Naked Medicine

3 of my predictions appeared here:

Industry consultant and entrepreneur Jane Chin (@janechin) goes even further, alleging that next year PhRMA will appoint its first ever ‘Chief Tweeting Officer.’

Jane Chin (@janechin) thinks social media will spur new approaches to customer care and technology, as “cutting edge pharma …companies will experiment with a blend of continuing medical education and cloud-based user-generated content for CME 2.0.”

Jane Chin (@janechin) emphasizes sound strategic judgment and an eye on the needs of a targeted audience for specific, relevant content by warning that “pharma will realize, once again too late, that data dumping fails both in real life and in social media.” [Thanks @skypen!]

I had no idea that September National Cholesterol Education Month, but it is, and I saw a press release about nonprofit nutrition education organization Weston A. Price Foundation on getting consumers to recognize the importance of cholesterol.

The press release made sense to me, but it seriously will meet lots of antagonism because of the prevalent trend of obese children in the USA these days. I bet these kids have ridiculously high cholesterol levels – and certainly not from eating too much “nutrient dense” foods. So while I as a scientist and also as mother of a toddler who needs lots of “good fats” can sympathize, I don’t think the argument here can stand up to even one voice saying “… then what about all this concern with childhood obesity?”

I sent my query off to the publicist, who got in touch with the Sally Fallon Morell, president of the Weston A. Price Foundation to respond to my challenge above. Sally’s response is here.

I followed the links given as references, including the one from the Foundation itself:
Dietary Recommendations for Children –A Recipe for Future Heart Disease?

“Just Say No!”
When it comes to feeding their children, parents should “just say no!” to the government’s dietary guidelines. Children need a diet rich in traditional fats in order to achieve optimum growth and development, as well as protection from heart disease later in life.

I wished it had addressed additionally the issue of fast foods – because this is the reality of “kids’ diets” these days… if saturated fat plays a role in children’s growth, at what point do parents draw the line in where that source of saturated fat comes from? (this question was answered by another link that Sally’s response included, but I wished the above information would address it immediately rather than me having to look at another (non-related to the foundation) link.

I also found the Swedish study findings interesting, mostly because I’ve been drinking more whole milk (full fat) since that’s what I give to my child, who is almost 2 at this writing. Our pediatrician had told us that at this point, we should cut back milk for him because it doesn’t really do much for him other than the calcium and vitamin D that he can be easily getting from other sources.

I don’t know how much this would convince you as a consumer about the benefits of cholesterol in children. On an objectivity scale, I would have preferred that the links I received were original source citations (i.e. links to the original scientific studies published – such as from PubMed) rather than what appears to be commercial pages or user-contributed pages.

In experiments conducted by the US Dept of Agriculture, volunteers were asked to ingest large quantities of fruits that have been identified as having high levels of antioxidants, and their blood were subsequently tested for antioxidant capacity. One important note is the large amount of fruit required per ingestion – for example – volunteers in the Kiwi fruit group must eat 4 kiwis. The cherry group? 45 cherries. This should give consumers an idea of the potential “starting” dose needed to gain an antioxidant benefit – and this is PER DOSE. (imagine eating 45 * 3 cherries a day – if you want to get the benefit of cherries’ antioxidant properties with every meal.)

This does make for an attractive commercial market to give consumers “concentrated” forms of antioxidants – except most of companies providing these types of nutrition products are not regulated by the FDA – that branch of the government regulating food and drugs to make sure that you as a consumer aren’t being ripped off or worse – physically harmed by ingesting unsafe products. Unfortunately, history has shown that the FDA only steps in when enough people get sick or if a few people begin to die from the so-called “nutraceutical” – just look at the ephedrine cases in the multi-billion dollar weight-loss industry.

Currently there is no agreed projection of antioxidant intake because this can fluctuate based on individual energy intake, caloric consumption, and especially environmental or confounding health related factors like exposure to cigarette smoke or disease (increasing body’s oxidation burden). There are researchers who are trying to determine what these individual needs may be, but for the most part, consumers have been inundated by commercial entities eager to profit on a perceived benefit of “high antioxidant intake”. For example, via Quackwatch:
http://www.quackwatch.com/01QuackeryRelatedTopics/PhonyAds/acai.html

The verdict? If you like to drink exotic berries for the taste, there’s no problem with indulging yourself but if you’re looking for some of these commercial products for bona fide healthcare benefits, require the claims to be backed up by randomized, double-blind placebo controlled clinical trials, with full disclosure of side effect profiles experienced by the human subjects.

