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."
New York City; Saturday, June 23, 2001--The Stop Global AIDS March today brought together thousands of AIDS, debt relief, anti-racist and anti-globalization activists from around the world
The concept captures fundamental characteristics of today's world order.
On a late June day that will surely have been picked by the political astrologers around him, Kofi Annan of Ghana will likely be coronated for a second five-year term as Secretary General of the United Nations. The 63-year-old Annan's first term doesn't end until December, but since there's no opposition to him, the Security Council--which decides on such things--seems inclined to formally name him in June.
The timing, of course, couldn't be better, both for Annan and the beleaguered UN system, which is hurting financially because the United States, its biggest donor, owes it more than $1.2 billion in arrears and continues to refuse to pay. A freshly crowned Annan will clearly wield re-energized clout as the General Assembly opens a special session on HIV/AIDS on June 25, a three-day conference that is expected to draw even leaders known to harbor antipathy toward the UN--such as George W. Bush.
Annan has made AIDS his special cause this year. He has established a global fund; the initial target was $7-10 billion. Bush has pledged $200 million, a sum that most AIDS activists consider inadequate. It's quite likely that Annan will coax another $300 million out of the Western Europeans. It's not at all certain that the AIDS session will end up as an exercise in effective fundraising, but its value may well lie in drawing unprecedented attention to the subject.
It's probably uncharitable to suggest that Annan's engagement with the AIDS issue flows from concern about the incipient actions of the Oslo-based Nobel Peace Prize Committee. But if Annan is honored by this body, it may well be because of the extraordinary steps he's been taking to advance public support for helping victims of HIV/AIDS. Until recently the UN's approach had been to let the issue be handled by a small, quiet unit in Geneva called UNAIDS. It is headed by a Belgian physician named Peter Piot, who has traveled the world articulating fearful statistics associated with the AIDS pandemic and gaining the reluctant cooperation of various feuding UN agencies. But Dr. Piot lacks Annan's stature and does not enjoy the benefit of his bully pulpit. Moreover, there are many competing issues within the UN system.
Whether Annan will be able to mobilize additional resources for AIDS is an open question. The world's thirty richest countries--members of the Organization for Economic Cooperation and Development--currently give less than $40 billion annually to the poorest 135 nations. The trend has been downward for several years now, since the record foreign-aid high of $75 billion some fifteen years ago. Some suggest that the $7-10 billion target for Annan's new global fund is a conservative figure, considering that the number of AIDS-affected people worldwide may well double in the next decade from the present 33 million. Most of the victims are in poor countries--especially in Africa--where economic and social development is already faltering.
Annan's strategy has been to link AIDS to the broader issues of jump-starting economic growth and insuring environmental security. The AIDS session in New York is only one of several international meetings that Annan is convening in the next eighteen months. The idea is that these conferences will serve as a sort of continuum and fashion a body of work on development issues. The idea is also to get leaders of rich and poor countries to commit at least modest new amounts of money to tackle the widening problems of poverty. And last, the idea is to project a recharged image of the UN.
Thus, a General Assembly special session on the plight of cities was held in early June; after the AIDS conference, there will be another assembly session, on the wide misuse of small arms and light weapons, especially in poor countries, where children are often employed as soldiers and vigilantes. During the summer, there will be a climate conference in Bonn, where the Bush Administration's stance against full recognition of the harmful effects of global warming--and renunciation of the 1997 Kyoto Protocol--will surely be a major item on the agenda. Then the UN will convene in Durban, South Africa, to mobilize world support against racism and other forms of discrimination. There's a summit on issues relating to children's rights and a world food summit in Rome, both in the fall; a conference on financing for development next spring in Mexico; and a conference on the problems of aging, also in the spring, in Madrid.
