Healthy Barbs

Approaching Gun Violence as a Public Health Problem: Who Gets to Have a Say?

Posted on January 16, 2013 by bbzinger

Disclosures

I’m a public health activist. I am also a member of the ACLU, and committed to the 1st Amendment (and all the other Constitutional Amendments, including the 2nd).

This blog argues that some organizations should be excluded from participating in the policy debate and decisions about how to reduce gun violence, so my public health

What do guns have to with protecting public health? Nothing

perspective and my civil liberties values come into conflict. Since I don’t think it’s possible, as a practical matter, to exclude organizations from the debate, I guess my argument is that, whatever they say, no one should listen.

I am not a gun owner. I have never fired a gun. I am not a member of the NRA or any other gun rights organization.

Gun Purchases Soar

We have recently experienced as a nation the worst non-military gun violence imaginable. The cry to “do something” about gun violence is louder and deeper than ever. Yet gun sales are going through the roof. Why?

President Obama and Jon Stewart have both explained it. Guns sales are skyrocketing because people are concerned that gun control laws that may be enacted in response to the

People who fear their guns will be taken liken themselves to people who fought the Revolutionary War. Really, the do.

latest outrage will mean the government takes all the guns away from private citizens. Nothing could be further from the truth, but the myth persists for two reasons that are connected.

The first reason is that there have always been people who fear government, and who see tyranny around every corner. For these folks, any talk of regulating any form weaponry confirms their concern about government run amok. As Jon Stewart said, these peoples’ fear of a dystopic future is a barrier to our addressing our dystopic present.

The second reason is that this irrational fear is fed by gun rights organizations like the National Rifle Association (NRA), who claim that the 2nd Amendment rights of gun owners will be trampled by any new law that attempts to regulate any aspect of gun or munitions sales. Can someone explain to me how a ban on military assault style weapons affects a hunter’s right to own hunting rifles or gun owner’s right to own a hand gun? Or how a restriction on sale of ammunition clips holding hundreds of rounds adversely affects any “good guy with a gun,” to use a phrase from the NRA?

The Current Gun Control Debate: A Few Words about some of the Players

The NRA claims to represent the interests of gun owners, but the organization’s true constituency is companies who make guns and rifles, and it’s objective is to make sure there are as many guns in circulation as possible.

Hence their proposed solution to the Newtown massacre is to arm teachers, school administrators and school guards. The NRA also threatened to sue the Tucson, AZ Police

Wayne LaPierre, NRA spokesperson who argues for making schools armed camps.

Department over a gun buy-back program (people were given certificates to purchase food at local supermarkets in exchange for turning in their firearms) if the Department insisted in melting down the weapons instead of re-selling them to willing buyers.

Right after President Obama announced his intentions about regulating some aspects of the firearms industry, NRA spokespeople said that the organization would not participate in these discussions. And they have been true to their word. They showed up at a meeting with Vice President Biden and claimed to be “disappointed” that gun control legislation was under discussion. Since Vice President Biden is leading the White House effort to find ways of controlling gun violence, the NRA’s disappointment was disingenuous at best. They could not have seriously believed that the White House would get on board with their notion of making schools into armed camps.

The violent video game makers are interested in making money: that’s why they advertise and sell the games. They spend considerable resources to ensure that Congress doesn’t limit their market, or require studies of the impact of these games on behavior, or impose

An actual image from a video game.

warning labels for the games. The industry asserts that there is no evidence that their games lead to violent behavior. In this case, the absence of evidence is not evidence of absence. The industry has succeeded in blocking the studies that might establish the harm these games do. It’s clever lobbying strategy. The NRA uses it too, to block federal funding to study the impact of gun violence on communities in the U.S.

How to Make Progress Against Gun Violence

If we are to have a prayer of advancing approaches that may, over time, reduce the gun violence in the U.S., groups like the NRA and makers of violent video games should not be listened to by anyone engaged in the debate. They are not interested in reducing gun violence. They are part of the culture that has created this horror.

As a society, we are willing to take extraordinary measures (without evidence that those steps work) to protect children from sex abuse. Shouldn’t we be willing to take small steps to protect our children from the risk of dying by gunfire?

Posted in Health Policy | Tagged Jon Stewart, NRA, Wayne LaPierre | 2 Comments

Adventures with a Feeding Tube Replacement: A Not So Funny Story, a Cautionary Tale, and A Call To Action

Posted on January 6, 2013 by bbzinger

I have had a feeding tube since January 2012 because, thanks to ALS, I can not swallow food or liquids. I have been nourishing myself since I got the tube. The tube is called a

Your dinner may look like this

PEG tube. I have a hole in my stomach to accommodate it.

A Clogged Feeding Tube

On Saturday, December 8, 2012 my tube became clogged. I couldn’t get anything through it. With the help of our hospice

My dinner (& breakfast & lunch & snack) come packaged this way

team, I ended up in the emergency room, where a knowledgeable and very kind doctor determined that he couldn’t replace the tube, but he could unclog it. He advised that I promptly contact the doctor who had put in the tube I had to find out about getting it replaced.

On Tuesday, December 11 (2 days after the ACLU awards ceremony (the speech I gave at that event is the last blog I posted before this one), I was at the hospital to have my tube replaced by the same gastrointestinal surgeon who placed the original tube. Unlike the original tube, the replacement did not require me to be under general (or any)

What a feeding tube looks like coming out of guy’s body

anesthetic. That was good: I didn’t want general anesthetic because I didn’t want to risk being permanently on a ventilator after surgery, or to expose myself to the risk that general anesthetic would hasten the progress of my ALS.

The replacement tube can easily be put in (or removed) by pushing it (or pulling it) through the hole in my stomach. It has a balloon that holds it in place in the stomach.

That’s the good news. Also, the replacement tube was not clogged. Also good news. The rest of the news about this tube is not good.

A Little Background About Nourishing with a PEG Tube

The nourishment process involves several steps. All of them involve putting the tip of a fluid-filled bolus [think of a cartoon-sized syringe] into the opening of the tube that’s called

Boluses: not recommended for heroin administration

a port. These are the steps:

1) Close the clamp on the tube so that stuff does not come out when the port is opened to insert the tip of the bolus.

2) The bolus is filled with water that will be flushed through the tube. The port is opened, and the tip of the bolus is inserted. The clamp is opened so the liquid can pass through. When the bolus is empty, the clamp is closed before the bolus tip is removed.

