From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology,talk.politics.medicine
Subject: Re: selling sickness to the well
Date: 2 Aug 2005 18:57:28 -0700
Message-ID: <1123034248.739102.250930@o13g2000cwo.googlegroups.com>

William Wagner wrote:
> Look at the reviews here some time.
>
> http://www.amazon.com/exec/obidos/tg/detail/-/0375508465/qid=1123018096/s
> r=1-3/ref=sr_1_3/002-7144342-8957643?v=glance&s=books


COMMENT From a doctor of medicine:

I don't think my blood pressure can stand much of this book. I'm taking
a "me-too" blood pressure drug, too. But one that (at last) has no side
effects. According to this book, I'm deriving no benefit from the stuff
(since consumers are said not to benefit from me-too drugs), and thus,
I should still be taking Aldomet, or whatever the proto-primal blood
pressure pill is considered to be.

Well, I refuse to take Aldomet. Marcia Angell is a physician and former
editor of the New England Journal of Medicine (NEJM). Supposedly, that
makes her uniquely qualified to write a nasty book about drug
companies, which she has. But somehow, she appears to have quit paying
attention to her own professional behavior. For example, I'll bet she
doesn't prescribe Aldomet for all her hyertensive patients, either, but
instead something developed in the last couple of decades (i.e., a
me-too drug). Of course, it's rather difficult to define what a me-too
drug is. Dr. Angell opines that it's a minor change in a same basic
molecular entity. Sort of like the difference between Vioxx and
Celebrex, which is to say, the drug now off the market due to side
effects, vs. the one still sold. Or perhaps between Rezulin and
Avandia. You remember Rezulin?  The premier drug in its class, now off
the market for causing liver failure?  Which a little tweeking of the
molecule prevented.  It seems there's a problem with Angell's
argument-- it costs a lot of money to do tweaking, and tweaking is how
people in technology get things right. Dr. Angell wants people to just
stop that tweaking. At least when it comes to drugs. So perhaps we
would and should be stuck with Rezulin and Vioxx, and perhaps Inderal
and  penicillin G?

But who will we blame for THAT?

Dr. Angell spends some time arguing that drug companies spend all their
research money on me-too drugs for high blood pressure and depression,
instead of drugs for killer diseases in third world countries. But, now
a second problem: WHY exactly are the third world's medical problems to
be laid at the door of drug companies? After all, the agricultural
industry in the West spends a lot of time putting expensive foods like
steak and ham on the tables of Americans and Canadians, while children
in African starve for lack of  a little of the grain we feed these
expensive animals. But why don't we read about "me-too Canadian Bacon"?
 Strangely, there are no progressive books about "Big Farm-a" in which
the starving children of Africa are discussed. Why?  Because even the
Left cannot go that far, without losing their straight faces.  And
ours.

So what is so special about the technology of the drug industry, which
allows this kind of argument to happen? Which allows an entire
industrial sector in the West to get blamed for some of the poverty in
the Third World (say what??).  My own feeling is that it's because most
of us understand food a little better than drugs, which is why we end
up listening to doctors like Angell when it comes to judging drugs. And
why we don't feel that the average North American farmer (say) has some
secret black spot of evilness and greed which presents him from
thinking about starving Africans rather than ham-eating Canadians. But
are willing to allow that the same may not be the case with drug
company executives....

And so we come to another problem. Just how ARE the public and doctors
to find out about the latest medical research involving drugs?

Dr. Angell doesn't like most drug advertising. Certainly not direct
advertising to patients, so that means she really wants doctors to
control the information flow. And she doesn't like drug company
advertising even to doctors when it involves giving them small gifts,
or even taking up much of their time.

However, it seems that time reading ads in magazines is not to be
counted.

Here is the problem. Dr. Angell was editor of a journal which informs
doctors of the latest breakthroughs in medicine (that's education!),
but that journal, the New England Journal of Medicine, would simply not
survive without massive drug company advertising. Most of their bills
are paid that way, just like the doctor-education companies that Dr.
Angell has problems wants to do away with. Therefore, it is a fact that
Big Pharma paid most of Dr. Angell's salary for years. Thus, not only
did drug company money make the modern NEJM possible, but Dr. Angell
herself spent a long time sucking full strength on the drug company
money teat, while now accusing doctors of putting a little milk in
their coffee.

Now, it would be one thing if Dr. Angell had seen the light, had the
scales fall from her eyes, and had lost her job as NEJM editor in a
titanic battle to wean them from drug company advertising. I would love
that story! But if that happened, the story would be too good to omit
from her book, and it's not there. So I presume it didn't happen
(unless the woman is not only saintly but modest also--corrections
invited). Instead, I presume she left her job or was fired, and THEN
began to become angry at the money people behind what she did for a
living. That's a much more familiar and human story.  But one expects
people who live it, to have some self-insight.  Dr. Angell worked in
the very industry that she wants to destroy in its present form, which
is getting information to doctors on the ticket of Big Pharma. It's one
thing to do something antisocial (though profitable) for a living, but
it's something else to be fired and THEN suggest that everyone ELSE not
do it. Please!

We'd all like drug companies to not pay for so much medical education,
myself included. It distorts facts. But Dr. Angell made her living as a
broker at this game, and never found a solution for it, except to quit
or be kicked out. Nor does she really suggest one in her book, either,
apparently, except that doctors need to spend their own money. As
though doctors didn't already spend enough on their educations. I don't
think THAT will work.

I want to be fair. This is not to say that some of Angell's "fixes"
don't make sense. It would be good (as Angell points out) if the NIH,
in their grant processing,  looked very hard at the design of trials to
make sure that generic drugs and non-drug therapies didn't get short
shrift in therapy trial designs. And it would be nice if the FDA's
regulations didn't put the economic bar so high on development of new
drugs.  But a book fully addressing all this would have had to put the
"blame" in many places for the distressing fact that we know more about
new drugs than we'd like to in medicine, and less that we'd like to
about almost everything else.  And some of that blame would have to go
to places where drug companies could not be blamed for it.

