmasse.htm to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis. This month, read a review of EDWARD W. YOUNKINS'S PHILOSOPHERS OF CAPITALISM , a multifaceted endeavor to integrate the ideas of Ayn Rand's Objectivism and the Austrian School of Economics as developed by Carl Menger (1840-1921) and Ludwig von Mises (1881-1973) at www.quebecoislibre.org/06/060514-3.htm.

•                      The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca for an overview of the extensive research articles that are available. You may want to go directly to their health research section at www.fraserinstitute.ca/health/index.asp?snav=he. Don't miss the Round Table discussion with John Stossel on Myths, Lies & Downright Stupidity at www.fraserinstitute.ca/shared/readmore.asp?snav=ev&id=395. You may be outraged as you learn how conventional wisdom is often wrong.

•                      The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at www.heritage.org/research/healthcare/index.cfm.

•                      The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. To read the current essay on how the TSA is killing us a hour at a time, please go to www.mises.org/story/2186. You may also log on to Lew's premier free-market site at www.lewrockwell.com to read some of his lectures to medical groups. To learn how state medicine subsidizes illness, see www.lewrockwell.com/rockwell/sickness.html; or to find out why anyone would want to be an MD today, see www.lewrockwell.com/klassen/klassen46.html.

•                      CATO. The Cato Institute (www.cato.org) was founded in 1977 by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio at www.cato.org/people/cannon.html. Read his latest Policy Analysis: Health Savings Accounts: Do the Critics Have a Point? at www.cato.org/pub_display.php?pub_id=6395.

•                      The Ethan Allen Institute, www.ethanallen.org/index2.html, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.

•                      The Free State Project, with a goal of Liberty in Our Lifetime, http://freestateproject.org/, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.] Read the latest newsletter on the Porcupine Freedom Festival at http://freestateproject.org/news/fspnews/may2006.

•                      Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. You may join them to explore the Roots of American Republicanism on a British Isles cruise on July 10-21, 2006. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Read President Arnn's comments at www.hillsdale.edu/arnn/usnews.asp. Also read his comments on Ronald Reagan, RIP, at www.hillsdale.edu/newimprimis/default.htm. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read Rebecca Hagelin on Taking Back Our Homes at www.hillsdale.edu/imprimis/default.asp. The last ten years of Imprimis are archived at www.hillsdale.edu/imprimis/archives.htm.

* * * * *

Stay Tuned to the MedicalTuesday.Network and Have Your Friends Do the Same


Please note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.


ALSO NOTE: MedicalTuesday receives no government, foundation, or private funds. The entire cost of the website URLs, website posting, distribution, managing editor, email editor, and the twenty hours per week of writing is solely paid for and donated by the Founding Editor, while continuing his Pulmonary Practice, as a service to his patients, his profession, and in the public interest for his country.


Spammator Note: MedicalTuesday uses many standard medical terms considered forbidden by many spammators. We are not always able to avoid appropriate medical terminology in the abbreviated edition sent by e-newsletter. (The Web Edition is always complete.) As readers use new spammators with an increasing rejection rate, we are not always able to navigate around these palace guards. If you miss some editions of MedicalTuesday, you may want to check your spam settings and make appropriate adjustments. To assure uninterrupted delivery, subscribe directly from the website, rather than personal communication, at www.medicaltuesday.net/newsletter.asp.

 

Del Meyer

Del Meyer, MD, Editor & Founder

DelMeyer@MedicalTuesday.net

www.MedicalTuesday.net

6620 Coyle Ave, Ste 122, Carmichael, CA 95608

Words of Wisdom

Theodore Roosevelt, 1907: "In the first place, we should insist that if the immigrant who comes here in good faith becomes an American and assimilates himself to us, he shall be treated on an exact equality with everyone else, for it is an outrage to discriminate against any such man because of creed, or birthplace, or origin. But this is predicated upon the person's becoming in every facet an American, and nothing but an American . . . There can be no divided allegiance here. Any man who says he is an American, but something else also, isn't an American at all. We have room for but one flag, the American flag... We have room for but one language here, and that is the English language … And we have room for but one sole loyalty and that is a loyalty to the American people."

Mark Twain, (1866): There is no distinctly native American criminal class save Congress.

Some Recent Postings

Medicare Reform: Pharmacy Benefit Program - What Must Be Done - A Clinician's Point of View www.delmeyer.net/hmc2005.htm

The Health Insurance Marketplace: http://hiu.nahu.org/article.asp?article=1386

In Memoriam

Stanley Kunitz, American poet, died on May 14th, aged 100
IN A very long life, Stanley Kunitz did not seem to move around much. Apart from a spell in Pennsylvania in the 1930s and a lecture tour of the Soviet Union in 1967, he spent almost all his days in New York or New England, and most of those in Massachusetts. . .

Yet Mr Kunitz was a poet, one of America's best of the past century, and therefore travelled incessantly. Much of the time he was on the sea, voyaging to the ends of the earth. In imagination he "strode years; stretched into bird;/ Raced though the sleeping country where I was young." He could sink deep into his own mind, through gorges and ravines, "from the known to the unknown to the unknowable". Or he could coil through life like a fish in a river . . .

 . . . Later in life he kept the usual poet's habits, shut up by himself, writing in scrupulously neat longhand with no deletions. Every decade or so, a book of poems would appear. Very gradually, out of this slim oeuvre, a reputation grew and prizes came. In 2000, at the age of 95, he was made poet laureate of the United States . . .

As for his own endless travelling, each poem hinted at an end to it. "I have the sense", he said, "of swimming underwater towards some kind of light and open air that will be saving." Or,

Becoming, never being, till
Becoming is a being still.

To read the entire obit, please go to www.economist.com/obituary/PrinterFriendly.cfm?story_id=6970943.

On This Date in History - June 13

Alexander the Great, who had no more worlds to conquer, died on this date in 323 B.C.

First Black Supreme Court Justice, Thurgood Marshall, was nominated by President Lyndon B.  Johnson on this date in 1967.

The missile age was born on this date in 1944, as the Germans launched flying bombs that hit England in World War II.