3) The bolus is filled with liquid nourishment that will be pushed slowly through the tube. This is repeated until multiple times until the amount of nourishment for the meal is consumed. The clamp is closed and opened and closed again with each bolus.

4) The bolus is filled two more times with water that is flushed throughout the tube. The clamp is closed and opened and closed again with each bolus.

Medications are also dissolved in water and put through tube, with a water flush preceding and following the meds.

The Replacement Tube

The replacement tube came with no clamp! As you can see from the description above, this lack of a clamp is a big problem. If there is no clamp, there is no way to keep liquid from coming out through the port when the bolus is removed and before the port can be closed.

There’s a second problem: the port for receiving the bolus is very shallow, so the bolus can and does slip out, spilling liquid. The first time we used the new tube, I needed a shower afterwards.

With the help of the surgeon’s nurse and our hospice nurse, we obtained a surgical clamp to solve the clamp problem, but this requires two people when the tube is in use: one to hold the bolus securely in the port, and another to open and close the clamp.

The manufacturer of this tube, called an EndoVive, is Boston Scientific. I contacted the Boston Scientific rep for this area by email. In that message, I laid out the design problems

If this is defining tomorrow today, I’ll stick with today.

with the replacement tube.

I closed my email with the following paragraph:

“ALS patients have many problems. Boston Scientific should not add to those problems with sloppy design. My previous tube had a clamp on it that I could open and close easily with my thumb. It’s not rocket science. Boston Scientific should be able to quickly add such a clamp to the EndoVive product. While you are doing that, I believe it should be possible to modify the valve to accept a standard-sized 60 ml bolus.”

The Boston Scientific rep passed my email on to the person at the company responsible for managing this product. He agreed that the company should not be making products that make my day-to-day life (or presumably anyone’s day-to-day life) more difficult. In a telephone conversation with my partner Susie, he told her that he regretted that no one at the company thought of these issues. He also said there was not quick fix, since any changes to the design would have to approved by the FDA.

In the meantime, our contact at the California Home Medical Equipment, which supplies my nourishment and necessary accoutrements, began to pursue solutions. He found a clamp that could be added to after the tube was in place, and an extension tube with a much deeper port. The only remaining challenge at the moment that is keeping me from being able to nourish myself is that my weakened hands can not close the new clamp. So, for that, I need help.

Of course, at some point, I won’t be able to nourish myself as the ALS progresses. But the tools needed by ALS patients and others with disabilities should be designed to allow them to function independently as long as possible. This feeding tube by Boston Scientific does the opposite.

In looking on line for other replacement PEG tubes that are balloon anchored (and therefore can be inserted without general anesthetic), I found several others, none of which come with a clamp. I could not tell the depth of the ports on those tubes from the information I found on line.

I am frankly appalled that companies and the FDA seem to think that these types of replacement PEG tubes are appropriate. It seems to me that there were never tested on patients or with caregivers who might know what the practical issues are. After all, I can’t possibly be the first person with PEG tube to have this problem. Why was this design approved in the first place?

A Call to Action

If you agree, send an email to the FDA Center for Devices at dsmica@fda.hhs.gov. Demand that the FDA consider patient needs in the device approval process.

Posted in ALS, Disability | Tagged Boston Scientific, CHME, FDA, PEG tube | 9 Comments

What I Learned as A Volunteer

Posted on December 13, 2012 by bbzinger

On Sunday, December 9, 2012, I was awarded the Lola Hanzel Courageous Advocacy Award by the American Civil Liberties Union of Northern California (ACLU-NC) at their annual Bill of Rights Day Celebration. Below is my acceptance speech for the award.

I delivered the speech using text -to-speech software on my iPad. If you are interested in speech technology, you might be interested my blog post on that topic, entitled Having a

That’s me.

Voice, Communicating and Somewhere in Between or the post entitled You Don’t Have to Talk Like Stephen Hawking.

I have put in brackets explanatory information for folks who are not familiar with ACLU-NC.

When Micky Walsh [Chair of the ACLU-NC Board of Directors] emailed to tell me that I was to receive this award today, I was incredulous, and humbled. I know a lot of the people who have gotten this award in previous years, and I am honored to be included in this august company.

I embarked on my relationship with the ACLU when I volunteered for the New Jersey affiliate in 1975. Little did I know that the work I did then on prison reform was just the beginning of many years of working with the ACLU.

I won’t bore you with all of the volunteer jobs I’ve had at various ACLU affiliates and the National office. Though I think it’s important to point out, that the ACLU always had the wisdom not to appoint me to a finance committee. What I want to talk about is not how I helped the ACLU, but how I was helped by the many roles I had with ACLU over time, one of the two organizations that are closest to my heart.

My experience with the ACLU confirms that volunteering is its own reward. I’m sure that my work with the ACLU — as a board member, a legal intern, a member of the Legal

Lend A Hand When You Can

Committee, a member of the board nominating committee, a representative to the Biennial Conference, a member of the National board, a fundraiser — was of value to the organization. At the same time, I learned so much — about civil liberties, about justice, about organizing, about effective campaigns and about how great non-profits are run — and I met some lifelong friends. At the ACLU, I learned how to be an effective activist. And, much to my surprise, I developed skills that would allow me to be an effective staff leader of another organization.

I was in my third term on the ACLU N C board (not 3 consecutive terms, that would be a no no) [ACLU-NC policy requires board members to cycle off the board after 2 consecutive terms], when I was diagnosed with breast cancer. I was 42 years old. While I was in treatment, I resigned from the board, and decided to stop practicing law to look for a job in health advocacy.

I ended up as the Executive Director of Breast Cancer Action, a tiny organization trying to tell the truth about breast cancer. There were already a lot of organizational players making their voices heard with a pretty pink and deeply misleading story. I was the first full time employee of Breast Cancer Action –or as I referred to it, BCA — with no experience in running or building an organization except what I’d learned at the ACLU. It turned out that that was plenty.

I had learned at the ACLU that an important part of getting your organizational message out was an effective press strategy. And one of my good friends from the ACLU was Elaine Elinson, the mistress of [ACLU-NC] press relations — I think she had a slightly less grand official title. I asked Elaine, who had a connection to breast cancer, to join the Breast Cancer Action board of directors and guide me in a media strategy. That may have been the smartest thing I ever did at BCA.

It was also at the the ACLU that I learned about board term limits as a way of balancing board members knowledgeable about organizational history with new people with fresh energy and ideas. We modeled Breast Cancer Action’s board term limits on those of ACLU-NC.