The truth is the FDA has every incentive not to speed drug development
if it carries any risks, even if they never took a nickel from Pharma.
Why? Because the FDA isn't ill or dying, and the only pain it feels is
political pain, when it approves a new drug which causes problems
later. So the immortal FDA is naturally far more conservative than
patients and doctors are about trying new treatments, and that's not
good. A book about drug-related evils in the medical world should at
least acknowledge this very simple one.

I have a last problem with this book, and that's one of economic
honesty. Dr. Angell looks at the profits the top 10 drug companies made
up to 2002, and then cuts off her analysis there. But those same
companies took quite a beating in 2003 and 2004 (Vioxx!), and some
notice of that in the book, would have been instructive. It's not like
the data had no time to make into the manuscript in this electronic
era-- these companies report quarterly, and we well know editing is now
done by email at the speed of light. Basically, the latest drug company
profit figures were inconvenient to Dr. Angell's arguments. But leaving
out inconvenient data is dishonest.

Here's an economic truth that Dr. Angell doesn't confront. Drug
discovery is risky, and (despite what you would think from this book)
there is in fact no license which congress has somehow given the drug
companies which allows them to print money. (A license to practice
medicine would actually be closer to such a thing, but I won't go
there).

The point about Big Pharm and its supposed guaranteed profits, should
be obvious. Why?  If it weren't true, then anybody who needed money in
medicine could simply make all they liked, by **investing in a small
stock fund made of the 10 top drug companies.**  The NEJM could do this
to run itself, and could then stop accepting specific drug advertising.
Medical schools could do it, and could then stop accepting deals with
specific drug companies. Even people feeling the pinch of expensive
drugs in their lives could make up for it, by re-financing the home and
putting the proceeds into a pharma sector stock fund, and then simply
using the profits to buy Crestor with. There's not limit: charities who
want new drugs for children in African could finance their development
with drug company stock-funds also. It's all so simple, if the world is
as Dr. Angell paints it.

Except, in real life, it wouldn't work. In real life, the last two
years would have bankrupted anybody who wanted to try it. And when Dr.
Angell comes to grips with this simple fact, she (and all who criticize
the fat-cats in pharma) will have a better understanding of just how it
is that we win even the knowledge of drugs that forms the basis of
standard medical practice. Fact: we do it at great risk. And if you
don't think so, let's see you put YOUR money where your mouth is.

When we win the knowledge of how to treat a disease with a drug, we do
so ONLY because our legal system has "figured out" how to make people
who benefit from the knowledge, pay for it.  When we stop doing that,
new knowledge will mostly go away (I won't go into that, but see the
case of India, which suffered a 95% collapse in drug discovery when
they temporarily stopped protecting it with IP rights). The solution,
then, is not so much to attack medical drug and device companies, but
to adopt some of their methods, and to structure a patent system and
discovery system which will allow the drug industry's methods and
progress to become available in ALL areas of medical care. THEN, we'll
really have medical progress, which is knowledge progress, on all
fronts.

Steve Harris, MD
(And no, I don't work for the pharm industry, and never have).

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology,talk.politics.medicine
Subject: Re: selling sickness to the well
Date: 3 Aug 2005 08:42:53 -0700
Message-ID: <1123083772.972863.277780@g44g2000cwa.googlegroups.com>

george conklin wrote:
>    There is no reason why the AMA's expenses have to be so high that they
> need to depend on drug advertising to run a journal.  Other disciples have
> loads of journals which run quite nicely without ads, mainly because they
> are not available or needed.


COMMENT:

Oh, really?  Okay, George, let me call you on that. Name me some
peer-reviewed professional journals that go for $3.50 an issue to
non-society members (since otherwise society dues count), and which do
not charge a per-page publication-defrayment charge to authors (which
in many other smaller medical journals goes can run $70 to 100 per
page), and carry NO advertising. This should be amusing. Don't try to
BS me, because I *WILL* check what you come up with.

>If the
> AMA wanted to get rid of drug ads, it could do so tomorrow and survive
> nicely.  ASR and AJS do not do drug ads....no need.

COMMENT:

Another person deciding what other people outside their profession and
institutions, of which they know nothing, NEED.

Are you Canadian, George?  Or just one of those academic socialists who
is disconnected even from the finances of the academic institution he
belongs to?

You're certainly not a department chairmen, or you wouldn't be so
cavelier about how much money people and institutions NEED to opperate.

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology,talk.politics.medicine
Subject: Re: selling sickness to the well
Date: 5 Aug 2005 20:08:28 -0700
Message-ID: <1123297708.544730.26640@g14g2000cwa.googlegroups.com>

MassiveBrainInjury@SleazyISP.edu wrote:
>> Dr. Angell wants people to just
> >stop that tweaking. At least when it comes to drugs. So perhaps we
> >would and should be stuck with Rezulin and Vioxx, and perhaps Inderal
> >and  penicillin G?
>
> Harris, you're great at pointing out logical fallacies and assigning
> their Latin names (such as "post hoc ergo procter hoc"). How about a
> name for taking an exception and presenting it as the general rule or
> in this case arguing that because some exceptional item deviated from
> the point the author was trying to make that his/her generalized
> argument was totally wrong.
>
> Further, how about a more sophisticated term for disingenuousness?
> Maybe in Latin or the original Greek?
>
> This "Not a doctor of medicine" (or of anything else for that matter),
> little me, can give you two off-the-cuff me-too drugs just out of his
> own knowledge: Cialis and Levitra. Me-too drugs from Lilly and Bayer
> respectively "too-ing" Pfizer's Viagra. [....[ Could we (the consuming
> and largely ignored public) have spent this money more wisely in
> dealing with the other impotency-related problems (presuming you keep
> it in the same general area)?


