Give the Healthcare Bill a Chance

Dr. Atul Gawande (Photo:

The health-care bill has no master plan for curbing costs. Is that a bad thing?

In medicine, as in agriculture, efficiency cannot be achieved by fiat.

by Atul Gawande The New Yorker Magazine

Cost is the specter haunting health reform. For many decades, the great flaw in the American health-care system was its unconscionable gaps in coverage. Those gaps have widened to become graves—resulting in an estimated forty-five thousand premature deaths each year—and have forced more than a million people into bankruptcy. The emerging health-reform package has a master plan for this problem. By establishing insurance exchanges, mandates, and tax credits, it would guarantee that at least ninety-four per cent of Americans had decent medical coverage. This is historic, and it is necessary. But the legislation has no master plan for dealing with the problem of soaring medical costs. And this is a source of deep unease.

Health-care costs are strangling our country. Medical care now absorbs eighteen per cent of every dollar we earn. Between 1999 and 2009, the average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400, and the average cost per Medicare beneficiary went from $5,500 to $11,900. The costs of our dysfunctional health-care system have already helped sink our auto industry, are draining state and federal coffers, and could ultimately imperil our ability to sustain universal coverage.

What have we gained by paying more than twice as much for medical care as we did a decade ago? The health-care sector certainly employs more people and more machines than it did. But there have been no great strides in service. In Western Europe, most primary-care practices now use electronic health records and offer after-hours care; in the United States, most don’t. Improvement in demonstrated medical outcomes has been modest in most fields. The reason the system is a money drain is not that it’s so successful but that it’s fragmented, disorganized, and inconsistent; it’s neglectful of low-profit services like mental-health care, geriatrics, and primary care, and almost giddy in its overuse of high-cost technologies such as radiology imaging, brand-name drugs, and many elective procedures.

At the current rate of increase, the cost of family insurance will reach twenty-seven thousand dollars or more in a decade, taking more than a fifth of every dollar that people earn. Businesses will see their health-coverage expenses rise from ten per cent of total labor costs to seventeen per cent. Health-care spending will essentially devour all our future wage increases and economic growth. State budget costs for health care will more than double, and Medicare will run out of money in just eight years. The cost problem, people have come to realize, threatens not just our prosperity but our solvency.

So what does the reform package do about it? Turn to page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is . . . pilot programs.

This has provided a soft target for critics. “Two thousand seventy-four pages and trillions of dollars later,” Mitch McConnell, the Senate Minority Leader, said recently, “this bill doesn’t even meet the basic goal that the American people had in mind and what they thought this debate was all about: to lower costs.” According to the Congressional Budget Office, the bill makes no significant long-term cost reductions. Even Democrats have become nervous. For many, the hope of reform was to re-form the health-care system. If nothing is done, the United States is on track to spend an unimaginable ten trillion dollars more on health care in the next decade than it currently spends, hobbling government, growth, and employment. Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet—here’s the interesting thing—history suggests otherwise.

At the start of the twentieth century, another indispensable but unmanageably costly sector was strangling the country: agriculture. In 1900, more than forty per cent of a family’s income went to paying for food. At the same time, farming was hugely labor-intensive, tying up almost half the American workforce. We were, partly as a result, still a poor nation. Only by improving the productivity of farming could we raise our standard of living and emerge as an industrial power. We had to reduce food costs, so that families could spend money on other goods, and resources could flow to other economic sectors. And we had to make farming less labor-dependent, so that more of the population could enter non-farming occupations and support economic growth and development.

America’s agricultural crisis gave rise to deep national frustration. The inefficiency of farms meant low crop yields, high prices, limited choice, and uneven quality. The agricultural system was fragmented and disorganized, and ignored evidence showing how things could be done better. Shallow plowing, no crop rotation, inadequate seedbeds, and other habits sustained by lore and tradition resulted in poor production and soil exhaustion. And lack of coordination led to local shortages of many crops and overproduction of others.

You might think that the invisible hand of market competition would have solved these problems, that the prospect of higher income from improved practices would have encouraged change. But laissez-faire had not worked. Farmers relied so much on human muscle because it was cheap and didn’t require the long-term investment that animal power and machinery did. The fact that land, too, was cheap encouraged extensive, almost careless cultivation. When the soil became exhausted, farmers simply moved; most tracts of farmland were occupied for five years or less. Those who didn’t move tended to be tenant farmers, who paid rent to their landlords in either cash or crops, which also discouraged long-term investment. And there was a deep-seated fear of risk and the uncertainties of change; many farmers dismissed new ideas as “book farming.”

Things were no better elsewhere in the world. For industrializing nations in the first half of the twentieth century, food was the fundamental problem. The desire for a once-and-for-all fix led Communist governments to take over and run vast “scientific” farms and collectives. We know what that led to: widespread famines and tens of millions of deaths.

The United States did not seek a grand solution. Private farms remained, along with the considerable advantages of individual initiative. Still, government was enlisted to help millions of farmers change the way they worked. The approach succeeded almost shockingly well. The resulting abundance of goods in our grocery stores and the leaps in our standard of living became the greatest argument for America around the world. And, as the agricultural historian Roy V. Scott recounted, four decades ago, in his remarkable study “The Reluctant Farmer,” it all started with a pilot program.