I also thought, based on my experience with the ACLU, that having written policy statements was important as a guide for people working for the organization either as staff or volunteers, and as educational tools for others. So I worked with the board to write policies on topics on which Breast Cancer Action was involved.

But the biggest thing I brought to BCA was a social justice perspective that had been honed through my work with the ACLU. It’s a rare issue that can be successfully addressed without understanding the context in which it occurs. But there were no breast cancer organizations operating at the national level who addressed breast cancer through a social justice lens. It was fine to talk about new treatments, but we also needed to focus attention on who could get them, and how much that depended on patients being able to find out about them, on the doctors they saw or the clinics they went to, and having money to pay for them.

And the information people got about treatments was often prepared by the drug manufacturer, focusing on the benefits and downplaying the risks.

The talk about differences in breast cancer incidence and mortality among different racial groups is always labeled as a focus on disparities. But disparity just means difference. BCA called these differences inequities, and raised questions about the social, cultural, physical, and economic realities of different racial groups that go a long way to explaining the incidence and mortality differences. Only by addressing inequities can we hope to minimize the differences.

When places like Marin County got attention about its high breast cancer rates, Breast Cancer Action would point out that there were a lot of black women dying at young ages in Bay View Hunters Point that needed at least as much attention.

On the subject of environmental links to breast cancer, BCA called for studying the usually poor communities that are often situated near pollution sources and therefore at highest risk.

When it came to programs providing mammography screening for poor women, Breast Cancer Action took the position that if the government was going to pay for breast screening for poor women, then women diagnosed with the disease should also have their treatment paid for by the government. Remarkably, that was not the law. It is now.

And there were areas where, as the leader of Breast Cancer Action I took a different course from the one that the ACLU national organization had adopted when I was on the board. I had been in the dissenting minority at the national board when I and others urged the organization to endorse limiting corporate contributions in elections. This affiliate [ACLU-NC] endorses these limits. The area of corporate influence in cancer advocacy isn’t about elections so much as it is about the reality or the perception that corporations that make drugs and devices for cancer use donations to influence the advocacy that cancer organizations do around treatment issues.

Breast Cancer Action was the first cancer advocacy organization to make it a matter of policy not to accept funding from corporations profiting from cancer or contributing to cancer by environmental harm.

It was the corporate contributions policy that in many ways enabled BCA to have, in a small way, an impact on breast cancer advocacy similar to that of the ACLU on a wide range of civil liberties issues. We launched our Think Before You Pink campaign in 2002, raising questions about all the products sold with pink ribbons on them. We called for more transparency in these sales efforts. After all, if shopping could cure breast cancer, shouldn’t it be cured by now.? We also called out “pink washers,” companies that sold some product to raise money for breast cancer while at the same time making products that were likely contributing to the breast cancer epidemic. There’s now a documentary film about the pinking of breast cancer and pink washers. It’s called Pink Ribbons, Incorporated, and you saw a clip from it here this afternoon. The film is available on DVD and Netflix.

There’s one more area of social justice where Breast Cancer Action’s goals overlapped completely with those of the ACLU. That issue is the patenting of human genes, in this case the breast cancer genes known as BRCA1 and 2. BCA had tried unsuccessfully to get someone in Congress to address this issue when the patents on these two human genes were first issued. When the ACLU started examining the issue, they contacted us, and when the lawsuit was prepared to challenge the patents, Breast Cancer Action was the only national organization to sign on as a plaintiff. We could do that because we didn’t accept funding from the patent holder, Myriad Genetics.

Sooner or later, all issues of social justice are connected. And we as individuals can advance the arc of history towards justice by volunteering. The world changes because we work for change. I am deeply grateful for the privilege of volunteering for the ACLU, and very honored to be the recipient of this Lola Hanzel Courageous Advocacy Award.

Posted in Uncategorized | Tagged ACLU, ACLU-NC, Breast Cancer Actiion, Lola Hanzel | 1 Comment

One More Time With Feeling: Can We Be Done With Mammography Screening?

Posted on December 7, 2012 by bbzinger

October was long over when the New York Times ran an op-ed about mammography screening and over-diagnosis. The op-ed makes a compelling case for ending

Why are all these doctors here?

population-based mammography screening for breast cancer, based on the on the numbers of women who will be treated unnecessarily as a result.

This happens because screening mammograms: that is, mammograms given when there is no evidence of a breast lump or any other problem in the breast find cancers that, untreated, will never be life-threatening. In the medical field, this is referred to as over- diagnosis. Women experience it as unnecessary treatment.

Neither the op-ed nor I is talking about the need for diagnostic mammograms, mammograms given when a woman has a lump or another breast condition that needs to be figured out.

I wrote briefly on this topic a year ago in blog called Is October Over Yet? at. In that post, I talk about Komen’s responsibility for push mammography screening, and their refusal to educate people on the risks of screening.

The New York Times op-ed prompted the usually number of outraged letters from members of what I call “A Mammogram Saved My Life” chorus. No one who has undergone surgery, and possibly radiation and drug treatment or chemotherapy wants to believe they didn’t need treatment.

As I explained in the film Pink Ribbons, Inc.at the time of a breast cancer diagnosis, women fall into one of the three categories:

— They have a kind of cancer that, left untreated, will never be life threatening. If they are treated, the treatments will very likely make them feel bad. Cancer won’t.

— They have a kind of cancer that can be effectively treated with currently available treatments. If they get treatment in a timely manner, the treatment may make them feel bad for a while, but it will keep them from dying of breast cancer.

— They have a kind of cancer that is so aggressive, no matter how small the tumor is, that no currently available treatment can stop it. They will be made very sick by the treatments, seriously affecting the quality of their remaining lives.

Of course, everyone diagnosed who is treated wants to believe that they are in the second group. If their cancer comes back after treatment, they will learn that they were in the third group. But people in the first group will never learn that they are in that group: they will continue to believe that are in the second group.

Folks, these realities are about biology, not mammography. Mammograms have always had their problems: they are radiation based, they miss things that might be life threatening and find things that aren’t. We have been promised a better technology for more than 20 years, and we’re not close. What we need are diagnostic tools that can tell us whether a cancer needs treatment. And we need to reduce the amount of over-treatment while not jeopardizing the availability of treatment for cancers that can and should be treated.

We should stop doing population-based mammography screening and focus on screening those at highest risk of breast cancer.

