Wednesday, October 8, 2008

Suit Alleges Pfizer Spun Unfavorable Drug Studies -

Pfizer Inc. marketers urged the suppression of medical studies that reached unfavorable conclusions about the effectiveness of the company's big-selling drug Neurontin, according to internal Pfizer documents submitted in a lawsuit against the company.

In 2004, Pfizer's Warner-Lambert unit pleaded guilty to felony charges that it promoted Neurontin for uses not approved by the Food and Drug Administration, including bipolar disorder and chronic nerve pain. The FDA originally approved the drug as an antiseizure treatment for epilepsy and in 2002 for one kind of pain related to shingles.

Pfizer paid $430 million to resolve the charges and reimburse state Medicaid programs for unapproved, or off-label, uses of Neurontin. Pfizer said it made sure there was no improper marketing after it purchased Warner-Lambert in 2000. Pfizer has booked about $12 billion in Neurontin sales since then and, though the drug is now subject to generic competition, it remains a strong seller.

Documents and emails released this week in the case in U.S. District Court in Boston suggest Pfizer's marketers influenced the drug's scientific record to boost sales at least until 2003 by declining to release or altering the conclusions of studies that found no beneficial effect from Neurontin for various off-label conditions. The case consolidates lawsuits by health insurers and consumers seeking refunds for their Neurontin expenditures, based on alleged civil fraud. Plaintiffs are seeking $4.9 billion.

In a statement, Pfizer said it was "committed to the communication of medically or scientifically significant results of all studies, regardless of outcome." The company pointed to examples where it published studies of Neurontin with negative outcomes.

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Tuesday, October 7, 2008

In ‘Sweetie’ and ‘Dear,’ a Hurt for the Elderly -

Professionals call it elderspeak, the sweetly belittling form of address that has always rankled older people: the doctor who talks to their child rather than to them about their health; the store clerk who assumes that an older person does not know how to work a computer, or needs to be addressed slowly or in a loud voice. Then there are those who address any elderly person as "dear."

"People think they're being nice," said Elvira Nagle, 83, of Dublin, Calif., "but when I hear it, it raises my hackles."

Now studies are finding that the insults can have health consequences, especially if people mutely accept the attitudes behind them, said Becca Levy, an associate professor of epidemiology and psychology at Yale University, who studies the health effects of such messages on elderly people.

"Those little insults can lead to more negative images of aging," Dr. Levy said. "And those who have more negative images of aging have worse functional health over time, including lower rates of survival."

In a long-term survey of 660 people over age 50 in a small Ohio town, published in 2002, Dr. Levy and her fellow researchers found that those who had positive perceptions of aging lived an average of 7.5 years longer, a bigger increase than that associated with exercising or not smoking. The findings held up even when the researchers controlled for differences in the participants' health conditions.

In her forthcoming study, Dr. Levy found that older people exposed to negative images of aging, including words like "forgetful," "feeble" and "shaky," performed significantly worse on memory and balance tests; in previous experiments, they also showed higher levels of stress.

Despite such research, the worst offenders are often health care workers, said Kristine Williams, a nurse gerontologist and associate professor at the University of Kansas School of Nursing.

To study the effects of elderspeak on people with mild to moderate dementia, Dr. Williams and a team of researchers videotaped interactions in a nursing home between 20 residents and staff members. They found that when nurses used phrases like "good girl" or "How are we feeling?" patients were more aggressive and less cooperative or receptive to care. If addressed as infants, some showed their irritation by grimacing, screaming or refusing to do what staff members asked of them.

The researchers, who will publish their findings in The American Journal of Alzheimer's Disease and Other Dementias, concluded that elderspeak sent a message that the patient was incompetent and "begins a negative downward spiral for older persons, who react with decreased self-esteem, depression, withdrawal and the assumption of dependent behaviors."

Dr. Williams said health care workers often thought that using words like "dear" or "sweetie" conveyed that they cared and made them easier to understand. "But they don't realize the implications," she said, "that it's also giving messages to older adults that they're incompetent."

