KOLAHUN

$1 a day

Meandering over the various open-access journals unlocked this gem from PLoS Medicine, where giants in the field (from the famous like Paul Farmer and Jeffrey Sachs to not-so-famous but no-less-valuable community workers) answer the following question: "which single intervention would do the most in the world to improve the health of those living on less than $1 a day?"

(picture from Flickr user Eclipse Pics)

Here are some of the responses:

Jeffrey Sachs - "In tropical Africa, a mass distribution of free long-lasting insecticide-treated bed nets to fight malaria accompanied by free access to artemisinin-based combination anti-malaria medicines. In other parts of the world, the situation will be different. I should add that I've spent years objecting to posing the question this way, since at low cost we could achieve major health advances through more comprehensive approaches."

Paul Farmer (echoing a recurring argument by Dr. AN) - "Hire community health workers to serve them. In my experience in the rural reaches of Africa and Haiti, and among the urban poor too, the problem with so many funded health programs is that they never go the extra mile: resources (money, people, plans, services) get hung up in cities and towns. If we train village health workers, and make sure they're compensated, then the resources intended for the world's poorest—from vaccines, to bednets, to prenatal care, and to care for chronic diseases like AIDS and tuberculosis—would reach the intended beneficiaries. Training and paying village health workers also creates jobs among the very poorest."

Mushtaque Chowdry: "Ensure two square meals a day; I believe for the poorest food is the most effective first intervention for health improvement."

Hector Garcia: "The greatest improvement in health will come from general education (i.e., not specifically health education); there will be an initial lag period (which is why politicians do not like it), but after that it should improve income, living conditions and use of health facilities—and money for its implementation can be made available if all sectors force decision makers to stop purchasing weapons."

Costs of Medicine

From the good people over at the Common Ground Health Clinic comes insulin prices from Wal-mart:

• HUMULIN 70/30 $37
• NOVOLIN 70/30 $41
• RELION/NOVO 70/30 $20
• RELION NOVO N $20
• HUMULIN N $37
• HUMULIN R $37
• RELION/NOVO R $20
• NOVOLIN R $41
• LANTUS $84

Now these are for 100U/ml x 10ml vials. 

On a related note, a patient came into clinic from the Tulane Hospital ER, where they diagnosed a UTI and empirically prescribed him Levaquin.  He feels much better after the Levaquin, but spent about $106 on it.  Meanwhile, the sensitivities of the e. coli that grew in his urine showed pan-sensitivity, including to bactrim...meaning an empiric treatment with Bactrim (or Cipro, for that matter) would only have cost this guy $4 at Walmart or Target. 

That being said, when told that his hypertension medicine, Cartia - for which he spends $60 a month, could be changed to excellent medicines at Wal-mart for $4, which in fact are the first line medicines per JNC-7...he hesitated on the verbalized belief that they couldn't work as well if they were cheaper. 

Conclusion: victory to the drug companies.   

UPDATE: Thank you very much to GCGeorge.net for including this post in the Medical Grand Rounds.  For visitors from the Grand Rounds...welcome.  Feel free to explore the site - which usually has at least one post a day on issues from indigent care medicine to international health to New Orleans topics.  And for my three loyal readers, please visit the Grand Rounds - it's always a great introduction to the breadth of wealth of medical blogging.    

Superboring: Impact Factors

Dr. LB, a bright young clinical epidemiologist, began to discuss the role of Impact Factors in publications yesterday.  Which obviously begs the question, um..."What's an Impact Factor?" Well, simply put it's the ranking of scientific journals based on citations.  The simple way to calculate it is:

number of citations/number of articles

SCI-BITES has a pretty comprehensive list of Impact Factors as does Dr. Popescu.  And clearly when one talks of such lists, one always wants rankings.  So here are a few from SCI-BITES:

By country (again showing the fallacy of US medical xenophobia, the US is not #1):

