The drug industry’s uncool move

Two antibiotics –  Pyrimethamine (branded Daraprim) and Cycloserine (branded Seromycin) were in the news recently for the same reason. Both of them were subjected to price increases of astronomical proportions, in a feat of price gouging that seems to be the new modus operandi of drug companies.

Turing Pharmaceuticals recently acquired Daraprim from Impax pharmaceuticals. It then promptly increased the drug price from $13.50 to $750, an increase of about 5000%. Daraprim is an important drug that is used to treat Toxoplaxmosis, a parasitic disease of the brain that affects people with weakened immune systems. Around 3 billion people in the world are said to be carriers of the protozoan.

In a similar move, Rodelis Therapeutics acquired Cycloserine from the Chao Center  (a Purdue Research Foundation affiliate) and increased to increase the price of the drug from about $500 dollars to an astronomical $10,800 for 30 pills. Rodelis later backtracked after protests by Chao, and now has returned the drug back to them.

Cycloserine is used as a second line therapy for the treatment of multidrug resistant TB. At the new prices, the price of cyclosercine alone required to treat  MDR-TB for the 24 month course would have been an astronomical 500,000 dollars. Manufacturers in the developing world make generic Cycloserine for as little as $20 per 30 pills. Chao says it will increase the price of the drug to about $1,050 dollars. The manufacture of Cycloserine has been a loss making operation for Chao.

And these are not stand alone incidents. The price of Doxycyclne has been up to $1849 dollars per bottle from about $20 dollars in 2013. Some cardiovascular drugs, that have been around for a long time, have seen price increases as well.

The script for the story seems eerily prototypical. Take a relatively rare or neglected disease drug that is  off patent, has no local manufacturing competition, and market it as a specialty drug with a hefty price tag. Althuough these drugs may be manufactured for much cheaper outside of the OECD countries, they can’t really be imported to the rich world because these manufacturers have not been approved by the regulatory bodies. Chao for example is the only FDA approved manufacturer of Cycloserine in the world. Furthermore, some of these drugs could find indications that are currently not in use for. D-Cycloserine has a putative role in increasing neuroplasticity, thereby potentially lending itself to use in schizophrenia and tinnitus treatment. This would mean a huge increase in the market for a drug that has already been available for more than 50 years.

The general public has always been a little ambivalent about its opinion of the  pharmaceutical industry. On the one hand drug companies bring valuable skill and expertise to the drug discovery, manufacture and marketing process. On the other, they seem to leverage thier valuable role in healthcare by running, what appears to many as  an extractive inudustry  bent on maximizing profits at the cost of everyone else. Incidents like these will only work to reinforce the latter notion.

The scare of the Trans-Pacific Partnership Agreement

The Trans-Pacific Partnership (TPP) agreement is the current US administration’s signature multinational trade policy initiative in the last several years. The policy  is seen as a means to facilitate trade around 12 pacific rim countries currently sans, importantly China.  Some see this as President Obama’s attempt to give some economic muscle to his Asia pivot policy. However from a public health point of view, the TPP is turning out to be a potentially scary monster  –  what some people are calling the restrictive WTO IP regime on steroids.

Terms of negotiations for the TPP are highly secretive, as negotiators feel open negotiations could undermine their bargaining chips. However, some drafts of the negotiations have been leaked by Wikileaks. If the provisions outlined on the leaked documents were to pass, the TPP could seriously jeopardize public health, especially access to medicines, here in the US, but also across the rest of the world.

The TPP attempts to further tighten current intellectual property laws, heavily in favor of the originator companies. First, it has proposed additional impositions on data exclusivity, making them unavailable for generics manufacturers to use these data before launching their own generic drugs. Second, it makes it easier for holders of originator molecule patents to file for process patents and renew their patents, in a process that is often derisively called evergreening. Third and more dangerously, it extensively expands the the purview of what’s called the Investor State Dispute Settlement (ISDS) tribunals, an extra-judicial mechanism mostly comprised of corporate lawyers that will enable corporations to bring on cases against states for curtailing or perceived curtailing of their profits.

