Saturday, October 19, 2013

A Push to Sell Testosterone Gels Troubles Doctors -

The barrage of advertisements targets older men. "Have you noticed a recent deterioration of your ability to play sports?" "Do you have a decrease in sex drive?" "Do you have a lack of energy?"

If so, the ads warn, you should "talk to your doctor about whether you have low testosterone" — "Low T," as they put it.

In the view of many physicians, that is in large part an invented condition. Last year, drug makers in the United States spent $3.47 billion on advertising directly to consumers, according And while ever-present ads like those from AbbVie Pharmaceuticals have buoyed sales of testosterone gels, that may be bad for patients as well as the United States' $2.7 trillion annual health care bill, experts say.

Sales of prescription testosterone gels that are absorbed through the skin generated over $2 billion in American sales last year, a number that is expected to more than double by 2017. Abbott Laboratories — which owned AbbVie until Jan. 1 — spent $80 million advertising its version, AndroGel, last year.

Once a niche treatment for people suffering from hormonal deficiencies caused by medical problems like endocrine tumors or the disruptive effects of chemotherapy, the prescription gels are increasingly being sold as lifestyle products, to raise dipping levels of the male sex hormone as men age.

"The market for testosterone gels evolved because there is an appetite among men and because there is advertising," said Dr. Joel Finkelstein, an associate professor at Harvard Medical School who is studying male hormone changes with aging. "The problem is that no one has proved that it works and we don't know the risks."

Dr. Eric Topol, a cardiologist and chief academic officer at Scripps Health in San Diego, is alarmed by the high percentage of patients he sees who use the roll-on prescription products, achieving testosterone levels that he described as "ridiculously high."

The gels are of questionable medical benefit for many of the millions of men who now take them, he and other doctors say, and their side effects may well prove dangerous.

"These medicines come with a risk of coronary artery disease," Dr. Topol said.

"When I ask patients why they're on it, the instant response, is, 'I have low T.' I ask, 'Why would you even get tested for that?' There isn't really a normal," he said. Other side effects include anenlarged prostate, he added.

Nevertheless, many insurers cover the cost of the high-priced hormone treatments, requiring only a small co-payment from patients. AndroGel and another popular testosterone gel, Axiron, by Eli Lilly & Company, sell for more than $500 a month retail, and about $400 with pharmacy coupons.

Many experts say that pharmaceutical advertising promotes excessive and inappropriate drug use by convincing patients that they are ill — or have a more serious condition than is genuinely the case — and need medicine to treat it. While television viewers are barraged with advertising warning men they may have "low T," Dr. Finkelstein said, "There is no such disease."

Such advertising also leads patients to seek out more expensive treatments, rather than cheaper ones that are often equally effective. Drugs that are advertised are almost always the ones that are costly.

In response to an article Sunday in The New York Times on prescription drug costs for asthma medicines in the United States, a number of readers complained about the high price of inhalers, and that the costs were inflated by the millions of dollars pharmaceutical companies spend on advertising for them.

Jack D. from Philadelphia, for example, wrote that he mail-ordered his prescription steroid nasal spray from overseas, for 20 percent of the price in the United States. "I refuse to pay for ads featuring talking bees with Spanish accents," he wrote. Merck spent $46.3 million last year advertising Nasonex, its popular steroid spray.

Patients of any age may benefit from testosterone replacement if their levels are severely low because of serious medical problems, experts say. But testosterone normally declines as men age — just as estrogen does in women.

The F.D.A. has approved the gels "for use in men who either no longer produce the male sex hormone testosterone or produce it in very low amounts." But that directive is ambiguous, and the F.D.A. office did not respond to questions because of the government shutdown.

Should testosterone be replaced in older men, and will it safely redress frequent ordinary symptoms of male aging, like decreased muscle mass and libido? And what constitutes a very low amount?

Dr. Finkelstein said, "Until there are big long-term studies to address the issues of testosterone replacement, we're not ready to make recommendations on that."

But drug companies defend their efforts to reach out to potential users. Testosterone deficiency is "a recognized clinical condition, with signs/symptoms that can impact millions of patients," said Morry B. Smulevitz, a director of communications for Lilly, which makes Axiron. While he said the company did not condone the use of medicine for purposes other than those approved by the F.D.A., it "encouraged patients to talk to their physicians to weigh the risks and benefits."

David Freundel, director of public affairs for AbbVie, which makes AndroGel, said the company's "low testosterone efforts" were "developed to educate men who may be at risk for, or have, low testosterone, so they can have the appropriate dialogue with their physician to determine if testing and treatment may be appropriate."

