First of two columns on American public health issues.
Americans are fascinated by drugs, the quick cure for whatever ails you. Take a pill for that pain, physical or mental. As a consequence, we have built two empires of folly. First, we mixed drugs, moral righteousness and criminal justice, converting a public health problem into a costly police, legal and prison establishment, employing millions in a tragic, wasteful enterprise criminalizing many smaller nations.
Secondly, though thousands die by gunfire every year in drug incidents, more Americans die from the use and misuse of drugs manufactured by our pharmaceutical industry than from consuming illegal drugs. No doubt pills extend a large but unknown number of lives for unknown lengths of time, but at staggering costs. Since the pharmaceutical industry and the Bush administration pushed through the deceptively titled Medicare Modernization Act (MMA), $60 billion has been appropriated annually to give more free pills to seniors.
At some point Americans will wake up to the self-destructive force of our perpetual "war on drugs" but this year the treatment disarray and profit structure of drugs ordained legal and profitable compete for public attention. If only you could patent a drug called "placebo." Yes, recent investigations show that the placebo does as well or better than many drugs for which we pay millions, the mood altering drugs in particular.
The wrong foot forward in health care modernization came in 2003 with the adoption of the MMA. This act opened federal coffers to support profits for the pharmaceutical industry. The proliferation of pill-popping forms of treatment and prevention illustrates much of what is wrong with having a health system based on the profit motive.
Several books, reviewed in the June 23 and July 14 issues of the New York Review of Books by Marcia Angell, a former editor of the authoritative New England Journal of Medicine, describe the process by which drugs are approved by the FDA and marketed by the companies, a process that reeks of slick practices, poor science and greed.
The placebo is the alternative, neutral substance that is distributed in clinical trials to test the effectiveness of a new drug being proposed by the industry. Using freedom of information requests, Irving Kirsch, author of "The Emperor's New Drugs," found that, in 42 trials of six popular antidepressants, most showed no improvement over the placebo. But only two statistically successful trials are required for an FDA approval. Kirsch suggested that in the few marginal cases where the tested drug showed some improvement over the placebo, the test patients, feeling side effects previously warned of, guessed they were taking the new drug. The net result suggests, of course, that if you think you are taking something that will make you feel better, you will feel better.
The overall impression is given of a boom in diagnosis and treatment (if not cure) of more broadly defined mental illnesses as a result of marketing aimed primarily at the general public to which psychiatrist providers too easily yield.
The pill boom points to the profound mistake in so much of our medical treatment systems that arises from its base in the profit motive. The patent on a new drug runs out in four years. To avoid the drop-off in profits, the industry is constantly looking for peripheral additions so a new pill can be patented and sold under a brand name that the public is trained to prefer over the generic.
The research that underlies the production of new drugs should be based entirely on the need to seek cures for disease. The use of research for quick profits works against long-term health goals. We are better served by the funding of national research institutes and universities and through them the medical communities and hospitals that directly serve the public.
The mess exposed by these public health specialists is big. You should demand action but your demand will be both drowned out and derailed as a result of a sickness in the American system of democracy whose cure should be our top priority.
John Havelock has taught public policy at UAA since to his retirement as professor of justice. Previously he served as Alaska's attorney general.