Pharmageddon (30 page)

Present day healthcare systems employ doctors, of course, but it cannot be certain that future systems will need to do so to the same extent. The kind of quality that can be achieved screening for and managing risk factors brings these medical services into the domain of commodities in a way that could not have been done with traditional medical care. In the current jargon, these interventions can increasingly be commoditized and, rather than delivered in clinics, they might be delivered in retail outlets such as supermarkets. Something similar can be done with many basic legal services, leading to a perception that the tide is going out on professionalism.
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In the case of many of these medical practices, furthermore, if the drugs work well and the basic need is to have them delivered according to guidelines and algorithms, the job is likely to be done not just less expensively but possibly with greater fidelity by nurses or others if given the legal authority to dispense medicines, as both nurses and psychologists have been doing in many settings in the United States and Europe.

That the work of physicians has seemed increasingly to have become something of a factory or office job, or that doctors may have to worry about job security for the first time, will not cut much mustard with anyone who has always had to work in a factory or office. But the problem for all of us now is that there are times when we do need to be treated for diseases and cared for rather than simply risk-managed.

BEYOND MEASUREMENT

Many observers of current practices of medical care, especially those who attempt to tackle the question of medicine's interface with the market, get dewy-eyed about the vocational aspects of healthcare. While the more hard-headed analysts point out that since antiquity doctors have charged for their services, that for long periods up to the nineteenth century physicians were often indistinguishable from charlatans and quacks, and that medical organizations have often operated more as quite ruthless trade associations than as scientific bodies concerned about the welfare of patients, caring has nevertheless been held to be a great part of the medical art. Although doctors make a living out of treating sickness, they are not ordinarily thought to exploit people who are ill and vulnerable.

This is beautifully caught in the following quote by James Spence, in his day one of Europe's leading pediatricians, from a book published posthumously in 1960: “The real work of a doctor is not an affair of health centers, or laboratories, or hospital beds. Techniques have their place in Medicine, but they are not Medicine. The essential unit of medical practice is the occasion when, in the intimacy of the consulting room or sick room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation, and all else in Medicine derives from it.”
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There is a difference between medicine of this kind, which still persists to some extent when we are very ill and in isolated pockets of practice, and the healthcare which offers us almost no time or opportunity to consult but which will screen, recall, educate, and sometimes coerce us into treatments, sometimes simply so that our “carers” can hit their targets. On one side is a healthcare in which patients unknowingly are helping doctors rather than being helped; on the other side is a form of practice that is beyond measurement.

The problem does not lie in our new technologies of curing. Penicillin and insulin allow much more effective caring than was possible before. But these drugs arose as part of a kind of medicine different from the statins for cholesterol lowering, biphosphonates for osteoporosis, or antidepressants. When doctors gave penicillin to patients they were in almost all cases helping their patients. When patients take a statin or a biphosphonate, they are in many cases, perhaps a majority of cases, helping their doctors, a drug company, or a government agency rather than themselves. Giving statins and biphosphonates routinely appears to be part of traditional medicine, but in fact these treatments are more closely linked to an approach now most commonly termed chronic disease management or preventive medicine. This approach emerged in the 1980s and led, for instance, to the establishment of the Preventive Task Force noted above. The initial impetus to this approach came from prior successes in the 1950s and 1960s screening for and eliminating infections through vaccination and other programs. A growing awareness of the role of raised blood pressure and diabetes in leading to deaths from heart attacks or strokes, as a result of reviews such as the Framingham study, appeared to provide comparable targets for screening.

There are solid economic arguments for a preventive approach to medicine. In the eighteenth century, France and Britain, wary about each other and about Germany, mapped out their citizenry and in so doing learned about links between environments and diseases, and how national productivity or defense might hinge as much on proper sanitation and the quality of food supplies as on industrial innovation. As James Lind remarked in the mid-eighteenth century, the British navy was losing more men to scurvy than to any hostile engagements with her enemies.
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Florence Nightingale produced figures to show that more soldiers were dying in hospitals than on the battlefield in the Crimean War and went on to create modern nursing in response.
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And Rudolf Virchow, a key person in the creation of both modern laboratory medicine and of the notion that citizens have a democratic right to health, went so far as to suggest that “medicine as social science and politics is nothing more than medicine on a grand scale.”
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Since then historical investigations have made it clear that poxes and pestilences have done more to bring down empires and economies than wars or failures in the marketplace.
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So what could be wrong with mass screening for cholesterol levels, mapping bone densities, and administering rating scales for undetected mood disorders? The first problem is that almost as soon as it appeared pharmaceutical companies realized that preventive medicine or chronic disease management offered the perfect cover for their marketing. Far better for companies to market a treatment doled out over decades than a brief course of antibiotics that saves a life. In the 1960s, when challenged by Senator Kefauver at the congressional hearings on the pharmaceutical industry about the high cost of their drugs, Francis Brown, the president of Schering Plough, responded “Senator, we can't put two sick people in every bed where there is only one person sick.”
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In the 1980s chronic disease management opened for industry a route to putting multiple diseases within the one patient, effectively having several different people being treated in the one body.

The second problem is that company marketing distributes the instruments that screen for what they want screened for while efforts by doctors or others to screen for more important risk factors are marginalized. In this way companies invert the hierarchy of risk. Where the advice should be “stop smoking and lose weight,” it becomes “take a statin.” There is little or no research on what it might be about our diets or lifestyles or environments that is leading to a surge in asthma diagnoses—the pressure is not there to research a disease that is not ordinarily fatal and for which the drugs available are so lucrative—Advair alone, the inhaler that Jane (described at the start of the chapter) was put on, is worth $8 billion per year to GlaxoSmithKline, while the Singulair she also took is worth $5 billion to Merck despite the fact that the published studies show a minimal benefit for this treatment.