Studies are just beginning to yield results to address the appropriate use of the drug in older men. For example, scientists have found that age-related male changes in body fat depend on a different hormone, estradiol, which also decreases with age. Likewise, while strength and libido do decrease with falling testosterone levels, that effect may not be significant until testosterone levels are very low, Dr. Finkelstein said. Low testosterone is rarely the main cause of erectile dysfunction.

Finally, he added, no one has really defined what is a "normal" or "physiological" testosterone level. And yet, physicians often order tests for "low T."

A survey this year by CMI/Compass found that more than half of physicians felt that pharmaceutical advertising to consumers should be scaled back, and 63 percent said it misinformed patients.

"I really don't understand why it's tolerated at a time we're struggling with health care costs," Dr. Topol said. "A lot of people bounce their legs in meetings, but that doesn't mean you have restless leg syndrome, and you shouldn't be taking drugs for that."

The Not-So-Hidden Cause Behind the A.D.H.D. Epidemic -

Between the fall of 2011 and the spring of 2012, people across the United States suddenly found themselves unable to get their hands on A.D.H.D. medication. Low-dose generics were particularly in short supply. There were several factors contributing to the shortage, but the main cause was that supply was suddenly being outpaced by demand.

The number of diagnoses of Attention Deficit Hyperactivity Disorder has ballooned over the past few decades. Before the early 1990s, fewer than 5 percent of school-age kids were thought to have A.D.H.D. Earlier this year, data from the Centers for Disease Control and Prevention showed that 11 percent of children ages 4 to 17 had at some point received the diagnosis — and that doesn't even include first-time diagnoses in adults. (Full disclosure: I'm one of them.)

That amounts to millions of extra people receiving regular doses of stimulant drugs to keep neurological symptoms in check. For a lot of us, the diagnosis and subsequent treatments — both behavioral and pharmaceutical — have proved helpful. But still: Where did we all come from? Were that many Americans always pathologically hyperactive and unable to focus, and only now are getting the treatment they need?

Probably not. Of the 6.4 million kids who have been given diagnoses of A.D.H.D., a large percentage are unlikely to have any kind of physiological difference that would make them more distractible than the average non-A.D.H.D. kid. It's also doubtful that biological or environmental changes are making physiological differences more prevalent. Instead, the rapid increase in people with A.D.H.D. probably has more to do with sociological factors — changes in the way we school our children, in the way we interact with doctors and in what we expect from our kids.

Which is not to say that A.D.H.D. is a made-up disorder. In fact, there's compelling evidence that it has a strong genetic basis. Scientists often study twins to examine whether certain behaviors and traits are inborn. They do this by comparing identical twins (who share almost 100 percent of the same genes) with fraternal twins (who share about half their genes). If a disorder has a genetic basis, then identical twins will be more likely to share it than fraternal twins. In 2010, researchers at Michigan State University analyzed 22 different studies of twins and found that the traits of hyperactivity and inattentiveness were highly inheritable. Numerous brain-imaging studies have also shown distinct differences between the brains of people given diagnoses of A.D.H.D. and those not — including evidence that some with A.D.H.D. may have fewer receptors in certain regions for the chemical messenger dopamine, which would impair the brain's ability to function in top form.

None of that research yet translates into an objective diagnostic approach, however. Before I received my diagnosis, I spent multiple sessions with a psychiatrist who interviewed me and my husband, took a health history from my doctor and administered several intelligence tests. That's not the norm, though, and not only because I was given my diagnosis as an adult. Most children are given the diagnosis on the basis of a short visit with their pediatrician. In fact, the diagnosis can be as simple as prescribing Ritalin to a child and telling the parents to see if it helps improve their school performance.

This lack of rigor leaves room for plenty of diagnoses that are based on something other than biology. Case in point: The beginning of A.D.H.D. as an "epidemic" corresponds with a couple of important policy changes that incentivized diagnosis. The incorporation of A.D.H.D. under the Individuals With Disabilities Education Act in 1991 — and a subsequent overhaul of the Food and Drug Administration in 1997 that allowed drug companies to more easily market directly to the public — were hugely influential, according to Adam Rafalovich, a sociologist at Pacific University in Oregon. For the first time, the diagnosis came with an upside — access to tutors, for instance, and time allowances on standardized tests. By the late 1990s, as more parents and teachers became aware that A.D.H.D. existed, and that there were drugs to treat it, the diagnosis became increasingly normalized, until it was viewed by many as just another part of the experience of childhood.