"The main task for a person with Alzheimer's is to maintain a sense of self or personhood," Dr. Williams said. "If you know you're losing your cognitive abilities and trying to maintain your personhood, and someone talks to you like a baby, it's upsetting to you."

She added that patients who reacted aggressively against elderspeak might receive less care.

For people without cognitive problems, elderspeak can sometimes make them livid. When Sarah Plummer's pharmacy changed her monthly prescription for cancer drugs from a vial to a contraption she could not open, she said, the pharmacist explained that the packaging was intended to help her remember her daily dose.

"I exploded," Ms. Plummer wrote to a New York Times blog, The New Old Age, which asked readers about how they were treated in their daily life.

"Who says I don't take my medicine as prescribed?" wrote Ms. Plummer, 61, who lives in Champaign, Ill. "I am alive right now because I take these pills! What am I supposed to do? Hold it with vice grips and cut it with a hack saw?'"

She added, "I believed my dignity and integrity were being assaulted."

Health care workers are often not trained to avoid elderspeak, said Vicki Rosebrook, the executive director of the Macklin Intergenerational Institute in Findlay, Ohio, a combined facility for elderly people and children that is part of a retirement community.

Dr. Rosebrook said that even in her facility, "we have 300 elders who are 'sweetie'd' here. Our kids talk to elders with more respect than some of our professional care providers."

She said she considered elderspeak a form of bullying. "It's talking down to them," she said. "We do it to children so well. And it's natural for the sandwich generation, since they address children that way."

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Sick Kids' Laugh Riot - The Nation - October 16, 2007

Dear Congressional Democrats,

Hi, how are you guys holding up? It really sucks that you have received so much criticism about the selection of the Frost family of Baltimore as an example of people deserving to benefit from the federal S-CHIP program.

Just thinking about it makes me so mad, it's enough to give me a heart attack, but that may not be covered in my health plan, so I've thought of a way to deflect further criticism. I'd like to offer my family. We really don't qualify for S-CHIP but did in fact take a few hundred dollars of state money when faced with a medical crisis. When the Republicans hear our story, everyone will take back what they've said about the Frosts. And you don't have to vet us; I'll tell you all the bad choices I've made right up front. I'll try to keep it light, since this is a humor column, after all.

OK, here's how it starts. In 1998, our son was born with VACTERL association, which is such an odd constellation of birth defects that our insurance company hadn't even heard of it. At first they didn't want to pay our benefits until they could establish it was a real thing. That was a laugh riot!

When our son came home from the NICU, he had to be fed through a gastronomy tube, with his fluids aspirated so he wouldn't choke on his own saliva. He had a colostomy bag that had to be monitored, and we were totally overwhelmed and underprepared to administer his care. Our private insurance, which we receive through our unions, didn't cover home healthcare. On top of that, neither of us could stop working, as our benefits depend on our continued earning. So the first year alone, we spent a whooping $35,000 out of pocket to get people to come and relieve us.

I'm not crafty and really suck at making colostomy bags, which you have to cut and paste on, sometimes twice a day, so we had to purchase balms to soothe his bloody rashes. That meant at least $2,000 in over-the-counter, unreimbursable costs, plus oatmeal baths to calm his skin, which added another $1,500.
Here's something really funny. Like the Frosts, our kid had to go to physical therapy, also. Some of his physical therapy didn't qualify for benefits either, probably because it was only supposed to help him learn to do totally unnecessary things like swallow and learn to speak. Some of the therapists we went to didn't even take insurance. The first year we spent at least $2,500 on that.

I've heard the Frosts being accused (falsely) of frivolous spending like purchasing a granite kitchen counter, but I've never read that the Frosts are unstable people. But we are! When the bills for the series of surgeries and five medical specialists my son required started pouring in, my insurance company decided to decline to be his primary carrier, instead giving that honor to my husband's plan. My insurance company sent me a threatening letter announcing that I personally needed to get his insurance to reimburse the thousands of dollars or it was going to hold me responsible for the fees and begin garnishing my wages.

