U.S. Sen. David Vitter, R-La., sponsored an amendment to the Democrats’ health reform bill prohibiting the government from using guidelines issued by the U.S. Preventive Services Task Force to craft policy. (WDCpix)

The message was clear: More screenings, not fewer, are better for women’s health.

Yet as the dust settles and Washington’s attention shifts elsewhere, some prominent physicians are questioning the wisdom of the congressional decision to swoop in so quickly to dismiss the expert recommendations. Writing this month in the Journal of the American Medical Association, or JAMA, these doctors are blasting Congress for politicizing an issue they say is better left to medical science.

It’s not a new argument. Preventive care specialists and some journalists were making it in November. Still, that a respected medical journal has returned to the issue now is a good indication that, even if the Democrats’ plans for health reform have hit a wall after last week’s special Senate election in Massachusetts, the thorny debate over preventive health care is far from dead.

“Screening is not simply about benefit, it also causes important harms,” Steven Woloshin and Lisa M. Schwartz, both physicians at Dartmouth Medical School, wrote in the Jan. 13 issue of JAMA. “To make good decisions about screening, patients should understand the trade-offs.”

In the case of routine mammograms, the authors contend, the benefits for women in their 40s are minimal. Without screenings, 3.5 of 1,000 40-somethings will die from breast cancer over the next decade, they note. With screenings, 3 of 1,000 will succumb to the disease — meaning that it requires 2,000 tests to save one life.

“For most women with cancer, screening generally does not change the ultimate outcome,” Woloshin and Schwartz argue.

On the flip side, they say, the harms can be considerable. In some cases, the test comes back mistakenly positive, subjecting the patient to the devastating, if temporary, thought that she’s got a life-threatening disease. In other instances, the test uncovers slow-growing cancers that, even if never found, pose no threat to the patient through her lifetime. The treatment of those latent cancers exposes women to the harms associated with surgery, chemotherapy, or radiation — as well as the constant fear of recurrence.

Steven H. Woolf, a physician at the Virginia Commonwealth University School of Medicine, said those harms shouldn’t be taken lightly.

“Advocates of mammography and cancer survivors often belittle these harms, but a moral duty exists when subjecting millions of asymptomatic women to a procedure that benefits relatively few,” Woolf wrote in the same issue of JAMA. “Whether hundreds of women should endure the consequences of inaccurate mammograms to save one woman’s life is a legitimate ethical question.”

The controversy spins around new recommendations, crafted by the U.S. Preventive Services Task Force, suggesting that 40-something women should no longer get routine annual mammograms, but instead should talk first to their doctors about the potential harms associated with those tests. The task force also recommended that routine screenings for older women occur every two years, rather than annually.

[A clarifier is in order here: Routine mammograms refer, under current protocols, to the annual tests given to asymptomatic women aged 40 and up. Diagnostic screenings, on the other hand, occur after a lump or other abnormality is detected. The task force controversy surrounded only the former. Some insurers cover only the latter.]

Many lawmakers defended the guidelines. But others pounced, voicing concerns that private insurers in search of greater profits — or governments in search of leaner budgets — might point to the guidelines as reason to scale back coverage of routine tests. It didn’t help that the recommendations were unveiled in the middle of the most ferocious health reform battle in generations, and that the Democrats’ reform bills would rely on certain task-force guidelines to steer minimum coverage standards for private insurers.

“This is when you start getting a bureaucrat between you and your physician,” Rep. Marsha Blackburn, R-Tenn., warned at the time. “This is how rationing begins.”

The irony, of course, was that Blackburn was the bureaucrat accusing an independent panel of preventive-care experts of being bureaucrats — a dynamic which raised immediate questions about the capacity of Congress to weed out unnecessary procedures if lawmakers stand ready to riot each time medical science calls into question the entrenched habits of patients and providers.

“The politicalization of medical care is wrong,” Woloshin and Schwartz warn broadly. “Promoting screening irrespective of the evidence may garner votes but will not create healthier voters. It may do the opposite.”

No matter. Less than three weeks after the guidelines were published, the Senate stepped in with an amendment to the Democrats’ health reform bill prohibiting the government from using them to craft policy. Sponsored by Sen. David Vitter, R-La., it passed unanimously without a tallied vote.

A second amendment, sponsored by Sen. Barbara Mikulski, D-Md., bars insurance companies from denying coverage for a host of preventive-care services to be named later by the White House. Aside from mammograms, the provision is designed to cover screenings — at no cost to women — for other prominent diseases, such as diabetes, cervical cancer and heart disease. The Mikulski amendment passed 61 to 39.

“We don’t mandate that you have a mammogram at age 40,” Mikulski said on the Senate floor before the vote. “What we say is, discuss this with your doctor. But if your doctor says you need one, you are going to get one.”

Though mischaracterized in the press and misunderstood on Capitol Hill, that’s precisely what the panel had recommended.

“[T]he controversy was fueled by a chain of false premises,” wrote Woolf, a former member of the task force.

Still, there remains a great deal of disagreement within the medical community about the wisdom of the new guidelines. Wendie A. Berg, a Maryland-based radiologist specializing in breast cancer, said the panel’s conclusions are both “puzzling” and “problematic.”

“There are downsides associated with screening, but most women would not consider these harms,” Berg, also a consultant to Naviscan Inc., a manufacturer of imaging equipment, wrote in JAMA. “The overwhelming majority of women are willing to accept these downsides as part of the process of saving lives otherwise lost to breast cancer.”