Stephen Hinshaw, a professor of psychology at University of California, Berkeley, has found another telling correlation. Hinshaw was struck by the disorder's uneven geographical distribution. In 2007, 15.6 percent of kids between the ages of 4 and 17 in North Carolina had at some point received an A.D.H.D. diagnosis. In California, that number was 6.2 percent. This disparity between the two states is representative of big differences, generally speaking, in the rates of diagnosis between the South and West. Even after Hinshaw's team accounted for differences like race and income, they still found that kids in North Carolina were nearly twice as likely to be given diagnoses of A.D.H.D. as those in California.

Hinshaw, as well as sociologists like Rafalovich and Peter Conrad of Brandeis University, argues that such numbers are evidence of sociological influences on the rise in A.D.H.D. diagnoses. In trying to narrow down what those influences might be, Hinshaw evaluated differences between diagnostic tools, types of health insurance, cultural values and public perceptions of mental illness. Nothing seemed to explain the difference — until he looked at educational policies.

The No Child Left Behind Act, signed into law by President George W. Bush, was the first federal effort to link school financing to standardized-test performance. But various states had been slowly rolling out similar policies for the last three decades. North Carolina was one of the first to adopt such a program; California was one of the last. The correlations between the implementation of these laws and the rates of A.D.H.D. diagnosis matched on a regional scale as well. When Hinshaw compared the rollout of these school policies with incidences of A.D.H.D., he found that when a state passed laws punishing or rewarding schools for their standardized-test scores, A.D.H.D. diagnoses in that state would increase not long afterward. Nationwide, the rates of A.D.H.D. diagnosis increased by 22 percent in the first four years after No Child Left Behind was implemented.

To be clear: Those are correlations, not causal links. But A.D.H.D., education policies, disability protections and advertising freedoms all appear to wink suggestively at one another. From parents' and teachers' perspectives, the diagnosis is considered a success if the medication improves kids' ability to perform on tests and calms them down enough so that they're not a distraction to others. (In some school districts, an A.D.H.D. diagnosis also results in that child's test score being removed from the school's official average.) Writ large, Hinshaw says, these incentives conspire to boost the diagnosis of the disorder, regardless of its biological prevalence.

Rates of A.D.H.D. diagnosis also vary widely from country to country. In 2003, when nearly 8 percent of American kids had been given a diagnosis of A.D.H.D., only about 2 percent of children in Britain had. According to the British National Health Service, the estimate of kids affected by A.D.H.D. there is now as high as 5 percent. Why would Britain have such a comparatively low incidence of the disorder? But also, why is that incidence on the rise?

Conrad says both questions are linked to the different ways our societies define disorders. In the United States, we base those definitions on the Diagnostic and Statistical Manual of Mental Disorders (D.S.M.), while Europeans have historically used the International Classification of Diseases (I.C.D.). "The I.C.D. has much stricter guidelines for diagnosis," Conrad says. "But, for a variety of reasons, the D.S.M. has become more widely used in more places." Conrad, who's currently researching the spread of A.D.H.D. diagnosis rates, believes that America is essentially exporting the D.S.M. definition and the medicalized response to it. A result, he says, is that "now we see higher and higher prevalence rates outside the United States."

According to Joel Nigg, professor of psychiatry at Oregon Health and Science University, this is part of a broader trend in America: the medicalization of traits that previous generations might have dealt with in other ways. Schools used to punish kids who wouldn't sit still. Today we tend to see those kids as needing therapy and medicine. When people don't fit in, we react by giving their behavior a label, either medicalizing it, criminalizing it or moralizing it, Nigg says.

For some kids, getting medicine might be a better outcome than being labeled a troublemaker. But of course there are also downsides, especially when there are so many incentives encouraging overdiagnosis. Medicalization can hurt people just as much as moralizing can. Not so long ago, homosexuality was officially considered a mental illness. And in a remarkable bit of societal blindness, the diagnosis of drapetomania was used to explain why black slaves would want to escape to freedom.

