I live in the state of Washington. I’m on Medicare. My primary-care physician tells me he loses money each time he sees me because what he gets from Medicare doesn’t cover his costs. He says that what he would get from Medicare would be almost two to three times as much if he were practicing in California. He also says the rates in Washington are lower because this state has a lower cost per patient. It seems like the doctors are in a Catch-22. The more he keeps costs down, the less money he gets from Medicare! Is this indeed the case?

JAC WYMAN Kirkland, WA

Dear Jac,

It is true that the Medicare system needs to be adjusted with more attention devoted to prevention and more incentives for cutting down on unnecessary testing. Also, overall doctors’ Medicare fees have been cut in all states in a way that does make it difficult for many doctors to practice and maintain their lifestyles.

At the same time, I am not as sympathetic as you might expect to bellyaching doctors with their eyes on the bottom line. Medicine is supposed to be a passion, a calling. I’d rather hear about doctors who have difficulties saying goodbye to certain patients because they’ve grown attached to them. Being educated to study the human body and being able to dispense care and get paid for it is a privilege, and the best doctors realize this. I am sympathetic to the mountainous paperwork, strain and excess demands that practicing modern medicine in the United States today seems to entail, but I don’t think the current Medicare scales are going to drive any physicians into poverty.

I was recently diagnosed with polycythemia vera. I am told it is a rare disease, but you wouldn’t know it from the numbers of people who tell me they know someone who has it. My doctor told me he thinks the disease is more common than is reported, but he insists it is indeed rare.

Given the horrible increases in toxins and other pollution, do you think the changes in the environment might be causing an increase in polycythemia vera?

RICHARD NATHAN Burbank, CA

Dear Richard,

There is some reason to believe that p vera, a pre-leukemic condition (which may well not progress to leukemia), is on the increase, and that this rise is related to environmental toxins, particularly given the evidence that these conditions are more prevalent in industrial areas. Far more research needs to be done to confirm these trends, but their presence should be a matter of grave concern and research.

I am a disabled World War II vet. I suffered a sacroiliac strain in the service and now have arthritis in my neck, back and knees. Nothing helped until I began using a duragesic patch, which works much better than anything I tried previously. It is rather expensive and the veterans hospital does not have it since our President started cutting funding to the VA. I am concerned about how long I can afford this medication. Do you know of any other medications that might help? I am 83 years old, so I will probably be dead before any cure will be found, but I would appreciate any information that you might have.

PAUL PETERS Phoenix, AZ

Dear Paul,

Pain is a complex subject. Duragesic can be very effective for chronic pain, since each patch lasts for seventy-two hours, but it is a narcotic, which means it has addictive potential. It is not all that dissimilar in many respects from morphine or Percocet, and I am wary of long-term use without monitoring by a pain specialist. This is separate from your other point that funding is being cut to the VA system, a woeful prospect for such a dependable source of healthcare and research in the United States, and another sign of the Bush Administration’s callous disregard.

I understand that mad cow disease is spread by the processed meat of dead infected cows being fed to living cows. Years ago, when I started a small garden, I was presented with a book on organic gardening. One of the homemade insecticides is startlingly similar to the method of spreading mad cow. If the garden was attacked by a particular pest, the gardener was to collect by hand as many specimens, living or dead, as he could. He would fill a blender with the bugs and some water and let it rip. The resulting slurry would be watered down to be an effective spray. The idea here is that the pathogens that were living in the collected bugs would be sprayed onto the plants to increase the chances that the pests would absorb enough of the pathogens to sicken and die. I would imagine that this recipe is in any organic gardening book.

WILLIAM METCALFE Arlington, VA

Dear Wllliam,

Interesting analogy. I do see your point. It seems to me that the screening of large numbers of sick-looking cows for prions and many other diseases that are far more prevalent than mad cow is a reasonable course of action. Feeding any sort of cow product to cows is unnatural (cows are natural vegetarians) and should be banned. Cows are herbivores; they are supposed to eat grass. We’d have a lot fewer problems with beef if we kept to the natural order of things.

A recent issue of the AARP Magazine contained a notice that kidney failure may be caused by excessive use of aspirin. Is this true?

DOROTHY SAXE Austin, TX

Dear Dorothy,

In a word, yes. All analgesics may cause kidney failure if used excessively or regularly over a long-enough period of time. Though the current state of world affairs gives us all a headache, I would urge cautionary use of all analgesics, under the direction of a trusted physician.

In September 2003 Pfizer manufactured and distributed a new form of Nardil without informing pharmacists, physicians or patients. The “new” Nardil contains the same 15 milligrams of phenylzine sulfate/tablet but the excipients have been dramatically altered. I have been a Nardil user for sixteen years. After fifteen years of suffering from panic disorder and depression and trying every antidepressant and tranquilizer in the PDR with no positive results, a doctor finally prescribed Nardil. I have led a panic/depression-free life ever since.

In September I started the new Nardil. The tablet looked different but I assumed it was just different packaging. After a few weeks, I noticed some depression returning and suffered one panic attack. I assumed that the stresses of my new “empty” nest and other midlife crises were probably simply taking their toll. But when my mood did not improve I went to the web to see if I could find any information. Pfizer had recalled some subpotent Nardil in the past couple of years, so I was interested to see if any had been recalled recently.

My Google search led me to an Internet forum where about twenty Nardil users had gathered to discuss the new Nardil and its efficacy problems. Some of the people were suffering quite severely, having returned to deep depressions. Others were more like me, in that the new Nardil seemed to work somewhat but didn’t have quite the same effect as the older formula. We’ve of course contacted the FDA and Pfizer, as well as consumer drug-watch sites. We’ve sent samples to Pfizer for analysis at their request. We’ve written to senators and representatives. So far, no adequate response to our complaints and inquiries has been received.

Each day brings more Nardil users to the forum. I worry that some Nardil users and their doctors simply don’t suspect that the drug is responsible for their current problems. As I’m sure you know, Nardil is an old drug and not widely prescribed, but for those of us for whom it works, it’s by far the drug of choice.

I would be most grateful if you could suggest any other avenues we might take to either persuade Pfizer that there is indeed a problem with the new Nardil and/or to alert the medical community to the problem.

PAULA ROBINSON Cleveland, OH

The best I can do on this is publish your letter. I’ve reviewed the website, and there do seem to be some difficulties with some recent Nardil preparations, as you discuss. I do not know if Pfizer has adequately addressed this going forward, but quality control and consistency of medication preparations is a crucial part of healthcare, as you don’t need me to tell you.