COMMENT:

Fine, there hasn't been a huge improvement in ED drugs, yet. However,
the field is young, and I think you're behaving in the mode you accuse
me of. I can out-example you, if you want to go point for point, I
promise.

I think my general point stands, and if I gave only a few examples it
wasn't because I only had a few, so you point above is groundless. I
already mentioned beta blockers, penicillins,
thiazolidinones/PPAP-blockers. Here are some more:

Tricyclics: the newer ones are significantly better than amitryptalline

SSRIs: newer ones arguably better than Prozac, though I'm on weak
ground here (I admit it).

Oral hypoglycemic agents that stimulate insulin release:  the prototype
sulfonuria drugs once often killed people with severe and prolonged low
glucoses-- there were more deaths from hypoglycemic shock from
chlorpropamide/Diabenese than insulin itself. That no longer happens,
by and large. The newer drugs are a lot safter.

ACE inhibitors--- Captopril was and is a good drug, but the once-a-days
are better and smoother. The same goes for the new once-a-day ATBs.

Cephalosporins-- things have come a long way since Keflex.  Whole
classes of bugs that Keflex didn't touch like H.flu and Pseudomonas can
now be treated.

Ever taken erythromycin estolate? Ouch! Then you'll appreciate the
newer macrolydes. The newer tetracylines are a distinct improvement
over plain tetracycline also. Try taking a 4-times a day drug on an
empty stomach, which hurts on an empty stomach.

The high potency steroids are big improvements over trying to use
cortisone skin creme.

The newer flourinated ethers are much less toxic than the original
halothane.

Diflucan is a vast improvement toxicity and brain-penetration-wise over
the old oral ketaconozole.

The newer H2 blockers won't lower your testosterone like cimetidine.
(As for PPIs, I don't think they've improved on Prilosec much, BTW,
that's a point to you)

These are off the top of my head, but without going through the whole
PDR, I'd say that major improvements in drug classes over the prototype
molecular entity are the rule, not the exception. The prototype
fluoroquinolone wasn't really good for anything but UTIs; Anthrax would
have laughed at it. Cipro came later.

We can have a separate argument over this--- I happen to think that our
present patent system which allows the prototype to be displaced by the
Johnny come lately drug in the same class that finally gets it right,
is probably unfair and interferes with innovation. But that's a basic
problem with our world PATENT system which punishes quantum leaps of
innovation. It's not JUST a problem in medicine--- this is medicine's
manifestation of a far larger intellectual property problem. Aim your
invective at the proper target.


> You mean the mis-allocation of resources? Failure of the capitalist
> system, dumb politicians, horrible electoral system, dumb voters, poor
> education, venal doctors, ... the list is endless.


COMMENT:

For YOU, maybe. But I see nobody to blame, because there's not really a
problem. Does anybody complain about "misallocation of resources"
because we have a bunch of "me too" trucks besides the Ford Pickup?  Or
SUVs beyond the venerable Blazer and Suburban?  Think of how much
development money carmakers squander in not collectively having one or
two good entries in each major car class. Shouldn't we make them all
specialize, and save all of that?  And look at what they pay for
advertizing. If they didn't spend all that money during the superbowl,
wouldn't you pay a lot less for major autos?  Can we look at money
spent for R&D vs advertising for *automakers?*  Do we care?

You seem to think there's something odd about drugs that doesn't apply
to food or cars or any other consummer item. But you have yet to
identify what it is.


> What I don't understand is why the drug industry doesn't make use of
> the starving Africans to test our drugs. They're starving in Niger at
> the moment according to the news. OK round up a few thousand
> Niger-ians (hmmm, wonder what they call themselves?), put them in
> interment camps, feed them food and feed them (say) Vioxx until it's
> coming out their ears. Much better testing than debating the
> significance of a few points in some pussy US sample that has so many
> flaws you could drive a truck through it. A few die. Shrug! Might want
> to follow the lead of Walmart though and use local contractors.

COMMENT:

Your modest proposal is more logical than you know. The antithesis
keeps us from using foreign workers in poor conditions (ie,
"sweatshops"), when the alternative is that their conditions are even
worse when they have no job and starve. But better to have them die
politically correctly than live and be exploited by capitalists.


[Other points addressed later]

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology,talk.politics.medicine
Subject: Re: selling sickness to the well
Date: 5 Aug 2005 21:45:06 -0700
Message-ID: <1123303505.973595.251880@o13g2000cwo.googlegroups.com>

Kurt Ullman wrote:
> In article <1123297708.544730.26640@g14g2000cwa.googlegroups.com>,
> Steve Harris <sbharris@ix.netcom.com> wrote:
>
> >SSRIs: newer ones arguably better than Prozac, though I'm on weak
> >ground here (I admit it).
>   The interesting thing with the SSRIs isn't so much that the
> me-too's are better than the lead drug (Prozac). Rather that which
> SSRI actually works seems to be very individualized. So, if Prozac
> doesn't work at optimal doses and optimal trial times, then another
> just might.
>     It looks as the me-too's weren't.


COMMENT:

A good point. And the same goes for the many NSAIDS (even in the days
when they are all more or less non-selective), each with its crowd of
diehard fans. It's true also for any of the many blood-pressure pills,
and so on. And for the statins, where one man's Persian is another
man's Meade, or something like that. For all kinds of other
supposedly-equivalent drugs, as anybody who's tried to work with a
limited formulary knows, there are differences that make all the
difference to somebody. No, this isn't *all* just a matter of fashion
and placebo effect; blinded studies show there's also a big interaction
with people's basic genetics and very specific small changes in
molecular moeties.