Today many sociologists and neuroscientists believe that regardless of A.D.H.D.'s biological basis, the explosion in rates of diagnosis is caused by sociological factors — especially ones related to education and the changing expectations we have for kids. During the same 30 years when A.D.H.D. diagnoses increased, American childhood drastically changed. Even at the grade-school level, kids now have more homework, less recess and a lot less unstructured free time to relax and play. It's easy to look at that situation and speculate how "A.D.H.D." might have become a convenient societal catchall for what happens when kids are expected to be miniature adults. High-stakes standardized testing, increased competition for slots in top colleges, a less-and-less accommodating economy for those who don't get into colleges but can no longer depend on the existence of blue-collar jobs — all of these are expressed through policy changes and cultural expectations, but they may also manifest themselves in more troubling ways — in the rising number of kids whose behavior has become pathologized.

Maggie Koerth-Baker is science editor at and author of "Before the Lights Go Out," on the future of energy production and consumption.

Thursday, October 17, 2013

Don't blame obese patients for being overweight, doctors told | Society |

Doctors must treat obese patients with respect and be careful not to blame them for becoming overweight, new draft official NHS guidance says.

The National Institute for Health and Care Excellence (Nice) says obesityis a serious problem not only for individuals who risk type 2 diabetes, heart disease and some cancers, but also for the NHS, which is having to spend an estimated £5.1bn a year dealing with the consequences.

In draft guidance on services to help people manage their weight, which is now out to consultation, Nice says that quick fixes do not work. Programmes such as those run by WeightWatchers and Slimming World are not a magic bullet, it says.

People should be referred to programmes that not only offer to help people cut down on the calories, but also change their eating and exercise behaviour for the long term.

"This draft guidance isn't about quick fixes, it is about ensuring lifestyle weight management services support people in the long term," said Professor Mike Kelly, director of the centre for public health at Nice.

"Programmes that address diet, activity and behaviour change can help people who are obese lose weight but they are only cost-effective if the weight is kept off."

Kelly stressed the severity and scale of the problem.

"Being overweight or obese can have serious consequences for an individual's health, not only physically, with increased risk of high blood pressure and type 2 diabetes, but it can also affect their mental health as a result of stigma and bullying or discrimination.

"Levels of obesity in England are rising, with a little over a quarter of adults classified as obese and a further 41% of men and 33% of women overweight. This is a huge proportion of our population."

People should not be blamed for being fat but nor should they be misled about what they can expect from a weight management programme, Nice says.

GPs and those who run programmes should explain that none of them is a magic bullet – motivation and commitment are needed to lose weight and maintain the weight loss. People should be told how much – or how little – they can actually expect to lose, but also of the health benefits of losing even a small amount.

Nice recommends that GPs should focus mainly on adults with a BMI (body mass index) of more than 30 – but among black African, African-Caribbean and Asian groups, a lower threshold can be used.

Wednesday, October 16, 2013

Uganda Fights Stigma and Poverty to Take On Breast Cancer -

KAMPALA, Uganda — Mary Namata unbuttoned her dress in an examining room at Mulago Hospital, revealing a breast taut and swollen with grape-size tumors that looked as if they might burst through the skin.

"How long have you had this?" a doctor asked gently. Ms. Namata, 48, an elegant woman with stylishly braided hair and a flowing, traditional Ugandan dress, looked away, shamefaced.

"About a year," she murmured. The truth, she admitted later, was closer to four years.

Such enormous tumors, rare in developed countries, are typical here. Women in Uganda, trapped by stigma, poverty and misinformation, often do not see help for breast cancer until it is too late.

For Ms. Namata, though, there was still hope that the cancer had not yet spread beyond the breast, her doctors said. Treatment could prolong her life, maybe even cure her — if it started soon.

But would she be treated in time? Women in Africa often face perilous delays in treatment as a result of scarce resources, incompetence and corruption. Would Ms. Namata wind up like so many women here, with disease so far gone that doctors can offer nothing but surgery to remove rotting flesh, morphine for pain and antibacterial powder to kill the smell of festering tumors that break through the skin?

Cancer has long been neglected in developing countries, overshadowed by the struggle against more acute threats like malaria and AIDS. But as nations across the continent have made remarkable progress against infectious diseases once thought too daunting to tackle, more people are living long enough to develop cancer, and the disease is coming to the forefront. Given the strides poor countries have made against other health problems, they should also be able to improve the treatment of cancer, public health experts increasingly say.

Two years ago, the United Nations began a global campaign against noncommunicable diseases — cancer, diabetes, heart and lung disease — noting that they hit the poor especially hard. Worldwide, at least 7.6 million people a year die from cancer, and 70 percent of those deaths occur in poor and moderate-income countries, according to the World Health Organization.

Breast cancer takes a particularly harsh toll. It is the world's most common cancer in women and their leading cause of cancer death, with 1.6 million cases a year and more than 450,000 deaths.

