Dr. Marc regularly answers readers’ questions on matters relating to medicine, healthcare and politics. To send a query, click here.

Dr. Marc reacts to the current direction of Medicare:

First: The rhetoric being used by the right wing arguing for healthcare privatization is basically that a better product at the lowest possible price occurs based on competition and the laws of supply and demand. The problem with this thinking is that in the world we live in today, where HMOs already control a significant segment of the health sector, the corporate upper crust gets richer (the CEO of Aetna earned $20 million two years ago), and there is no system in place to insure that the patient gets proper or even minimum care, and no guarantee that the working parts of the system (doctors, nurses, technicians) are properly reimbursed for their work.

So-called healthy competition can only be possible in an environment where healthcare workers have strong unions and patients have strong consumer advocates fighting for their interests. Unions and advocacy groups are crucial to the American way of life. But currently, the situation in healthcare is different. HMOs all look the same, they all offer similar inefficient, ineffective, insincere products at a premium cost to the patients. To be sure, they are constantly decreasing what they pay to providers, but the savings goes into their own pockets, not back into the system. The term for this uniformly poor product is not competition but collusion. Expanding this private system to include the elderly and the infirm would be to expand the problem, not its solution.

The solution is to centralize healthcare under governmental control, where there is at least a basic health insurance available for all. The government bureaucracy may have many inefficiencies, but it nonetheless better serves the public than a corporation motivated strictly by profit. Patients are a large constituency and can, and should, influence re-election if the system is not going well.

Second: Prescription drugs should be covered for all elderly, but the first question that must be addressed is, At what cost? Many of these drugs are overpriced duplicates of one another. The government should not be asked to swallow these prices but should use the entire group of elderly as a cohort to force lower, more reasonable prices. This is the current system throughout much of Western Europe, and one of the main reasons drug prices are so much lower there.

I live in Missoula, Montana, and, in the woods at least, we currently have a lot of mosquitos. How worried should I be about the West Nile virus? We’ve been told to wear bug spray with DEET in it for protection, but I wonder if DEET is safe for me or my child?

CATHERINE PRICE-ALICK Missoula, Montana

Dear Catherine,

DEET is safe, and good to have in insect repellent. West Nile will be back this summer, but only in small numbers (1,000 or more nationwide). The chances of you encountering it are extremely low. Still, removing stagnant water (mosquito breeding grounds) using insect repellent and wearing long sleeves are always good ideas when biting insects are around.

I noticed coral calcium mentioned by readers in your column. I learned that coral calcium may pose a danger to consumers because of lead contamination. Why aren’t supplements tested by the FDA? This is a poison–especially to pregnant women and children.

LOUISE M. McDONALD Cleveland, Ohio

Dear Louise,

Under current law, I believe the FDA is limited in terms of what it can do regarding a substance that is not strictly classified as a medicine. The problem with something like this is that the contents vary from pill to pill, and the FDA cannot regulate the individual products of each manufacturer unless the substance is officially sanctioned as a medication or the agency believes that the substance poses a public health threat. I’m not sure where I stand on that one.

I am 58 and have received conflicting information about how often I should have a sigmoidoscopy. The recommendations range from once every year to once every five years. Is there any medical consensus on this question?

I understand that I should have a colonoscopy once every ten years. Since I have not yet had one, am I at the age to begin?

RICH DALY Wyncote, Pennsylvania

Dear Rich,

Sigmoidoscopy as a screening procedure has largely been replaced by the use of colonoscopy. Routine screening is a colonoscopy every five to ten years after the age of 50 in a patient with no family history of colon cancer and no GI symptoms. Anyone with a family history of colon cancer should begin screenings at 40. It is high time you had one done.

I have high blood pressure and, among other medications, have been taking isosorbide mononitrate (sixty milligrams). I had my yearly checkup at the Heart Institute recently, and the doctor there told me that I no longer needed the above-mentioned medication. However, when I previously checked WebMD, it stated that this medication should not be stopped as it could bring on angina chest pains. Help!