In February, 1903, Seaman Knapp arrived in the East Texas town of Terrell to talk to the local farmers. He was what we’d today deride as a government bureaucrat; he worked for the United States Department of Agriculture. Earlier in his life, he had been a farmer himself and a professor of agriculture at Iowa State College. He had also been a pastor, a bank president, and an entrepreneur, who once brought twenty-five thousand settlers to southwest Louisiana to farm for an English company that had bought a million and a half acres of land there. Then he got a position at the U.S.D.A. as an “agricultural explorer,” travelling across Asia and collecting seeds for everything from alfalfa to persimmons, not to mention a variety of rice that proved more productive than any that we’d had. The U.S.D.A. now wanted him to get farmers to farm differently. And he had an idea.

Knapp knew that the local farmers were not going to trust some outsider who told them to adopt a “better” way of doing their jobs. So he asked Terrell’s leaders to find just one farmer who would be willing to try some “scientific” methods and see what happened. The group chose Walter C. Porter, and he volunteered seventy acres of land where he had grown only cotton or corn for twenty-eight years, applied no fertilizer, and almost completely depleted the humus layer. Knapp gave him a list of simple innovations to follow—things like deeper plowing and better soil preparation, the use of only the best seed, the liberal application of fertilizer, and more thorough cultivation to remove weeds and aerate the soil around the plants. The local leaders stopped by periodically to confirm that he was able to do what he had been asked to.

The year 1903 proved to be the most disastrous for cotton in a quarter century, because of the spread of the boll weevil. Nonetheless, at the end of the season Porter reported a substantial increase in profit, clearing an extra seven hundred dollars. He announced that he would apply the lessons he had learned to his entire, eight-hundred-acre property, and many other farmers did the same. Knapp had discovered a simple but critical rule for gaining cooperation: “What a man hears he may doubt, what he sees he may possibly doubt, but what he does himself he cannot doubt.”

The following year, the U.S.D.A. got funding to ramp up his activities. Knapp appointed thirty-three “extension agents” to set up similar demonstration farms across Texas and into Louisiana. The agents provided farmers with technical assistance and information, including comparative data on what they and others were achieving. As experience accrued, Knapp revised and refined his list of recommended practices for an expanding range of crops and livestock. The approach proved just as successful on a larger scale.

The program had no shortage of critics. Southern Farm Magazine denounced it as government control of agriculture. But, in 1914, after two years of stiff opposition, Congress passed the Smith-Lever Act, establishing the U.S.D.A. Cooperative Extension Service. By 1920, there were seven thousand federal extension agents, working in almost every county in the nation, and by 1930 they had set up more than seven hundred and fifty thousand demonstration farms.

As Daniel Carpenter, a professor of government at Harvard, points out, the demonstration-farm program was just one of a hodgepodge of successful U.S.D.A. initiatives that began as pilots. Another was devoted to comparative-effectiveness research: experimental stations were established—eventually, in every state—that set about determining the most productive methods for growing plants and raising livestock. There was a pilot investigation program, which, among other things, traced a 1904 fruit-decay crisis in California to cuts in the fruit from stem clippers and the fingernails of handlers (and, along the way, introduced modern packing methods industry-wide). The U.S.D.A.’s scientific capabilities grew into the world’s greatest biological-discovery machine of the time.

The department invested heavily in providing timely data to farmers, so that they could make more rational planting decisions. It ran the country’s weather-forecasting system. And its statistics service adopted crop-reporting systems from Europe that allowed it to provide independent crop forecasts—forecasts that, among other things, dramatically reduced speculation bubbles. (In 1927, Republicans, prompted by aggrieved New York speculators, managed to prohibit the U.S.D.A. from releasing the forecasts; the program was reinstituted three years later, following an outcry from farmers.) The department continuously updated its storehouse of technical assistance, so that when new technologies arrived—new hybrid varieties, new kinds of fertilizer, new forms of mechanization—farmers were able to make use of them more swiftly and effectively. The U.S.D.A. established an information-broadcasting service. A hundred and seventeen commercial and forty-six military radio stations carried crop reports; printed reports were distributed to fifteen million farmers a year. It also introduced a grading system for food—meat, eggs, dairy products, and fresh fruits and vegetables—to flag and discourage substandard quality.

What seemed like a hodgepodge eventually cohered into a whole. The government never took over agriculture, but the government didn’t leave it alone, either. It shaped a feedback loop of experiment and learning and encouragement for farmers across the country. The results were beyond what anyone could have imagined. Productivity went way up, outpacing that of other Western countries. Prices fell by half. By 1930, food absorbed just twenty-four per cent of family spending and twenty per cent of the workforce. Today, food accounts for just eight per cent of household income and two per cent of the labor force. It is produced on no more land than was devoted to it a century ago, and with far greater variety and abundance than ever before in history.

