This is the last in what was once the BarMittzva Romba series aimed at Bar(ack) & Mitt. These have now been renamed as a series of Dances – Dancing as fast as we can, Dance to the Music of Time, Dancing In The Dark, Dance of the Sugar Plum Fairies, & Shadow Dance. Between them they reprise the plot of Pharmageddon.
In Malaysia, Dancing with Pythons is an art form. Women dance to music with a large python draped over and around them. Just like walking on burning coals, it can be done if you know what you’re doing. In this case the art lies in ensuring you do not let the python’s tail attach itself to anything. If the tail can grip something, the python will squeeze the woman to death.
Close to 20% of US GDP now goes on healthcare, up from estimates of between 1-4% in the 1950s. In the 1960s, the consumption of healthcare in the US, which was the highest in the world, made the country the healthiest and wealthiest on earth. Now US life expectancy has fallen below that of Cuba. Has the pharmaceutical python gripped on to something and is it squeezing the life out of us – literally?
Money spent that makes a population more economically productive by getting people off sick leave and back to work is an investment. Money spent that gives people illnesses they were not complaining off, puts them on treatments that make them less economically competent, treatments that cause more death and disability than they alleviate, comes close to being a tax on us and our jobs but paid to corporations rather than government.
With many treatments, we are doing the equivalent of ensuring as many people take prescription alcohol as possible, and take it indefinitely, and we are reaping the economic consequences that would likely ensue from such a course of action (Shadow Dance).
If the economics don’t force a rethink, there is a cost in alienation besides the economic cost that may. The marketing of drugs is changing the fabric of what it means to be human. There are endless egregious examples, such as the rediagnosis of the “terrible twos” as bipolar disorder.
But a key area, because it shows that it is possible to fight back, has been the struggles over female sexual dysfunction. Where once women fell in love, scientists now try to tease apart the components of female desire so that it can be turned into a commodity. Viagra it appears has the same effects on women as men, but the women are not as motivated by these effects as men. The answer apparently is to coat Viagra with testosterone to mimic estrous when females are more likely to respond to the effects of Viagra. If marketed, any benefits that may accrue to some women are unlikely to outweigh the alienation inflicted on all by a marketing that will reduce love to physiology pure and simple. The movie Orgasm Inc shows how women have been successfully fighting back against this.
Doctors are also alienated. Where medicine was once a vocation, for a growing number it has become an industrialized enterprise that makes them increasingly likely to be sacked if they try to practice good medical care. But it is difficult to envisage doctors rising up to put things right for this reason. They are more likely to act if they realize that they are being replaced by cheaper prescribers – provided they realize in time.
But unlike climate change or mass starvation in Africa, where the complexity of the problems induce paralysis in most of us, these problems are ones that we can solve. There are several key changes any of which would radically transform the picture.
Access to the data
The leading problem is that the market is not free. Unless the data on treatments can be accessed and are as comprehensive as possible, no other part of the market can be free. Given that science by definition is based on accessible data, a great deal of what passes for evidence based medicine at present as promoted by pharmaceutical companies can perhaps be described as fraudulent. However it is described, it is costing us money in return for which we are getting on balance more disability and premature death than benefit.
Our current failure to ensure access to the data puts current Western science on a par with the science of the Lysenko era in the Soviet Union where ideology dictated what the science said. Our healthcare has become as totalitarian as the Soviet state once was and as vacuous as the patent medicine era of the nineteenth century once was (Dance to the Music of Time).
Patents not fit for purpose
The problems that stem from data sequestration are aggravated by product patents. Companies would be well rewarded by product patents even were the patent office stringent in their determinations of utility and originality. Having a lax patent system combined with lack of access to the data is the worst of all systems. It is a system that could not be better designed for the purpose of transforming pharmaceutical companies into the equivalent of tobacco companies (Dancing in the Dark).
Why have things worked out this way?
It is possible that as a matter of strategic national interest the USA decided to try to attract the pharmaceutical industry to its shores, by relaxing the application of patent requirements so that companies could print money in return for drugs that were no more useful than bottled water. Whether by deliberate strategy or not, this is what has happened. The price Americans are paying is very high. Everyone else is at growing risk.
Randomized controlled fetishes
Any of the sticking plasters we apply to attempt to stop what is now a hemorrhage of money only aggravate the problem. The latest wheeze is comparative effectiveness research. This rests on misguided notions of what randomized controlled trials can do and fails to understand healthcare. It assumes that people have a greater desire to get from Washington to Seattle 15 minutes faster than to get there alive. Applied to an airline it is easy to see that being a slightly quicker but less safe airline is not a formula that will work. But somehow getting to the healthcare equivalent of Seattle a few minutes earlier is supposed to solve all our problems.
Effectiveness was originally a component of safety. One of the key conceptual problems at the heart of our current difficulties is the failure to realize that the market will work if it is a comparative safety rather than a comparative effectiveness market. This is not a precautionary principle argument. It encourages innovation and will reward it out of the wealth created by making people healthier – we will be wealthier if we are healthier.
But it does require a shift in perspective. We will need for example to think about guidelines for people rather than guidelines for diseases. Doctors are increasingly killing people very effectively by faultlessly following an ever increasing number of disease guidelines, the results of which are to exponentially multiply possible interactions between treatments and to set up a series of prescribing cascades. Extirpating diseases is not the goal; keeping people safe is.
Keeping doctors safe
Congress likely thought it was creating a comparative safety market when it made new medicines available on prescription only in 1962. It did create one – for doctors. They have had a guaranteed income as a result. It is more difficult than ever to take malpractice actions against doctors even as evidence accumulates that people are likely to be injured unnecessarily for a decade or more by new treatment induced problems owing to the inability of doctors to pick up these problems. We need to find a way to re-educate doctors, or reward them for keeping people safe, or else we need to consider abolishing prescription-only status for many medicines.
The market Congress envisaged in 1962 is at odds with the realities of health today. Congress viewed citizens as dupes, in need of protection. The advent of the internet has meant that many quite average citizens know more about their treatments than their doctors do.
We need new collaborative models of care that recognize this and harness the drive and energy of patients to making medicines safer. It is this “Yes we can” idea that has driven the development of RxISK.org.
I first heard about Dancing with Pythons from David Weatherall, then the Professor of Medicine in Oxford. He had been struck by it. But mistakes can happen and he later learnt that the woman he had seen dancing made one in a subsequent performance and died.