Sigh. When the alternative-medicine boosters aren't complaining that
orthodox docs are too cookie-cutter and not wholistic enough, they're
complaining about all those redundant "me-too" drugs being developed.
:)  They don't know how bad it could truly be.

SBH


[And the Canadians, when not complaining about this week's polypharmacy
or side-effect disaster, are proudly proclaiming that they have access
to just as many drugs as Americans, and cheaper, too. :)) ]

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology,talk.politics.medicine
Subject: Re: selling sickness to the well
Date: 5 Aug 2005 21:17:44 -0700
Message-ID: <1123301864.014210.98010@o13g2000cwo.googlegroups.com>

MassiveBrainInjury@SleazyISP.edu wrote:

> >We'd all like drug companies to not pay for so much medical education,
> >myself included. It distorts facts.
>
> Wow, great. Something that Messrs Rubin and Conklin don't seem to get.
> The problem with drug-company advertising is not advertising per se
> but its combination with rest of the matter in the NEJM and its effect
> thereon. If the ads in the NEJM were just for products used by MD's
> themselves such as those in the mathematic journals Rubin refers to
> and indeed most ads in most professional publications there'd be no
> problem. But they're not.

COMMENT:
You'll have to explain this.  Ads in journals for professionals are
only for things the professionals use THEMSELVES?  Rather than (say)
stick their professional clients with?  Say what?  If Rubin buys stat
software, his next client gets stuck with him and it also.  And his job
as a professional may well involve having to recommend software to
others, even if he doesn't come with it. It's a common problem. I don't
see that it's any purer if the professional sells you the secondary
stuff along with his services, than if he recommends it AS his service.


> In my view the nearest analogy is to movie reviews. If the publication
> carrying the reviews accepts ads from the movie companies their
> reviews are worthless. The pressure to avoid offence is irresistible.
> Major newspapers sort-of get away with it because, after they stop
> laughing about the Chinese wall that supposedly separates the reviewer
> from the ad department, they advance three other arguments: the ad
> revenue is small in comparison to the integrity of the paper (your ad
> is a fleabite); where else will you advertise; and, most movies are
> not so bad that it's perfectly fair to find something good to say.
> Watch out however when you're dealing with small journals/newspapers.
> Serious publications such as The Film Journal accept no movie
> advertising.


COMMENT:

Just as Consumer Reports accepts none. But only because they need to
LOOK purer than Caeser's wife, not necessarily because they'd actually
be corrupted by it, if they did. There are, after all, a LOT of
consumer products out there, and both Consumer Reports and medical
journals in truth have the same defenses as the newspapers-- all pretty
good ones, as you point out, though none perfectly airtight.

> Sheesh! Maybe your CONTINUING education is too expensive for you too.
> Perhaps you'd be better off installing plumbing or selling stock on
> Wall Street. Much as you might like to resist it, the medical business
> comes with an obligation to keep up to date (as do the plumbing and
> stockbroker businesses BTW). Presently the consumer pays his health
> care plan either via a premium or foregone salary for his employer's
> portion plus a deductible or co-pay which go into the pockets of the
> drug company (via the pharmacy) which go to the NEJM or the like in
> the form of advertising dollars which supposedly educates the MD. How
> about cutting out the middlemen and have the consumer pay the MD
> directly who can then pay a real price for his CONTINUING education?
> Oops, we do that already (pay the MD)!

COMMENT:

So?  I think you're making the point that you pay either way for it.
Yes, drug companies are middle men. On the other hand, running some
fraction of medical education through them has the charm of
differentially loading SOME OF the burden of doing the cost of the
information processing work, upon the people who benefit from it, which
is to say those who use the product.

> Really though you're talking about nothing. If you depend on ads for
> your knowledge of new (or old or me-too) drugs I  for one would like
> to choose another doctor. Plenty of other (agreed partially corrupt)
> sources exist. Even Not-A-Doctor types like myself can find out about
> the latest FDA approvals via a personalized email from Medscape each
> week. Just a little checking around that site (and there are several
> similar others) can give me the drug monographs, comments and articles
> from  various researchers, and full prescribing information. It's not
> exactly brain surgery...er...rocket science <g>.

COMMENT:
Yes, but the balancing of all this, can be. Medscape is a totally
commercial site, of course. YOU may not pay them, but they're funded by
advertising, just like your standard channel TV. Most is pharm
advertising (the WebMD part). I don't know how much is skimmed off the
Emdeon practice management people who now actually own the company and
advertise their services to docs, not patients (mostly). But my guess
is they keep the WebMD part paying for itself.

In any case, the other point I want to make, is you get what you pay
for. You as citizen at large may get the drug monographs and FDA
approvals sent to you, but it takes a fair amount of sophistication to
get much out of them, and certainly so to get most of what they offer,
out of them. You can have LexisNexis send you various digests of legal
stuff, too. None of this equips you to be your own attorney-- all it
does is familiarize you with the way they think and what questions to
ask.
You can read the PI from the PDR like Sharon, and have it go right over
your head. The problem is not intelligence (I think she actually has a
background in programming), but she's just missing the needed
background in biology, statistics, and study design.

The insidious thing about the drug companies (as we agree) is that--
even if you do have the background to get what they are saying--- they
don't just provide information but do pre-processing, too. This by
paying other professionals in the field to do it, and it's very hard
(actually impossible) to get around this bias. Not that all professions
don't have the same problem, of course. Nothing special about medicine
there, except the size of the pot (size of the business). Can you
believe anything written by a biologist employed by an oil company? But
won't a biologist employed by Harvard have the other built in baggage
and bias?  If you're a climatologist and hold a politically incorrect
opinion about global warming, your NOAA grants may well disappear, and
in academia, funding is power and quite often eventual tenure. Many a
scientist has to be very careful about opinions, and we haven't even
gotten to the average profession, let alone to the law or politics. So
again, I'm a little unclear as to why doctors of medicine should come
in for undue heat. Most of us have far more freedom to express our
honest opinions and act on them, than most employees of government OR
academia, let alone business.  If we end up getting biased, it's
usually by a rather small amount considering who our detractors often
work for.