This transformation, though critical to America’s rise as a superpower, involved some painful dislocations: farms were consolidated; unproductive farmers were winnowed out. As the historian Sally Clarke, of the University of Texas at Austin, has pointed out, it’s astonishing that the revolution took place without vast numbers of farm foreclosures and social unrest. We cushioned the impact of the transformation—with, for instance, price supports that smoothed out the price decline and avoided wholesale bankruptcies. There were compromises and concessions and wrong turns. But the strategy worked, because United States agencies were allowed to proceed by trial and error, continually adjusting their policies over time in response not to ideology but to hard measurement of the results against societal goals. Could something like this happen with health care?

There are, in human affairs, two kinds of problems: those which are amenable to a technical solution and those which are not. Universal health-care coverage belongs to the first category: you can pick one of several possible solutions, pass a bill, and (allowing for some tinkering around the edges) it will happen. Problems of the second kind, by contrast, are never solved, exactly; they are managed. Reforming the agricultural system so that it serves the country’s needs has been a process, involving millions of farmers pursuing their individual interests. This could not happen by fiat. There was no one-time fix. The same goes for reforming the health-care system so that it serves the country’s needs. No nation has escaped the cost problem: the expenditure curves have outpaced inflation around the world. Nobody has found a master switch that you can flip to make the problem go away. If we want to start solving it, we first need to recognize that there is no technical solution.

Much like farming, medicine involves hundreds of thousands of local entities across the country—hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers. They provide complex services for the thousands of diseases, conditions, and injuries that afflict us. They want to provide good care, but they also measure their success by the amount of revenue they take in, and, as each pursues its individual interests, the net result has been disastrous. Our fee-for-service system, doling out separate payments for everything and everyone involved in a patient’s care, has all the wrong incentives: it rewards doing more over doing right, it increases paperwork and the duplication of efforts, and it discourages clinicians from working together for the best possible results. Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive. And the best way to fix all this is—well, plenty of people have plenty of ideas. It’s just that nobody knows for sure.

The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front. Government has a crucial role to play here—not running the system but guiding it, by looking for the best strategies and practices and finding ways to get them adopted, county by county. Transforming health care everywhere starts with transforming it somewhere. But how?

We have our models, to be sure. There are places like the Mayo Clinic, in Minnesota; Intermountain Healthcare, in Utah; the Kaiser Permanente health-care system in California; and Scott & White Healthcare, in Texas, that reliably deliver higher quality for lower costs than elsewhere. Yet they have had years to develop their organizations and institutional cultures. We don’t yet know how to replicate what they do. Even they have difficulties. Kaiser Permanente has struggled to bring California-caliber results to North Carolina, for instance. Each area has its own history and traditions, its own gaps in infrastructure, and its own distinctive patient population. To figure out how to transform medical communities, with all their diversity and complexity, is going to involve trial and error. And this will require pilot programs—a lot of them.

Pick up the Senate health-care bill—yes, all 2,074 pages—and leaf through it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be.

The bill tests, for instance, a number of ways that federal insurers could pay for care. Medicare and Medicaid currently pay clinicians the same amount regardless of results. But there is a pilot program to increase payments for doctors who deliver high-quality care at lower cost, while reducing payments for those who deliver low-quality care at higher cost. There’s a program that would pay bonuses to hospitals that improve patient results after heart failure, pneumonia, and surgery. There’s a program that would impose financial penalties on institutions with high rates of infections transmitted by health-care workers. Still another would test a system of penalties and rewards scaled to the quality of home health and rehabilitation care.

Other experiments try moving medicine away from fee-for-service payment altogether. A bundled-payment provision would pay medical teams just one thirty-day fee for all the outpatient and inpatient services related to, say, an operation. This would give clinicians an incentive to work together to smooth care and reduce complications. One pilot would go even further, encouraging clinicians to band together into “Accountable Care Organizations” that take responsibility for all their patients’ needs, including prevention—so that fewer patients need operations in the first place. These groups would be permitted to keep part of the savings they generate, as long as they meet quality and service thresholds.

The bill has ideas for changes in other parts of the system, too. Some provisions attempt to improve efficiency through administrative reforms, by, for example, requiring insurance companies to create a single standardized form for insurance reimbursement, to alleviate the clerical burden on clinicians. There are tests of various kinds of community wellness programs. The legislation also continues a stimulus-package program that funds comparative-effectiveness research—testing existing treatments for a condition against one another—because fewer treatment failures should mean lower costs.

There are hundreds of pages of these programs, almost all of which appear in the House bill as well. But the Senate reform package goes a few U.S.D.A.-like steps further. It creates a center to generate innovations in paying for and organizing care. It creates an independent Medicare advisory commission, which would sort through all the pilot results and make recommendations that would automatically take effect unless Congress blocks them. It also takes a decisive step in changing how insurance companies deal with the costs of health care. In the nineteen-eighties, H.M.O.s tried to control costs by directly overruling doctors’ recommendations (through requiring pre-authorization and denying payment); the backlash taught them that it was far easier to avoid sicker patients and pass along cost increases to employers. Both the House and the Senate bills prevent insurance companies from excluding patients. But the Senate plan also imposes an excise tax on the most expensive, “Cadillac” insurance plans. This pushes private insurers to make the same efforts that public insurers will make to test incentives and programs that encourage clinicians to keep costs down.