Survival rates vary considerably from country to country and even within countries. In the United States, about 20 percent of women who have breast cancer die from it, compared with 40 to 60 percent in poorer countries. The differences depend heavily on the status of women, their awareness of symptoms and the availability of timely care. At the same time, scientists' deepening insights into the genetic basis of cancer have introduced a complicated new dimension into the care of women globally.

Uganda is trying to improve the treatment of all types of cancer in ways that make sense in a place with limited resources. A new hospital and clinic, paid for by the Ugandan government, have been added to the Uganda Cancer Institute in Kampala, though they have not yet opened, for lack of equipment. A research center is being built.

But women like Ms. Namata, with breast cancer so advanced that there is just a tiny window of time, if any, in which to save their lives, will be among the toughest challenges here.

"The terrible part about breast cancer is that if we just did what we already know how do in other places, we could make major shifts in survival," said Dr. Benjamin O. Anderson, who heads the Breast Health Global Initiative, based at the Fred Hutchinson Cancer Research Center in Seattle.

There is a pressing need for action because breast cancer is "escalating," the initiative says, predicting that incidence and death rates in developing countries will increase by more than 50 percent in the next 20 years.

The breast cancer rate in Africa seems to be increasing, though cervical cancer kills more women in the sub-Saharan regions. It is not clear whether breast cancer is actually becoming more common, or is just being detected and reported more often, but physicians consider it a looming threat. Compared with breast cancer patients in developed countries, those in Africa tend to be younger, and they are more likely to die, in large part because of late diagnosis and inadequate treatment.

Doctors also suspect that more aggressive types of tumors may be more common in young African women, as they appear to be in young black women in the United States, though there is not enough pathology data from Africa to know for sure. Among women who die young (ages 15 to 49) from breast cancer, 72 percent are in developing countries, and many leave small children.

"The story of breast cancer here is a miserable one," said Dr. Fred Okuku, an oncologist at the Uganda Cancer Institute in Kampala, which treats about 200 women a year for breast cancer. "There is little information for the people who need to be helped. Only a few know how to read and write. Many don't have TV or radio. There is no word for cancer in most Ugandan languages. A woman finds a lump in her breast, and cancer doesn't cross her mind. It's not in her vocabulary."

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Avoiding Surgery in the Elderly -