This could seriously impede the government’s ability to advance a public health agenda and secure means to make drugs and health services more affordable. Under this provision, even arrangements like drug formularies, preferred drug lists or generic substitution may be considered anti-trade and be subjected to the ISDS tribunal, thereby forcing governments to pay hundreds of millions to corporations while attempting to safeguard public health. Drug companies like Eli Lily, and tobacco manufacturer Philip Morris have used this mechanism under provisions of various trade agreements to bring on cases worth hundreds of millions of dollars when governments tried to impose policies to ensure public health.

The greatest adverse impact however, could be on medicine access in some of the low and middle income countries like Vietnam, that are directly affected by the TPP. The TPP attempts to impose US standards of IP regulation on  signatories. This will have a direct effect of raising drug prices across much of the world, but more so in less developed countries. Furthermore because how sweeping the TPP proposes to be, its impact will be far reaching in that it will be a template for future such regulation.

In New England Journal this week, Amy Kapczynski in a commentary outlines the possible effects of the TPP on access to medicines all over the world. Several other organizations like Public Citizen and MSF have outlined the dangers imposed by the current draft of the TPP on medicine access. A few months ago, organizations including the MSF, AFL-CIO, AARP, Oxfam-America and Generics Pharmaceutical Association wrote to President Obama outlining their fears of the dangers posed by the TPP on public health, and especially access to medicines across the US and the world. Whether these fears are assuaged, or the TPP does indeed turn out to the scary monster that several public health advocates have been predicting, only time will tell.

The Truth about Tobacco Taxes

I am not going to drive up the traffic for someone with a clear intent on trolling the internet with disinformation, so I am not going to post a link here, but there is an story on the website called Hotair (right, the name is telling enough) about how the World Health Organization (WHO) is pushing a tobacco tax agenda. The story is prejudiced, but the prejudice clearly shows and most readers are likely to figure out soon enough that the writer has an axe to grind. (By comparison, even the Tax Foundation’s story from last year on the same topic reads much more balanced). However for the sake of truth and to crowd out the disinformation from the internet, I could not help point out why what’s peddled for sound logic in that story is in fact – in politer terms – faulty logic.

Here is the TLDR (too long didn’t read, if I must) version of the story’s thrust. That high cigarette taxes are responsible for the illicit trade in tobacco. But before I go into what causes the illicit trade in tobacco in the first place, a little bit of background.

Tobacco is the single most preventable cause of death in the world by far, causing as many as 6 million deaths every year. The WHO launched the Framework Convention for Tobacco Control (FCTC) back in 2005 to curtail this public health problem. The FCTC has been hugely successful in reducing global tobacco consumption, largely through a combination of supply as well as demand reduction strategies. As as result, today in many parts of the world, illicit tobacco is now the main source (57% in New York City for example) of tobacco consumption. In fact, curbing the illicit trade in tobacco may save up as many as 160,000 additional lives and increase revenues by about 31 billion dollars.

But illicit tobacco trade did not go up in absolute terms in most parts of the world because of high taxes or the FCTC. Research shows, illicit tobacco trade is directly a function of poor provision or lax implementation of laws to curb such trade. Places around the South China sea for example, like China and Malaysia have a huge illicit tobacco trade because it is easier to get away with illicit tobacco trade. In contrast, countries like the UK, which have very high tobacco taxes have been able to curb tobacco consumption as well as the illicit tobacco trade due to strong laws against illicit tobacco trade.

The data clearly shows, there is no clear relationship between high tobacco taxes and increase in illicit trade. Of course there are issues with differential tax rates within a close geography like the US. Differential tax rates have indeed been responsible for the increase in interstate smuggling of tobacco in the US. An article I wrote a while back dwells on this a little. But the way to reduce that is to harmonize taxes, much like the EU has managed to do.

Balanced discussion of this issue are made on this World Bank blog, and a paper on the MMWR from the CDC. Of course, supply reduction strategies like taxes aren’t the single solution to the problem of of tobacco consumption, and he FCTC recognizes that. The way to go about his problem is to make tobacco smoking “uncool” for the kids, to educate the public on the harmful effects of tobacco and to make it really hard for people to lay their hands on to tobacco by means of excise taxes and reducing illicit tobacco that makes tobacco cheaply available for people. If the WHO “Protocol to Eliminate Illicit Trade in Tobacco Products” is ratified, it will be a significant achievement in reducing the menace of tobacco – something that earns the unique distinction of being completely legal and at times even promoted by governments despite the overwhelming evidence that it is literally the most pervasive poison for people’s health.

