nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Friday, July 31, 2009



Update from Massachusetts


From my favorite experiment in universal healthcare coverage, Massachusetts, who recently had to eliminate some legal immigrants from coverage in order to keep going:  support for Commonwealth Care among the population has fallen to 1 in 4.  Note that the MA plan closely resembles the House Ways and Means bill.  See an article here:  While this is just a media article, data is also appearing in peer-reviewed medical journals on how big the problems are.



A Reflection on Longevity and Healthcare Quality. 


I keep hearing the experts claim that people live longer in other countries, therefore they have better healthcare than we do.  This has always bothered me; it’s at odds with my personal experience of healthcare here and what I’ve seen in several other countries.  Why do they all come here, if the results are less good than in their own country?  I’ve never been able to reconcile the feeling that the experts were wrong despite being convinced by the data they use to make the claim….the data seemed clear:  they DO live longer in Sweden, and France, and , etc.


I broke the code yesterday.  I was cruising when I came across a reader’s objection to their analysis of life expectancy. The US has significantly higher rates of fatalities from violent crime and fatalities from automobile accidents.  The “experts” who were making the claim that people in other countries live longer include these statistics, which skew the data to a longer average life expectancy elsewhere.  When you extract the data on violence and car accidents from the totals for all the countries, we have the longest life expectancy in the world. admitted that this objection was true.


When tasked with why they included violent deaths in the total, the experts have replied that, in their opinion, those data ARE a reflection of poor healthcare in our country.  Excuse me?


Look, violent crime and auto accidents are problems…serious ones that need to be addressed.  But, they are not an issue of healthcare access or quality. 


Not everybody agrees. said, after being criticized, that “We’re not sure why accidental death would be deemed irrelevant in a discussion of health care quality, especially in light of claims about emergency care in Canada versus the U.S.  The assumption they are making is that more people die in the US from these things because the care they get--once they get to the hospital--is less good, or delayed.  But, this violates Occam’s Razor:  don’t invent reasons when the simplest answer is staring you in the face.  There are MORE violent deaths because there are MORE violent events.  And, there’s no data that says you are less likely to survive upon reaching the hospital, if injured in the US


For more on this, see


The lesson to be learned here is, you can’t trust anybody’s conclusion from the data…even mine.




Update from the Politicial Process


I noticed that on the same day, President Obama, Speaker Pelosi, and Senator Reid all began blaming skyrocketing healthcare costs on the insurance industry, calling them villains, and morally corrupt, etc.  It’s interesting that the previous strategy that “reform is not going to cost more” is being abandoned (wasn’t working) …along with the tactic of blaming doctors for “doing unnecessary surgery” (like taking out tonsils, as the President claimed).  Senator Reid said that insurance company profits “have increased by 450%.”


So I went to Yahoo! Finance and pulled up data on Net Profit Margin by industry.  Interesting stuff…  Over the last five years, across all industries, the average has been ~5%.  Some industries like Agricultural Chemicals, and Software are doing great, while Auto Manufacturers, Auto Dealers, and Auto Parts are doing poorly…duh. 


But for Health Care Plans it’s 3.2%.  They range from about 1.5 - 4.0%.  And Long Term Care Facilities are losing money at -3.5%.


So we’ll see if the new political strategy works.  I’m against demonizing any particular part of the healthcare industry.  The issues are systemic, not particular, but you hear people yelling at businesses, doctors, drug companies, hospitals, or whatever their favorite culprit is, all the time.



And While We’re Talking About High Drug Prices…


People complain about this all the time.  The evil drug companies and pharmacies are “breaking our backs”, and “why can’t we get drugs cheaper like in Canada?”  And “I know it doesn’t cost the drug company $1.00 a pill to make my medicine.”


You’ll love this:  actually the American consumer is subsidizing the Canadian system.  You should be mad at Canada, not the US drug industry.  How can that be, you ask?  Well…


--About 90% of all the drug research and development in the world occurs here in the US.  Only six countries account for 100% of the new drugs. 

--It costs, on average, $1-2 billion to bring a drug to FDA approval.  The approval process takes 10-15 years. 

--Only about 1 in 300 chemical compounds the drug industry starts to investigate actually end up as an approved medicine.

