Category: Politics of Medicine

Finally A Plan To Help With The Cost Of Drugs In The US

For decades the citizens of this country have been ripped off by the big pharmaceutical companies and their intermediary distributors. I’ve written about this previously (What’s Wrong With The U.S Health Care System?), but now with the stroke of a pen and by executive order President Trump has finally been able to do what preceding presidents and congresses have never been able to achieve. There will now be a system whereby the cost of drugs for citizens of the U.S. will be on a parity with other countries. This a great day for all of us whether Republican or Democrat.  Let’s see how his works. Here are a few of the key points. 

  • Health and Human Services (HHS) will end the “kick back” system that allowed  middle men distributors to jack up the price of drugs that are sold at the pharmacy. Medicare patients will see these “kick backs” as discounts in their Medicare Part D plan instead of the money going to the middlemen. 
  • There will be particular savings on insulin products dispensed through federally qualified health centers (FQHCs). This will be especially helpful to many uninsured or underinsured patients.
  • Through the Medicare program seniors in the U.S.  will pay no more for Medicare Part B drugs than patients in other economically comparable countries.
  • A pathway will be created for safe, imported lower cost drugs.

This plan may not solve all of the problems regard the high cost of pharmaceuticals in the U.S., but it is certainly a step in the right direction.  This is a step which previous presidents and congresses should have taken decades ago.  No longer will U.S. citizens be the only ones paying for the innovative research which the pharmaceutical companies often use as an excuse for the exorbitant costs of their products.

 

Drug Costs

What Have We Learned From Covid-19

Hopefully we are drawing to a close of the Covid-19 pandemic or at least getting it under better control although the recent rioting the country has experienced may be leading to a new wave of infections far worse than the resurgence that was previously predicted. Nonetheless, the pandemic seems to have slowed down a bit for now so now may be the time to reflect on the state of the pandemic and some lessons that we may have learned.

First, it is clear that we were by no means well enough prepared for an event such as this. We had had warnings that something like this might happen, but we failed to recognize the warning signs. SARS, MERS and the H1N1 viruses were the warning signs that a worse virus was likely to occur at some point in the future, and it did so in the form of SARS-CoV-2.

The orginal  SARS (severe acute respiratory syndrome) broke out in 2002. SARS first affected people in southern China, but it eventually spread to 29 countries. It apparently started in animals, but then spread to humans. There were at least 8,000 cases world wide, and it killed about 800 people giving it a death rate of about 10%. The SARS virus is very similar to the current  SARS-CoV-2 virus which causes the illness that we now call Covid-19, but by 2003 there were only 8 laboratory confirmed SARS cases in the US. H1N1, otherwise known as the swine flu, is a different type of virus more closely related to the influenza virus. Between 2009 and 2010 it caused 60.8 million infections in the US and 12,469 deaths. Another coronavirus (MERS-Cov virus) first reported in Saudi Arabia in 2012 also caused a severe respiratory illness known as the Middle Eastern Respiratory Syndrome with (MERS). Only two people in the US have been know to come down with this virus and both survived. 

The U.S. should take Covid-19 as a warning and start preparing for the next pandemic as soon as possible. There are many reasons why this is likely to occur. Spontaneous mutations of the Sars-CoV-2 virus and introduction of new viruses from the wild into human populations are just a couple of reasons why this might happen. Given the interconnectivity of people traveling throughout the world, the spread of a new contagious virus in a pandemic fashion is very likely to occur. Shi Zhengli, a Chinese virologist, has warned that we are now dealing with the “tip of the iceberg” when it comes to impending viral epidemics.

This should tell us that we need to expand work on antiviral agents that will have as broad a spectrum as possible in terms of antiviral coverage especially since vaccines take a long time to develop and are not effective once the virus has taken hold in a patient. Think of vaccines  as preventive treatments, but treatments that may need to be changed frequently since the vaccines are often very type specific. We also need to develop better pharmacologic agents that will block entry of the virus into the cell so that it does not have a chance to propagate within the cell,  and treatments that interfere with the replication of the virus if it indeed manages to enter the cell.  Furthermore, we need to work on developing treatments for effects that the virus has on the body if it manages to enter the cells and replicate. This is what triggers intense inflammatory reactions such as the “cytokine storm” and “the multisystem inflammatory syndrome.”  So from a patient management point of view we need to work on three things: better antiviral agents with a broad spectrum of coverage; the ability to adapt manufacturing processes for vaccines quickly because the virus will change and new ones will appear; better regimens for treatment of the effects of the virus once it enters the body. Of course all of the above has to be achieved in such a way that we are never dependent on a foreign country, much less a potential adversary, to supply us with the medicines, vaccines or anything else needed for us to treat another pandemic. 