It was so confusing that sometimes I just paid the bills, even for covered services. That added maybe $3,000. That's when I developed a twitch in my eye. Not long after that, when I was informed my son had a 95 percent chance of needing a new kidney, I lay down on the floor of the pediatric nephrology clinic at Cedar Sinai Hospital and cried. I kept crying. For a few weeks. This added about $10,000 to our bills for my personal therapy, reimbursed at 50 percent, and we invested approximately $2,000 in bottles of Oregon pinot noir for my husband.

Then there were the costs you can't even begin to quantify. No one reimburses the parking fees at the hospital: at least 150 visits averaging $11 a pop, approximately $1,650. There were times I had to run to a pharmacy and forgot my insurance card (another bad choice), adding maybe $1,500 in tubes and clamps.

It wasn't until it was determined that my son wasn't getting enough food during the day and needed to be fed twice through the night--a process that for us included standing over his crib slowly pouring formula into his feeding tube over a twenty-minute period--that I turned to the state-contracted local Regional Center, which offered not only to fund some of his care but also to assist us in finding overnight nursing care. If you've ever tried to secure private nursing care, you know it is a full-time occupation. Ironically, when these nurses showed up, several demanded to be paid additional funds under the table! We received maybe $300 to $900 worth of services but had to pay out between $400 and $500 in cash to the caregivers. Again, I lost track, another bad choice.

All said, even if you subtract our pinot noir bills, our expenses totaled more than the Frost's combined income. That was just the first year.

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FDA Puts Medical Test Subjects in Danger - The Nation - May 19, 2008

With hardly a word in the mainstream press, the FDA has gutted the rules restraining drug companies from exploiting clinical trial subjects in developing countries.

Now that 80 percent of clinical trials fail to recruit sufficient numbers of test subjects on deadline, drug companies increasingly export their trials to developing countries, where sick, undertreated patients abound. It's faster, it's cheaper and it's easier to conduct the placebo-controlled trials that companies and the FDA prefer. There is precious little oversight of these trials. Unlike for domestic trials, the FDA does not require advance notice before drug companies take their trials outside US borders. And with 90 percent of trials failing to gain FDA approval, a massive number of trials are conducted, fail and then vanish with no agency review at all--and little public record, if any.

Until now, the FDA's sole requirement for these overseas trials is that they adhere to the Declaration of Helsinki (or local rules, on the off chance that they are more stringent). Signed by the United States and thirty-four other countries in 1975, the Declaration of Helsinki consists of several dozen pithy principles to govern ethical research on humans, and is widely considered the gold standard in research ethics. Crafted and updated by the World Medical Association, a group representing dozens of national physicians' organizations from around the globe, the Declaration of Helsinki (DOH) urges voluntary informed consent, the use of independent committees to review and oversee trials, that investigators prioritise their subjects' well-being, that research subjects be assured access to the best health interventions identified in trials and that their societies enjoy a "reasonable likelihood" of benefiting from the results of trials.

It's not a perfect document. It's very short. It's a little vague. The FDA does not bother to enforce it. Even when they know of infractions--such as in Pfizer's trial of the antibiotic Trovan in Nigeria, which not only failed to procure informed consent but didn't even have an oversight committee in place at the time of the trial--the FDA has done nothing and approved the drug anyway. We know of that particular trial's violations only because the Washington Post exposed them several years later. In researching a book I wrote on clinical trials in developing countries, I similarly found many examples of trials clearly in violation of Helsinki provisions that were nevertheless reviewed and approved by the FDA.

The FDA has been agitating against the DOH since the late 1990s, when the World Medical Association strengthened the document's restrictions on placebo-controlled trials, which an unlikely alliance of industry, public health and academic researchers angrily challenged. The strengthened DOH, the FDA's medical director Robert Temple railed, "doesn't look like a group of suggestions that are worth discussing." Under pressure from the agency and drug companies, the World Medical Association diluted the objectionable language about placebo trials--increasing the document's vagueness--but by then the FDA was on the warpath. Just as President Bush opted out of international treaties on climate change and anti-ballistic missiles, in 2001 the FDA bucked two decades of its own precedents and refused to adopt updated versions of the internationally sanctioned Declaration of Helsinki. That done, in 2004, the agency proposed dumping the DOH from its codes altogether, and on April 28 announced it would indeed be summarily excised starting in October.