Which of these programs will work? We can’t know. That’s why the Congressional Budget Office doesn’t credit any of them with substantial savings. The package relies on taxes and short-term payment cuts to providers in order to pay for subsidies. But, in the end, it contains a test of almost every approach that leading health-care experts have suggested. (The only one missing is malpractice reform. This is where the Republicans could be helpful.) None of this is as satisfying as a master plan. But there can’t be a master plan. That’s a crucial lesson of our agricultural experience. And there’s another: with problems that don’t have technical solutions, the struggle never ends.

Recently, I spoke with the agricultural extension agent for my home town, Athens, Ohio. His name is Rory Lewandowski. He is fifty-one and has been the extension agent there for nine years. He grew up on a Minnesota dairy farm, and got a bachelor’s degree in animal science and agronomy from the University of Minnesota and a master’s degree in agronomy from the University of Wisconsin. He spent most of his career in farm education, including eight years in Bolivia, where, as a volunteer for the Mennonite Central Committee, he created demonstration farms in an area where the mining economy had collapsed.

I had a vague childhood memory of the extension office, on West Union Street, near downtown Athens; kids in my school used to go to 4-H meetings there. But I had no idea what the agent really did. So I asked Lewandowski. “I just try to help make farming better in Athens County,” he said.

Athens is a green, hilly county at the edge of the Appalachian Mountains, and the farms there are small—an average of a hundred and fifty acres, Lewandowski said. There are six hundred and sixty of them, with, he estimated, as many as a hundred kinds of produce and livestock. His primary task is to help farmers improve the productivity and quality of their farms and to reduce environmental harm. A hundred years after Seaman Knapp, the difficulties have changed but they haven’t gone away.

I’d caught Lewandowski in his office on a Saturday. He routinely puts in sixty-five to eighty hours a week at his job. He has a five-week small-ruminant course for sheep and goat producers; a ten-week master-gardener course; and a grazing school. His wife, Marcia, who has written two knitting books, handles registration at the door. He sends out a monthly newsletter. He speaks with about half the farmers in the county in the course of a year.

Mostly, the farmers come to him—for guidance and troubleshooting. He told me about a desperate message that a farmer left him the other day. The man’s spinach plants had been afflicted with downy mildew and were collapsing. “He said he was going to lose his whole crop by the weekend and all the markets that he depended on,” Lewandowski said. He called the farmer back and explained that the disease gets started with cooler temperatures and high humidity. Had the farmer been using overhead watering?

Yes, he said, but he had poked around the Internet and was thinking about switching to misting.

Not a good idea. “That still leaves too much moisture on the leaf,” Lewandowski said. He recommended that the farmer switch to drip irrigation, and get some fans in his greenhouse, too.

The farmer said that he’d thought about fans but worried that they would spread the spores around.

They will, Lewandowski said. “But you need wetness on the leaves for four to six hours to get penetration through the leaf cuticle,” he explained. If the plants were dried out, it wouldn’t be a problem. “You’ve got to understand the biology of this,” he said to me.

He doesn’t always understand the biology himself. He told me about a beef farmer who had been offered distiller’s grain from a microbrewery, and wanted to know whether he could feed it to his cows. Lewandowski had no idea, but he called the program’s beef extension expert and got the answer. (Yes, with some limits on how much he put in a ration.) A large organic farm called with questions about growing vegetables in high tunnels, a relatively new innovation that the farm had adopted to extend its growing season. Lewandowski had no experience with this, but an extension agent in Wooster, Ohio, was able to supply information on what had worked best elsewhere.

“You have to be able to say, ‘I don’t know, but I can figure that out for you,’ ” Lewandowski said.

If he could change one thing about farming in Athens, I asked, what would it be? “Grazing management,” he said. “Think about how the grass grows in your lawn. A grass plant needs at least a few days after a mowing to grow.” If you mowed your lawn every day, the grass would become thin and patchy. That’s what happens when farmers leave their animals out in one big pasture—which is what most small farmers do—or rotate them too slowly. In his grazing school and in demonstrations, he asks farmers to keep their animals in a given area for only a few days, then move them to a section where the grass is eight inches tall and has reached its highest nutrient value. This way, the pastures won’t erode, and the cattle will grow better, yielding higher-quality meat and more of it. The technique requires discipline, though, and extra work, and farmers have been slow to give it a try.

I asked him if he has had any victories. All the time, he said. But he had no illusions: his job will never end.

Cynicism about government can seem ingrained in the American character. It was, ironically, in a speech to the Future Farmers of America that President Ronald Reagan said, “The ten most dangerous words in the English language are ‘Hi, I’m from the government, and I’m here to help.’ ” Well, Lewandowski is from the government, and he’s here to help. And small farms in Athens County are surviving because of him. What he does involves continual improvisation and education; problems keep changing, and better methods of managing them keep emerging—as in medicine.

