Leon Beswick, of Australian Institute of Political Science, writing in The Australian March 20th (Make way for our leading ladies)- 

Medicare Gold is no more Left than the Government's 12.5 per cent tax on new medicines to fund more welfare for seniors.

Recent revelations about the way Merck manipulated data in rofecoxib trials support arguments for vigilance.

Slashdot: Merck's Deleted Data (links back to very interesting Forbes article).
NYT: Editorial: Manipulating a Journal Article
NYT: Doctor Suggests Merck Trial May Have Led to Demotion
ABC (US):Vioxx Editorial May Bolster Merck Suits

From the New England Journal of Medicine editorial:
Expression of Concern: Bombardier et al., "Comparison of Upper Gastrointestinal Toxicity of Rofecoxib and Naproxen in Patients with Rheumatoid Arthritis," N Engl J Med 2000;343:1520-8
Curfman G. D., Morrissey S., Drazen J. M. Abstract | PDF 
... Lack of inclusion of the three events resulted in an understatement of the difference in risk of myocardial infarction between the rofecoxib groups. It also resulted in the misleading conclusion that there was a difference in the risk of myocardial infarction between the aspirin indicated and aspirin not indicated groups.
In addition, the memorandum of July 5th, 2000, contained other data on cardiovascular adverse events that we believe would have been relevant to the article. We determined from a computer diskette that some of these data were deleted from the VIGOR manuscript two days before it was initially submitted to the Journal on May 18, 2000.
Taken together, these inaccuracies and deletions call into question the integrity of the data on adverse cardivascular events in this article. We have asked the authors to submit a correction to the Journal.

From Prescription rates fall as pill poppers give up their drug habits
... Medical leaders believe the drop in drug use reflects a more cautious approach by doctors and patients, triggered by better pharmaceutical education and findings of potentially lethal side effects in some drugs, including the once popular pain-killer Vioxx. Sales of that drug, which previously cost about $150 million a year in subsidies, have plunged after it was linked to an increased rate of heart problems. ...

In a letter to The Australian, Oct 15th, from Julia Gillard,
[...] The truth is that savings to the taxpayer would have been achieved on the private health insurance rebate due to Labor's Medicare Gold policy, a policy Mr Abbott obviously still fears. Medicare Gold meant older Australians would no longer need to have private health insurance, and consequently, would not have needed the private health insurance rebate. The savings on the rebate from Medicare Gold were made clear in the election policy document. [...]

Medicare Gold rested on an understanding of root-and-branch reform of healthcare, and the way it is funded. Other statements by Labor in last week's Parliament suggest Ms Gillard needs to keep testing herself on what she really means to achieve. What would she say in response to this, from Background Briefing Oct 9th, Getting Older, Getting Cosmeceuticals?
[...] David Le Couteur: The large pharmaceutical companies, which are huge multinational billion-dollar companies, have moved out of doing early phase drug development and really only start to develop drugs when there’s a short-term horizon in the order of three to five years. So any drug that looks like it’s going to be a genuine therapeutic advance is taken up by the big companies at that point. So most of the early-phase drug development is being done now by small start-up, often biotech companies, and these are high risk companies, analogous to the gold and mining exploration companies of decades gone by. So that’s one force. On the other hand there’s a competing force which is the fact that the universities now are being forced to consider themselves as being economic entities whose role is to generate profit rather than education and research that benefits society. So there is enormous pressure on scientists on all areas to be involved in some aspect of commercialisation of whatever they’re doing research in, and it’s the pressure on these scientists that is probably fuelling the start-up companies as well. So you’re getting a meeting of the two forces: the academics that are being forced to be shown to be commercialising their products, and small start-up companies that are wanting to look like they’ve got a product, or want to convince the share market that they’ve got a product.
Stan Correy: And if that product is for age-related disease, then there are special problems for biopharmaceutical companies who are trying to develop new treatments. Professor David Le Couteur:
David Le Couteur: The companies working on age-related diseases are a very big area simply because that’s a huge market. Ageing is the major risk factor for every disease that you can think of: heart disease, bone disease, cancer, diabetes, dementia, the lot. So obviously, if you want to produce a product for a big market, you’ve got to be producing drugs for diseases of older people. The big problem with drug development in older people however, is that the drugs are tested on middle aged people, people in their 50s and 60s, and then used often with considerable problems in terms of side effects, in much older people who can’t tolerate the medications nearly as well.
Stan Correy: That’s very interesting, so you say there are particular factors in dealing with drug development for older people?
David Le Couteur: Very much so. The risk of side effects of medications increases exponentially as you get older. The probable cause of the diseases, the underlying mechanism for the diseases changes as you get older. Yet much older people, and I’m talking people in their late 70s and 80s and 90s, are the ones that have all the disease and are by far and away where the medications are used the most. And what I can tell you is that information on their usefulness in those age groups is almost non-existent, yet information on the harm caused by those medications is well established. So we really have a major problem here that drug development is done in younger adults, the market is in much older people and these people are often being harmed by the inappropriate use of drugs in these groups, and I think they’re being exploited. [...]