SBH

From: David Rind <drind@caregroup.harvard.edu>
Newsgroups: sci.med,sci.med.cardiology,talk.politics.medicine
Subject: Re: selling sickness to the well
Date: Sat, 06 Aug 2005 09:10:00 -0400
Message-ID: <dd2cra$78o$1@reader2.panix.com>

Steve Harris wrote:
> SSRIs: newer ones arguably better than Prozac, though I'm on weak
> ground here (I admit it).

> The newer H2 blockers won't lower your testosterone like cimetidine.
> (As for PPIs, I don't think they've improved on Prilosec much, BTW,
> that's a point to you)

The SSRIs and the PPIs are good examples of really irresponsible
behavior by the drug manufacturers. In both cases, a single stereoisomer
with no apparent advantages over the racemic compound has been pushed
hard as the racemic compound moved toward going off patent.
Nexium/Prilosec is probably the best example of this, but Lexapro/Celexa
is a close second.

And the marketing works. The manufacturers seem to have convinced both
doctors and patients that Nexium is more effective than Prilosec.
However there is essentially nothing in the studies to suggest this
other than the sort of absurd interpretation of studies performed by
people with an interest in a specific outcome. The real benefit of
Nexium is indicated best on this medical humor website:
www.qfever.com/20010801/nexium.html

--
David Rind
drind@caregroup.harvard.edu

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology,talk.politics.medicine
Subject: Re: selling sickness to the well
Date: 6 Aug 2005 21:22:57 -0700
Message-ID: <1123388576.932098.145360@o13g2000cwo.googlegroups.com>

David Rind wrote:
> Steve Harris wrote:
> > SSRIs: newer ones arguably better than Prozac, though I'm on weak
> > ground here (I admit it).
>
> > The newer H2 blockers won't lower your testosterone like cimetidine.
> > (As for PPIs, I don't think they've improved on Prilosec much, BTW,
> > that's a point to you)
>
> The SSRIs and the PPIs are good examples of really irresponsible
> behavior by the drug manufacturers. In both cases, a single stereoisomer
> with no apparent advantages over the racemic compound has been pushed
> hard as the racemic compound moved toward going off patent.
> Nexium/Prilosec is probably the best example of this, but Lexapro/Celexa
> is a close second.
>
> And the marketing works. The manufacturers seem to have convinced both
> doctors and patients that Nexium is more effective than Prilosec.
> However there is essentially nothing in the studies to suggest this
> other than the sort of absurd interpretation of studies performed by
> people with an interest in a specific outcome. The real benefit of
> Nexium is indicated best on this medical humor website:
> www.qfever.com/20010801/nexium.html


COMMENT:

Indeed, indeed. I actually have a patient who claims no effect from
brand name Prilosec, but Heap Big Effect from Nexium. I do not argue
with him, but merely ascribe it to benign shamanism and Visual Purple.
You know, the SPIRITUAL aspect of the healing arts. Which would be fine
if the taxpayer didn't have to participate in the spiritual ceremony by
footing the bill. :)

I'm taking some heat in this very thread about how I fulmanate about
socialism and fight with people who like shamanism.  How is it all
relevent to sci.med, they want to know? I guess I just make too many
wild connections and should narrow my focus on life, eh?

And I might even jump the fence and inject some history!  You never
know where my squirrely mind will go. But BTW, this particular drug
dodge is not a new thing. Before Nexium and Lexapro, there was....
Dexadrine. Mirror, mirror on the wall, what's the cutest patent trick
of all?

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology,talk.politics.medicine
Subject: Re: selling sickness to the well
Date: 6 Aug 2005 21:41:03 -0700
Message-ID: <1123389663.872635.205450@z14g2000cwz.googlegroups.com>

Sharon Hope wrote:
> Do you have any patients who are alive?


That depends on your definition of "alive" (he said Clintonesquely).
What about the severely metabolically challenged?  The thermally
different?  The flexionally differently-abled?

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,talk.politics.medicine,sci.med.cardiology
Subject: Re: selling sickness to the well
Date: 6 Aug 2005 20:55:46 -0700
Message-ID: <1123386946.857077.155660@o13g2000cwo.googlegroups.com>

bae@cs.toronto.no-uce.edu wrote:
> In article <1123303505.973595.251880@o13g2000cwo.googlegroups.com>,
> Steve Harris <sbharris@ix.netcom.com> wrote:
> >
> >[And the Canadians, when not complaining about this week's polypharmacy
> >or side-effect disaster, are proudly proclaiming that they have access
> >to just as many drugs as Americans, and cheaper, too. :)) ]
>
> Steve, you've said:
>
> 	One Canadian says A.
> 	Another Canadian says not A.
> and you conclude:
> 	All Canadians are inconsistent idiots who claim A and not A
> simultaneously.

COMMENT:
Seems to me I remember at least one Canadian ("Zee Walanga") who did
hold both positions. But don't make me go back through her messages to
prove it; it's too nauseating.


> In earlier postings you've claimed:
>
> 	Jews are genetically smarter than everybody else.
> 	Jews are almost all socialists.
> and implied that
> 	Socialists are stupid and deluded.
[snip]
>
> You're a knowledgable and intelligent man, Dr. Harris, and I value the
> technical material you post to sci.med.  However, as at least one of
> your colleagues has pointed out, you're letting your prejudices and
> political opinions overwhelm the considerable value of the scientific
> information and opinions you present.