NAME/CITY WITHHELD

Dear Friend,

Believe your doctor if you have a good rapport with him. The medication you mention is a heart medicine usually used for angina rather than high blood pressure–but I’m sure he has his reasons for stopping it. You should discuss it with him immediately.

Recently you replied to an inquiry about someone who had twitching eyelids, and said it was probably stress-related or due to overconsumption of caffeine. Did you also know that this is a sign of mercury toxicity? This is relevant to those who have the old mercury/silver amalgam dental fillings, those who consume certain large ocean fish and others who may have been exposed.

ROBERT SMILEY Lake Forest, Illinois

Dear Robert,

Thanks for alerting me to this. Rare, but a relevant part of the differential diagnosis.

I have a rash on my arms, torso and neck. It’s been diagnosed as Tinea Versicolor. I’ve tried topical medications and oral medications like Nizoral, but it keeps coming back. Is there any way to rid myself of this skin condition for good, or is it chronic?

SCOTT A. COOPER Gaithersburg, Maryland

Dear Scott,

You need to see a good dermatologist as soon as possible. Tinea Versicolor is a fungus, which is hard to eradicate completely. However, vigorous use of topical antifungal medications should get rid of it, as your doctor should tell you.

My insurance company is very limited and it doesn’t have any mental health benefits other than inpatient care. Why is it so hard to get coverage for mental health problems? Everything I’ve read says that a combination of therapy and medication works best for most people.

Also, my prescription coverage is very limited. I am only allowed ten prescriptions a year. I now buy Paxil online from an Indian company on the Internet. It costs $71.89 a month with shipping for one month’s supply.

I know that there are a lot of other people with the same problem, but I don’t see any politicians addressing these problems.

NAME/CITY WITHHELD

Dear Friend,

Our healthcare system is broken. Not that it has a big break right down the middle, but there are numerous cracks and fissures in crucial places. This often means that stigmatized, politically powerless and unpopular groups are often overlooked.

I believe many drugs like Paxil are overpriced to begin with. I do think the Democrats should be taking all this on, and should be courageous enough to back a system where patients’ needs are promoted rather than those of the private companies. This would suggest a basic insurance for all, where the weight of such a large cohort is used to negotiate for lower prices, the way things work in Europe and Canada (see my article in the Washington Post Outlook section, June 22, 2003).

Even though I have decent medical insurance, I stopped going to the doctor altogether over the past several years. Although I live in a town with an abundance (perhaps an overabundance) of physicians, it is always difficult to get an appointment, and even the doctors with good reputations treat patients very badly.

Many years ago I developed rheumatoid arthritis, but my primary care doctor and the rheumatologist I had to drive seventy miles to see had attitudes of “Here, take these pills and be quiet about it.”

I’ve since just learned to live with it, but perhaps not so well, because I’ve also fought clinical depression for many years, and tried to kill myself twice. The first time, the insurance company and my psychiatrist fought over where I could be hospitalized, and I ended up not being hospitalized. The second time, I slept it off for two days at home and didn’t even call the psychiatrist. Again, the attitude of the doctors is “Here, take these pills.” Only, I haven’t taken them, I’ve stockpiled them in case I make a third attempt at suicide someday.

The medical system in this country is badly broken. I would gladly give up “the latest” treatment just to get someone to look me in the eye and act like I was more than just an interruption. I have decided that the only reason I will seek medical treatment is for physical trauma. Anything else will simply have to take its course or kill me.

I bet I’m not alone.

NAME/CITY WITHHELD

Dear Friend,

You need treatment for depression, immediately. Though you are right that the healthcare system is broken, and though you are right that the managed-care model has sent doctors in the direction of becoming pill dispensers, at the same time, as with any group, you will still find those who care about what they are doing, those who entered medicine because of a passion for people and for treating illness with a progressive, directed, holistic approach.

You need one of this type of doctor pronto. They do exist. Perhaps one of your family members or friends knows one. If it’s not a psychiatrist but a primary care doctor, that’s okay too, because a caring doctor in one field tends to work with caring doctors in related fields. Please do make every effort to seek help immediately. It’s critical that you do.