What we know now is that mammograms alone never save a life. If a life is saved, it’s saved by treatment, no matter how the cancer is found. The chorus notwithstanding and Komen are damned.

Posted in Breast Cancer, Health Policy | Tagged Komen, mammography screening, overdiagnosis, overtreatment | 6 Comments

Sitting Down to Call Out Stand Up To Cancer (SU2C)

Posted on November 4, 2012 by bbzinger

I’m a baseball fan. And a San Francisco Giants fan. I watched a lot of baseball in the post-season. (If you’re wondering, Giants won the World Series, sweeping the Detroit Tigers in 4 straight games. But that’s not really the subject of this blog.) During many of those games, viewers were pummeled with ads for Stand Up to Cancer (SU2C), an effort to raise money for cancer research. One night during the game, MasterCard presented a check to SU2C for $4 million, and many fans and even the game’s announcers held up SU2C signs showing names of people with cancer on them. Mine might have been the only dry eyes in the country when the presentation was over. Here’s why.

The Origin of SU2C

The story as I first heard it about how SU2C came to be has disappeared from the historical annals, replaced by the “official” version. Here’s what I heard at the time. Seems someone high up in the television business had a wife with cancer. He wondered to himself why there wasn’t a big effort to connect highly-watched TV to the cancer cause. He knew, if I remember correctly, the baseball commissioner, who agreed that the TV guy was onto something. Baseball endorsed the effort. And, since the TV guy had access to a lot of TV stars, SU2C was born.

The effort is a charitable program of the Entertainment Industry Foundation (EIF),

An industry it certainly is.

established by media, entertainment and philanthropic leaders who have been affected by cancer. The EIF describes itself as Hollywood’s leading charity. They describe their mission as “to fund ground breaking cancer research through innovation and collaboration, and to accelerate translational research to new target treatments to patients sooner.” Founded May, 2008, SU2C has so far has raised $180 million, $100 million that with its first telethon.

SU2C is so bold as to say of itself: This is where the end of cancer begins.

Really?

Where the Money Goes

Of course, EIF isn’t qualified to do cancer research, let alone innovative and collaborative research that will translate quickly in new targeted treatments of patients. So they subbed that task out. To whom, you might wonder, since nothing in the publicity about SU2C tells you.

The organization that gets these gobs of money is called AACR — American Association for Cancer Research. Unless you’re in the cancer field, you’ve probably never heard of them because, until now, they didn’t do any glitzy public campaigns.

Promising cures for over a century. What’s to brag about?

AACR was founded in 1907. (That’s the beginning of the last century. You would be perfectly justified in wondering what is taking so long.) Its mission is “to prevent and cure cancer through research, education, communication and collaboration.”

They describe what they do with the SU2C funds as giving “cutting edge” grants to “great scientists” doing “innovative high-risk hi-reward research.”

Same Old, Same Old

Of course, most cancer research organizations (and there are tons of them) make the very same claims that AACR and EIF do about the kind of research they fund. They will cure cancer. Where have we heard that before? The proof should be in the outcomes of the research. What new discoveries have been made by AACR/EIF-funded scientists that are benefiting patients today with targeted therapies? Answer: None, zero, zip.

And I don’t think that is only a matter of time. As I understand AACR, their focus is basic cancer research, not translational research. They fund science that looks at cells and sub-parts of cells, and sub-parts of the sub-parts of cells ad nauseum, not patients. AACR is mired in the reductionism that has characterized cancer research for decades, and produced very little of use to people with cancer, relative to the money and time invested.

As for MasterCard, why do you think they spent $10 million to advertise their $4 million

Goodwill goes a long way.

donation to SU2C? Cynical me thinks they were mostly in for the corporate good will.

Don’t be Fooled

Stand Up to Cancer is a highly successful effort to pull at people’s heartstrings and purse strings to get them to contribute to “life saving” cancer research. If you rearrange the letters, you can think of it as a campaign 2 SUC(K) off of peoples’ fear of cancer.

With billions being spent on cancer research, it’s time to re-think how we do cancer research. If money could solve the cancer the problem, it should be solved already. But it can’t, and it hasn’t been. It’s way past time for a new approach.

Posted in Breast Cancer, Medical Science | Tagged AACR, EIF, Entertainment Industry Foundation, major league baseball, MasterCard, Stand Up to Cancer | 10 Comments

NBCC — The Promise, the Process and the Problems

Posted on October 21, 2012 by bbzinger

I have a reputation as an expert on the breast cancer and breast cancer advocacy organizations, gained during my 15 years as the (now former) Executive Director of Breast Cancer Action. Since it’s once again October — Breast Cancer Industry Month — I thought I should use that expertise to talk about an organization that does a lot of good, but seems to be misguided in a couple of important ways. That organization calls itself the National

NBCC’s logo. A little arcane from my point of view. Not to be confused with the National Board of Certified Counselors.

Breast Cancer Coalition, or NBCC.

NBCC promotes nuanced messages about breast cancer, does not overhype treatment news, and encourages an evidence-base approach to treatments. It also encourages people to move beyond breast cancer “awareness,” which Lord knows we have enough of.

But, despite its name, NBCC does not represent all breast cancer organizations. No group does. It is the brainchild and under the close control of Fran Visco, its founding Executive Director and now President. Like many charismatic leaders, Fran surrounds herself with people and groups who agree with her, declining to confer or

Fran Visco in a happy moment.

collaborate with those who disagree or don’t sing her praises. Unfortunately, that limits NBCC’s effectiveness.

A Breast Cancer Deadline?

NBCC’s current focus is on a “deadline” to end breast cancer by January 1, 2020. When they field tested this campaign with some of the breast cancer researchers with whom they work, they were told in no uncertain terms that setting a deadline would be counter- productive to research. But set a deadline they did.

Of course, they are not the first to set a deadline for solving the breast cancer problem. Susan Love set one in the mid-90’s. For what happened to that see, Susan Love: Time to

Deadlines can be very troubling.

Think Before You Pink. And how many times have we been told by doctors and researchers that, in the next 5 or 10 years, the problem will be solved?

One problem with deadlines is that they assume that you have control over the problem you’ve identified. NBCC does not have that control. It’s an advocacy organization. It doesn’t do or fund research, though a lot of researchers work with them. NBCC also doesn’t control the legislative agenda for research, try as they might to do so. Under these circumstances, how might they expect to meet their deadline? They have a stated strategy, but it doesn’t seem to include working with other groups that know a thing or two on the topics being addresses. The NBCC strategy is: leave it to us.