We learned that social distancing, as controversial as it may be,  likely had great impact on the mitigating the spread of Covid-19, and it is a practice that in all likelihood should be implemented again quickly as soon as the next pandemic arises.  The current pandemic showed us that certain areas of the country were more impacted than others for a variety of reasons that we are still being investigated. 

Very importantly this pandemic was also a lesson in logistics that should not be forgotten, and it goes hand in hand with the evidence that not all parts of the country were similarly affected by this virus. There has to be mobility in terms of the delivery of healthcare in any crisis situation we may face in the future so that we can deliver medical personnel, equipment and medications where they are needed. This includes the ability to to get mobile hospitals up and running anywhere in the country they may be needed. We demonstrated some of that capability when the Javits Center in New York was converted into a hospital, the hospital ship Comfort arrived in New York and Samaritan’s Purse set up camp in Central Park to help out with the hospital bed shortage. However, for reasons that are as yet puzzling and distressful, none of these facilities was used effectively in terms of terms of relieving the overwhelming burden of the those city hospitals that were inundated with Covid-19 patients.  For future medical catastrophes, which are sure to come, we need to be able get mobile hospitals up and running quickly wherever they may be needed. 

 

 

 

The World Health Organization

WHO and the Covid-19 Pandemic

What did the leader of the World Health Organization know and when did he know it?

First, let’s look at some background information about the World Health Organization and it current director general Tedros Adhanom Ghebreyesus.

What is the mission of the World Health Organization (WHO)?  According to its charter it is supposed to “aim for the attainment by all peoples of the highest standard of health.”  It’s object is “to improve peoples’ lives and reduce the burden of disease,” and it is supposed to be the “coordinating authority on international health.” However, regarding the coronavirus pandemic it has failed miserably in its stated objectives. Much of the responsibility for this failure can be laid at the feet of its current Director General, Tedros Adhanom Ghebreyesus.  He is not a physician though he has a master’s degree in immunology and PhD in community health from colleges in Great Britain. He is Ethiopian and served as minister of health in Ethiopia from 2005-2012 and then minister of foreign affairs for Ethiopia from 2012-2016 following which he became Director General of the World Health Organization in 2017. It should be noted that Tedros Adhanom Ghebreyesus, who apparently according to Ethiopian tradition prefers to be addressed as “Tedros,” won the election for Director General of the World Health Organization largely because of the support of China which may explain why the WHO has seemingly become a tool of China in regard to the current coronavirus pandemic. It should be noted that the U.S., Canada and the UK supported British physician, Dr. David Nabarro for this position. The U.S. has been by far the largest financial supporter of the WHO for decades.

Tedros’ tenure as Director General of the WHO and before that as health minister for Ethiopia has not been without controversy.  The most recent of which has been his handling of the coronavirus pandemic (see below). While minister of health in Ethiopia he was accused by some of his country men of covering up Cholera epidemics. The organization “Human Rights Watch” also criticized Tedros during his campaign for the Who Director General position accusing him of being a proponent of an authoritarian regime in Ethiopia that persecuted its political opponents (Tedros). At one time he appointed Zimbabwe dictator Roger Mugabe as a goodwill ambassador for WHO. His appointment of a Russian to head WHO’s tuberculosis program was also regarded as controversial because of Russia’s poor history of tuberculosis management. Putting aside some of the controversial issues regarding his tenures as health minister and foreign affairs minister for Ethiopia, let’s focus in on how his actions concerning the coronavirus led to a worldwide pandemic.

How WHO’s Actions Promulgated  the Coronavirus Pandemic.

To do so Let’s look at the timeline beginning when the virus first arose in China.

  • Various reports suggest that the first case arose in Wuhan, China in early December or perhaps as early as November
  • December 30, 2019 an ophthalmologist at Wuhan Central Hospital alerted other physicians about the emergence of a SARS like illness. He was subsequently detained by police. Reports indicate that China also took measures to prevent information about the human to human transmission of the disease from being disseminated by people in its medical and scientific communities.
  • In late December 2019 the Wuhan Health Commission reported 27 cases of viral pneumonia.
  • On December 31 the Taiwan government contacted WHO and expressed its concern that that there was human to human transmission of this virus. WHO ignored this report in deference to China because Taiwan is not an official member of the WHO and China does not acknowledge Taiwan’s independence. 
  • January 1, 2020 Wuhan official close the Hunan wet market in an apparent attempt to blame the wet market as the source of the infection as opposed to the virology lab in Wuhan. We now know that it is much more likely that the virus somehow escaped from the Wuhan Institute of Virology either accidentally (or intentionally if  you suspect that China has some ulterior motives).
  • Beginning in January  2020 China begins a campaign to acquired more medical supplies in anticipation of the pandemic occurring.
  • By January 14 the WHO is still reporting that investigations by the Chinese found no clear evidence of human to human transmission. This is the official position that the Chinese maintained until January 21 in spite of protests to the contrary by some of its own physicians and scientists. However, internal documents obtained by Associated Press indicate that Chinese officials knew a pandemic was occurring much earlier (AP) .
  • The Chinese New Year was on January 25th. Many Chinese returned to Wuhan in January to celebrate the holiday after which they returned back to various parts of the world where they were living and working carrying the virus back with them to be disseminated throughout the world.
  • Jan 23 China puts Wuhan in lockdown. Chinese nationals can apparently leave Wuhan for other parts of the world, but are prohibited from flying to other parts of China in an obvious attempt to prevent the spread of the virus within China.
  • Jan 21 First Case Confirmed in the US.