It may take members of our parents' generation (and our own) a long time to get over thinking of hospitals as refuges of safety and operating rooms as harbingers of better days ahead. But it's gradually becoming clearer that for the very old and frail, and for nursing home residents in particular, hospitals are places to avoid whenever possible, and surgery can become a source of danger in itself.
Even operations considered fairly routine in younger patients, like appendectomies, become high-risk for nursing home residents. "Something about undergoing anesthesia, the surgery's physiological assault on the body, impacts older people much more than we think," said Dr. Emily Finlayson, a colorectal surgeon at the University of California, San Francisco, and lead author of arecent study published in The Annals of Surgery.
In fact, the study, which compared mortality risks and subsequent interventions for four types of major abdominal surgery, found that even compared with adults of similar age who had the same number of chronic illnesses — but who weren't in institutions — nursing home residents fared sharply worse.
Bluntly put, surgery is much more likely to kill them.
Dr. Finlayson and her colleagues used national Medicare claims and nursing home surveys to identify nearly 71,000 nursing home residents who had surgery from 1999 through 2006. They compared them with more than a million elders who underwent the same four procedures but did not live in a nursing home. The researchers chose operations frequently performed on older adults: removal of an infected appendix (appendectomy), removal of an infected gallbladder (cholecystectomy), surgery for a bleeding ulcer in the upper part of the intestine, or surgery for noncancerous colon diseases like diverticulitis or colitis. These are painful conditions requiring immediate decisions, as opposed to diagnoses like breast or prostate cancer, in which a patient and his or her family can take a few days to figure out the best course.
Typically, Dr. Finlayson explained, the surgeon gets a call from the emergency room, frequently at 3 in the morning: an 85-year-old nursing home resident is being admitted with acute appendicitis. The response is almost always: Prepare the O.R.
But after an appendectomy, 12 percent of nursing home residents died, compared with 2 percent of Medicare recipients who weren't in nursing homes. Gallbladder surgery was also more dangerous: an 11 percent mortality risk for nursing home residents, versus 3 percent in elders who weren't institutionalized.
The risk of dying rose sharply for the other two operations. For colon surgery, it was nearly a third for nursing home residents, and 13 percent for others. Ulcer surgery proved the most dangerous; 42 percent of nursing home patients died, compared with 26 percent of others.
Even when the researchers matched these two groups of patients by age and by the number of other diseases they had, those in the nursing home group (and in this study that meant long-term residents, not those in temporary rehab) were significantly more likely to die in each case. Just by virtue of living in a nursing home, "they've demonstrated they don't have the strength and mobility to live independently," Dr. Finlayson said. "They don't have the energy and vitality" — in doctorspeak, they lack "physiologic reserve."
But even those who survived surgery — and they're a majority, in some cases a large majority — weren't out of the woods. Nursing home residents were far more likely to undergo "invasive interventions" afterward; they required mechanical ventilators for days to help them breathe, feeding tubes inserted in their abdomens when they couldn't eat, venous catheterization (known as a central line) to monitor their hearts. Each of these painful procedures presents additional risks, of course.
We know that a substantial proportion of older people who enter hospitals will never fully regain their physical or mental capabilities, even when the illness that brought them there is successfully treated. (More on this syndrome later.) These interventions, which typically also keep people in bed, even though getting out of bed is critical to their recovery, may help explain why.
"Surgeons are very resistant to hearing this," Dr. Finlayson said. "We're focused on 30-day mortality. If patients leave the hospital alive, that's success. We don't see what happens three months down the road."
So here's a key question family members can ask before the surgeon starts scrubbing, especially if their older relative is frail enough to require nursing home care: Is there any alternative to surgery we could try?
"We think of appendicitis as a surgical disease — you take it out," Dr. Finlayson said. "But if you get appendicitis in England, it's often treated with antibiotics, whatever age you are." Gallbladder attacks can also be treated with antibiotics, or sometimes with a drain inserted under local anesthesia. A stent inserted by a gastroenterologist can relieve a bowel obstruction.
In each case, the treatment is less of an assault than surgery with general anesthesia. And if it doesn't work — if a 24-hour course of intravenous antibiotics, which can be administered in the nursing home, avoiding hospitalization, can't overcome the infection — surgery remains an option.
It might take a confident surgeon (because invasive surgery can provide protection against lawsuits, even if it's hard on patients) and a persistent family to pull off this alternative approach.
Surgeons, like most other physicians, are trained to save lives. "But with older patients, there's less length of life to protect," Dr. Finlayson pointed out. "So the other variables become way more important: maintaining cognitive status, living independently, caring for yourself. Quality of life."
Paula Span is the author of "When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions."

Health Resources | Oral Health America

The Wisdom Tooth Project aims to change the lives of older adults especially vulnerable to oral disease. This web portal,, is a large component of the program, which is tailored to A State of Decay: The Oral Health of Older Americans, Vol. II.

Monday, October 14, 2013

The Soaring Cost of a Simple Breath -

 The kitchen counter in the home of the Hayes family is scattered with the inhalers, sprays and bottles of pills that have allowed Hannah, 13, and her sister, Abby, 10, to excel at dance and gymnastics despite a horrific pollen season that has set off asthma attacks, leaving the girls struggling to breathe.

Asthma — the most common chronic disease that affects Americans of all ages, about 40 million people — can usually be well controlled with drugs. But being able to afford prescription medications in the United States often requires top-notch insurance or plenty of disposable income, and time to hunt for deals and bargains.

The arsenal of medicines in the Hayeses' kitchen helps explain why. Pulmicort, asteroid inhaler, generally retails for over $175 in the United States, while pharmacists in Britain buy the identical product for about $20 and dispense it free of charge to asthma patients. Albuterol, one of the oldest asthma medicines, typically costs $50 to $100 per inhaler in the United States, but it was less than $15 a decade ago, before it was repatented.

"The one that really blew my mind was the nasal spray," said Robin Levi, Hannah and Abby's mother, referring to her $80 co-payment for Rhinocort Aqua, a prescription drug that was selling for more than $250 a month in Oakland pharmacies last year but costs under $7 in Europe, where it is available over the counter.

The Centers for Disease Control and Prevention puts the annual cost of asthma in the United States at more than $56 billion, including millions of potentially avoidable hospital visits and more than 3,300 deaths, many involving patients who skimped on medicines or did without.

"The thing is that asthma is so fixable," said Dr. Elaine Davenport, who works in Oakland's Breathmobile, a mobile asthma clinic whose patients often cannot afford high prescription costs. "All people need is medicine and education."

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