--Once approved, it’s very cheap to produce the pill…on the order of 10-20 cents apiece (WAG).


OK, a hypothetical.  You’re the CEO of ABC Pharmaceuticals.  You’ve got a product.  How do you recoup the fixed costs ($1-2B) and the production costs (20 cents a pill)?  Simple.  You charge a premium while you still have “biological exclusivity” (nobody else can make it but you), and set the price at $1.00 per pill. 


Here’s the interesting part:  Canada comes along and passes a law that says they will only pay 50 cents a pill for your drug.  You say to yourself:  “OK, I’m getting back my cost to produce the pill, but only part of my investment. Do I sell it to Canada?”  The answer is yes, because you are getting at least some of your investment back:  if you don’t, you get none.


So, how do you solve your business problem?  Again, simple.  You go back to the free market in the US and raise the cost even further, to $1.50 a pill, until you lose rights to the drug, or recoup your costs…then, you drop the price.


When you, the US patient, pay $1.50 a pill for a new drug, 50 cents goes to pay for Canadian patients’ treatment.  Such a sweet deal for Canada, huh?  Other countries do the same, on the backs of Americans.  Maybe we should feel virtuous about this.  We provide a lot of direct aid to developing countries, but we’re also helping developed countries, too.  No wonder their healthcare costs are lower, and ours are higher.


This analysis applies to other medical technology (stents, implants, pacemakers), also.




Physicians contend EARLY Act would do more harm than good.

In an op-ed in the Los Angeles Times (7/31), physicians Steven Woloshin, MD, MS, and Lisa M. Schwartz, MD, both professors of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, write that the proposed Education and Awareness Requires Learning Young (EARLY) Act, now before the House, "seeks 'to increase public awareness regarding the threats posed by breast cancer to young women.'" The physicians call this "well-intentioned and emotionally appealing" bill "a big mistake," arguing that the measure "would end up doing more harm than good" and even "runs counter to" scientific evidence. They point out that the measure "targets women between the ages of 15 and 39," when "fewer than five percent of breast cancers occur before age 40."


Doc D:  I put this in because saying we shouldn’t have a program for a low risk population might be viewed as “rationing healthcare.”  The fact that this bill targets women who are in a relatively low risk group is only part of the problem.  The other part is that in the process of raising awareness we increase worry, for the wrong age group.   The bill also proposes to teach women in the young age group how to avoid breast cancer.   Whether there are any strategies that do this is controversial.


I would rather women and their doctors assess the risk together as a patient-focused action.  Some young women ARE more at risk than others:  if they have a family history of breast cancer at a young age, for instance.  Others are not.  Why paint a broad brush?


Sebelius does not expect adjuvants to be used in vaccine.

On Thursday, the CBS Evening News (7/30, story 4, 2:20, Couric) interviewed HHS Secretary Kathleen Sebelius on H1N1 efforts, asking, "How many adults and children will be tested before the vaccine is available to the general population?" Sebelius said, "I don't know the exact numbers, but there will be testing on adults, testing on children, and testing on pregnant women to make sure that again, we have a safe vaccine. Now, Katie, this is a vaccine that is going to be very similar to seasonal flu vaccine, and we know that millions of children, millions of adults, pregnant women take seasonal flu vaccine year in and year out. The strain is a little bit different, but our scientists have determined that this virus is reacting very much like seasonal flu." She said that adjuvants or additives are "not anticipated" to make it into the vaccine, but "if we somehow have a mutation of the vaccine, it's possible that adjuvants will be used to both boost the reaction...and also to stretch the vaccine further."

        Lancet criticizes US plan to forgo adjuvants. Bloomberg News (7/31, Randall) reports that the US plan not to use adjuvants to "stretch the supply" of swine flu vaccines "would reduce the number of available shots just when other countries need them most, the British journal Lancet said in an editorial." In its editorial, "the Lancet criticized the US for plans to rely exclusively on standard formulations," writing that the "USA must support the use of dose-sparing strategies to avoid depletion of an already short vaccine supply. ... All countries will require the vaccine, but current manufacturing capacity will not be able to meet this demand." HHS spokesman Bill Hall said that the US will "review all clinical data to inform our decision on their potential use" of adjuvants after conducting "human tests to determine safety and effectiveness of flu adjuvants."