I also should say that I think ending breast cancer is a promise that no one can keep. As I wrote in Breast Cancer Action’s Cancer Policy Perspective, breast cancer has been with us since before the Greeks. I think it will be with us always. The questions are (1) can the incidence be reduced and (2) can the treatments be improved?

What will happen when 1/1/20 rolls around and breast cancer persists? I assure that you NBCC will find some other mission to pursue that will allow them to continue to raise funds. Will they acknowledge failure? I doubt it. Barring a miracle, I won’t be around to witness that date, but I hope some people who read this will be here and will remember.

NBCC’s Legislative Strategy

NBCC has been active in lobbying Congress, and has had some success getting bills addressing breast cancer research passed. As far as I know, their efforts have focused on the Department of Defense (DOD) Breast Cancer Research Program, environmental breast

Congress: Where OUR representatives work

cancer research, and, most recently, an Act to Accelerate the End of Breast Cancer.

The DOD program — which drives funding through the DOD: it does not restrict its funding to the military — is NBCC’s longest-standing success. For background on the program and some of its challenges, see ERA of Hope or Hype?

What all these legislative efforts have in common is a commission of some sort to guide the program efforts. The commissions, set up by the laws for which NBCC advocates, are composed of lay people and scientific experts. The participants are selected with NBCC approval.

These are efforts funded with taxpayer dollars. Why should NBCC and Fran Visco get to decide who the deciders are? Who elected them? And who will NBCC veto who is important

This guy said he was the decider, and we elected him.

to the discussions?

Time for New Leadership?

The competition among breast cancer organizations — for funding and for influence — is fierce. It leads to deadlines and promises that can’t be met and to steps that are more effective at achieving influence and dominance than at addressing the incidence and treatment of the disease. Witness the Komen Foundation, for example. It’s time for leaders who can bring people and organizations together. We need new approaches. In fact, I think the movement needs new leaders.

Posted in Breast Cancer, Health Policy | Tagged BCA, Breast Cancer Action, DOD Breast Cancer Research Program, Fran Visco, National Breast Cancer Coalition, NBCC, Susan Love | 3 Comments

Who Shall Live and Who Shall Die? — A Yom Kippur Reflection

Posted on September 29, 2012 by bbzinger

Introduction

This past week marked the end of what we Jews call the Days of Awe, the 10 days between Rosh Hashanah, the Jewish New Year, and Yom Kippur, the Day of Atonement, which is the holiest day in the Jewish Calendar. Susie, my beloved partner, and I attended services

The Shofar is blown on Rosh Hashanah and Yom Kippur

at the Mendocino Coast Jewish Community, where we have been members for many years.

This year, our friend and Rabbi Margaret Holub asked me to do a teaching on a prayer that we say at Yom Kippur, called the Unataneh Tokef. The prayer’s most famous lines, at least to Jews, are: “On Rosh Hashanah it is written; on Yom Kippur it is sealed, who shall live and who shall die . . .”

The Days for Awe are so named because it is during the time between Rosh Hashanah and Yom Kippur that Jews are called upon to examine their lives, their relationships with people, and their relationship with God. They are called to turn, through these examinations, towards God.

Below is the text of the talk I gave on Yom Kippur. I’ve decided that images will distract from the text. I promise to return to them next post.

Thoughts on Unataneh Tokef

Our High Holiday mohzor (prayer book) is filled with reminders — as if we needed to be reminded — that life is cyclical. As Emmy Lou Harris sings, we are all born to live; we are all bound to die.

Some of these reminders are relatively gentle. That cannot, however, be said of the best known part of Unataneh Tokef, a prayer that many of us know at least a part of by heart. That part is: “On Rosh Hashanah it is written, on Yom Kippur it is sealed, how many will leave this world and how many shall be born into it, who will live and who will die . . . .”

After a long litany of the many ways we might die, we are told that, while we cannot change the decree, tshuvah (turning), tefillah (study) and tzedakah (charity) will make our fate easier.

If tshuvah, tefillah and tzedakah could reverse the decree, I suspect the world would already be filled with many more devout and very old Jews.

I think it’s odd that this prayer is a central part of the Yom Kippur liturgy, because by the time it rolls around, it’s time for the ledger to be sealed and may be too late to do anything about it. At the same time, I don’t find any indication in the mohzor that what is written on Rosh Hashanah ever changes by the time Yom Kippur arrives. Nonetheless, like others more steeped in our tradition than I am, I have been struggling to understand what this prayer means, how to take it in.

I wonder if anyone still believes that God actually has a ledger book in which all our names appear, and that God makes an entry each year for each of us. But even if we don’t believe this, this prayer captures our attention and imagination, prompting us to wonder and pray that we end up on the living side of the ledger on Yom Kippur.

Because of this hope, it is during these days of awe that we ask ourselves questions about how we live our lives, ask whether our lives have purpose and meaning. Yom Kippur drives us to examine our lives, not because we’re necessarily going to die in the next year, but because doing so may result in tshuvah — turning towards God. Since we can’t know (not even I know despite my illness) whether we are written and sealed for another year, we strive to turn towards God so that, whenever our time comes, we have done our best to lead meaningful lives.

In a perfect reflection of Judaism, I think that what’s important in the Days of Awe are the questions we ask ourselves, not necessarily the answers to those questions. Because questions prod us to examine our selves and our lives deeply. The questions aren’t just for the Days of Awe; they are for everyday.

It’s not about getting to heaven, especially if you don’t believe there is one. It’s about examining ourselves to be sure we are living our lives to the fullest, with purpose and meaning. I think this is part of what Margaret was talking about in her drosh on Erev Rosh Hashanah (the evening service of Rosh Hashanah). While being inscribed in the book of life is a thing to pray for, it’s how we live the lives we are given — however short or long — that indicates how we incorporate tshuvah, tefillah and tzedakah.

The singer song writer Keven Welch, who I doubt is Jewish, has lyrics that go like this: There’ll be two dates on your tombstone. And all your friends will read ’em. But all that’s gonna matter is that little dash between ’em.

The poet Mary Oliver, in a poem called The Summer Day, expresses it a little differently:

Tell me, what is it you plan to do

With your one wild and precious life.

The point of personal, self-reflective questions is to focus us on how we live now and how we need to change. If we do this, it does not matter a lot whether we’re not inscribed this year or next or ten years from now. Because we all die. The question is: are the lives we’re leading ones of connection, contemplation and good deeds?