In its place, the FDA will incorporate "Good Clinical Practice" rules. Good clinical practice sounds, well, good, but these rules are no replacement for the Declaration of Helsinki. Unlike Helsinki, which describes ethical principles agreed upon by the international medical community, GCP rules are bureaucratic regulations crafted by regulatory authorities and drug industry trade groups, behind closed doors. They offer little by way of ethical precept. There is no injunction, for example, that research subjects be assured access to study drugs after trials end, or that their communities have a reasonable likelihood of enjoying the benefits of the research, principles of justice enshrined in the DOH.

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Who's Afraid of Gardasil? - The Nation - March 8, 2007

The HPV vaccine story has gotten all tangled up.

As recently as June 8, 2006, public health advocates, progressives and many parents were celebrating a huge victory: The Food and Drug Administration had approved Merck's new vaccine Gardasil, a shot series that would help protect girls from cervical cancer and genital warts. To their continuing delight, the Centers for Disease Control's immunization committee recommended less than a month later that the shots immediately be given to all females between the ages of 9 and 26. The committee acted on persuasive data indicating that the vaccine, which prevents the sexually transmitted human papillomavirus (HPV), works best before girls are sexually active.

Human papillomavirus is the most common sexually transmitted infection in the world, and most women have had it-- 80 percent of US women, by the CDC's estimates. Often it goes away on its own, without its carrier's awareness. But each year hundreds of thousands of women and girls in the United States develop persistent infections from it, more than 10,000 get cervical cancer and 3,700 die from the cancer.

Gardasil, given in a series of three shots, protects against four strains of HPV. Two of those strains cause 70 percent of the nation's cervical cancer cases, and two of them cause 90 percent of genital warts. This new vaccine, widely given, has the potential to make cervical cancer almost obsolete here.

All good news, right?

Apparently not.

Today, as thirty-one state legislatures consider mandating the vaccine for middle school girls, skepticism about the wisdom of embarking on this swift and widespread inoculation program has bubbled up from critics who span the political spectrum. These strange bedfellows include Christian conservatives and their abstinence-only ilk, who have long argued that safe sex encourages profligate sex; a slew of Big Pharma critics, who see how Merck (which stands to make $4 billion a year on the vaccine by most estimates) is angling to corner this huge new vaccine market; the growing antivaccine movement, which objects to all such school-entry requirements; the parental-rights folks with a libertarian strain, who bridle at any mandates regarding their children's health; and a smattering of women's health advocates, who worry that the pace of the vaccine's introduction is jeopardizing its ultimate success.

What's all the noise about?

Some of it is predictable and comes from the usual quarters. Cultural conservatives and abstinence-only hardliners have been trotting out familiar arguments: Safe sex leads to more sex, they insist. Conservative California State Senator George Runner told the Los Angeles Times recently that he objected to this immunization because the disease was a result of lifestyle decisions, as opposed to contagion. He wondered: "Is there a more productive way for us to spend the money that may help someone who's in a health situation that has nothing to do with their personal choices? Where do you want to focus your resources?" Conveniently avoiding any logical extension of his argument to lifestyle decisions like, say, smoking, Runner and his allies insist Americans have to distinguish between the deserving and the undeserving ill.

The face of the undeserving ill, according to the moral conservatives, belongs to Illinois State Senator Debbie Halvorson, who, as co-sponsor of a bill to require the vaccine in her state, admitted that she herself had HPV and underwent a hysterectomy because of precancerous cells. Pro-abstinence bloggers and columnists see this as permission to grill her regarding her sexual history: "You would think she'd focus on her behavior that caused her to contract that sexually transmitted disease," Jill Stanek wrote in the online Illinois Review. "Halvorson could discuss the number of sex partners she has had in her lifetime and how each one increased the likelihood of contracting HPV...whether it was her husband who passed HPV on to her after sleeping with other women...[or] if Halvorson contracted HPV through rape, she could discuss ways to avoid rape."