COMMENT:

Ooooh, you almost goaded me into a long and probably politically
incorrect diatribe, there. But then, only one paragraph away, you shot
your own argument right in the foot! If you'd just put those two
paragraphs in separate messages, they would have individually been far
more effective. As it is, looking at them together I can simply answer
that a not completely naive "explanation" is that I'm not the only
intelligent person for which this is true. Certainly YOU believe it's
possible. So there you are.  Happy?

And here's a shocker: Not only is it possible, but you may not be
immune yourself, Spocko.

Look, it's always difficult to assess one's only irrational prejudices
(vs rational prejudices), except possibly through lens of time.
Oppenheimer blamed his early flirtations with Communism on youthful
curiousity. Einstein wrote widely about socialism for newspapers and
claimed it was the most rational political outlook. But at the end of
his life he said he knew a little about physics but nothing about
people and politics. And he was only being a little modest.

Perhaps I'll have a chance to repent of some of my opinions later in MY
life. Meanwhile, I call them as I see them.

> You also posted a "joke" that claimed that only stupid, sentimental and
> irrational people ("liberals") would object to the notion that killing
> many thousands of unarmed civilians in retaliation for the violent
> actions of a few individuals was moral and justified.  The joke implied
> that such massive retaliation was identical to killing the individual
> perpetrators themselves.  How was this relevant to sci.med?

COMMENT:
Search me! I don't remember the incident or the joke, and you'll have
to remind me (you're being very oblique here).

You may be keeping better track of my writings than I do. Which would
be... weird.

More on the rest of your post, which really merits a separate response,
in another message.

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,talk.politics.medicine,sci.med.cardiology
Subject: Re: selling sickness to the well
Date: 7 Aug 2005 00:17:18 -0700
Message-ID: <1123399038.936320.318330@g14g2000cwa.googlegroups.com>

bae@cs.toronto.no-uce.edu wrote:

> If you've got to make great sweeping generalizations about the
> characteristics and opinions of groups of many millions of people, you
> might at least try to be consistent about them, or perhaps confine the
> political stuff to the talk.politics group.  Sinking to the level of
> your opponents is not the way to win the respect of onlookers to a
> debate.

COMMENT:
Great sweeping generalizations about the characteristics and opinions
of groups of many millions of people in other venues gets called
epidemiology, sociology, anthropology, psychology, social psychology,
etc, etc. And on into political science and voter analysis. And if we
kept all political discussion out of medicine, there won't be much left
in this forum.

I can only say that I didn't start any of the sci.med discussions on
liberals or Jews or Canadians, or the ACLU, but merely commented on
material posted here by somebody else. Feel free to ignore such threads
if they threaten you.

And I am consistent about them. I'm under no illusions that every
generalization I make about any group of people applies to every person
in the group. These are statistical tendencies which allow one to judge
behavior better than if you were flipping a coin.  That's it. Nor am I
under the impression that I'm always right in my ideas.  However, I do
strongly believe in the search for such generalizations.  If you don't
like my conclusions, feel free to tell me. If you feel, for example and
contra me, that US Jews are, on average, more likely to be rural,
Republican, and stupid (say), then just say so. I can take it.


> I really don't want to killfile you.  I hope you're not in some early
> stage of the process that transformed Dr. Chung from a knowledgable
> source of information about cardiology to the irrational fanatic he's
> gradually become.

COMMENT:

Gee, I hope not, either. But by all means, feel free to killfile me.
I'll obviously make us both feel much better.  As for politics,
understand that most people don't even notice their own political bias,
anymore than a fish notices water, even when it colors nearly
everything that they say and think. They only notice when they come
across somebody from a different milieu, who they immediately decide is
being overly "political."

I myself, FYI, was raised in a very conservative religious Republican
culture, and made the transition to secular libertarianism, so I can
see both kinds of those "water." But most lefties don't see liberalism
at all. They just think they're being human, and everybody else is
stupid or ill-willed or religiously fanatic.

"Why of course you can't generalize about groups," they say. "That's
like profiling." Yes, it is. It's called "induction" and it applies to
people, too. See "thinking."  For example, my chronological age hurts
me when I apply for medical insurance, and my gender hurts me on
driving insurance. Any liberal can explain why this logically should
be, but if it came down to similar criteria which differentially (and
negatively) affected women or minorities, the circuit breakers would
trip out and logical thinking would cease, in a liberal. That's the
water.

I point out situations like this here, all the time. Most are connected
with medicine, but a few are not. I'm not alone. The LANCET now has
gone to a format with one semi-hysterical sentence on their front page,
whereas before they had a pretty staid format. And half the time it's a
politically loaded statement, too. They too, think they're just being
human. They don't always consider unintended consequences. Everybody
always wants to help, but there's always a cost to it, and in life
there are very few free lunches. Somebody needs to point that out, I
think. That's one job I try to do, here. I'm the FOX NEWS of sci.med
for the moment, it seems. You may disagree. Fine. Stay in your own
world if you choose.

> At any rate, think about this, or not, as you please.  I'm not
> attacking you.  I'm trying to point out a direction of drift in your
> postings which you may not be aware of, and may wish not to continue.

"May not wish to continue?"  Of course I'll continue.

As for my "drift," I am aware of having gotten more thin-skinned, but
then I've been the subject of an unusual number of highly personal
attacks here, of late.  If you've not personally had that experience on
USENET, I suggest you withhold judgment. Otherwise, it's still the same
old me. Where have YOU been?