Doc D:  I put both news stories in here.  If you develop a product that you hope will produce an immune response in the body that will protect the person from a disease, you hope the product is strong enough by itself to build the protection, but sometimes it’s not enough.  Along come “adjuvants.”  They are additives that boost the immune response to higher levels, or more quickly, or for a longer period of time.  Their use frequently causes controversy.  They can worsen the side effects at the same time they make the vaccine more protective.  Some people say, since we don’t know whether they will do any harm, leave them out.  Others say, put them in if it helps to be more effective.   Blah, blah, blah…


What the Brits are complaining about is the US reluctance to use something that will make the amount of vaccine go farther.  If the US adds no adjuvant there are fewer adverse reactions and a reduced risk of law suits against the government and the vaccine maker.  For those old enough to remember, the Carter administration attempted a nationwide immunization against the flu.  Over 40 million doses were given, but there were several hundred cases of Guillain-Barre syndrome, a paralytic complication, and 32 deaths.  The outcry undermined the program, although it probably saved tens of thousands of lives.  And, guess what?  Guillain-Barre is a rare complication of a number of viral diseases…and of all the flue vaccine you’ve been getting all your life.


So, it’s going to be interesting when we see the press start reporting complications as if they are a result of the new vaccine, rather than a longstanding risk.  I think the government is trying to avoid the political damage that Carter suffered, despite the fact that we may be able to make enough vaccine only for us, but the rest of the world is SOL.  Let’s see if they come up with a principled plan in the end.



Medical quote of the Day:

To preserve one’s health by too strict a regime is in itself a tedious malady.—Maxims, Duc Francois de La Rochefoucauld [1613-1680]


Nature Note:   From Quackwatch:  “The U.S. Court of Federal Claims has upheld the decision of a Special Master that the family of William Yates Hazelhurst had presented no credible evidence that vaccination had caused him to develop regressive autism. The ruling is part of the Autism Omnibus Proceeding in which more than 5,000 families who claim that vaccines caused their children to become autistic are seeking compensation under the National Vaccine Injury Compensation Program (VICP). In February 2009, Special Masters ruled in this case and two others selected to test how similar cases should be handled. The decisions completely debunked the alleged vaccine/autism connection and implied that the doctors who promote (it) are acting unethically.” (emphasis mine)


This is another blow to the “Invisible Evil” crowd that substitutes their own psychological fears for science.  The “Special Masters” initiative is an effort to use experts to rule on a scientific question, instead of judges with little scientific training or knowledge.


Recommended Reading:

--The Joyless Economy:  The Psychology of Human Satisfaction, by Tibor Scitovsky. Originally written in 1976, and rated one of the top 100 books of the 20th Century by the Times Literary Supplement, Scitovsky’s book explored the notion that “there can be little real joy in the lives of people whose every appetite is gratified almost instantaneously,” according to the Foreword by Robert Frank.  Up to that point, economists had assumed that if you get what you desire, you get what satisfies you.  But, these are not the same.  Can what we want be different from what makes us happy?  The answer seems to be “yes.”  Fascinating discussion of the psychology of human happiness.


ERRATA:  I said last week that the House healthcare reform bill requires End of Life counseling (page 425 of the original HR 3200) and appeared to levy a care-terminating provision on one age group.  In looking back at it, it’s not clear that this is a requirement, but also not clear that it isn’t.  The provision references the Social Security Act, where the types of care that are authorized under the plan are defined, and adds this type of counseling to the list of what can be covered.  But when you go back to the House bill, the language is still obscure, listing the counseling, and its frequency of “no more than five years” interval for those over 65.  I can’t figure it out.

When tasked by constituents complaining that they haven’t read the bills they vote on, some members of Congress have said that it does no good to read the bill, because you can’t figure it out anyway.  Maybe this is one of those cases.  But it’s pretty sad when the confusion is allowed to stand.

Sorry for leading you astray.


Doc D

Opinions are entirely my own.  Quotations are from AMA Morning Rounds (© U S News Custom Briefings),, and other sources in the public domain.  As always, you may share this column, with appropriate attribution (here and in the text) included.  Please don’t forward my email address.




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