The poet Rilke offers this: Have patience with everything that is unresolved in your heart. And try to love the questions themselves. Don’t search for answers which couldn’t be given to you now, because you wouldn’t be able to live them. In poetic terms,

And the point is to live everything.

Live the questions now.

Perhaps, then, someday far in the future,

You will gradually, even without noticing it,

Live your way into the answer.

Rilke also offers this poem, which I think speaks to how we live our lives in relationship to God.

God speaks to each of us as he makes us,

then walks with us silently out of the night.

These are words we dimly hear:

You, sent out beyond your recall,

go to the limits of your longing.

Embody me.

Flare up like flame

and make big shadows I can move in.

Let everything happen to you: beauty and terror.

Just keep going. No feeling is final.

Don’t let yourself lose me.

Nearby is the country they call life.

You will know it by its seriousness

Give me your hand.

In this day and age, I think Unataneh Tokef’s true significance is not whether God in fact sits in judgment of each of us, but whether we believe that, in some meaningful way, our lives depend on our power to change, to take God’s hand, to engage in tshuvah, tefillah and tzedakah. These things make it easier to bear what God may decree. I think they do so by helping us to live lives of learning, connection and good deeds that benefit the communities in which we live. That brings us closer to God in all of God’s many manifestations.

Since we cannot know where our names appear in the book, maybe the purpose of acknowledging that on Rosh Hashanah it is written and on Yom Kippur it is sealed is to remind us that, whenever and however we die, our obligation is to notice — ourselves, our relationships with others, the good we do in the world. We are finite, but we transcend death by the way we live our lives and connect with each other and with God. The good we do lives on through the lives we’ve touched.

Life, death, and birth are mysteries that are in God’s hands. We cannot control them. But we can control our attitude towards them. I don’t think my having ALS is a way that God is punishing me. We’re all going to die of something. My challenge is to live whatever life I have left in tshuvah, tefillah and tzedakah. I think that is the challenge for all of us, even those of us who are perfectly healthy today.

As I explained to someone else with ALS who was asking why I call myself a “practicing Jew,” I see myself as constantly striving toward a meaningful life and, through that life, a relationship with God. It’s a practice. Some people may get it perfectly right, but I think most of us — myself included — keep working to achieve tshuvah. I think that is the message of Unataneh Tokef.

Posted in Uncategorized | 7 Comments

Not So Funny Things Happened on the Way to a Diaphragm Pacer: When “Informed” is Not “Consent” and Related Adventures of an ALS Activist

Posted on September 13, 2012 by bbzinger

Regular readers of this blog have read a lot about my adventures trying to get Biogen Idec, the makers of dexipramipexole (dex), to let me get a diaphragm pacer without being dropped out of the dex trial in which I’ve been participating for the last 15 months. When the company proved intransigent, I turned my efforts and readers’ considerable energies to the trying to get the FDA to “do the right thing.” This blog post updates those efforts, and, for me, brings to close, at least for now, this chapter of my ALS activism.

What the FDA Says Now: A Chance to Make Changes?

A number of people at the FDA actually read my blog, and I guess the title of the last one (FDA to ALS Patients: Fuck You), as well as the comments posted to it, got their attention. On September 6, I got the following message from the Deputy Director of the Division of Drug Information for FDA’s Center for Drug Evaluation and Research (CDER):

Dear Barbara,

The FDA would like to assure you that we are taking your concerns seriously. The issues that you have raised have been under discussion internally, and the Agency is considering your arguments about how to design and conduct trials in ALS that put the patient first.

Additionally, we would like to let you know that the Agency is in the process of planning a public meeting that will address your general concerns as well as the more specific concerns you and others have raised, such as an independent patient ombudsman. Once a meeting date has been set, I would be happy to provide you with the details.

The passion for ALS treatment that you and the readers of your blog have is obvious from your posts and the comments you receive. Please know that patients’ perspectives are an integral part of the drug approval process, and we value and appreciate these comments.

I understand that the scheduled date for your pacer implant surgery is quickly approaching. I want to extend our best wishes to you for a successful surgery. Please email me afterwards to let me know how you are doing. Best regards,

Catherine Y. Chew, PharmD

Deputy Director, Division of Drug Information

Center for Drug Evaluation and Research

Food and Drug Administration

While this doesn’t help in my current circumstances (see below: Treatment Delayed is Treatment Denied), the prospect of a public meeting at which people affected by ALS will have an opportunity to influence the future structure of ALS trials is heartening.

I hope everyone concerned about these issues — and everyone should be — will contact the FDA to be sure they get notice of when this meeting will take place. Normally, the FDA accepts written comments as well as in-person testimony, and I have asked if that will be the case with this meeting. Write to DRUGINFO@fda.hhs.gov.

Activism can work. Try it. You’ll see.

The IRB Should Be Called the CYA

In the earlier response from the FDA, which I described as “fuck you,” it was suggested that I approach the IRB (note: that stands for “Institutional Review Board,” not “Independent Review Board”) at CPMC, where the Forbes Norris clinic is based. I did so.

This is a covered ass.

The basic position of the IRB was that, since the research folks had followed all the informed consent procedures, they did not need to take action. The ethical issue of holding me — and others with ALS — hostage to irrational rules was not considered.

Interestingly, CPMC has a medical ethicist on staff, but that person said the ethical issue in this setting was for the IRB to address. Evidently, the IRB didn’t think so.

The response from the IRB, and my contact with other ALS folks about this topic, led me back to look at the informed consent I signed. There was not one word in it about the diaphragm pacer. The rules of the trial changed in the middle. I explained this to the IRB, and told them that, while I know I had signed one or two consent forms after the first one, no one had mentioned to me whether subsequent forms precluded a diaphragm pacer.

The IRB thought this might be problem, so they asked the ALS research team for documentation of what I supposedly knew. (Nothing like asking the folks who may have dropped the ball whether they did or not, eh?) After reviewing what the ALS research team provided, the IRB again turned me down. They acknowledged that I had never signed a consent form precluding the pacer, but since I had acknowledged receiving a email from Forbes Norris informing me of the pacer limitation, I had no basis to complain.

Before I get to my rant on “informed consent,” I should say this about my email communication with Forbes Norris about the diaphragm pacer. I did get an email from the research coordinator saying that a pacer would bounce me from the trial. In response, I told the coordinator that I would spare her my views of the ruling since she had already heard my rant about how irrational that was. Consent?