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,talk.politics.medicine,sci.med.cardiology
Subject: Re: selling sickness to the well
Date: 7 Aug 2005 11:39:19 -0700
Message-ID: <1123439959.491444.128280@f14g2000cwb.googlegroups.com>

David Wright wrote:
> In article <1123399038.936320.318330@g14g2000cwa.googlegroups.com>,
> Steve Harris <sbharris@ix.netcom.com> wrote:
>
> >That's one job I try to do, here. I'm the FOX NEWS of sci.med
> >for the moment, it seems.
>
> Do you mean this in the sense of claiming to be "fair and balanced,"
> or in the sense of "a wholly-owned subsidiary of the Republican
> Party?"


COMMENT:

Oh, both. FOX is certainly biased, but one needs some right-bias to
make up for the pervasive and relentless left-bias everywhere else. FOX
at least TRIES to present both sides.

FOX's idea of the "Right" BTW seems to be Irish Catholics like Bill
O'Reilly and Sean Hannity, which tickles me no end.  From my end of the
country in the West, such people barely make it to center. So what if
they don't like abortion? As Catholics they don't like the death
penalty either, and makes for some interesting mixups with the actual
right in this country--- what is sometimes called the "evangelical
Right" (read, Southern baptists, Mormons, and so on), who are really
the people who got the Bushes elected, not Irish Catholics from Boston.
THOSE guys have been drifting leftward for years, like Massechussetts
and the Kennedys they kept electing. So O'Reilly, a self-admitted JKF
and RFK fan, stands in for the "RIGHT" on FOX, and the left hardly even
notices. He look like Rush Limbaugh to them, because from their
vantange point, Hilary Clinton is "centrist" and "moderate," and
anything rightward of her is redneck and neonazi.

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,talk.politics.medicine,sci.med.cardiology
Subject: Re: selling sickness to the well
Date: 7 Aug 2005 12:26:46 -0700
Message-ID: <1123442806.881366.275760@z14g2000cwz.googlegroups.com>

David Wright wrote:
> In article <1123399038.936320.318330@g14g2000cwa.googlegroups.com>,
> Steve Harris <sbharris@ix.netcom.com> wrote:
>
> >That's one job I try to do, here. I'm the FOX NEWS of sci.med
> >for the moment, it seems.
>
> Do you mean this in the sense of claiming to be "fair and balanced,"
> or in the sense of "a wholly-owned subsidiary of the Republican
> Party?"

COMMENT:

And BTW, at least FOX makes SOME attempt at balance. Their idea of Left
really is Left: Alan Colmes. Who comes from a NYC radio station called
WEVD which used to broadcast in Yiddish and is relentlessly NYC Left,
as are all the people on it. (The W means it's East of the Mississippi,
but these last three call sign letters, I kid you not, stand for Eugene
V. Debs....)

Where is the conservative equivalent of Alan Colmes at (say) PBS?  Or
even CBS?

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,talk.politics.medicine,sci.med.cardiology
Subject: Re: selling sickness to the well
Date: 7 Aug 2005 15:56:18 -0700
Message-ID: <1123455378.447143.184250@g14g2000cwa.googlegroups.com>

Bill wrote:
> Steve Harris <sbharris@ix.netcom.com> wrote in message
> news:1123442806.881366.275760@z14g2000cwz.googlegroups.com...
> > Where is the conservative equivalent of Alan Colmes at (say) PBS?  Or
> > even CBS?
> >
> > SBH
> >
>
> Colmes is liberal but he is very ineffective. He reminds me of a wet puppy.
>
> PBS TV has the Wall Street Journal report every Fri. Only editors of the WSJ
> editorial page.


COMMENT:

I didn't know that. Well, that should be good, inasmuch as people
talking about the health of companies in the market won't be wringing
their hands about how these companies aren't giving away enough to the
poor of the world.

It was long a mystery to me why liberals hate businesses so much---
even honest businesses (save perhaps for the ones they happen to own--
and there are plenty of liberal businessmen). Every honest business
earns every dollar by doing good deeds, and that's even before it pays
taxes and provides jobs.  The good deed you do by earning a dollar in
sales in a free and open market, with no coercion and money-back
guarantee, is that you provide your product to somebody somewhere who
would rather have your product than the dollar. And continues to be
happy with the trade in the future. And indeed may turn out (should
turn out) to be a repeat customer. Thus, you've done him a favor, and
the dollar is your certificate that you did.

How all this got associated with negative acts, is a mystery. Perhaps
it's the hucksters and cheats poluting the waters. But such a large
fraction of business IS repeat business, that it's very strange we
don't remind ourselves of the essentially benign and helpful nature OF
any repeat business deal and thus, of most business per se.

To NOT recognize this simple fact of economics and ethics, really does
require a mind that believes that most people are not capable of making
their own trades, and this act must be guided for them, or else even
the deals they are happy with, are evil (ie, where somebody is rooked).


So my fundamental argument with the Left, is this essential piece of
narcissism they have, that individuals cannot be trusted to act in
their own best interests, and need looking after, like children. I
think I finally have come down to the core of what leftist philosophy
is about, and that is really it. It's the idea that you know better
than the other guy, what's good for him.

Well, I'm onto `em.  And I'm going to stick it to the Left for this
paternalism and narcissism, wherever I can. Including here.

And of course, I'll be doing the same to the Right about their idea
that they have a pipeline to god, but that's another matter.

SBH

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med,sci.med.cardiology,talk.politics.medicine
Subject: Re: selling sickness to the well
Date: 10 Aug 2005 21:28:02 -0700
Message-ID: <1123734482.758672.89450@z14g2000cwz.googlegroups.com>

MassiveBrainInjury@SleazyISP.edu wrote:
> There are plenty of things wrong with SUV's but, other than at a minor
> level, competition among brands and models is not among them. That's
> because most of us believe that by allowing and encouraging the free
> competitive market in motor vehicles we gain more in innovation and
> efficiency than we lose in advertising, duplicated design effort, and
> other such costs.
>
> However, you will notice that in motor vehicles the lion's share of
> the cost paid by the consumer goes to raw materials and labor to
> assemble and deliver the product: for drugs the similar costs are
> trivial. Thus even by looking at the raw numbers and despite such
> blockbuster ads as on the Super Bowl, one can see that for MV's
> there's not a tremendous amount of saving to be had.