Big pharma is more than capable of looking after itself. With pressure on the government to ensure supply of effective anit-influenza vaccines, companies like CSL will be able to name their price, more or less. Why do CSL and Merck need sponsorship from politicians?

In her speech about the HPV vaccine, Ms Gillard called it a "miracle". An advertisement by Ian Frazer's employer, University of Queensland, in the weekend papers, used the same terminology about Frazer's foundational work that enabled the vaccine to be produced. Frazer, himself, says the "miracle" happened 20 years ago, in basic research.

All the work on the vaccine since then, has been to industrialise and commodify it. It's odd that Labor is beating up a commercial product, another commodity that will be offered to buyers according to market rules. Merck and CSL, and all their employees, are solely about giving maximum return to shareholders. On an influenza vaccine, CSL "[...] will make it a commercial product but we'll certainly not be looking to make it an obscenely profitable product." No, but the compensation will be based on figures cobbled together by CSL insiders, without the benefit of public audit. The spirit of commercial-in-confidence will ensure that details about production costs are not disclosed, and CSL will be able to call on industry competitors to vouch that a figure of around $1billion will be appropriate.

Why does Ms Gillard, or any other Labor MP, need to get on the bandwagon in praise of Merck? (See Lifestyle vaccines.)

The message about Australia's investment in basic research, and the broader R&D effort, is that we are not putting enough into it. And we can't simply focus on giving better laboratories for today's researchers. Our involvement in the discoveries of the future begins with our children, and more specifically the smart kids from families who do not have access to the best private schools. This is what Labor should be about, if it still believes in the underpinning philosophy of Medicare Gold. Industry giants can look after themselves, as can the Scotch Colleges. Labor's future is in people who need assistance to reach their potential. The sooner Labor gets back on track, the better the chance of giving a helping hand to a young person who can make a huge difference to humanity.

But Labor must be careful, as well as adventurous. From Pylori pioneers: a long and Nobel journey (only available to subscribers):
[...] The discovery by Warren and Marshall that ulcers were caused by infection posed a major challenge to the pharmaceutical industry and there is no doubt that acceptance of antimicrobial therapy for ulcers was slowed by a reluctance of companies to include the hypothesis in their educational activities. To put this in perspective, it has to be appreciated that at this time the anti-ulcer therapies were the biggest-grossing products on the market, bringing in millions of dollars annually. Ten per cent of the population could expect to suffer from ulcer disease in their lifetime. The antisecretory drugs were the perfect pharmaceutical for a company. They caused instant and complete symptom relief for ulcer patients, acid secretion was stopped quickly and thus the ulcers would rapidly heal. However, should this wonderful treatment with huge patient satisfaction be stopped, the duodenal ulcers recurred in most patients within a year. Thus many patients were put on maintenance therapy for life. This continuing usage contributed greatly to company profits. These profits were jeopardised by the discovery of H pylori. Ulcers could now be cured by a two- to four-week course of therapy. The ulcers did not come back and so maintenance therapy was not needed. Until the evidence became overwhelming, it was not in a salesman's best interest to promote the new discovery. [...]

The HPV vaccine isn't going to keep sexually active women (or, more to the epidemiological point, women who had multiple partners in unsafe sexual practice) from the need for regular Pap smears, or equivalent, for the next 50 years, even if it is licensed today. There are at least three different areas where good money could be put down for more research, to remove the necessity for those ugly gynaecological examinations. They are:
1) A blood test for antibodies to HPV, could show that a mature woman has no evidence of previous infection with the strains of HPV that are associated with cancer.
2) Self-administered test (vaginal swab) to detect the specific HPV DNA.
3) New generation fibre-optic (not traumatic) inspection of the cervix for microscopic changes due to HPV.

Labor should be thinking, also, in terms of the lucrative cytology industry, and how changes to the taxpayer-funded status quo will be resisted.