All these conferences will lead up to a World Summit on Sustainable Development in Johannesburg, in September 2002. Annan wants every head of state or government to attend, and he wants to review what's happened in the fields of environmental protection and poverty alleviation since the June 1992 Earth Summit in Rio de Janeiro. World leaders, including Bush the Elder, promised to act on the Earth Summit's Agenda 21, a sort of blueprint for global economic development, and said that the world's thirty richest nations should commit $125 billion each year in development assistance to the 135 poorest countries. Of course, no one's kept the promise.
Annan and India's Nitin Desai, his Under Secretary General for Economic and Social Affairs, aver that the decline in development assistance is unacceptable, especially at a time when globalization is leaving more and more people further behind. They cite the fact that despite worldwide improvements in such matters as infant mortality and literacy rates, some 2 billion people out of a global population of 6 billion live in poverty.
But Annan knows it's unlikely the rich nations will pony up more cash for development, particularly when public support for foreign aid is steadily losing ground in many wealthy countries. So he's trying to rally big business behind his plans. On the eve of the UN meeting on AIDS, former US ambassador to the UN Richard Holbrooke said that with Annan's encouragement, he has agreed to head the Global Business Council on HIV and AIDS, a UN initiative. Annan also recently persuaded outgoing Shell chairman and CEO Sir Mark Moody-Stuart to chair a new "business action council" for the Johannesburg 2002 summit. Moody-Stuart, a soft-spoken man who acknowledges that the energy industry's environmental record has been less than commendable, wants to devise ways whereby the business community can generate culturally and socially sensitive economic development in the poor countries; he says more economically healthy and socially stable societies are in everyone's self-interest: "Less confrontation, more cooperation--let's give it a try," he said in a London interview.
Nice sentiment. But already some nongovernmental organizations are alarmed that big business may unduly influence the UN at a time when the world body has never been more vulnerable financially. While it's unlikely that various UN organizations would rescind carefully negotiated protocols on subjects like the environment, it's not at all clear that the UN would be able to resist some sort of reciprocity for business largesse. What might such reciprocity consist of--co-branding, such as combining corporate logos with that of the UN? Or perhaps something more troublesome, such as designating UN personnel to serve as de facto commercial representatives?
No one is insinuating, however, that Kofi Annan can be bought. Indeed, the prevailing consensus in the donor community and in the corridors of the UN is that a cozier UN/big business relationship can bring another source of strength to the world body, not to mention burnish Annan's own reputation as a dynamic secretary general.
Third term, anyone?
An early US AIDS group employs direct action to oppose injustice everywhere.
Behind closed doors at the UN and in Western capitals, government and corporate officials are arguing over the size and governance of a fund that is going to be the primary international response to the greatest public health pandemic since the Black Death.
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Prevention and treatment require a focus on overall health and development.
A campaign to help sick people in need of unaffordable medicines is clashing with forces in the global pharmaceutical industry.
A woman two months pregnant goes to see her Ob-Gyn for prenatal care. As required by law, her doctor informs her that her condition places her at greater risk for a wide range of medical problems: hypertension and diabetes if she is overweight; complications of surgery if, like one in four women, she has a Caesarean section; permanent weight gain with its attendant problems, including heart disease; urinary tract infections and prolapsed uterus if she has had multiple pregnancies; postpartum depression or psychosis, leading in rare cases to suicide or infanticide; not to mention excruciating childbirth pain, stretch marks and death. There are ominous social possibilities, too, the doctor continues, reading from his state-supplied script: increased vulnerability to domestic violence; being or becoming a single mother, with all the struggles and poverty that entails; job and housing discrimination; the curtailment of education and professional training; and lowered income for life.
No state legislature would compel doctors to confront patients with the statistical risks of childbearing, serious though they are; a doctor who did so on his own would strike many as intrusive, offensive and out of his mind. Should a woman seek abortion, however, anti-choicers are pushing state laws requiring that she be informed of a risk most experts do not believe exists: a link between abortion and breast cancer. Like the supposedly widespread psychological trauma of abortion, which even anti-choice Surgeon General Dr. C. Everett Koop was unable to find evidence of, the abortion-breast cancer connection is being aggressively promoted by the anti-choice movement. (Even Mother Jones, always quick to take feminists down a peg, leapt on this bandwagon, with an April/May 1995 piece entitled "Abortion's Risk.")
