Dr. Marc Siegel is a practicing internist and an associate professor of
medicine and a fellow in the Master Scholars Society at New York
University School of Medicine. He is a weekly columnist for the New
York Daily News, a frequent contributor to the Los Angeles Times, the Washington Post and The Nation. He is a member of the board of contributors at USA Today. He appears frequently on CNN, the Fox News Channel, and the NBC Today Show. He is the author of False Alarm: the Truth About the Epidemic of Fear and most recently, Bird Flu: Everything You Need to Know about the Next Pandemic (Wiley).
It seemed like a straightforward invitation. Dinner at an upscale uptown
restaurant, sponsored by a drug company, where the topic was to be
Dr. Marc answers readers' question every other week. To send a query, click here.
Dr. Marc answers readers' question every other week. To send a query, click here.
How many of you believe that crucial healthcare issues are falsely
represented by corporate America for profit or political advantage?
As corporations push new medicines, sound and affordable healthcare
Bureaucratic timidity and turf battles needlessly put many Americans at risk.
Muhammed Butt, a 55-year-old laborer from Pakistan who was detained for a day as a terrorist suspect after September 11 and then imprisoned for a month on a simple visa violation, was said by authorities to have died of a heart attack. In fact, his heart was misshapen from birth and his coronary arteries were blocked. Wrongly suspected of anthrax exposure and isolated from the world, he was overcome by the stress. As a doctor, I can say that in all ways, he was a man who died of a broken heart.
Muhammed Butt's death illustrates a central problem that is the direct consequence of a zealous backlash against terrorism. Hundreds of people are rounded up without justification, and once interned, they are kept for weeks behind bars without ready access to their families or to lawyers. It is hard to imagine a situation better designed to produce severe stress and depression.
Butt worked all his life as a laborer, often traveling between oil fields in Qatar and Dubai to provide for his family. Last year he came to New York on a temporary visitor visa. His goal, as it often is for those who leave their families behind, was to send home money for his three daughters' weddings and to give his two sons the opportunities in life he'd never had. But he was only able to find odd jobs, first in a deli, later stacking boxes and waiting on tables in a restaurant in Queens. His nephew, Muhammad Bilal Mirza, a longtime resident of Brooklyn, gave him cash whenever he could, but he couldn't drive a taxi like his nephew because he didn't know how to drive.
Mirza describes his uncle as a large man. His picture shows a broad face featuring oversized, oblong ears, a rough, pear-shaped nose and small, squinty, suspicion-raising eyes. He was graying visibly and gaining shadows and lines from rapid aging mixed with worry. Mirza says his uncle never complained of not feeling well. Not long before September 11, he told his nephew that he was considering giving up and returning to Pakistan.
In late September a local pastor reported to the FBI that several men who had arrived in two vans had entered Butt's residence, leading the FBI to investigate. Butt was arrested for overstaying his visa, but, finding nothing to interest them, the FBI turned Butt over to the INS after holding him only one day. Meanwhile, knowing that his uncle had been arrested, Mirza tried to obtain a lawyer, but couldn't afford the $7,000 fee the lawyer quoted. For the next month, the INS held Butt in the Hudson County, New Jersey, jail pending his deportation, during which time Mirza tried unsuccessfully to locate his uncle. Alan Apselbaum, a prison social worker, said that prisoners may call collect on pay telephones inside the prison. "I have no idea why Mr. Butt didn't call anyone," he said.
On October 1 Butt underwent a routine physical. His blood pressure and medical findings were normal, but the dentist started him on an antibiotic for gingivitis. Dr. Francis Molinari, a prison doctor, said that the guards and other prisoners were worried that Butt might have been handling anthrax because he was now taking antibiotics--despite the fact that the antibiotics had been prescribed by a prison dentist--and Butt was compelled to undergo a nasal swab test for anthrax. Dr. Molinari tried to downplay the persecution and isolation experienced by Butt and others. "It's calm here," he said. "Nothing strange is going on."
However calm Butt may have appeared, not complaining of chest pain or anything else, his stress was apparently building. On October 23 he rose as usual before dawn, ate breakfast and passed several hours on his cot, where he was found dead just before 11 am. The New Jersey state medical examiner, Dr. Faruk Presswalla, like many pathologists a keen puzzle-solver after the fact, said, "The stress must have killed him. He already had a bad heart, even if it never affected him before. His coronaries were 70 percent blocked and one of the coronary sinuses was missing. His heart wasn't made to handle a crisis." The seasoned coroner found no sign of trauma, anthrax or even gingivitis, which may have been cured by the antibiotic. "This man was basically healthy," he said. "He could have lived a long time even with his heart like this."