In general, Labor should be redefining the practical outworkings of social democracy, and learning about new ways to apply them, while pitting Labor thinking against market-driven philosophies. Rolling along with the spruikers and lobbyists will keep Labor in opposition.

From Doctors With Ties to Device Makers (NY Times)

While health reformers are struggling to curtail undue influence by drug companies on the prescribing practices of doctors, a comparable problem has surfaced in the field of medical devices. An article by Reed Abelson in The Times on Thursday reveals that many surgeons have ties to manufacturers, ties that are often not revealed to their patients or to hospitals. These connections raise questions as to whether some doctors are choosing devices primarily for the good of their patients or primarily for the benefit of their own bank accounts. ...
... Ties between manufacturers and doctors are surely a factor in driving up spending on medical devices. Hospitals, insurers and patients have been squeezed as such costs have soared and companies have earned profits of nearly 20 percent a year. ...
... Perhaps the most important reform would be full disclosure by doctors - to their patients, their colleagues and their hospitals - of their lucrative contracts with the manufacturers. That would alert patients and institutions to look hard at whether the devices recommended by a doctor-consultant were really the best to use.

Is this type of scam happening in Oz, with surgeons, private hospitals and the private insurance industry helping each other along? Why not? How would we know? We can be pretty confident that the Tories will not bother to look too hard into commercial transactions. Meanwhile, they hammer away at the principle of universal health insurance. Labor's Medicare Gold policy is the vestige of universality. MG receives a battering every week in parliament, eg on Sep 14th,
QUESTIONS WITHOUT NOTICE: Health > Haase, Barry, MP; Abbott, Tony, MP > 14:36:00.
... I call on the Leader of the Opposition to prove he is a tougher leader than the member for Lalor by getting her policy off his web site.

The latest barrage was delivered by Christopher Pearson, in The Weekend Australian for Sep 24-5, Deluded by the flame.
... Whether she can be persuaded to abstain from bold social policy is another question. I doubt it myself. Her biggest claim to fame was Medicare Gold. It was Whitlamite in its boldness, an extravaganza of geriatric welfare, perhaps the single most irresponsible exercise in public policy since the 1970s. The Department of Finance predicted its costs would blow out to $7 billion in the first two years of operation. Econtech, the private consultants, warned of longer-term troubles. Within weeks Barry Jones called it "a turkey". Peter Botsman, a Left-Labor policy analyst, described it as "a hoax ... the head of a donkey ... on the body of a wombat". Various health economists and the Australian Medical Association concluded that it couldn't possibly deliver on its promises. But it was her brainchild, beyond criticism, and not once, in all the intervening months, has Gillard made any concessions to reality on the matter of Medicare Gold.

Nice one, Chris, quoting the AMA as an authority on containment of healthcare costs.

The sustained attacks on MG suggest it may not be such a bad idea. Gillard must know, by now, where the excesses, the graft and the greed are placing burdens on the system. If she wants the job, she will have to face up to the power elites and medical specialist colleges, sooner or later.

Julia Gillard in pursuit of Tony Abbott, Hansard for May 31st:

We know that Minister Abbott has not broken his word—he has smashed it. We know there is a conspiracy which lies behind the breaking of his word, because of what Minister Abbott has said on the public record. He has tried to justify this broken promise by saying that when he gave the promise he had not the ‘slightest inkling’ that the Medicare safety net would be changed after the election. There are reasonable grounds to believe that in making that ‘slightest inkling’ statement Minister Abbott was not really being frank with the Australian community on yet another occasion. It is those matters that the opposition are pursuing and will pursue in Senate estimates, through freedom of information requests in this parliament, and in any other forum available to us until we get the truth.

This will come up Senate
estimates committees in the next few days.

There was some hope the PM's own review of the health system, under
Andrew Podger, would provide incentive for the government to be more
interventionist. Ms Gillard thinks that is not going to happen.

The one thing the Howard government was going to do—and it was not the
minister for health who was going to do it; it was the Prime
Minister—was to have Mr Podger review the health system and have the
outcomes of the Podger review go to the Council of Australian
Governments meeting. We were very critical of the Podger review. It was the ultimate black box review—a bureaucrat literally sitting in an
office and not seeing anyone, not talking to anyone, not consulting
with anyone and not asking anyone with expertise what they thought
should be done next. It was the ultimate black box review, but it was
the only thing going. And now we understand that even that is off the
table, that the Prime Minister has indicated that the Podger review
document is now cabinet-in-confidence and will not be made available to the states, and that whilst he is willing to discuss some issues in
health reform there will be no system-wide health reform. That failure
by the Howard government is going to continue to cost our health system over $1 billion each year in waste. It is not good enough. It is an abandonment of the single biggest thing that needs to be done in
health. That is what more than 40 professional health organisations
say, as do I. It adds to the Howard government’s track record of
failure in the area of health.