Opinion on Obamacare among the tweeple is changing

The Affordable Care Act (ACA), now colloquially known as Obamacare, passed with a narrow margin in March 2010, with congressional votes roughly along party lines. Such ideological divide over the law has cast a long shadow over people’s opinion about it  – some well considered, others may be not so much. Now that the law has been implemented, people’s opinion about the law may be changing. History tells us, there was  similar opposition to the Social Security Act (1935) and the Medicare Act (1965), with opinions deeply divided over idealogical lines. However, both the social security and medicare are well accepted in the american society today; so much so that the same stripe of politicians who opposed them some decades earlier, are now seen to scamper to its defense.

Tracking if opinion about the law has been changing over time may provide us with insight about whether it is gaining acceptance in the country. Organizations like Gallup conduct telephone surveys every few months to gather data on people’s opinion about the law. Newer techniques like Sentiment analysis may offer an easier and faster way of finding people’s opinion about the law.

In order to do such analysis I used data from Twitter to mine people’s opinion about the law. I used the TwitteR package for R, written by Jeff Gentry, to download 1000 tweets every week about Obamacare. I then used an approach used by Jeff Breen to score the sentiment in these tweets  over a period of time. With this approach, each tweet is chopped down to its individual words and these words are then compared to a lexicon of positive and negative words. A score is then given for each tweet depending upon the number of positive or negative words present in the tweet. A positive score denotes a positive sentiment whereas a negative score denotes a negative sentiment. A score of zero denotes a neutral sentiment.

I labelled all tweets with a negative score as  a negative sentiment and those with a positive score as a positive sentiment. Tweets with a score of zero were labelled a neutral sentiment.

Here are the results from the data for the last few months.



Overall opinion about Obamacare seems to be more negative than positive. However, based on these results the total number of tweeple (read Twitter people) with either a negative or a neutral opinion about Obamacare seems to be falling while the number of people with a positive opinion about Obamacare seems to be increasing. The dotted lines in the adjacent graph represent the overall temporal trend of opinion about the law among Twitter users. If these trends were to continue, opinion about Obamacare will be more positive than negative in the next few weeks.

As a comparison, here are the results from Gallup’s survey until May 2014. It is difficult to exactly compare between the two results for  1) Gallup’s survey asked people a dichotomous question about opinion about the law 2) they cover different time periods

One concern about using Obamacare as a search term was that the word essentially had derogatory connotations about it when it was first used. That may be changing with time, as the word finds more use in the mainstream, but using ACA as a search term for the law in Twitter gave inaccurate results and #ACA just does not seem to be used often enough in twitter.

While democratic controlled states have chosen to expand Medicaid, a key element of the law, some republican controlled states have chosen to do so while some others have chosen not to. This forms a sort of natural experiment where we could study if implementation of the law in any state changes opinion on the law one way or the other. In order to study such temporospatial trend, I downloaded tweets from 10 cities around the US: 2 blue state cities: Chicago and LA, 4 red state cities that expanded Medicaid under Obamacare: Columbus, Denver, Phoenix and Louisville and 4 red state cities that did not expand Medicaid under Obamacare: Memphis, Miami, Milwaukee and Houston.

Here is the spatial variation of opinion on Obamacare for these 10 cities and the US in general for the week leading unto August 1.



And here is the same for the week leading up to August 18.



Future results will follow on this blog.

I will post the code on github shortly.