Mirza learned of his uncle's death from the Pakistani consulate, which had been notified by the INS. He also heard from the lawyer he had contacted after Butt's detention. Mirza recalls, "I tell him, 'What kind of help you bring him now?'" At the ceremony of remembrance, he joined irate friends circulating a petition to protest Butt's long internment. This petition was presented to the Pakistani ambassador, in the hope that it could be sent to the State Department and would lead to changes in INS policy. Butt's body was shipped back to Pakistan, and according to Mirza, Butt's wife said she wanted nothing to do with the United States ever again.
Restricting freedom in the name of freedom, our intelligence community risks forgetting why our society chose to call itself free in the first place. Hundreds of people like Butt have been rounded up because of someone's suspicions and remain in prison awaiting deportation. Not charged with a real crime or provided access to lawyers, these people must be deported promptly or freed, or many will languish, and more will die. Our agencies must not terrorize innocent people in their search for terrorists.
Mirza, a US citizen for fifteen years, still says he's proud to be an American: "American people have a wonderful heart. All Americans suffer now and pray for the people who have died." Mirza halts in his speech, listening, wanting to be believed, afraid that because of his uncle he will be lumped into a group that is automatically mistrusted. Mirza says sadly that he has been burning vigil candles since September 11 and volunteering at the Family Assistance Center in Manhattan. "All who died," he says, "are innocent."
Every closet in my medical office is suddenly filled with samples of Ciprofloxacin, an ordinary antibiotic intended primarily for use with bladder infections. This week, every patient phone call I receive and almost every patient visit to my office includes a request for this antibiotic. Physicians as well as patients are stockpiling the drug. One of my patients returns home to his wife, and she relays to me that instead of reassuring her with news of his normal test results, he instead brags, "I've got it. I've got it," brandishing his hoard of Cipro samples that he must have smuggled from my closet. Another patient calls me from Philadelphia to ask whether she can take Cipro to prevent anthrax. "Not unless you live by a certain building in Boca Raton," I reply. Five minutes later she calls me back frantic--her neighbor is returning from Boca wheeling her possibly contaminated luggage down the hall. "No," I groan. "No Cipro."
Bayer, the Cipro manufacturer, is stoking this frenzy and playing into public hysteria by promoting the drug. The drug reps drop off hundreds of sample cartons at my office without saying what for, though I can see them frowning when they hear me say, "I am not prescribing Cipro for anthrax."
Why Cipro? What the drug company is not telling either patient or doctor is that Cipro was originally tested as an alternative treatment for anthrax only for penicillin-allergic patients. Antibiotics have never been properly tested for prophylaxis, so Cipro's usefulness for prevention is speculative, though there is clearly some rationale for prophylaxing patients with close exposure. But doxycycline, a generic, is just as effective and costs one-tenth of what Cipro costs. A month's supply of Cipro costs more than $300; the equivalent amount of doxy is $32. In fact, there are multiple antibiotics available with similar efficacy, many of which are cheaper.
Which is not to say that any of these antibiotics should be prescribed. Prolonged use of Cipro, for example, without a real treatment target or reasonable endpoint, could cause significant side effects--including diarrhea, rash, colitis, gastrointestinal bleeding and insomnia--in a large population. Insomnia affects 5 percent of Cipro users, a fact that may be of interest to the drug rep for Ambien who follows the Cipro rep into my office to encourage me to prescribe more sleeping pills.
Another problem is drug resistance. Cipro, a milestone drug when it first appeared, has already lost some effectiveness because of excess use over the years and has largely been replaced by other drugs in its class, such as levofloxacin. I worry that continued unnecessary use will further cripple Cipro until people who really need it, for conditions ranging from the most minor kidney infection all the way to life-threatening cystic fibrosis, could find it useless.
Plus, if all the antibiotics stores are used up by a panicking though healthy public, people who really need the drugs for life-threatening conditions may find that they are out of luck. If antibiotic prophylaxis on a small scale does become necessary, then doxycycline or other relatively inexpensive antibiotics will represent a more cost-effective approach.
Most of all, I am concerned about a perpetuation of unsavory sales practices. In contrast to the altruism and heroism that rescue and healthcare workers have shown in the wake of the disaster of September 11, many of them working through the night without sleep or food, a drug company is attaching itself to the exact fear that is crippling us. The well-dressed Cipro rep whose territory includes my office and who plies me with "free lunches" is justifying the fear by pretending that there is a treatment for it. With the drug industry returning to what it knows best, parasitism, we find our dread exploited by a monolith that can't resist an opportunity to make more money.