In fact, when I spoke with Lewandowski about farming in Athens, I was struck by how much it’s like the health-care system there. Doctors typically work in small offices, with only a few colleagues, as in most of the country. The hospital in Athens has less than a tenth the number of beds that my hospital in Boston has. The county’s clinicians could do much more to control costs and improve quality of care, and they will have to. But it will be an ongoing struggle.

My parents recently retired from medical practice in Athens. My mother was a pediatrician and my father was a urologist. I tried to imagine what it would be like for them if they were still practicing. They would be asked to switch from paper to electronic medical records, to organize with other doctors to reduce medical complications and unnecessary costs, to try to arrive at a package price for a child with asthma or a man with kidney stones. These are the kinds of changes that everyone in medicine has to start making. And I have no idea how my parents would do it.

I work in an academic medical group in Boston with more than a thousand doctors and a vastly greater infrastructure of support, and we don’t know the answers to half these questions, either. Recently, I had a conversation with a few of my colleagues about whether we could accept a bundled payment for patients with thyroid cancer, one of the cancers I commonly treat in my practice as a surgeon. It seemed feasible until we started thinking about patients who wanted to get their imaging or radiation done elsewhere. There was also the matter of how we’d divide the money among the surgeons, endocrinologists, radiologists, and others involved. “Maybe we’d have to switch to salaries,” someone said. Things were getting thorny. Then I went off to do an operation in which we opened up about a thousand dollars’ worth of disposable materials that we never used.

Surely we can solve such problems; the reform bill sets out to find ways that we can. And, in the next several years, as the knowledge accumulates, I suspect that we’ll need our own Seaman Knapps and Rory Lewandowskis to help spread these practices county by county.

We’ll also need data, if we’re going to know what is succeeding. Among the most important, and least noticed, provisions in the reform legislation is one in the House bill to expand our ability to collect national health statistics. The poverty of our health-care information is an embarrassment. At the end of each month, we have county-by-county data on unemployment, and we have prompt and detailed data on the price of goods and commodities; we can use these indicators to guide our economic policies. But try to look up information on your community’s medical costs and utilization—or simply try to find out how many people died from heart attacks or pneumonia or surgical complications—and you will discover that the most recent data are at least three years old, if they exist at all, and aren’t broken down to a county level that communities can learn from. It’s like driving a car with a speedometer that tells you only how fast all cars were driving, on average, three years ago. We have better information about crops and cows than we do about patients. If health-care reform is to succeed, the final legislation must do something about this.

Getting our medical communities, town by town, to improve care and control costs isn’t a task that we’ve asked government to take on before. But we have no choice. At this point, we can’t afford any illusions: the system won’t fix itself, and there’s no piece of legislation that will have all the answers, either. The task will require dedicated and talented people in government agencies and in communities who recognize that the country’s future depends on their sidestepping the ideological battles, encouraging local change, and following the results. But if we’re willing to accept an arduous, messy, and continuous process we can come to grips with a problem even of this immensity. We’ve done it before. ♦

Read more

Atul Gawande MD, (Photo: WBUR/Jesse Costa)

When Corporations Cooperate it’s Win/Win for Everyone

Dave Blaus, 41, in Deptford, N.J., stocking freezers at Wal-Mart, the nation’s biggest grocer

Ryan Collerd for The New York Times

Michelle Obama, the first lady, has joined the Wal_Mart’s effort to get consumers to eat

healthier foods  —  Alex Wong/Getty Images

The New York Times, January 20, 2011, by Sheryl Gay Stolberg  —  WASHINGTON — Wal-Mart, the nation’s largest retailer, will announce a five-year plan on Thursday to make thousands of its packaged foods lower in unhealthy salts, fats and sugars, and to drop prices on fruits and vegetables.

The initiative came out of discussions the company has been having with Michelle Obama, the first lady, who will attend the announcement in Washington and has made healthy eating and reducing childhood obesity the centerpiece of her agenda. Aides say it is the first time Mrs. Obama has thrown her support behind the work of a single company.

The plan, similar to efforts by other companies and to public health initiatives by New York City, sets specific targets for lowering sodium, trans fats and added sugars in a broad array of foods — including rice, soups, canned beans, salad dressings and snacks like potato chips — packaged under the company’s house brand, Great Value.

In interviews previewing the announcement, Wal-Mart and White House officials said the company was also pledging to press its major food suppliers, like Kraft, to follow its example. Wal-Mart does not disclose how much of its sales come from its house brand. But Kraft says about 16 percent of its global sales are through Wal-Mart.

In addition, Wal-Mart will work to eliminate any extra cost to customers for healthy foods made with whole grains, said Leslie Dach, Wal-Mart’s executive vice president for corporate affairs. By lowering prices on fresh fruits and vegetables, Wal-Mart says it will cut into its own profits but hopes to make up for it in sales volume. “This is not about asking the farmers to accept less for their crops,” he said.

The changes will be introduced slowly, over a period of five years, to give the company time to overcome technical hurdles and to give consumers time to adjust to foods’ new taste, Mr. Dach said. “It doesn’t do you any good to have healthy food if people don’t eat it.”