At no point through all of this did the World Health organization under Tedros leadership raise any warning signs about the coming pandemic. Instead, it took the World Health Organization until March 11, 202 to declare the pandemic (WHO).

 

 

 

 

 

 

 

Pandemic

Capital Hill and the Politics of the Pandemic

Where Do We Go from Here?

Yesterday we heard from our scientific leaders and our leaders in Congress about plans for handling the Covid-19 pandemic, but it still seems that we are just feeling our way as we go along. To a large extent that may be all that we can do.  However, are we really emphasizing what we should be emphasizing ? There are some basic facts that we do know about this pandemic even though there is a lot that we do not know. For example, we know that this coronavirus is more communicable that the influenza virus and potentially more deadly. Based on the history of prior flu pandemics we know that this pandemic is likely to last one and half to two years assuming that there are no major mutations of the virus. Also, based on past history we know that the pandemic will not be over until somewhere between 60-70% of the population is immune either because of vaccination or naturally occurring infection. We know that a vaccine will take a least a year to develop, but it is also likely that it will take much longer to really find out if the vaccine is effective. In addition, it is likely that there will be different vaccines by different developers, and it will take some time before we know which is best. One other thing we really don’t know yet about this pandemic is whether infection or vaccination will confer long term immunity, and this makes it even more imperative that medications be developed to treat the active infection and its sequelae such as the so -called “cytokine storm” and the new Covid -19 related “Pediatric Multi-System Inflammatory Syndrome.”

So where do we go from here? Instead of spending trillions of dollars on fiscal stimulus packages, concentrate on TESTING. The sooner we have the ability to provide universal testing both for the presence of the virus and for antibody titers to detect prior infection, the sooner we define who is at risk and who has presumably had the infection and is likely to be immune. We have come a long way in terms of testing both for antibody and actual virus, but the sooner we have universal testing the sooner we can get everyone back to work and resume a more normal societal pattern. Identify those who have the virus and are presumably carriers. Isolate them as best we can until they are clear of the virus. That should slow transmission. Identify those who have had the virus and are presumably immune. Allow them to go back to work and maintain mitigation practices. Allow those who test negative to also go back to work while they likewise continue mitigation practices. If we do this, we can slow progression of the pandemic until we have better anti-viral treatments and vaccines. We can get people back to work,  and we can begin to resume more normal lives. If we don’t do this, we hasten the onset of economic catastrophe and the collapse of our way of life. 

The importance of getting the country back on its feet as quickly as possible cannot be overestimated. That means letting people go back to work, resume normal activity as much as possible and socialize. Testing is the the way to do this while we develop vaccines and treatments. If we don’t do this soon, will have no economy, no stability, no future and no country. We have the resources to ramp up testing and that is definitely what we should be doing at this point. Testing should become so easy that we can go to the drug store or our local doctor and get the test for both the antibody and the virus any time we want. Instead of spending trillions on subsidies and loans, let’s spend a large portion of that money on the testing we need. We have definitely increased the testing over the past few weeks, but we can do much more.  Testing needs to become so easy that any one at any time can get it done. We have the testing technology down. We just need to mass produce the tests. It can be done. Let’s spend the money needed to do that instead of pouring all the money into subsidies and bailouts. Once we do that, we will have gone a long way toward solving the problem of who can go back to work and who can enter society.  Identify those who are risk, especially the elderly and those with predisposing conditions, and isolate them when needed to protect them. Identify those who have had the illness and are potentially immune so they can go back to work. Identify those who are carriers and sequester them until the carrier state is resolved. While we are doing all of this, we continue to work on vaccines and improve them. We continue to work on antiviral medications and the medications needed to treat the various conditions associated with this infection. Spend our money on doing these things, and we will come out winners in the long run with much less of a national debt.  If we delay the testing and identification, the pandemic will last longer than it should while our economy and country continue to suffer.