Enter, stage left, anticorporate muckrakers and consumer rights activists. These players fret about the role Merck has played in peddling this drug and are wisely skeptical of a pharmaceutical industry with a track record for putting profits before safety.

A couple of things set off alarm bells. First, what was the pro-abstinence Republican Governor of Texas, Rick Perry, doing fast-tracking this vaccine by issuing an executive order that would make the shots compulsory for all sixth grade girls? This made everyone sit up and say, hmmm. (His conservative constituents expressed their befuddlement by screaming bloody murder. Perry did his best to mollify them in a linguistic high-wire act that laced the language of abortion foes with reproductive rights rhetoric: "While I understand the concerns expressed by some, I stand firmly on the side of protecting life. The HPV vaccine does not promote sex, it protects women's health.")

But that was only the beginning of Perry's problems--and by extension the problems many state politicians were having as they tried to get the vaccine mandated. The press discovered Perry's ties to Merck: Not only did his former chief of staff now work as a lobbyist for Merck but the Governor had accepted $6,000 in campaign contributions from Merck's political action committee. It didn't look good.

And it got worse.

A nonprofit called Women in Government, comprising female state legislators, has been behind the push to make the vaccine compulsory, educating members about its value and urging them to introduce bills in their respective states requiring the shots--even going so far as to offer sample wording for the legislation on its website. It turns out Merck--whoops!--was a big WIG donor.

Fueling everybody's mistrust was Merck's own image problems. As maker of the arthritis drug Vioxx, which may have been responsible for 28,000 deaths before it was withdrawn from the market in September 2004, Merck was, well, suspect. Especially since it stands to make a bundle by charging $360 for each shot series. And it has a motive to corner the market quickly: GlaxoSmithKline is hot on its heels with an HPV vaccine of its own that it hopes to introduce before the end of the year. What's more, if it's lucky Merck stands to double its money. When seeking approval for the vaccine, the company also submitted data on clinical trials for Gardasil and boys. Though the vaccine thus far appears safe for young men, it may be more complicated to prove it effective--and to sell to parents. (After all, the cancer-preventing imperative is more circuitous: Boys aren't the ones being protected from cancer; their future partners are.)

In an effort to defuse the controversy, Merck backed off a bit in late February, issuing a statement saying, "We are pleased that Gardasil has been so widely embraced and do not want any misperception about Merck's role to distract from the ultimate goal of fighting cervical cancer, so Merck has re-evaluated its approach at the state level and we will not lobby for school requirements for Gardasil." 

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Robert Gallo on No Nobel: Don’t Cry for Me, Karolinska - PharmExecBlog

It's Nobel Prize season again, and Monday morning delivered news of the first gold medal and wad of dough. The 2008 Nobel Prize for Medicine went to three virus hunters, one who discovered the human papilloma virus (HPV), the cause of many cervical cancers, and two who isolated the human immunodeficiency virus (HIV), the source of the AIDS scourge.

For anyone concerned with sexual health, it's gratifying that science's top honor has gone to researchers who devoted their careers to tracking the most deadly sexually transmitted diseases—in the early '80s, at a time when professional stigma was virulent. And it may not be stretching advocacy to see the choice as a subtle slapdown of governments worldwide, including the US and others acting at its behest, that persist in promoting an abstinence-only approach to HIV prevention. It may also increase acceptance of, and demand for, the HPV vaccines recently developed and marketed by Merck and GSK.

But the big news, of course, is that neither of the two virologists honored for nabbing HIV was Robert Gallo, who has long been recognized, in official histories, as the "co-discoverer," with France's Luc Montagnier. No, the judges at the Karolinska Institute tapped Montagnier and his former colleague Françoise Barré-Sinoussi, snubbing Gallo in their own attempt at revisionist history. The AP titled its coverage "Nobel Is Postscript to Bitter 1980s HIV Dispute"; Reuters chose "Nobel Medicine Prize Reopens Old AIDS Wounds". Newsweek went with "The Shocking Nobel Prize".