"It's yet another example of efforts to encumber this legal choice and make it more difficult and painful for women," says Dr. Wendy Chavkin, professor of public health and clinical obstetrics and gynecology at New York's Columbia Presbyterian Hospital, and editor in chief of the Journal of the American Medical Women's Association. It's also an attempt by anti-choicers to reframe their opposition to abortion as concern for women's health, something not usually high on their list. These are, after all, the same people who fight health exceptions to "partial birth" abortion bans and who have successfully prevented poor women from receiving medically necessary abortions with Medicaid funds.
Nonetheless, such is the power of the anti-choice movement that laws have been passed in Montana and Mississippi, and bills are pending in fifteen other states, mandating a breast cancer warning (and in some cases, a waiting period for it to sink in). Along with laws come lawsuits: In Fargo, North Dakota, the Red River Women's Clinic is being sued for failing to give such a warning; a 19-year-old Pennsylvania woman is suing a New Jersey clinic for her abortion two years ago, which left her, she claims, with an overwhelming fear of contracting breast cancer. In ferociously anti-choice Louisiana, a new law permits women to sue for damages--including damages to the fetus!--up to ten years after their abortion. Given today's high rates of breast cancer, a deluge of litigation is in the making.
Does abortion cause breast cancer? Some studies have appeared to suggest a connection: Dr. Janet Daling, for example, an epidemiologist who says she is pro-choice, compared the abortion histories of 1,800 women with and without breast cancer and found that, among those who had been pregnant at least once, the risk of breast cancer was 50 percent higher for those who had abortions--but her cancer-free sample was obtained through telephone interviews with women chosen at random from the phone book. Not everyone has a phone, of course, which raises questions about the comparability of the samples, and besides, how many women would volunteer information about their abortion history to a voice on the phone? Like other studies showing a link, this one was marred by "recall bias": Cancer patients are more likely to volunteer negative information about themselves than healthy people. They are looking for an explanation for a disease--and one many feel must somehow be their fault. Demographic studies, which are free from recall bias, produce different results: Lindefors Harris, analyzing the national medical database of Swedish women in 1989, found that women did deny their abortions, that breast cancer patients were less likely to do so--and that women who had had abortions were less likely to get breast cancer. The largest study to date, of 1.5 million Danish women, found no correlation.
"The supposed link between breast cancer and abortion is motivated by politics, not medicine," says Dr. David Grimes, clinical professor of obstetrics and gynecology at the University of North Carolina. "The weight of the evidence at this time indicates no association. To force this on women is just cruel." Indeed, the National Cancer Institute, the American Cancer Society and the World Health Organization, none of which have an ax to grind, reject the notion. The standard medical textbook, Diseases of the Breast, concurs. The main figure advocating the link is Dr. Joel Brind, professor of biology and endocrinology at Baruch College, who has done no original research on this issue but is a tireless anti-choice propagandist--plug "abortion breast cancer" into a search engine and the top half dozen sites are his.
Abortion is just about the only medical procedure in which doctors and patients are hemmed about by lawmakers. No other operation has legally mandated waiting periods, although many are dangerous, life-altering and irreversible; with no other operation are doctors legally required to give specific information--certainly not information that the vast preponderance of medical opinion believes to be false or at best unproven. Good medical practice calls for discussion of the pros and cons of particular courses of treatment, not burdening the patient's choice with unsubstantiated fears. Will we ever see a law requiring doctors to tell pregnant patients that abortion is statistically safer than carrying to term--which it is? Sure, the day state lawmakers put a waiting period on Viagra prescriptions, to let male patients really consider whether an erection is worth a heart attack.