A third problem is that while there may have been a cost in terms of injuries from the vaccines and other treatments necessary to eliminate polio and other medical scourges, the benefits overwhelmingly outweighed the costs, but this is not often the case for the statins, biphosphonates, hypoglycemic agents for diabetes, beta-agonists or combined beta-agonists and steroids for asthma, or antidepressants, especially when all these drugs are given in primary care as they have to be to become blockbusters.

When it comes to managing risk factors or chronic treatment, medical discretion is called for, but such discretion is regarded as suspect by those who frame guidelines for diseases. To managers, permitting discretion appears to be a recipe to return medical practice to the cottage industry era. It is, moreover, difficult to exercise discretion when healthcare systems have been redesigned so that a doctor rarely sees the same patient on consecutive occasions or knows much about their family or circumstances.

Right through to the 1960s medicine remained a rather pure market catering to our needs to have cures to life-threatening diseases. But just as satisfying our basic needs for industrial goods half a century earlier led modern companies to focus then on marketing and the creation of ever-larger consumer demand, our liberation from servitude to many diseases laid the basis for a creation in both doctors and patients of medical wants that has underpinned the marketing of conditions such as osteoporosis, raised cholesterol levels, and a range of behavioral disorders from female sexual dysfunction to ADHD.

It also laid the basis for the emergence of the medical consumer, who would shop not just for drugs but also for services, especially services whose specification includes not only an adherence to guidelines but friendliness and the appearances of concern for the consumer. For advocates of free markets it was just this kind of consumer who would drive healthcare costs down.

But while a market of consumers of this sort can readily be envisaged for enhancement technologies from designer vaginas to optimal cholesterol levels and is perhaps the only way to handle these healthcare products, real disease is not something we consume. Like death, albeit slower, it consumes us. It may transform our identities irreversibly, in a way that no subsequent purchases can undo. We make our accommodations with disease as best we can, and since the time of Philippe Pinel that accommodation has involved a medical realization that sometimes the greatest wisdom is to do nothing other than have the medical team and the patient endure together.

Companies, however, have been so successful at restructuring the market in terms of the wants of both doctors, the primary consumers of blockbuster drugs, and patients, who are corralled by direct-toconsumer ads to seek out these treatments, that few medical or patient consumers now understand no. And this new consumer-driven market has all but swept away traditional medicine.

Is there any alternative to the health products market that appears to have replaced what once was medicine? To see where medicine might go instead, let us look at another set of productive relationships: the caring a parent, often in tandem with a whole village, gives a child that helps to produce a person. Caring of this sort remains in touch with the child's zone of proximal development so that they get the right challenges, opportunities, protections, and discipline at the right time. The right caring by a teacher or school similarly helps children develop. Caring of this sort is not at odds with technologies—mothers and teachers will want their children to have computers at an appropriate stage of development and make use of other tools of culture. It is a people, rather than raw material or technology, that ultimately forms the bedrock of an economy, especially a knowledge-based economy. It involves discretion—although this discretion is rapidly being eroded by increasing regulations about schooling requirements. These are areas, furthermore, where most of us want to limit the intrusions of both the market and the state.

This is very close to the kind of caring once found in the best of medicine, as exemplified by James Spence or Alfred Worcester—often delivered now as much by a multidisciplinary team as by an individual and increasingly dependent on cooperation between doctor and patient. Medical care of this kind is productive of people, and of human dignity—or as much dignity as a disease will allow. This caring will readily embrace the appropriate technologies, from insulin to surgery, in order to get the best possible outcome for the person. The focus on real disease that comes with such caring relegates consumption to a secondary role. No pharmaceutical company is ever likely to provide a scanner, meter, or rating scale for medical care that focuses on the person rather than a disease.

What is at issue can be illustrated by considering a doctor's role as the gateway to sick leave and disability payments. One of the most striking lessons doctors learned in World War II was that soldiers due to go on leave would often fail to report serious illness, while others with no prospects of leave became strikingly ill. The doctor was the passport out of active service, if he could be fooled into thinking you were ill. These insights were brought back from war by a generation of physicians who were more sensitive, accordingly, to the ways in which we might all be trying to escape from the prison of our circumstances—an element present in many consultations that cannot readily be measured but which may lead all of us to play along with suggestions that we have disorders like osteoporosis or mild asthma in need of management with the latest drug.

But it was only some doctors who had learned these lessons—not health economists or health planners or even all doctors, which may explain what happened next. The discovery of penicillin and streptomycin in the 1940s eliminated tertiary syphilis and tuberculosis and with these diseases the costs linked to the occupancy of thousands of beds. These cures returned thousands of people to able-bodied and productive status, thereby increasing the wealth of the nation. Further breakthroughs in the 1950s with the first treatments for asthma, first oral antidiabetic agents, first antihypertensives, first antipsychotics and antidepressants, should, if used judiciously, have increased national productivity by many multiples of what the treatments might have cost, but instead sickness rates and disability payments began to skyrocket and the costs of healthcare grew faster in the United States than elsewhere, growing from $100 per person per annum in 1950 ($500 per annum in today's prices) to $7,681 per person per annum in 2008.
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