Rank	Country	Papers 1993-2003	Avg. citations per paper
1	Switzerland	142,982	13.24
2	United States	2,799,593	12.63
3	Netherlands	202,184	11.33
4	Denmark	79,929	11.14
5	Sweden	158,136	10.85
6	Scotland	96,571	10.75
7	England	619,707	10.74
8	Canada	370,928	10.25
9	Finland	74,106	10.17
10	Belgium	103,181	9.74

and for the most commonly read journals around these parts (from 2001):

• Annals of Internal Medicine - 8.25
• BMJ - 3.64
• JAMA - 6.03
• Lancet - 12.41
• New England Journal of Medicine - 19.68
• Pediatrics - 2.72

oh and the Journal of Healthcare for the Poor and Underserved - um...it didn't quite make the list yet...

New Disdain for the AMA

To the layperson, the AMA may seem like an ideologically infallible organization - a group of physicians working for the good of their patients.  But the truth may be that the organization really shills for a minority of clinicians and only carries the veneer of benevolence for its own (profitable) end.  Only recently, I was agnostic towards the AMA, even giving them the benefit of the doubt on some issues, but recent readings from two different clinical sources have soured me. 

The first comes from today's New York Times.  In the middle of a fairly forthcoming reflection on his own shortcomings as an ethical physician, Dr. Daniel Carlat offers this about the AMA's allegiance to profit over patient:

"The American Medical Association is also a key player in prescription data-mining. Pharmacies typically will not release doctors’ names to the data-mining companies, but they will release their Drug Enforcement Agency numbers. The A.M.A. licenses its file of U.S. physicians, allowing the data-mining companies to match up D.E.A. numbers to specific physicians. The A.M.A. makes millions in information-leasing money." (emphasis added)

Excellent.  The AMA, an organization whose mission is "to promote the art and science of medicine and the betterment of public health", feels that's it's in the best interest of the public's health to allow pharmaceuticals to better understand the prescribing patterns of clinicians so they can use tactical maneuvers to increase their products' market share.

But if these millions don't fill the coffers of the members enough, perhaps disguised advocacy in the form of promoting specialty reimbursement through it's RUC machinations will do the trick.  Dr. John Goodson breaks down this highly opaque and complex process whereby a group of representatives, including those from very the specialized fields of ENT, neurosurgery, and plastic surgery, set a large portion of Medicare's reimbursement schedule.  Needless to say, the RUC generally favors reimbursements for procedural work rather than primary care work - even though the vast majority of clinical research shows that primary care services are the most cost-effective clinical method of increasing the public's health. 

(Ironically, Dr. Goodson's commentary is in the AMA's journal - JAMA.  Unfortunately, this particular article hides behind JAMA's subscription service - but visit your local medical library and read the whole thing in the 11/21 edition.)

Love in the Time of Katrina

a couple came into clinic the other day; he a spanish speaking day-laborer who arrived here after the storm and she a native of the treme.  when the clinician asked him if he had a translator, he pointed towards her.  her idea of translating, however, consisted of vague gesticulations...her loud body language asking him to point where it hurt, 'la espalda', how it happened, 'cuando trabajaba', how long it had been there, 'por tres dias', and so forth.

she spoke less spanish than the clinician...he spoke less english. 

and yet, they'll have been together for two christmases this december.  they met when she saw him working on her neighbor's house.  she asked him to help her, one thing led to another...

...and the rest is the happenschance of love in new orleans after katrina. 

NIH Funding

A fervent non-reader of this blog brought up the concern that the NIH may be receiving funding from private sources, clouding their objectivity.  This appears not to be the case however, as the NIH gets one-hundred percent of its funding from the feds: "The National Institutes of Health (NIH) is an agency of the United States Department of Health and Human Services and is the primary agency of the United States government responsible for biomedical research."