“Informed” v. “Consent”

I deeply appreciate all the people who stood up some years ago to say that people in trials need to understand for what they are signing up. There was a time when people got no information. (A terrific book about one aspect of this is The Immortal Life of Henrietta Lacks by Rebecca Skloot.) Unfortunately, the noble effort to change that reality has turned into another sort of nightmare for patients.

Is there really such a thing anymore?

Informed consent documents for trials, if the Biogen forms are any indication, now run 20 to 30 pages long. While they included information about the trial and the risks and benefits, they also include things like the follow up schedule, the information sharing rules, and a myriad of other things. The notion that being informed amounts to consenting to all the things these forms contain is folly.

And consider the patient’s option. S/he can sign the consent form as written, or not join the trial. There is no give and take in the process of “informed consent.” So is it really consent?

Add to these problems what happens when drug company sponsor like Biogen Idec decides to change the trial rules after the trial has started. Patients are then “re-consented,” asked to sign a new altered consent form. Again, they can sign or be dropped from the trial. The drug company holds all the cards.

And, evidently, the company can play those cards without even getting a signed consent document. An email stating the change in trial rules evidently binds the patients.

It is a misnomer to call this process “informed consent.” The law has name for it: unilateral contract.

Treatment Delayed is Treatment Denied — No Diaphragm Pacer for Me

While all this effort to try to stay in the dex trial if I got a diaphragm pacer was going on, I was trying to get set up to get a pacer implanted.

Here are a few dates to consider as you read about this. The pacer was approved by the FDA in late September, 2011. On October 11, 2011, I let the clinic know I was interested in getting a pacer.

I had been in discussions with my neurologist at Forbes Norris since early April about getting the tests I need to establish my eligibility. I had respiratory tests at the clinic in February, 2012, which I passed. On April 30, 2012, after arguing with my neurologist about which other tests to get, I had a SNIFF test (a flouroscopic view of my diaphragm). I had to argue with my neurologist to get that test.

I heard nothing about pacers from the clinic again until early June, 2012, when I was asked the clinic folks if I was willing to be the first person at Forbes Norris to get a pacer. I said yes.

I assumed — incorrectly — that things would move along with scheduling the surgery.

The only hold up I heard about was in June, 2012. MediCare approval had not yet been confirmed. For some reason, the clinic was unwilling to start scheduling the surgery until coverage was confirmed, even though it involved several doctors with busy schedules. MediCare coverage was obtained in late July, 2012. At that point, the earliest available date for surgery was September 12.

ALS, as the neurologists certainly know, is a progressive disease that effects respiratory capacity. Since there is no effective treatment, the respiratory numbers go only in one direction: down. Yet the doctors at Forbes Norris did nothing that I know of to expedite getting me a diaphragm pacer while my respiratory numbers were good enough to be eligible.

By the time I got to the clinic on September 10 and had my respiration checked again, my function had dropped below the eligible criteria. So, I cannot get the pacer.

In ALS, as in many diseases, treatment delayed is treatment denied. The people at Forbes Norris know this. I would love to see them act like it mattered.

Posted in ALS, ALS Treatment, Health Policy | Tagged actiivism, Biogen Idec, CDER, CPMC, FDA, Forbes Norris, informed consent, IRB, SNIFF test | 18 Comments

FDA to ALS Patients: Fuck You

Posted on August 18, 2012 by bbzinger

If you like this blog, please pass it on to your friends. Let’s keep the conversation going.

I will spare my readers the long saga of my fight with Biogen Idec about the dex trial and my plans to get a diaphragm pacer. If you want all the background, you can read it in three installments: here, here, and here.

When the company refused to budge, I appealed to the FDA Ombudsman both for help with my situation and to assure that every large trial had an ombudsman to resolve disputes between trial participants and the drug company running the trial.

Great friend to drug companies everywhere.

The FDA has spoken. In short they turned me down flat on both requests — apparently without seriously considering my arguments or the letters that many of you sent on my behalf. Here’s what the FDA said.

****************************************************************************************************

Dear Barbara,

Thank you for writing to the Food and Drug Administration (FDA). This is in response to your email to Dr. Janet Woodcock, Dr. Russell Katz, and Ms. Virginia Behr concerning access to dexpramipexole. The issues you raised have been carefully considered, and I’ve been asked to explain our thinking to you.

We understand that Amyotrophic lateral sclerosis (ALS) is a very serious disease which deeply affects patients and their loved ones. We appreciate you sharing your concerns

No thanks to the FDA

about your possible lack of continued access to the study drug, dexpramipexole, if you begin using a diaphragm pacer before Biogen Idec’s EMPOWER trial ends in September.

FDA works with drug developers like Biogen Idec to ensure that patients volunteering to take part in studies are treated fairly and ethically. We understand your argument for being allowed to start use of a diaphragm pacer while staying in the dexpramipexole trial. We also understand Biogen Idec’s argument that making exceptions to the rules of the study would jeopardize the ability of the study to show if dexpramipexole is effective. We wish we had a way to resolve dilemmas like this, but we simply do not. We are acutely aware of the immediate need for effective treatments for ALS, but the only way we know how to learn if a drug is effective is to require sponsors to conduct studies with rules about the types of treatments patients receive, including, of course, rules that assign one group of patients to the experimental drug and a comparison group to placebo for some set period of time. The rules for these studies must be consistent with established ethical and scientific principles, but, within these standards, the specific elements are generally chosen by the sponsors for reasons that are specific to the particular study.

In response to your request for an ombudsman and independent review of each clinical trial, please be aware that in addition to FDA’s responsibility to ensure that clinical trials are conducted ethically, clinical trial procedures are reviewed by institutional review boards (IRBs) which essentially act as an independent ethics committee for clinical trials. These boards are composed of at least five members who include scientists, doctors, and lay people, and they must approve every clinical trial taking place within their jurisdiction- generally a hospital or clinic.

We wish you the best with your continued treatment.

Best regards,

Catherine Y. Chew, PharmD

Deputy Director, Division of Drug Information

Center for Drug Evaluation and Research

Food and Drug Administration

This communication is consistent with 21CFR10.85(k) and constitutes an informal communication that represents our best judgment at this time but does not constitute an advisory opinion, does not necessarily represent the formal position of the FDA, and does not bind or otherwise obligate or commit the agency to the views expressed.