Here’s why developing countries should invest in health

20 years ago to this month, Rwanda was the reflection of humanities’ most self destructive instincts. Within a matter of 100 days in 1994, almost 1 million people – 20% of the population – were killed in an ethnic genocide between the Hutu and the Tutsi. Back then, when gory images of the genocide in Rwanda spread across the world, it was impossible to imagine that the country would one day in the future become some sort of a paragon for humanities’ instincts to nurture and nourish.
Yet Rwanda has done exactly that: from the ashes of the war, it has built a health system that is the envy of much of sub-Saharan Africa, and the rest of the world can’t help but stop and take notice. From having almost no health facility, public or private, worth the name at the end of the war, this nation of 11 million people has created a health infrastructure that has helped double life expectancy in almost 20 years.
Close on the heels of the genocide, as if the carnage left by the war were not enough, an epidemic of HIV usurped Rwanda much like the rest of sub-Saharan Africa. Scores upon scores of fathers, mothers, breadwinners were being wiped out, leaving behind all the but the dependents: children and the elderly. Things got so bad at one point, some people had the courage to suggest that the frail must be left to die, to enable a Malthusian purge and make way for a rejuvenation from the remains.
Better sense prevailed and Rwandans took to the onerous task of retooling and rebuilding their country. They came up with a “Vision 2020” that heavily stressed on making Rwanda a middle income country by the year 2020 and proposed that investing in health of the people as a major pillar of that strategy. Health was taken up as a rights issue and equity in health was thought instrumental in achieving the vision.
Their first battle in health care was HIV itself. With assistance from other nations and partners it heavily expanded HIV care, within the 10 years after 2000 the number of people in HIV treatment went up almost 100 fold. HIV rates have now fallen by a third, and facilities that were earlier on established to provide HIV care have now been expanded to provide integrated care.
Life expectancy has doubled from around 30 years in the mid-nineties.  Lesser number of children die today than they ever did, more than 90% of children get vaccinated, two-thirds of the mothers give birth assisted by a trained provider.  Rwanda remains one of the two African countries on track to meet the health related millennium development goals. A community health insurance scheme has been instituted, the poorest of people receive subsidies to participate in such insurance scheme.
Such health outcomes have had economic dividends for Rwanda. Per capita income has gone up three fold to $600 ($1300 in terms of purchasing power parity) in the last 20 years. The experience of Rwanda has but corroborated what has been felt all over the world in the recent times- that health expenditure is not just watering the quicksand, it can make way for real economic gain. Health expenditures have been known to provide at least 3.3 to 10 times the return on investment over a period of time. If the  moral or the legal argument for providing health care were not adequate enough, policymakers could at least pay heed to how it makes economic sense to invest in health care.
For developing nations that aim to rapidly steepen their arc of progress, investing in people’s health makes tremendous sense, not to mention the fact as Rwanda has shown, an equitable health care system helps bury the scars of a difficult past and make way for a new beginning. We would all do well to pay attention.

Patient is the new kind of provider

It doesn’t take much effort to discern the fact that patient and provider dynamics are changing. People, especially physicians rue what they call was once a sacred relationship, that has now been overtaken by corporate interests, the government, overzealous hospital administration or even the annoyingly-attention-demanding radio-buttons and check-boxes in the EMR. These external forces are certainly influencing the way patients and providers interact with each other. But a more fundamental force may be turning the relationship on its head.

Traditionally providers have been called so because they bring two things to the table:  unique knowledge and know-how and the services they provide using that knowledge. When illnesses were short lasting, few-times-in-a-lifetime events this was largely true: providers saw a large volume of patients and overtime accumulated a wealth of information and experience that they used to the benefit of their patients. In fact this information asymmetry between the provider and the patient was and is exactly the reason physicians demanded such a premium in the health system.  However of late the nature of illnesses has changed.

Illnesses are now protracted and lifelong events that the patient has to deal with every single day. As a result not only does the patient have more longitudinal experience with the illness, he also has unique experience about how his body reacts with various therapies and treatment methods. This knowledge in very valuable especially given the individual differences in the natural history of chronic illnesses. True, specialist physicians are likely to bring in unique learning to the table but there is no denying the importance of  the patient’s learned knowledge, specially at a time when personalized medicine is the new rage in town. Oftentimes, young doctors to come across patients who have lived with an illness for longer than they have been in medical training and practice. Such patients are as valuable a source of learning to the doctors as any medical text.

Patients who live with chronic illnesses have to provide the majority of the services by themselves. They take their own medications, they work on a healthy way of life for themselves and they use their knowledge about the disease to manage through the course of the illness. It is not uncommon at all to come across a diabetic who correctly diagnoses their atypical hypoglycemia symptoms or a patient who points out he has only rectal pain with a Crohn’s flare. And since majority of the care in any chronic illness is delivered at the home itself than the hospital or the clinic, the patient, and may be his family, is suddenly the greater care provider!