(…and if there is really some miracle plant bearing amazing therapeutic properties, the pharma companies would outrun anyone to isolate the agents, synthesize/mass produce, and submit it through the proper legal govt channels for commercialization! that was how we got cancer drugs from the pacific yew tree.)

I received what is probably the most passionate email from a reader of this blog that I’ve ever gotten since creating NakedMedicine.com in 2006. The email concludes with this:

I can’t figure out what your agenda is Ms Chin. Are siding with the poor hard working physicians who are fighting a losing battle with their idiot patient’s lifestyles? Are you siding with the tirelessly industrious pharmaceutical scientists who are selflessly dedicating their efforts to cure our ills? Are you siding with the poor neglected suffering individuals who are bravely pushing onward in their lives, struggling with disease, possible disease, possible pandemics, or just plain plainness requiring cosmetic medicine? Doctors, business, persons, for whom are you advocating?

I was shocked by the email, because this reader “hit the nail on the head”! He can’t figure out what my agenda is, because my agenda is in NONE of those sides he described. In other words, if I were guilty of picking “a side”, it wasn’t part of the “usual suspects”.

Here’s my very long response to my reader, to whom I’m grateful, because he took the time and effort to share with me this question that obviously is frustrating him.

******

You wrote what you felt, and I don’t fault you for that. I can sense a real feeling of frustration from you, and I don’t blame you for feeling frustrated about the healthcare system that seems to be broken in many ways.

I want to address specific points you brought up – first one being ‘cures’. I genuinely don’t think that the drug industry is prevented from, or are resistant to, discovering cures for diseases. It’s not about ‘cure’ versus ‘not the cure’ that is the problem. It is often the economy of scale that is the problem, and a very understandable one when you consider that the drug industry is – and has to run like a business – in order to remain in business. I have no doubt that the drug industry would love to find a cure – because they can charge for the price of a ‘cure’ and be justified in charging such a price.

The problem on the one hand is that many times we simply cannot find ONE underlying factor of a disease, especially the chronic diseases like diabetes and heart disease (in fact, many diabetics die of a heart attack and don’t live long enough to die of diabetes complications, especially those consuming a western diet). It is not like a bacterial infection where we can pinpoint ONE origin of the disease and target that specifically, the way we can target an infecting bacteria with an antibiotic and ‘cure’ the patient.

The other problem is about the number of people with a certain disease. For example, there may be fewer companies willing to research rare diseases that may be ‘repaired’ let alone ‘cured’, simply because the companies need to get the money somehow to do all the experiments and clinical trials necessary to jump through regulatory hurdles to even get the drug approved. When i was a graduate student, doing what are pretty simple experiments (and not even in people – i worked off the petri dishes), i was often using reagents that cost my employer thousands of dollars to purchase from reagent companies. Each of my experiments has to cost at least a thousand bucks, and many of my experiments failed and produced no result.

These prices are nothing compared to the amount of money it costs to run a clinical trial at the scale required by the FDA. Now the drug companies have to pay for the drugs, the cost of mountains of paperwork needed to get the clinical trials started, the doctors who do the clinical trials (and some doctors get really snobby and brag to each other about how much $ they can muscle out of drug companies “per patient” to enroll in the drug companies’ trials), not to mention the “overhead” that the academic institutions charge the drug companies because their doctors work there (and these overhead costs can mean more than 50% of the total study budget).

And then most of the drugs end up not passing the FDA’s requirements and fail to get approved. So if you’re running a company, you will tend to want to go into areas where you will likely have more customers – heart disease for example – just so you stand a better chance of keeping your company operating should it succeed in getting a drug treating that disease approved. This is also why the government has to create incentives for companies that are willing to go into rare or “orphan” diseases – for example, Gaucher’s disease is a rare lysosomal storage disease affecting maybe 1 in 40,000 people. A drug company that competes in this market will be happy selling 1 prescription every 3 months.

I honestly do not view drug companies as entities that profit from the suffering of others, because of the logic of this assumption: If drug companies are creating diseases in people in order to make drugs for the very diseases they created, then that to me qualifies for the statement. However, drug companies happen to offer the tools to treat the disease, not unlike device companies making scalpels and surgical tools to allow doctors to cut us open should our illnesses demand it. It seems illogical to me to accuse device companies for profiting from people having tumors that require scalpels to operate and excise the tumors – unless we’re also implying that the scalpel companies are putting tumors in people that only their brand of scalpel can remove.