Wal-Mart is hardly the first company to take such steps; ConAgra Foods, for example, has promised to reduce sodium content in its foods by 20 percent by 2015.

But because Wal-Mart sells more groceries than any other company in the country, and because it is such a large purchaser of foods produced by national suppliers, nutrition experts say the changes could have a big impact on the affordability of healthy food and the health of American families and children.

Some say the company has almost as much power as federal regulators to shape the marketplace.

“A number of companies have said they are going to make voluntary reductions in sodium over the next several years, and numerous companies have said they are going to try to get trans fat out of their food,” said Michael Jacobson, executive director of Center for Science in the Public Interest. “But Wal-Mart is in a position almost like the Food and Drug Administration. I think it really pushes the food industry in the right direction.”

But Wal-Mart is pushing only so far. The company’s proposed sugar reductions are “much less aggressive” than they could be, Mr. Jacobson said, noting that Wal-Mart is not proposing to tackle the problem of added sugars in soft drinks, which experts regard as a major contributor to childhood obesity. And he said it would be “nice if Wal-Mart’s timeline were speedier” than five years.

Wal-Mart has been planning the initiative for more than a year; the effort was in its early stages when Ms. Obama joined it. The first lady’s appearance with Mr. Dach and other Wal-Mart executives when they make the announcement at a community center in Washington’s Anacostia neighborhood on Thursday morning is out of the ordinary and a prominent effort by the administration to spur further moves toward healthier food.

“We’re not just aligning ourselves with one company; we’re aligning ourselves with people who are stepping up as leaders to take this country to a healthier place,” said Sam Kass, the White House chef who doubles as Mrs. Obama’s top adviser on matters of nutrition.

“There’s no qualms about that,” Mr. Kass said. “The only question that we have is do we think this is a significant step in that direction, and do we think there is a method in place to track progress, and do we think this will have the impact we are pushing for.”

Over the last year, Mr. Kass and other aides to the first lady have spent countless hours in meetings with company officials; both Mr. Kass and Mr. Dach said Mrs. Obama pushed the company to hold itself accountable by issuing public progress reports. The Partnership for a Healthier America, a nonprofit organization that works with the first lady on her Let’s Move initiative to reduce childhood obesity, will monitor the company’s progress.

The changes will not happen overnight. Wal-Mart is pledging to reduce sodium by 25 percent, eliminate industrially added trans fats and reduce added sugars by 10 percent by 2015. Its other plans are less specific. In addition to proposing to lower prices on healthy foods, Wal-Mart is planning to develop criteria, and ultimately a seal, that will go on truly healthier foods, as measured by their sodium, fat and sugar content.

The company says it will also address the problem of “food deserts” — a dearth of grocery stores selling fresh produce in rural and underserved urban areas like Anacostia — by building more stores. And it will increase charitable contributions for nutrition programs.

A range of studies has shown that low-income people, especially those who receive food stamps, face special dietary challenges because eating healthy costs more and healthier food is harder to get in their neighborhoods. James D. Weill, president of Food Research and Action Center, an organization that has been pressing Wal-Mart to help tackle this problem, said the company seemed to have recognized “how much hunger and food insecurity there is in the country.”

Mr. Dach said the lower prices and food reformulations were motivated by the demands of Wal-Mart’s own customers. He said the company believed that, if it was successful, the price reductions would save Americans who shop at Wal-Mart approximately $1 billion a year on fresh fruits and vegetables alone.

“Our customers have always told us, ’We don’t understand why whole wheat macaroni and cheese costs more than regular macaroni and cheese,’ ” Mr. Dach said, adding, “We’ve always said that we don’t think the Wal-Mart shopper should have to choose between a product that is healthier for them and what they can afford.”

Mr. Jacobson, of the Center for Science in the Public Interest, said that reducing sodium was the trickiest of the food reformulation challenges. Sodium is in every food category, and it is more difficult to replace than the partly hydrogenated oil that composes trans fats, or than sugars, because there are easy substitutes for oils and sugars. But sodium, which contributes to hypertension and raises the risk of heart disease, must simply be reduced, which can greatly alter taste.

Mr. Dach said the company had yet to conquer its reformulation challenges, and described the goals as both aspirational and realistic. “We think it’s a realistic target, but it’s aspirational in the sense that we can’t tell you today how it’s all going to get done,” he said.

William Neuman contributed reporting from New York.

Public release date: 13-Jan-2011

Room light before bedtime may impact sleep quality, blood pressure and diabetes risk

New study shows indoor lighting has profound suppressive effect on the hormone melatonin

Chevy Chase, MD—According to a recent study accepted for publication in The Endocrine Society’s Journal of Clinical Endocrinology & Metabolism (JCEM), exposure to electrical light between dusk and bedtime strongly suppresses melatonin levels and may impact physiologic processes regulated by melatonin signaling, such as sleepiness, thermoregulation, blood pressure and glucose homeostasis.