Behind Montagnier's and Gallo's title of "co-discoverer" lies a tangled, almost-bloody trail of scientific and perhaps criminal intrigue. The brief reads something like this: Barré-Sinoussi, in Montagnier's lab at the Pasteur Institute in Paris, first isolated a retrovirus she believed to be the cause of AIDS in a biopsy specimen of a lymph node in early 1983. She wrote up her discovery, dubbed LAV, in Science and sent samples of LAV-infected cells to Robert Gallo, at the National Cancer Institute in Washington, DC.

Gallo was Mr. Retrovirus himself. He had pioneered the field for a decade, discovering HTLV-I, the cause of T-cell leukemia and lymphoma, and HTLV-II. And since this new and terrifying disease was a ruthless targeter of T cells, Gallo was America's greatest hope to find the cause—as he was the first to tell everyone. And sure enough, not many months after getting the LAV from Paris, Gallo announced that he had discovered the cause of HIV in his own lab.

Claiming it was a member of the family of blood-cancer viruses he had been tracking, he named it HTLV-III and rushed a flurry of papers into Science. The Reagan administration's secretary of health, only too glad to distract attention from her boss's silence on AIDS, quickly called a now-infamous press conference at which she congratulated Gallo for this scientific triumph and announced that a vaccine would follow in less than six months—a prediction that not a single scientist in the room believed remotely possible.

Back at the Pasteur Institute, the French understandably found this all beyond outré. And as more and more genetically different strains of the AIDS-causing virus were isolated, the fact that the French LAV and the American HTLV-III were exactly the same rallied supporters to their cause. Clearly, someone in Gallo's lab had contaminated Gallo's virus pool with the samples sent by Barré-Sinoussi. The only question was, was it accidental or intentional?

One thing was certain: What had begun as a scientific collaboration to fight the new plague was rapidly deteriorating into an ugly—and very public—international incident. Accusations flew back and forth across the Atlantic. Prestige was at stake, and so were profits. A legal battle royale over royalties for the HIV antibody test erupted in 1986; the test was being used in massive numbers worldwide to diagnose patients and screen blood. It was left to President Reagan and Prime Minister Jacques Chirac, in an absurdly pompous signing at the White House, to crown both Gallo and Montagnier as codiscoverers—and split the treasure between the two nations.

In 1990, the Office of Scientific Integrity asked a group of Roche researchers to try to settle the matter from a scientific rather than a political perspective. After analyzing archival LAV/HTLV-III/HIV samples from the two labs, they found that contamination was responsible for the uncanny resemblance of the two discoveries. How that contamination occurred may never be known, though such incidents are hardly uncommon. And yet.

In 2002, Montagnier and Gallo penned a series of high-profile articles, separately and together, in which they agreed that the most accurate way of looking at the whole mess is in the true spirit of codiscovery: If the French lab was the first to isolate the retrovirus, Gallo was responsible for the science on which it was based as well as for its subsequent demonstration as the cause of AIDS and its crucial growth in cell lines.

What made the Nobel judges decide to put all that painful history through the shredder?

In their citation that accompanied the announcement of this morning's prize, no mention was made of Robert Gallo. Montagnier was quick to tell the AP, "It is certain that [Gallo] deserved this as much as us two." Gallo, for his part, said it was "a disappointment." When Pharm Exec contacted the Institute of Human Virology to check his mood a few hours later, he offered only this official statement:

"I congratulate this year's Nobel Prize winners. I am pleased my long-time friend and colleague Dr. Luc Montagnier, as well as his colleague Francoise Barré-Sinoussi, have received this honor. I would also like to congratulate my friend, Harold zur Hausen, in recognition of his discovery that human papilloma viruses cause cervical cancer. I was gratified to read Dr. Montagnier's kind statement this morning expressing that I was equally deserving.

"I am pleased that the Nobel Committee chose to recognize the importance of AIDS with these awards and I am proud that my colleagues and I continue to search for an AIDS vaccine at the University of Maryland School of Medicine's Institute of Human Virology."