In a budget that is a record post-election spend it was health that missed out. It was Minister Abbott who could not secure sufficient funds for his portfolio to make good his word. That will count against him for all time. No-one in this country will again believe any promise he ever makes about our health system. We will get to the bottom of the Medicare safety net conspiracy.

Earlier in the speech, she promised:

Let me assure you, Mr Deputy Speaker, we will never let this matter rest until we get to the truth of it. We will never let this matter rest until the truth is in the public domain, and that will spark Minister Abbott’s resignation. He ought to have resigned already for breaking his word to the Australian people. He has not done the right thing, but we will pursue this matter until he does.

I thought Ms Gillard did a good job of laying out the reasons why Mr Abbott knew all along, even before he made his 'ironclad guarantee', that the excessive expenditure under the Medicare Safety Net was flowing straight into the pockets of AMA members and the private health industries.

But let me predict - Mr Abbott will not resign over this failed promise. Ms Gillard will get more value out of following the money trail, instead of seeking 'the truth'. She will have to show she can confront the AMA, and the special interest groups, at some stage.

I went to one of the Deakin Lectures at Melbourne Town Hall. The topic was The Ethics of Innovation.

Prof Miles Little spoke on the way the ethical framework is built from the community values of the time. He used the example of Colles, an Irish surgeon who experimented with the use of mercury to treat syphilis, in the early1800s. Not only was mercury poisonous (to the person as well as to the bacterium that causes syphilis), but Colles used experimental methods that would appal us. Colles was noticably discriminatory in his publications, cloaking the better classes of patient in anonymity that he denied to the servants. Prof Little reviewed the outstanding medical advances introduced during the period of his life, but suggested we should be looking less to trusted
experts, and more to a collegial method of making decisions.

Prof Fotis Kafatos took us through the looking-glass of modern molecular biology, and opened up some of the many promises for control of diseases, from selection of embryos to tailored drugs.

He reminded us of the dangers, not only in the moral dimension, but also of actual physical harm to experimental subjects. He used the example of vaccines, but he could have said the modern fertility industry (1 million born through assisted conception) is built on the bones of women who died from CJD contracted from pituitary glands. [An Australian book (Cannibals, Cows and the CJD Catastrophe by Jennifer Cooke) suggests some of our eminent scientists and companies were pretty skilful in evading responsibility for the deaths due to HGH treatment.] I would like to have challenged Kafatos on his claim that a measure of what we have to pay for innovations, is the estimate that it costs $800m to bring a new drug to market. This is drug company propaganda, pumped out by an offshoot of pharma, and can be disregarded as blatant bullshit. It's a pity that scientists of that calibre continue to regurgitate nonsense.

Helena Kennedy worked from a Margaret Attwood book, Oryx and Crake.

She talked quite a bit about the perils of discrimination, and the power of the enlightened public to resist. She said there are a number of crucial steps toward adequate information, and one of these is financial disclosure. The people who are being rewarded by corporations, right through the chain from laboratory discovery to promotion of final product, must declare their connections openly. [The Human Genetics Commission in the UK has done that.]

Bob Phelps of GenEthics Network asked a question or three. Gus Nossal, Barry Jones, Alan Trounson and other dignitaries I didn't see, were there.

Disclosure of financial interests is a, er, ahem ... novel ... concept to the Oz medical establishment. 'Novel', as in 'why the hell would we want to do that?'. This nation, under the present regime, could become the last bastion for crooks, frauds and confidence tricksters, in the whole of the West, unless someone with authority takes an urgent stand on principle.

Sam Lipski, the moderator, asked how it was possible to get good legislation on biomedical and scientific matters, when the parliaments
contained so few scientists. Kennedy said she hoped the Lords tradition, of appointing eminent people from all walks of life, will be continued in the democratisation process. She hoped that, while popularelection is desirable, about 20% of members could be appointed for the expertise accumulated during the life's work in the public interest. She cited the Science & Technology Committee as one that does good work of great public significance.