Melatonin is a hormone produced at night by the pineal gland in the brain. In addition to its role in regulating the sleep-wake cycle, melatonin has been shown to lower blood pressure and body temperature and has also been explored as a treatment option for insomnia, hypertension and cancer. In modern society, people are routinely exposed to electrical lighting during evening hours to partake in work, recreational and social activities. This study sought to understand whether exposure to room light in the late evening may inhibit melatonin production.

“On a daily basis, millions of people choose to keep the lights on prior to bedtime and during the usual hours of sleep,” said Joshua Gooley, PhD, of Brigham and Women’s Hospital and Harvard Medical School in Boston, Mass. and lead author of the study. “Our study shows that this exposure to indoor light has a strong suppressive effect on the hormone melatonin. This could, in turn, have effects on sleep quality and the body’s ability to regulate body temperature, blood pressure and glucose levels.”

In this study, researchers evaluated 116 healthy volunteers aged 18-30 years who were exposed to room light or dim light in the eight hours preceding bedtime for five consecutive days. An intravenous catheter was inserted into the forearms of study participants for continuous collection of blood plasma every 30-60 minutes for melatonin measurements. Results showed exposure to room light before bedtime shortened melatonin duration by about 90 minutes when compared to dim light exposure. Furthermore, exposure to room light during the usual hours of sleep suppressed melatonin by greater than 50 percent.

“Given that chronic light suppression of melatonin has been hypothesized to increase relative risk for some types of cancer and that melatonin receptor genes have been linked to type 2 diabetes, our findings could have important health implications for shift workers who are exposed to indoor light at night over the course of many years,” said Gooley. “Further research is still needed to both substantiate melatonin suppression as a significant risk factor for breast cancer and determine the mechanisms by which melatonin regulates glucose metabolism.”


Other researchers working on the study include: Kyle Chamberlain of the University of Surrey in the United Kingdom; and Kurt Smith, Sat Bir Khalsa, Shantha Rajaratnam, Eliza Van Reen, Jamie Zeitzer, Charles Czeisler and Steven Lockley of Brigham and Women’s Hospital and Harvard Medical School in Boston, Mass.

The article, “Exposure to room light prior to bedtime suppresses melatonin onset and shortens melatonin duration in humans,” appears in the March 2011 issue of JCEM.

Founded in 1916, The Endocrine Society is the world’s oldest, largest and most active organization devoted to research on hormones and the clinical practice of endocrinology. Today, The Endocrine Society’s membership consists of over 14,000 scientists, physicians, educators, nurses and students in more than 100 countries. Society members represent all basic, applied and clinical interests in endocrinology. The Endocrine Society is based in Chevy Chase, Maryland. To learn more about the Society and the field of endocrinology, visit our site at Contact: Aaron Lohr,, 240-482-1380, The Endocrine Society

Monarch Butterfly, Thursday, 20 January 2011

How will we characterize our age? By the birth of the internet? The rise of China? The first black US president? Perhaps in all those ways. But we could also say, less obviously but perhaps more fundamentally, that ours is the age when the insects disappeared.

Edward O Wilson, America’s greatest naturalist, called invertebrates – the insects, the spiders, the worms, the snails and all their fellows – “the little things that run the world”. He meant that these tiny creatures were at the very base of much of life. For example, in the case of pollination, where bees and other insect pollinators fertilize plants, and enable them to produce fruit and seeds, by transferring pollen between flowers.

In the past five years or so, pollinators, honeybees in particular, have started to vanish in many places, and governments have woken up to the problem, as pollination is worth billions.

In fact, insects such as butterflies, moths, bumblebees and mayflies have been disappearing for a long time, although hardly anyone except specialists has noticed or cared.

Their decline began half a century ago with the introduction of pesticides and other agricultural chemicals. But the decline has gathered pace over the past decade with the introduction of systemic insecticides such as the neonicotinoids, which are absorbed into every part of the plant, including the pollen and nectar which pollinating insects collect.

It is too simple to say that one has caused the other, but the link is being made. In his book The Systemic Insecticides – A Disaster In The Making, the Dutch toxicologist Henk Tennekes argues that neonicotinoids are now present in much of Holland’s surface water, killing off aquatic insects and leading to a decline in insect-eating birds across the country.

If we care about the little things that run the world, we must wake up to what could be their biggest threat yet.

Exclusive: Bees facing a poisoned spring

AFP – A bee collecting pollen hovers above a golden rape bloom

New kind of pesticide, widely used in UK, may be helping to kill off the world’s honeybees

By Michael McCarthy, Environment Editor,, Thursday, 20 January 2011

A new generation of pesticides is making honeybees far more susceptible to disease, even at tiny doses, and may be a clue to the mysterious colony collapse disorder that has devastated bees across the world, the US government’s leading bee researcher has found. Yet the discovery has remained unpublished for nearly two years since it was made by the US Department of Agriculture’s Bee Research Laboratory.

The release of such a finding from the American government’s own bee lab would put a major question mark over the use of neonicotinoid insecticides – relatively new compounds which mimic the insect-killing properties of nicotine, and which are increasingly used on crops in the US, Britain and around the world.