Roles are changing. Chronic disease care providers now are more like a coach or a guide rather than the know-it-all Dr Welbys of yesteryear. As illnesses become more complicated, numerous professionals work with the patient, not very different from an athlete in an individual sport, a large team works in tandem but its finally up to the athlete to execute the game.

The current state of rueful confusion among care providers is representative of birth pangs of this new paradigm. Physicians and allied professionals however need not worry, there will always be more service needed than they can comfortably provide; they just need to recognize the fact that there has been some reassignment of the roles and designations.

The art of prognostication

One night in the ICU, I told two loving sisters to a 43 year old sickly cancer patient that their little sister was doing well. As the patient’s admitting doctor, the sisters were banking their hopes on me. They were trying to ask me probing questions, but fumbling. Then one of the sisters managed to spew out her fear. “Okay doctor, how is she doing? Is she going to be okay tonight? You can be honest with us”. 

I could see what the harried sister was not  able to put a voice to. I thought I would cut through the sisters’ fears and help them out with an honest answer.

“Are you asking me if she is going to die tonight?” I volunteered.

“Yes”, they nodded in affirmation, probably relieved that I could see through the veiled question.

“No she is not”, I said. “Thank god”, the sisters resounded together in great relief.

Immediately after, a sickening feeling ran through my stomach. I looked around. The nurse who was by the bedside gave me a hidden look of incredulity. I can’t believe you just said that, his eyes seemed to scream. The intern who was working with me walked out of the room. Later I learnt, he had just told the sisters he wasn’t too sure of the prognosis.  

It felt like a weird contortion of the Murphy’s law: the one time you say something isn’t going to happen for sure, it is going to happen. Was my patient going to die just because I had predicted confidently that she was not going to die?  

I had my reasons to feel confident about the patient. A few hours earlier in the ER, she had been in a rather bad shape. She was not breathing well, and appeared to be anxious and confused. We got her upstairs to the ICU, put  her on a breathing machine and she started doing much better- she calmed down, her blood pressure was holding up well. The reversal was very visible. I felt happy.

Calmed by what was to be my ignominious hubris, the sisters decided to leave the hospital and go home. An hour later, I had to call them to say that their sister wasn’t doing well. An hour more or so later, I had to examine the patient with the the two sisters and the rest of the other siblings  by the bedside, and declare her dead.

Talk about eating your own words.

Such is the treachery of the art and science of prognosticating patient outcomes. In order to deal with the complexity of such an arcane endeavor, doctors often resort to defensemanship: an art of ambivalating, avoiding sticking the neck out  and commiting oneself to an answer.  That way you may not really be right about your answer, but then you are never really wrong either. Sadly, the common understanding is that this is the best strategy for the doctor. There is hardly any incentive for the doctor to rightfully predict patient outcomes, whereas there may be a huge amount of liability associated with getting your prognostication wrong.  

Despite all the numbers that you memorise from texts, generous experience and a dollop of common sense, it isn’t very difficult to make an idiot out of yourself trying to predict how a particular patient is going to fare in the immediate or the long term. You sure have tools to calculate average outcomes, but they are just that, at best a rough shot at predicting outcomes averaged over a population. There may be little corelation with the individual patient at hand.

Then how do you prognosticate immediate outcome on a ciritcally ill patient at an acute care setting. Is it even a wise idea to prognosticate outcomes in a critical care setting? Is the standard, this is the ICU, so anything can happen answer still the best we can come up with?

The reason I stuck my neck out and volunteered a definitive answer  with this patient was two fold: first, the patient was really doing better and there was little reason to believe based on clinical experiene as well as the available data that this patient was going to die in the next 12 hours.  Second, always saying I can’t really predict the outcome almost felt dishonest, when I know majority of the times a patient like this is not going to die in a situation like this. So if a more straight forward and honest answer was going to ease the sisters’ anxiety greatly, why not volunteer with an answer?  

It is easy to rationalise this experience as a vital element of learning. Such experiences however, are double edged swords I believe. True, in the future, before I venture out with a definitive answer, I will swallow my words three times over and probably chicken out with an “anything can happen”. I will not get my answer wrong, and thus avoid the ignominy of it, but far more often than that, I will fail to get it right, and thus lose out on a chance to provide some solace to the patient and the family and provide a positive approach around a practise of medicine that is increasingly being usurped by the self defeating black art of the negative and the defensive.