At age 71, Robert Gallo remains a vital force in HIV research, as much for his leadership at the Institute of Human Virology and his outspoken advocacy for HIV funding as for his impressive string of discoveries after 1984. For a true scientist, the work itself may be prize enough.'t-cry-for-me-karolinska/

Comment: Was Robert Gallo robbed of the Nobel prize? - New Scientist

One of the tackiest sagas in the history of medicine unfolded in the decade after HIV was discovered in 1983.

On the face of it, celebrations were in order because it had taken scientists just two years to discover what was causing AIDS after the first cases emerged in 1981.

Instead, the world's public were treated to an interminable squabble between two teams – one in France and one in the US – over who actually discovered the virus, whose test for the virus was patented first, and whether one team had "appropriated" viral samples from the other.

Now, the whole saga has been raked up again because the leaders of one team, but not the other, have been awarded the Nobel Prize for Physiology or Medicine.

One team, at the National Cancer Institute in Bethesda, Maryland, was led by Robert Gallo. The other, at the Pasteur Institute in Paris, was led by Luc Montagnier.

On Monday, Montagnier and his colleague Françoise Barré-Sinoussi, shared half the prize. The other half of the prize went to Harald zur Hausen of the German Cancer Research Centre in Heidelberg for a completely unrelated achievement – the discovery that human papilloma viruses (HPV) cause cervical cancer.

So one has to ask: why did the Nobel committee decide against including Gallo?

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Privatizing health care is not the answer: lessons from the United States -- Marcia Angell -- Canadian Medical Association Journal

There are strong moves within Canada to make the Canadian health care system more like the US system by partially privatizing it. Those who favour this approach claim that the US system offers more choice and better quality of care and spares the public purse. Some proponents even go so far as to claim that it is more efficient.  My purpose here is to disabuse Canadians of these myths by taking a close look at how the US system works and comparing it with the Canadian system.

In 1972 the Yukon Territory became the last jurisdiction in Canada to adopt the Medical Care Act, which set up a system to provide hospital and physician care to all Canadians.  Before then, the Canadian and US health care systems were similar. Both were partly public, partly private, partly for profit and partly nonprofit. Both also left a great many citizens uninsured. The costs were also about the same — a little over $300 per person in 1970 — as were outcomes. At that time, life expectancy was about a year longer in the United States.

But with the implementation of Canadian medicare, the 2 systems rapidly began to diverge in all respects. The US system became more and more costly, leaving increasing numbers of Americans — now about 46 million people —uninsured. In 2005, expenditures were twice as high in the US as in Canada — US$6697 per person v. US$3326 in Canada. And although Canada insures all its population for necessary doctor and hospital care, the US leaves 15% without any insurance whatsoever. Those who are insured often need to pay a substantial fraction of the bill out-of-pocket, and some necessary services may not be covered.  In a recent survey, 37% of Americans reported that they went without needed care because of cost, compared with 12% of Canadians.

Outcomes also now favour Canada. Instead of living a year longer, the life expectancy of Americans is now 2.5 years shorter than that of Canadians.2 Infant mortality rates are higher in the US, as is preventable mortality (death before the age of 75 years from diseases that are amenable to treatment). Furthermore, contrary to popular belief, people in the US do not receive more health care services. They visit their doctors much less often and spend less time in hospital than Canadians do (Table 1). Per population, there are also fewer nurses and hospital beds in the US, although there are slightly more doctors and many more magnetic resonance imaging (MRI) units.

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Key points

• Health care costs per person are twice as high in the
United States as in Canada.

• The US health care system has worse outcomes, is less efficient
and provides fewer of many basic services than the
Canadian system.

• The United States is the only industrialized country that
treats health care as a market commodity, not a social service,
and leaves uninsured those who cannot pay.

• In the United States, for-profit health care is more expensive
and often of lower quality than not-for-profit or government
care, with much higher overhead costs.

• The notion that partial privatization in Canada will shorten
waiting times for elective procedures is misguided.

• Partial privatization would draw off resources from the
public system, increase costs overall and introduce the inequities
of the US system.

• The best way to improve the Canadian health care system
is to put more resources into it.