The issue might go away for a while. In the wake of Republican Scott Brown’s Senate win in Massachusetts last week, the Democrats no longer have the 60 votes to usher a merged health reform bill through the upper chamber. The astonishing development has left party leaders at a loss for what to do next. Some are suggesting that they move on to other issues and return to health reform later in the year. Whenever they do, Woloshin and Schwartz have some advice.

“It is important for the public to remember that the goal of medicine is to help patients live healthier longer lives,” they wrote. “Sometimes more testing helps to reach the goal, but other times less testing does.

“Suggestions to do less may be as much in an individual’s interest as suggestions to do more.”

Mike Lillis covers Congress for The Washington Independent, a Center for Independent Media site.

Dr. Regina Benjamin, a family physician, established a rural health clinic in a small Alabama shrimping village along the Gulf Coast in the early 1990s. Although the clinic was later lost in a hurricane, it remains one of Benjamin’s best-known accomplishments, and its success prompted correspondence from professionals in other under-served regions of the country hoping to replicate Benjamin’s work.

Benjamin came to the small village when she was just out of medical school, as  part of a national program that forgave tuition for doctors who would agree to serve in an impoverished area. When her commitment was met, she stayed. Even as she gained national notoriety and higher-profile job offers, she stayed.

Benjamin also served as the first African-American woman president of a state medical association and was one of 25 recipients of a 2008 award from the John D. and Catherine T. MacArthur Foundation totaling $500,000.

In the recent past, the post of surgeon general, which falls under the umbrella of the U.S. Department of Health and Human Services, has mostly focused on whatever immediate health message the president’s administration needed to convey to the public. The duties of the office also indicate that a surgeon general can “provide leadership in promoting special departmental health initiatives.”

It remains to be seen exactly how much influence will be afforded to the office by the Obama administration, but having an individual in the post who has intimate knowledge of doctor drain, the nursing shortage and other basic barriers to access in rural areas can only benefit under-served areas throughout the nation.

Benjamin is poised to be the third woman to serve in as surgeon general, and the first woman from a non-military background.

Saturday, the Clinton campaign announced their first Johnson County visit in two months: a 7:30 p.m. Monday stop in Coralville.  That’s the Monday night of finals week.  Last weekend, she held events in two neighboring small counties, Iowa and Washington… without an Iowa City event.

Clinton’s last Johnson County appearance was as the closing act at the Johnson County Democrats’ fall barbecue on Oct. 6.  None of the five candidates at the event took questions from the stage.  Clinton, who appeared with 1972 Democratic nominee George McGovern, was the last speaker and spent close to 45 minutes greeting the crowd afterward. 

Iowa City caucus goers expect to ask the candidate a question, and usually not a soft one.  Clinton has sent top-level surrogates to campus to take questions, including her husband Monday and former Secretary of State Madeline Albright.  But those are very different experiences than asking the candidate herself a question.

Senator Clinton’s only University of Iowa stop was in July, with the former president.  The event was attended by thousands, but she did not take questions.  This is only one campus, and we Iowans may set high expectations.  But compare this to the other leading candidates.  Virtually every John Edwards event, including several on campus, includes questions and answers.  He most recently spoke in Iowa City on Wednesday, at the close to campus public library.  And, while there was some grumbling from backers of other candidates that he hadn’t done it earlier, Barack Obama did a Q & A on the U of I campus on Oct. 3.  Obama also visited campus at a student-oriented Dec. 4 rally, bud did not take questions.  Joe Biden, Chris Dodd, and Bill Richardson have also, with varying frequency, done events with questions on campus or in downtown Iowa City at student-friendly times.

The last Iowa City event at which Hillary Clinton took a public question was on April 3, at a mid-day event at a hotel on the edge of town, attended largely by people who already supported her.

Perhaps students don’t fit the working mom and senior women target groups the Clinton campaign seems to be aiming for. Or perhaps there’s another concern.

“If the most important thing to any of you is choosing someone who did not cast that vote or has said his vote was a mistake, then there are others to choose from.” — Hillary Clinton, February 17, 2007

That’s a general election statement, meant to make Clinton look tough like a Commander in Chief.  The vision of a woman taking the salute as she gets off the Marine One chopper is not yet battle-tested at the ballot box.  But the statement is classic Clinton 42 triangulation, and positions her between the Peace Freaks and Bush.

The University of Iowa is well-known as a peace-movement stronghold, and among the Democratic candidates, Clinton has drawn particular vitriol from the peace movement.  The Des Moines-based “Seasons of our Discontent: a Presidential Occupation Project” (SODaPOP) group, with only enough willing to get arrested bodies to occupy two presidential campaign offices, chose Clinton and Rudy Giuliani.  Clinton might argue, as she has in debates, that she’s attacked because she’s ahead, at least nationally.  But a look at the schedule begs the question: is Hillary avoiding the bleeding heart of the People’s Republic of Johnson County?  Does she want to steer clear of a confrontational question or a raucous student protest?

Probably.  And from her campaign’s perspective, that’s not dumb.  Witness the robot who’s still mad about Sister Souljah who bothered Bill last week.  But the difference from other campaigns, and from John Edwards’ apology for his war vote, certainly needs to be pointed out.  The anti-war left, already mad that Congress hasn’t shut off war funding and started impeachment hearings, is not a sure thing for the “any Democrat is better than any Republican” argument.  Observers will note Green Candidate Cynthia McKinney making the rounds, and stopping where else but Iowa City.  Democrats needs a two to one win out of Johnson County to win statewide, and a few thousand peace protest votes could swing the state, and the nation.