The sisters were understandably shaken, but then they were immensely thankful for the vigil that we’d provided and the care that we had given through their sister’s final hours. They did not hold me up for venturing with an answer- they knew the impossibility of mastering this art. Much like I was able to decipher the intentions of their words, the sisters were able to decipher the intentions of my words- they were grateful that I had volunteered to say them aloud.

Healthcare’s performance report: Virginia

That was Virginia’s second visit to the hospital in the ten days of the new year. It also ended up being the last.

Virginia was a patient we all knew. She came to the hospital frequently. The aphorism of our intern year was, if you had not taken care of Virginia once, you were not going to graduate out of internship. And that was hardly an exaggeration- almost no one in my internal medicine residency class had been through their internships without admitting her at least once. I admitted her twice. She knew our faces- she never really knew our names though- although she would give us a bored “I know you” every time we met her in the ER exam bay for an admission.

That evening I was signing out in the ICU after a rather long shift; an attending physician came asking if we knew about a certain patient who had died in the OR the previous night. “Some Vivian Hunt or something”, he said. “She used to come frequently to the hospital”. You mean Virginia Hunt? I suggested. “Yes that’s the one”.

She died? A sigh of incredulity escaped my mouth; it suddenly felt as if a wall had fallen off the room we were standing in. Virginia had become some sort of an irrefutable constant in our working lives- I had met Virginia in the ER just a few day ago, she was in with some cold- and the constant was suddenly gone.

Memories flooded my mind on the drive back home. The first time I met her must have been sometime in October 2010, when I was still a greenhorn of an intern. She had come in with chest pain. “Are you my doctor?”, she asked, when I walked into the room. Yes I am, I said. “I need my Benadryl. I take 25 mg four times a day. And don’t give me the pills, they don’t do me no good. I need IV.” I was almost taken aback by my patient’s surefootedness. Her skin was dry all through, maybe it’s the kidney failure giving her the itch, I thought.  I ordered the Benadryl. Virginia was happy.

On any given day, Virginia was as sick as anyone able to walk on two legs could get. She had a barely pumping heart  with valves that leaked like a sieve, her kidneys did not work- she was on dialysis, she had seizures, she had had strokes in the past, her heart rhythm was abnormal and without blood thinning medications, she had a chance upward of 10 percent of being felled with a blood clot in the brain year on year. Barely in her early 50s, and  Virginia was already walking in and out of death’s door everyday.

Every other week or so, she would come to the hospital with chest pain, or some variation thereof. Although the vessels in her heart were not blocked, she had enough reasons to have heart related symptoms. The constant fuelling on heroin did not help. Yet Virginia was rather unapologetic about her habits- any conversation about the risks of drug abuse ended with a terse “I know”.

In April 2011, Virginia had a major heart surgery to replace the leaky valves in her heart. The surgery went well, but within a week or so she was back in the ER. We were worried the new valve may have something to do with the chest pain she came with. The valve appeared okay, it was the surgical wound on the chest that was hurting. She had also managed to lay her hands on some heroin.

Every time she came in with something like chest pain, she would often develop some other problem in the hospital completely unrelated to the first one, like an infection. She would be discharged in a few days and then she would be back in  a week or two. This went on in an unending loop. Virginia’s being in the hospital at any time was almost a given, not to mention the times she was admitted to some other hospital.

Stunned by her death, the next day I sat at a computer to reflect on her hospital visits. In 2012 she had been to the hospital 19 times. In 2011 she was in the hospital a whopping 51 times. After her surgery in 2011, we changed her primary care provider. She had 4 visits with him in the 20 odd months since then. She had a home health nurse visiting her every so often. In the last few years, she had had in excess of 100 x-rays, close to two dozen CT scans and every other kind of test imaginable. The only test she did not get done seemed to be a urine study- she just did not make any urine.

That fateful evening when she died Virginia had a fall at her home. She was dizzy when she came to the hospital. An initial CT scan was normal however within a few hours she was progressively worse. She was then found to have bled in her head. She was whisked to the OR and the blood collection evacuated. However she was not able to make it out of the OR- after half an hour of desperate resuscitation Virginia was declared dead.