Now looking over at the actual breakdown of how it has spent its money over the past few years reveals some oddities.  Here are some examples:

Item                            2003 (in millions)                     2008 (in millions)             Percentage change

• Alzheimer's Disease        658                                     642                        -3%    
• American Indians           108                                     152                          +40%
• Childhood Leukemia       70                                       53                           -25%
• Global Warming              0                                        58                           +infinity
• Lung Cancer                  296                                     265                         -11%

Well...I really don't have much analysis on this subject other than to dump all reasoning into the waste bag of politics - surely it's not due to any real or perceived incidence/prevalence disease fluctuations.  Perhaps it's the Bush administration's priorities and budgeting battles trying to get more money into the war-chest and the general 'privatization' milieu.  Perhaps this just occurs in a large bureaucracy with rampant infighting.  Or perhaps it's part of the internal struggle going on in the NIH, well documented in this editorial by David Resnick in 2005, where the nexus of public/private necessity tangles with the ethics of government employees being 'funded' by private entities. 

      

Non-patent Drugs by the WHO

I wanted to write another post on the subject of prize money for drug innovations rather than patents, but this Doctors Without Borders news brief explains the matter much more succinctly than I can :

"Today’s model, where the cost of researching and developing medicines is paid for through drug prices, means that drug development is steered towards areas where the profit rewards are the greatest, so diseases which predominantly affect developing countries are neglected. At the same time, patents are used to sustain artificially high prices for medicines, so many in need are quite simply priced out of the market.

The UN talks risk being derailed by opposition from some governments. Although this meeting is based on a World Health Assembly Resolution which puts intellectual property on the agenda, the USA and the European Union countries are questioning an expanded role for the World Health Organization regarding intellectual property and health. Some governments are also trying to narrow the scope of the meeting to a restricted number of diseases, whereas developing countries seek comprehensive solutions."

Now, I haven't researched the USA/EU position carefully (or at all) but I'd guess that they're scared of the 'slippery slope' of expansion of non-patent medicines for diseases which in the future may affect more of the world than just developing countries, like hypertension and diabetes, rather than direct opposition to the use of prize money for innovations of neglected diseases or HIV/TB/Malaria. 

Historical Pediatrics

I remember reading an essay a decade ago about the transfer of 'history' in the antebellum South through carnies and folklore and how people were able to digest the new news over days and months.  Over the last century, the news cycle has accelerated to an unbelievable pace, unfortunately leading to a societal 'mal-absorption' of news.  We get the news and before we're able to process it, there's a new story whooshing in on Fox News or beeping on the Blackberry. 

It's no different in the historical understanding of medicine.  Even the most revered figures can't penetrate the consciousness of today's clinicians: from Avery to Flexner, from Osler to Halsted, and from Fauci to Braunwald. 

The Journal of Pediatrics, one of the highly regarded pediatric journals and free on-line, is trying to reverse this trend.  Each month, multiple guest editorialists remark on the historical practice of pediatrics from 50 years ago.  Here's a recent one which describes the progression of strep throat treatment from intramuscular to oral penicillin - which, remarkably, is still the first-line treatment today:

Breese BB, Disney FA. J Pediatr 1957;51:157-63

The first patient treated successfully with penicillin was documented in 1942. By the 1950s, a single intramuscular (IM) dose of 600,000 U of benzathine penicillin G had been established to be highly effective in the treatment of β-hemolytic streptococcal infections in children. In a comparative study, the efficacy of the oral form of benzathine penicillin G was compared to its IM regimen, in what is now recognized as a non-blinded, randomized, prospective interventional trial. Children bacteriologically confirmed to have β-hemolytic streptococcal infections (n = 463) were assigned randomly to the IM regimen or to varying dose regimens of oral benzathine penicillin G. All cases were followed up for clinical response, and a repeat bacterial culture was obtained at 3 weeks. Clinical response with bacterial eradication was considered a cure, whereas failure included either recurrent streptococcal infection or throat carriage of β-hemolytic streptococcus at 3 weeks. The initial total oral dose given over an 8-day period was either 3,600,000 U in those <4 years old or 4,800,000 U in those aged ≥4 years. Interim analyses at 2-month intervals indicated statistically significant inferiority with the oral treatment arm that necessitated 2 further dose adjustments to 6,000,000 U and 8,000,000 U given over 10 days.