Bayer, the German chemicals giant which developed the insecticides and makes most of them, insists that they are safe for bees if used properly, but they have already been widely linked to bee mortality. The US findings raise questions about the substance used in the bee lab’s experiment, imidacloprid, which was Bayer’s top-selling insecticide in 2009, earning the company £510m. The worry is that neonicotinoids, which are neurotoxins – that is, they attack the central nervous system – are also “systemic”, meaning they are taken up into every part of the plant which is treated with them, including the pollen and nectar. This means that bees and other pollinating insects can absorb them and carry them back to their hives or nests – even if they are not the insecticide’s target species.

In Britain, more than 1.4 million acres were treated with the chemical in 2008, as part of total neonicotinoid use of more than 2.5 million acres – about a quarter of Britain’s arable cropland.

The American study, led by Dr Jeffrey Pettis, research leader at the US government bee lab in Beltsville, Maryland, has demonstrated that the insects’ vulnerability to infection is increased by the presence of imidacloprid, even at the most microscopic doses. Dr Pettis and his team found that increased disease infection happened even when the levels of the insecticide were so tiny that they could not subsequently be detected in the bees, although the researchers knew that they had been dosed with it.

Dr Pettis told The Independent his research had now been put forward for publication. “[It] was completed almost two years ago but it has been too long in getting out,” he said. “I have submitted my manuscript to a new journal but cannot give a publication date or share more of this with you at this time.”

However, it is known about, because Dr Pettis and a member of his team, Dennis van Engelsdorp, of Penn State University – both leaders in research focusing on colony collapse disorder (CCD) – have spoken about it at some length in a film about bee deaths which has been shown widely in Europe, but not yet in Britain or the US – although it has been seen by The Independent.

In The Strange Disappearance of The Bees, made by the American film-maker Mark Daniels, Pettis and van Engelsdorp reveal that they exposed two groups of bees to the well-known bee disease nosema. One of the groups was also fed tiny doses of imidacloprid. There was a higher uptake of infection in the bees fed the insecticide, even though it could not subsequently be detected, which raises the possibility that such a phenomenon occurring in the wild might be simply undetectable.

Although the US study remains unpublished, it has been almost exactly replicated by French researchers at the National Institute for Agricultural Research in Avignon. They published their study in the journal Environmental Microbiology and said: “We demonstrated that the interaction between nosema and a neonicotinoid (imidacloprid) significantly weakened honeybees.”

Neonicotinoids have attracted growing controversy since their introduction by Bayer in the 1990s, and have been blamed by some beekeepers and environmental campaigners as a potential cause of CCD, first observed in the US in 2006, in which billions of worker bees abruptly disappear from their hives.

Between 20 and 40 per cent of American hives have been affected, and CCD has since been observed in several other countries from France to Taiwan, though it has not yet been detected in Britain. Although Bayer insists its products are bee-safe, French and German beekeepers have blamed them for large bee losses. Neonicotinoids have been banned, to different degrees, in France, Germany, Italy and Slovenia, although they are freely sold and widely used in the US and Britain.

In the UK, the Co-op has banned them from farms from which it sources vegetables, but the Government has rejected appeals from beekeepers and environmentalists for their use to be suspended as a precaution. This week, however, an Early-Day Motion was tabled in the Commons by Martin Paton, the Labor MP for Gower, calling again for the Government to suspend use of the compounds following major new controversy in the US surrounding Bayer’s latest neonicotinoid – clothianidin – which is increasingly being used in Britain. In November, a leaked internal document from the US Environmental Protection Agency showed that it was continuing to license clothianidin, even though its own scientists reported that the tests Bayer carried out to show the compound was safe were invalid.

Leading the calls for neonicotinoids to be banned in the Britain is Buglife, the invertebrate conservation charity, which last year published a review of all the research done on the chemicals’ impact on “non-target” insects such as honeybees and other pollinators.

Yesterday the Buglife director, Matt Shardlow, said of the Pettis study: “This new research from America confirms that at very, very low concentrations neonicotinoid chemicals can make a honeybee vulnerable to fatal disease. If these pesticides are causing large numbers of honeybees, bumblebees, solitary bees, hoverflies and moths to get sick and die from diseases they would otherwise have survived, then neonicotinoid chemicals could be the main cause of both colony collapse disorder and the loss of wild pollinator populations.

“The weight of evidence against neonicotinoids is becoming irresistible – Government should act now to ban the risky uses of these toxins.”

Bayer insists its neonicotinoids are safe for bees when used properly. Dr Julian Little, a spokesman for Bayer CropScience UK, said it was difficult for it to comment on an unpublished study. “It makes it impossible to look at their methods, it makes it impossible to check whether you can repeat the work, you don’t know where they got the imidacloprid from, you don’t know how they gave that to the bees,” he said. But he added: “I’m sure there are some very interesting effects Dr Pettis has seen in a laboratory, but in reality, when you get to what’s important to everybody, which is what happens in the field, you don’t see these things happening. Bees are very, very important insects to Bayer CropScience and we recognize their importance.”