COMMENT:

So I'll use another metaphor closer to pharm, which is closer to
selling pure information.

Why is there all the competition in "me-too" murder-mysteries and other
genres, and in computer software? And (for that matter) in genres of
movies and pop music, where the production cost may be high, but the
marginal cost of selling each additional copy is very tiny compared to
when it sells for. We're very far from minimal cost there, and there is
a "tremendous amount of saving to be had." Once Sue Grafton finishes a
novel and the she and the editor have recouped the investment in time
in writing and publishing, it's all gravy. And you have to pay it
because she has monopoly on it.

>Further, while
> there might be small individual areas where one manufacturer's design
> is unique and protected by patent, the vast majority of the
> fundamentals of the product have been known (and patent free) for
> years.

COMMENT:

So?  That's not true of computer programs. Do you want to socialize
them?


>In drugs, the patent holder has exclusive rights to the drug
> for (IIRC) 16 years and in order to do a me-too drug the competitor
> has to go right back to the basics.


COMMENT:

No farther back than you have to if you want to be a successful author
of murder mysteries or wordprocessing software.

> Hence producing that me-too drug
> is a vastly more expensive process (proportionally) than just
> producing a new SUV design. Only recently has the auto industry
> started spending (still trivial amounts) on the basics such as
> hybrids, fuel cells etc.


COMMENT:
Just as the semiconductor industry is doing joint research.

Actually, whether or not you start from "square one" in drug design is
something of a glass half-empty or full proposition. In many cases, the
mechanism has been worked out. You have the chemicla patents in front
of you. The basic research tools for doing chem synthesis and enzyme
binding and so on, are long off-patent, and are part of the tool kit of
every researcher.

Drug discovery would actually be pretty cheap if we didn't have to
worry about side-effects and lawsuits.


> But it's worse than that. The drug companies, even when they have a
> me-too drug, don't play by the competitive free market rules. They
> don't go mano-a-mano with their therapeutic competitor.

COMMENT:

Sure they do. What, you said you watched all those ED drug commercials,
did you not?


> They act far
> more like the airlines before deregulation, Where the airlines
> competed on color of planes, length of stewardesses skirts, and
> luxuriousness of their "clubs"; the drug companies compete by buying
> more ads and creating a more favorable view of their product in the
> eyes of the consumer and probably the MD.

COMMENT:

Not as much as you think. And the the extend that it's true is due to
the same kind of overregulated environment existing for both drugs and
airlines, where the "safety" issues has been artificially removed from
discussion. It's assumed all choices get you where you want to go
without killing you. But in both cases, that was a mistake.  There's
always a risk in everything in life, and leaving it out of market
decisions, just causes inefficiency.  The makers of Zocor should be
allowed to make the point that Crestor hasn't been though nearly as
many clinical tests and until it has, it's a riskier proposition.  But
legally, they aren't allowed to. The public would freak. But one day if
Crestor has to be removed from the market like Baycol, the public will
be incensed that it wasn't warned. And will probably blame the drug
companies. Instead of itself. Actually, the public doesn't really want
to know these things about drugs, anymore than it really wants to know
the differential safety record of airlines. Too scary. We have some
sense of control with automobiles. If we had crash safety ratings for
drugs the way we do with autos....


>Nothing like the auto ads
> where there seems to be (as there should be) a never-ending attempt to
> sell the vehicle for less than the competitor's. Far be it from me to
> accuse the drug companies of collusive pricing but it's amazing how
> they seem to end up with exactly the same price as their therapeutic
> competitor.

COMMENT
I think if you look at the % difference in comparable class autos,
you'll find it thinner than that differential for drugs in the same
class. It just looks larger because you're talking about larger
absolute values.


> So me-too drugs could serve a purpose and keep the original patent
> holder from gouging the public but unfortunately they don't. So why do
> we put up with the duplicative effort when it doesn't seem as though
> we're getting the advantages?

COMMENT:

You are getting the advantages. If you weren't, no "me-too" drug would
even sell.  And I can name a few that didn't sell well. Lescol
(fluvastatin) never really found a niche. It tried for lower price, but
wasn't really cheaper per unit of effect. The studies were crappy and
it never made much money in comparison to its competition. It will
probably be replaced in a few years with a high potency model. There
are similar stories with me-too beta blockers that never took off.


> (Note that I'm just dealing with the difference between your example
> of SUV's and me-too drugs. There are many other differences such as:
> no one needs an SUV; many people only avoid death, pain, and suffering
> with the aid of drugs. A mis-allocation of resources in the auto
> industry has trivial consequences: a mis-allocation of resources in
> the drug industry means that people die or suffer needlessly.)

COMMENT:

A misallocation in autos means people suffer and die "needlessly" also.
The GEO Metro has killed a lot more people than or Ominiflox or Rezulin
or Baycol ever did. And not particularly though bad design. It's just
that these little critters weren't meant to share the same roads with
pickups and SUVs that look right over the top of them, then roll over
the top of them. Did that "need" to happen? Or is it just a chance that
some people took because they wanted to have cheap transportation, and
lost out on the casino of life?

You don't HAVE to take the drug, anymore than you MUST ride in that car
(you might be having a heart attack and the car is very good lifeline,
but that only makes the analogy richer). There are usually alternatives
to just about everything in life. Don't treat drugs as though they were
something different. They aren't. They are just another tool.

SBH