Virginia is the very reflection of our healthcare system, it’s performance report: everything that is wrong and right about it, from over and inappropriate use, poor coordination, goals and priorities that are at times misplaced,  to the availability of modern advances and plenty resources at our disposal. Too bad such bottomless resources were not able to save Virginia’s life. Worse still, our failure to steward such resources threatens to pull the entire economy, and everybody else down together in a landslide.

Name changed.

The challenges of tobacco control

The WHO FCTC (Framework Convention on Tobacco Control) has been trying to regulate tobacco production the world over by restricting the use of land available for tobacco farming. The reasoning behind this is  two-fold: first tobacco has been singled out as the greatest preventable cause of death. Second the use of scarce farmland, especially in food deficient areas around the world, has been said to contribute to food shortage and hunger.

As expected, the convention has drawn the ire of tobacco farmers, the tobacco industry and their interest groups. Focal interest groups have amassed a war-chest to put up a fight. The FCTC isn’t any far behind; it has painted tobacco use as the greatest evil plaguing public health today.

What makes this battle interesting to watch is that both the sides have a valid point to the argument. The farmers point out, nothing gives them as much of a return from the land as tobacco. That is a valid argument, though not entirely so. Tobacco farming is very high up indeed in the value chain but projects elsewhere have  shown that it is indeed possible to derive as much returns from the land by means of farming other suitable cash crops.

Tobacco related illnesses are known to cause almost 100 billions dollars of healthcare costs in the US alone every year. Such costs have to been borne by pooled resources, either through the government or through private insurance. So it is no surprise that people will look to curb such costs for the sake of the greater common good.

The FCTC isn’t the first blow anti-tobacco campaigners have managed to land at the tobacco industry. Tobacco tariffs are already stiff in many parts of the world. A few months ago the Australian government passed a legislation to enforce uniform (read visually unattractive) labeling on tobacco products, a move that has been upheld by the Australian High Court. Similar attempts are underway in many part of the world.

And some people are even talking about disallowing cigarette smoking without a license.

Legislating tough tobacco laws may however be the easy part. The exorbitantly high cigarette tax in New York has proliferated an entire industry trafficking cigarettes along I-95, from Virginia where such taxes are almost non existent to New York where such taxes are the highest. Gangsters that used to engage in gun and narcotic trade earlier now engage in the much easier and lucrative tobacco trade. This not only defeats the public health purpose of such legislation, but also causes loss of much needed revenues (illegal tobacco trade costs as much as 10 billion dollars in lost revenues in the US).

Our attempt at enforcing a strict ban on drugs holds valuable lessons. While enforcement has been very heavy in the US, drugs of abuse are still very easily available undercover and usage is alarmingly high in the general population. What this has essentially done is drive the whole trade underground. In the meantime, strict enforcement of drug control related rules has resulted in the largest prison population in the world in the US (25% of the entire global prison population). Incarceration on the other hand leads to its own irreversible social rot in the affected. Furthermore, underground drug trade in the US has fueled and fanned a drug Mafiosi in Mexico that has been declared almost impossible to wipe out even after the loss of tens of thousands of people in drug related violence and billions of dollars spent in the fight.

Tobacco certainly is one of the greatest preventable public health threats; tobacco use in no way should be encouraged or facilitated or condoned. However trying to force tobacco use to one dark corner using all our might may prove to  be another social disaster the with hitherto unfathomed consequences, the way our battle with drug enforcement has been.

Educating  and subtly modulating behaviour against tobacco use will likely give us the best results; trying to ham-handedly force people out of tobacco may ultimately backfire. After all, humans are a creature defined by free will; they certainly appreciate better health but also appreciate the the right to exercise their free will at least equally so.

The Adoption of EMR

It is no news a lot of doctors like to stick up a rather snotty nose to EMR, despite all the rage in town. The defenders of the EMR tend to label such doctors as archetypal Luddites, sticking to their archaic ways and unbecoming of change and the new times. But as is usually the case with any two heated but opposite arguments, the truth likely lies somewhere between the two extremes.