This study established the treatment duration of 10 days with oral penicillin in streptococcal throat infections. The oral form of benzathine penicillin is a poorly soluble salt of benzylpenicillin and achieves very low plasma concentrations. Oral benzathine penicillin G was quickly replaced by phenoxymethylpenicillin (penicillin V), a chemically improved form that combines acid stability with immediate solubility and rapid absorption.

Most β-hemolytic infections in children are due to Group A streptococcus. It is remarkable that even now the recommended drug of choice for such infections remains as penicillin (penicillin V, 800,000 U three times daily) for 10 days. Additionally, Group A streptococcus and other β-hemolytic streptococci remain exquisitely susceptible to penicillin. In terms of efficacy, subsequent studies and meta-analyses of randomized controlled trials in treatment of group A β-hemolytic streptococcal tonsillopharyngitis demonstrated bacteriologic and clinical cure rate significantly favoring cephalosporins compared with penicillin (OR, 1.83; 95% CI, 1.37-2.44, OR for clinical cure rate 2.29, 95% CI, 1.61-3.28, P < .00001). However, in the era of concern for antimicrobial resistance, cephalosporins have a wider spectrum of antibacterial activity and are often more costly, thus precluding their routine use in Group A streptococcal infections."

Read the rest at the Journal of Pediatrics and re-live the wonders of discovery which we now take as paradigm.

Photo by braimee at Flickr

Kickbacks or good policy?

One of the unsettled issues in health economics is the basic question of why private insurers don't use generics more.  Take for example, this chart from a Wall Street Journal article by Sarah Rubenstein:

Given the relative ease of acquiring this information, why wouldn't drug companies not necessarily drive down the costs of all medicines to the lowest retailer/wholesaler?  Moreover, why don't clinicians provide their own driving force to the lowest common price after reading articles like this? 

The answer may be hidden in this November 22 article:

"For the first time, the American Medical Association is warning that doctors who switch their patients off brand name drugs, including Lipitor, and onto generics could face criminal and civil punishment.  NewsCenter 5's Janet Wu reported that the warning from the AMA comes after numerous inquires from physicians nationwide. The AMA's answer could not be more clear.  A physician accepting payment from an insurer in exchange for moving a patient from a brand name to a generic drug could potentially face both criminal and civil liability exposure under the federal anti-kickback statute." (emphasis added)

What the fuck? 

The article goes on to put some of the blame on physicians in expecting to receive $100 to convert their patients to generics.  True.  The clinicians should be doing it without 'kickbacks'.  But who's behind this whole inane policy of subverting the conversion of unnecessarily expensive brand names to generics?  The AMA? Well, it has a written policy advocating for expansion of generics but there's much anecdotal history of untoward partnerships with PhARMA. Googling around a bit and scouring through the AMA on-line 2004 annual report lead to dead ends.  So is big PhARMA the culprit?  Perhaps, archaic Medicare regulations?

For right now the responsible parties remain obscured...but hopefully the story breaks further. 

The Same Old PhARMA story

These stories and posts are getting old (though no less important).  So I'm going to take a moratorium on discussing the corruptness of drug companies for a while after this little story from today's New York Times:

Prescriptions for the cholesterol-lowering drugs Zetia and Vytorin are written for almost 800,000 Americans every week, at a cost this year of about $4 billion. Yet it still is not clear how well the drugs work.

 

Nearly two years after the medicines’ makers, Merck and Schering-Plough, completed a clinical trial of the drugs, they still have not released the findings. The delay has led to a growing chorus of complaints from cardiologists. And yesterday, the companies responded by promising to publish a portion of the results next March — but not the entire set of data.

The article goes further to say that the study designers may be changing the endpoints, namely omitting atherosclerotic effects of the drug on the femoral artery while publishing the results on the carotid artery.  They initially designed the trial to report both.  And while the benign conclusion would be that just the results of the femoral aspect are unfavorable, I'll take the more malignant conclusion that the whole damn study is crap. 

The problem is that this kind of stuff goes on all the time in real life, and if you're sick of it, don't watch movies like this, where the central murder revolves around the falsified safety data of the fictional drug, Provasic.