The recurrent theme of the evening was for a process of continuing conversation, under the guidance of Discourse of Ethics, to inform both the public and the law-makers. Community Juries, Constitutional Conventions and Communities of Practice were mentioned as models already working in other countries. The idea is to work in directions, along pathways, NOT with a pretence of offering solutions, and avoiding dogma. The readers of tabloids will want black and white (eg, safe or not safe) answers, but an educated public will learn other ways.

It was strange to hear Prof Little remind us that we all have to die, at the same time Peter Costello was trying to tell us we could all live long and happy lives, as long as we work harder and pay less tax. Prof Little confronted our consumerist mentality with the sobering reflection that we will have to account for the cost of extending the lives of the wealthy, in terms of services taken away from the less well-off, especially among our indigenous peoples, and most horribly in the developing nations.

Snowman.

This has so much to say about our own health system, I have included the whole article here, in the interests of the common good. I have emphasised some of the text, and hope that does not detract from the message.

The Lancet 2005; 365:1515

DOI:10.1016/S0140-6736(05)66428-8
The unspoken issue that haunts the UK general election

Superbugs. Waiting times. Patient choice. More doctors. New investment. Efficiency savings. Foundation hospitals. National Health Service (NHS) reorganisation. Free personal care. These are some of the issues that have been identified by the main political parties as battlegrounds for
the UK election on May 5. The Economist, more likely, perhaps, to identify financial and business health as key issues, opted instead for the NHS as the “most important

Nicholas Kristof in New York Times - Greediest Generation.

The solution is not to force the elderly to get by on cat food again. But we boomers need to resist the narcissistic impulse to ladle out more resources for ourselves. Our top domestic priorities should be to ensure that all children get health care and to get our fiscal house in order.

Otherwise, we boomers may earn a place in history as the worst generation.

Just a short note to say, at New Matilda -

Don't mention the economy Wednesday, April 27, 2005
'To overcome this obstacle, Labor needs to integrate its policies in a clear vision and set of values - social values - rather than categorising its policies into 'economic', 'social' and 'environmental' headings with their implications of compromise, trade-off, and contradictions.' More by Ian McAuley.

Medicare Gold is referred to in a positive light. (NM is open only to paid-up subscribers.)

The tone of McAuley's article seems in keeping with Barry Jones latest encouragement to his party.

An article by Ross Gittins on healthcare funding is in SMH (Medical miracles that will cost an arm and a leg) and The Age (The bitter pill of our health boom: pay up).

This is at the root of the dilemma.

Health care is quite unlike most industries for two reasons. First, what economists call "information asymmetry" - because doctors and other medical professionals know far more about the subject than we do, the providers of the services have far more say over what's done than the customers do.

The notion of Informed Consent is at the core of ethical interventions. The client must be given enough information to enable informed choices to be made. Such as, in the case of metastatic colon cancer, whether to sit out your days under a tree with a supply of books and street heroin, or subject your living corpse to medical experimentation with new oncology drugs.

But the essential nature of the professions is to guard their specialist knowledge. How does the community construct paradigms that allow it to assign dollar amounts to a priorirised list of interventions? The worst possible way of assigning reimbursement costs is to allow politicians to play their wedging games. This is what is happening right now, with Abbott & Costello feigning to decide how many IVF treatments the government will pay for. In truth, they know the decision will be made by wealthy families that need to secure their assets under the laws of inheritance. There is as much risk that Costello will offend the Howard base in this instance, than there is he will disturb the negative gearing nexus.

We are, once again, letting the commercial media lead us by our noses.

The public expect informed leadership. The experts in significant domains of health care reside in our public hospitals. Are our public hospital physicians willing and able to pay their dues to the public interest, and give it top priority?

In New hospital short of cash for equipment The Age reports Austin Health is seeking public support to buy medical gear, despite a $353 million revamp.

In [a fundraising letter sent to thousands of households], the hospital's new chief executive, Brendan Murphy, says despite hundreds of millions of dollars of Government money for the redevelopment, it still needs $275,000 to buy "urgently needed" equipment.

What is going on? The Austin Hospital medical staff are probably treated to half that amount in free meals by pharmaceutical companies in the course of a year of medical "education". Yet the hospital management has the pure arse to dress a minor accounting discrepancy up as a crisis, and go off begging to taxpayers?

Suppose a corporate benefactor, such as Hardies, Tabcorp, Fosters, Altria or Merck make a donation to cover this handy deficit? Would any of the contracted medical experts then be forbidden from speaking out against asbestos, gambling, alcohol, tobacco or bad medicines?

It could be time to put the inner workings of public health care agencies under the knife of democratic principles.