****************************************************************************************

Essentially, the message is patients have no recourse once the trial design has been approved, no matter what the circumstances are. As I understand it, the IRB’s to which the FDA refers consider issues before the trial begins, not after.

Here’s what I wrote back to Dr. Chew:

********************************************************************************************

Dear Dr. Chew,

This is an outrageous response.

You take Biogen’s argument hook, line and sinker.

I guess I know now who the FDA works for.

I see nothing here that addresses the issue a subset analysis for participants who have been in the trial at least 12 months.

I’m now in a situation where, with this decision, I will be forced out of the trial 11 days before it ends.

This decision makes ALS patients hostage to an irrational rule. If I am forced out of the trial by Biogen, I want to bar them from using any data gathered from me during the course of the trial. But I’m betting you will say that I cannot do that.

***************************************************************************

This would have been a shorter and clearer message from the FDA

Bottom line here is that ALS patients are screwed, first by their disease, and then by the companies and agencies who claim to want to help them. For shame.

Posted in ALS, ALS Treatment, Health Policy | Tagged Biogen Idec, Catherine Chew, CDER, Dexpramipexole, FDA | 28 Comments

Fool Me Once, Shame on You. Fool Me Twice . . . : Nothing New at Komen

Posted on August 11, 2012 by bbzinger

If you like this blog, pass it on to your friends. Let’s keep the conversation going.

Maybe you were wondering what I would have to say about the Chick-fil-A. It’s a good story, but not the subject of this blog.

Sorry, not writing about this.

Besides, since that story broke, the Susan G. Komen for the Cure Foundation has been in the news twice. The first time was a story about the dangers and misleading nature of Komen’s messages about screening mammography. The second time was a story about leadership changes at the Foundation. I want to comment briefly on the first story, and more extensively about the second, though they may well be related.

One More Time With Feeling: Komen Sends the Wrong Messages on Mammography Screening

If you’ve seen Pink Ribbons, Inc., or you are a member of Breast Cancer Action, you will not be surprised to read here that Komen oversells mammography, to the detriment of women’s health. I’ve said it for years, but I’m not the only one saying it. Most recently, in an article in the British Medical Journal, two health professors pointed out in detail how Komen distorts statistics to encourage women to get mammograms, ignoring the realities

Not as a good a technology as Komen says it is

of what screening mammograms can and cannot do. In an article entitled “How A Charity Oversells Mammography,” the professors analyze a prominent Komen ad that reads “What’s the key to surviving breast cancer? You — get screened.” It’s a short article, but available on line only to British Medical Journal subscribers. If you search the internet the title of the article, you’ll find quite a few stories discussing it.

What’s remarkable is not the conclusion that Komen distorts statistics to overstate the benefits of mammography screening, while ignoring the risks. Like I said, I’ve been reading or saying things like it for many years. But Komen’s response is simply astonishing. Chandini Portteus, is Komen’s VP of research, evaluation and scientific programs (who, unlike many other VP’s has not resigned or been forced out over the Planned Parenthood mess). Ms. Portteus actually said the

Maybe Ms. Portteus knows something we don’t.

following to a t.v. reporter covering the story: “We have long advocated for women to be informed about the benefits and risks of early detection . . .”

I challenge anyone at Komen or anywhere else to point to anything that Komen has ever said, let alone promoted, that talks about risks from mammography screening. (I will send this blog to Ms. Portteus. Maybe she’ll be able to meet the challenge, but I doubt it.)

The public needs to have balanced information about screening so we can make informed choices about our care. What will it take to make sure they have it? It’s clear that an occasional news story won’t get us there, because there have been many stories over the years that haven’t done the trick. Komen won’t change its message (see below). So maybe it’s time for Komen to go out of business (following the lead of the strangely named Y ME Breast Cancer Organization which recently did). On mammography (and several other things), Komen is doing more harm than good.

A PR Stunt Masquerading As A Leadership Change

My email was about to explode recently when the news hit of leadership changes announced by Komen. The President, Liz Thompson will soon be gone, and Nancy Brinker will step down as CEO as soon as they fill current leadership vacancies for President, Chief Executive Officer, and Chief Operating Officer. The Foundation’s statement announcing these changes neglects to mention the recent departures of the VP of Communications VP, VP for Policy, Executive VP and Chief Marketing Officer, VP of Global Networks, and Director of Affiliate Planning and Strategy.

That Brinker will not leave her CEO post until leadership vacancies have been filled is a

30 years at the helm at Komen. Time to move on, Nancy..

clear indication that she will be deciding who fills these positions. And, when she does step out of the CEO job, Brinker will continue on the Board and as chair of its Executive Committee. Her new role, as yet untitled, will be a “management” role focused on global growth, fundraising, and overall strategy. New title; same control.

For the story on what Nancy Brinker really wants and how she is the Komen Foundation to get it, see this story in New York Magazine

I sure wouldn’t want to be the CEO if someone else in the organization has that portfolio. And, as a breast cancer activist, I am horrified at the prospect of Brinker spreading Komen’s misleading messages (mammography screening is the tip of the ice berg) all over the world.

Nancy Brinker has done this before. Several years ago, she took a “step back” when she was given the Ambassadorship to Hungary in exchange for her fundraising for George W. Bush. She hired Hala Moddelmog to be CEO of Komen. But Brinker was still in charge, which she proved by firing Moddelmog and returning to the CEO position herself when her Ambassadorship ended.

How About Some Real Change at Komen

What we seem to have here is founder syndrome run amok: a founder who did great work getting the organization going and growing, but cannot imagine how the organization could survive without her. So she surrounds herself with people who feed that myth, and ignores the reality that it’s time for new leadership. On the subject of leadership, see my previous post entitled Thoughts on Leadership.

Komen is always delighted to tell us how many billions of (your) dollars it has invested in breast cancer research. It would be nice to hear about the return on that massive investment, but, in the meantime, maybe Komen should spend some of that money on a consultant to help Nancy Brinker figure out her exit strategy. Someone has to do it. It sure won’t be her hand-picked board chair.

When is change not change: when it involves Nancy Brinker and the Komen Foundation. If you agree, tell Nancy Brinker so. Her email address is NBrinker@Komen.org

If you would like to join others calling on Brinker to step down — really down — from Komen now, you can do so at here.

Posted in Breast Cancer, Health Policy | Tagged British Medical Jouirnal, Chandinia Portteus, Liz Thompson, mammgraphy screening, mammograms, Nancy Brinker, YME | 2 Comments