John Elias, my patient, has a dilemma. He can't afford to buy his medicines and also pay his rent. I'm sure he won't give up his apartment just to keep his veins filled with my chemical suggestions. But he is willing to take whatever free drug samples I provide. Luckily, drug company representatives visit my office regularly and drop off oversize, brightly colored boxes of pills, one or two pills per box. Sometimes I can fill a plastic bag with enough medicine to supply a patient's needs. Still, my sample closet is not as well stocked as the local pharmacy.
The explosion of samples occurs most often when two drug companies are competing over a similar product. When I have one set of pills, it's Elias's diabetes that's treated; when I have another set, it's the hypertension. He does not die, but his blood pressure goes up and down, and his blood sweetens with rising sugar, which lowers whenever I happen to have the right pills. Elias leaves my office smiling, more comfortable with his predicament than I am.
"See you in a month, Doc. And don't worry. I got enough pills here to last me a good ten days."
I do worry--about the remaining twenty days, about his risk of a heart attack or a stroke--but samples arrive at the drug company's rate, not in response to my urgent requests.
Elias is disabled, the result of a spine operation that didn't go his way. He has Medicare, but like millions of other disabled and elderly Americans, he's unable to afford the secondary insurance that would include a drug plan. He earns too much in his part-time clerical job to qualify for Medicaid, which also covers prescriptions, or to be accepted into a drug company's "Share the Care" program. He does qualify for New York State's EPIC plan, which allows some Medicare patients to fill all their prescriptions for under $100 per month, but he says he can't afford even that. He says he won't consider leaving his job to get Medicaid as others have done; he's proud of the fact that he can still work.
Elias lives in his wheelchair; the levers and locks are extensions of his arms, the wheels his legs. He navigates the street outside my office, leaning back on two wheels to jump the curb. His arching wheelies are another man's sidestep. But he has not managed to navigate his other diseases the way he has his paralysis. When I tell him the dangers of not controlling his diabetes and his high blood pressure, his smile fades. "When you're out, then I'm out," he says simply.
Meanwhile, the same company that makes his diabetes pill offers to fly me, all expenses paid and with a $1,000 stipend, to a frolicking weekend in Naples, Florida, where I would hear lectures for three hours a day on a drug I already prescribe, before adjourning to the surf and a sightseeing sunset booze cruise. The competitor invites me to the corporate box at the ballgame, with a lobster buffet and a live calypso band to entertain us between innings.
The drug salesman infiltrates the somber atmosphere of my medical office, trailed by a huge sample case on tiny wheels. It's uncanny: He knows how much of his drug I prescribe, and he wrongly assumes that I will respond to his enticements. He provides catered lunches to my office staff where the only apparent cost is listening to him harp on about a product that he freely admits I know more about than he does.
Despite the money spent on massive advertising, the manufacturers insist that exorbitant drug prices are the result of research and development. Several of the industry's best researchers are former professors who have been wooed away from the universities for higher salaries and better laboratories, and for every participant in the drug pipeline, from discovery to production, the excitement is almost palpable. New medicines for arthritis, hypertension, high cholesterol and diabetes improve the quality of life with fewer side effects. However, the new drugs are sold in Canada and Europe for a much lower price--a $15 pill in Detroit may cost $5 across the river in Windsor, Ontario--and there are foreign chemists producing these drugs in the laboratory and companies selling them for a fraction of their cost in the United States.
The more expensive the drug, the more difficult it is to determine how it is going to be paid for. Recently, a new wonder drug for arthritis became available in two formulations, one oral, the other intravenous. The choice of which form to use illustrates a basic problem in reimbursement. Since Medicare pays only for the more expensive intravenous, patients are being hospitalized unnecessarily to receive it.
As a doctor, I'm frustrated by the current system's inability to consistently provide for a patient's medicinal needs. Clearly, there is a need for government to intervene, but it's crucial that this intervention include an understanding of inflated costs and a plan for combating this inflation. As Medicare expands to cover pills, will the federal government drive a hard bargain and negotiate a lower price per pill the way HMOs, hospitals and other countries already do? I don't see how taxpayers can avoid being penalized if the government agrees to pay top dollar.
This year, after many insufficient attempts to maintain his health with samples, Elias wheels into my office with, if wheels were legs, an almost detectable swagger. All his years in service as a clerk have finally paid off. He is now the recipient of secondary insurance with a drug plan. He is one of the lucky ones. Now all his medications will be covered, at least for the moment.
"I'm ready to be healthy," he says with a grin that reveals his neglected teeth. "Lay those prescriptions on me."