On an objective basis, there is no denying that automatisation of medical record keeping is the new way forward. In theory, if the machine could keep records for you and give it back to you when and where you want it, thus freeing up valuable time for the patient encounter, that should be winsome for everyone. That alas, is a vision of the EMR utopia, and let alone being anywhere close to such utopia, it is difficult to ascertain if we are even set in the road leading us there.

Sometime ago, exasperated at the sheer waste of time that the clunky new discharge module was causing because it would not work the way it is supposed to (my hospital is means challenged, so they are building a patchwork of cheapskate EMR suite on top of their legacy system from the 90s, just to placate the gods of CMS), I complained to the IT guy that the thing barely works! The guy was sympathetic and said- “look I know the discharge module sucks, just bear with it until the end of the year when we should be able to weed out the bugs” But that’s not all, I said, even if it were working just the way it is supposed to, the discharge still takes me longer than what it used to with paper. “That’s something you will have to learn to live with” he retorted, “computer records do take a longer time than paper, and there is nothing I can do to change that”.

Right there, I think is where EMR loses a lot of ground against paper records. At any practice, time is the most valuable resource, and anything that doesn’t offer a straight off benefit to save time will have a hard time being adapted. Add to that the inertia people have about their old ways and you have a deal breaker right there. (digression alert) I once heard an attending at the hospital say, “I really like the feel of pen on paper. Computers just don’t give me that feel.” The attending has beautifully symmetric cursive handwriting that looks like artwork on paper. And needless to say, she hates EMRs from the bottom of her guts!

That’s not all. Driven by the constant government whip to adopt EMR- no EMR, no pay (reminds me of junior Bush’s iconic rhetoric- if you are not with us, you are with them!), and an EMR industry that is hell bent upon imposing itself on healthcare (they can’t believe they don’t have a sizable share of the multi-trillion dollar healthcare bounty) a lot of makeshift EMR adoption has taken place. So you have hospitals where one part is using one system while the other is using a completely different one. At one clinic I recently worked at, we had to switch between 3 different EMR systems, just to get the patients records. And there still was the paper records not to mention the dictation.The constant juggling not only made the patient encounters time consuming and cumbersome, it literally made us curse at the computers and ruin an otherwise perfectly normal day at work. Patient volumes have gone down from 15-16 patients per day to a half of that after EMR adoption.

What’s wrong with the current adoption of EMR? Why are even the converted like me (most of us doctors trust me, are the opposite of Luddites, the first thing I learnt to do with a computer was write code; I freely use LaTeX and R) questioning EMR?

I think there are two reasons for such seemingly epic failure. First, how we interface with an EMR. Second how the EMR tries to impose its will on to us instead of the other way around. A keyboard and a point and click device may well have worked for many other interactions with the computer, but with an EMR it doesn’t always appear to be nifty. It is a common experience that most people find dictating their notes much faster than typing them. Accurate automated transcribers (current bunch of transcribers are known to be as much a 6 times more inaccurate over human transcribers) could really speed up record keeping, thereby selling EMR to the unconverted while saving costs over manual transcription. On the same note, no EMR is going to be see a faster adoption if something like writing a prescription takes a minute when in paper it barely takes  10 seconds. Right now doing something as simple as writing a prescription feels like running through a bunch of fire breathing hoops. Someone may argue, you can at least read it better, but don’t get me started on how the EMR can come up with its own ludicrous set of errors, something that would never be possible with paper.

Trying to impose a readymade architecture on to health care will not work. “It works for retail and banking”, some people seem to offer cluelessly. But a patient encounter is no visit to your bank cashier. And human body is not your bank account, it is way more complicated and it is bound to generate way more complex information that is difficult to straight jacket into the rigid and rudimentary pipeline of set information pathways. An ideal EMR is supposed to be a seamless body-glove; today they feel like the hangman’s cloak, not only are they cumbersome, dark and dreary and suffocating, under their apparition, they force things you to do things you wouldn’t otherwise do.

Such forced behaviour modification may make the administrator, the insurance company the government happy but I can’t understand how selecting a dozen pesky radio buttons (like the one that tells the patient to shower everyday; another one says- don’t smoke, if you do quit- tobacco counseling for the sake of the payer!) while doing the discharge makes the patient lead a healthy life or make his doctor particularly enamoured with the EMR, just because the government said so or that it made the IT companies a few million dollars richer.


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