Additionally, I have observed that for the most part, people in our society today tend to prefer that we “have a pill to treat XYZ”, so that they do not have to do the hard work required to get their own health back on track. And then you add to the fire media agencies that charge pharma companies millions of dollars to come up with brainless gimmicky advertisements, and it is no wonder why many people feel like the drug companies are “profiteers of suffering.” Some years ago, there was a government funded study that shows that rigorous diet and exercise will help reduce diabetes risk at a very real level – in fact – the study patients who had diet and exercise regimen did as well in reducing their diabetes symptoms as study patients who took an anti-diabetic drug.

But why hasn’t the government or the doctors (not the drug companies – their responsibility is in making drugs) done anything about this amazing result? Because the of costs involved to the clinics in order to make “diet and exercise” possible in patients at a therapeutic level. Clinics would need to hire case workers and nurses whose job is to counsel and support and follow each and every single patient who opts for this “natural and effective” treatment. OK then, how about asking patients themselves to do this? Seriously, if you are a patient at risk for diabetes (i.e. risk factors are there, but patient is still “pre-diabetic” and not yet requiring drugs to control their blood sugars), you have everything you need at your disposal to go for the natural and effective (and less expensive than prescription drugs) cure! why aren’t patients doing this? because willpower and discipline are key – and you’re going to need both for a lifetime to prolong the onset of disease.

I can share this true experience – my husband had prediabetic blood work results some years ago when I urged him to see an endocrinologist, because his side of the family also suffers from diabetes. the endocrinologist told him that because he was so young (not yet 40 at the time), she preferred that he try the old fashioned diet and exercise, and see if he could get the risk factors down, before she put him on a drug. He happens to have a level of willpower and discipline that even I don’t have – and he altered his lifestyle dramatically – and it was enormously difficult. 6 weeks later he went back and the endocrinologist was so impressed with his results that she told him that most of his blood work results were approaching normal numbers. But she also told us that not every patient she sees can make this happen – and often she is forced to give the patient drugs to make sure that the patient doesn’t end up with uncontrolled diabetes symptoms (resulting in all sorts of nasty things including death).

I see drugs as exactly what you said you wished to see – repairs and cures. However, the reality is, few are truly cures because of the complexities of most diseases, and repairs don’t always “fix” things without creating new problems (called side effects) EXACTLY because of the complexities of most diseases.

The doctors’ hands are tied not by pharma companies, but by insurance companies as well as their own malpractice lawsuit concerns. Your average primary care doctor has to track how many patients he sees everyday because he needs to make sure he breaks even. That’s not the drug companies doing, but the insurance companies that capitate how much doctors are paid for doing what. So you also have a system that don’t reward doctors for spending more time with patients – in fact – you’re making it very bad business for the doctor to spend too much time because then he’ll lose money that day – and this does not do well to cultivate trust with patients who then need to heed the doctors’ advice about doing the hard things they need to do to steer their health status back on track.

I hope my email begins to help you understand where I am coming from – perhaps I can’t take any sides because I don’t think there are any sides that I can reasonably take without acknowledging that there are other entities that also need to be held accountable. the healthcare ‘system” is truly a “system” and a staggering, complex one at that. the best I can do is to help the consumers – people like you and me – to think for ourselves about what is being “sold” to us whether it’s from the drug companies, insurance companies, the government, the doctors, even patient groups. If I am guilty of siding with anything, it will be on the side of “critical thinking” about the system of healthcare with all of its players.

Best wishes,
Jane Chin

You’ve probably seen it coming – smelled hints of it on TV – pharmaceutical companies are getting into what we call “lifestyle drugs”; products that focus on “enhancing” your life rather than “extending” it.

Yes, there is a big difference, and you may think that “extending” life pays big, “enhancing” life may pay even BIGGER. (just ask the Botox people.)

It’s only a matter of time before pharmaceutical companies shift their focus from “therapeutic intervention” to “lifestyle / recreation” because they now deal with a ready-and-willing customer base who are willing to pay.

This also creates a more dramatic shift: one of bargaining power from the physicians to the patients. Eventually, pharma’s customers will become the patients more directly than before, with doctors becoming more of a “broker” – the people who writes the drugs but apart from that having no real power. Doctors are already complaining about patients leaving them if they don’t do what they’re told by the patients – “if you don’t write me this drug, I’ll go to someone else who will!”

There’s a bit of theatrical irony if this happens, because doctors will get a taste of what pharma sales reps have dealt with for years: being punted to the position of a measly “order taker” or “human sample dropper”. How about doctors eventually becoming “order takers” and “human Rx writers”?