at the Atlantic has written an interesting post on the developing (or perhaps ossifying) dogma in the Democratic party that holds that good and universal health care will not only be good for the people that have it, but will also be cheaper. This "have your cake and eat it too" notion may be, as she points out, reasonably compared to the notorious "Voodoo economics" of the Laffer curve. There is one way that medical costs might well (unfortunately) end up being controlled however.
A very large percentage of these national health care systems around the globe (and most developed-world health care systems are substantially nationalized) negotiate low costs for medications because drug companies take cost-of-additional-production + profit as a basis for pricing drugs sold to national systems. Cost of research and development is commonly not included in the price or at least is not included fully, and national health systems are able to enforce this preferential pricing, which externalizes the cost of developing medicines, by not making available all of the medicines on the market.
The structural reluctance of a national health care system to add new drugs to the national formulary is countered by observation of the success of a given medicine ELSEWHERE. It is difficult to deny medication and treatments that are well demonstrated to be useful and effective in another nation, but such a system naturally tends towards stasis, and is quite dependent on external benchmarking of medical quality for PARTICULAR treatments. Low-cost but high-quality treatment in unitary health care systems is thus quite dependent on non-unitary health care elsewhere.
The United States has been, for many years the non-unitary market of choice, and indeed is the market of choice for drugs and medical devices altogether. Medical research and development efforts around the globe, including in unitary markets, will generally take for granted that any drug or medical device that is effective and improved is likely to repay its research costs if it is approved in the US. Comparisons between the US and a unitary health care system will naturally cause American health care to seem thoroughly overpriced, because a unitary system that takes the natural and obvious steps to control drug costs becomes a free rider on the research, development, and effectiveness evaluation of other nations. The US, due to lack of comprehensive coverage, is not a great standard bearer for quality medicine when all the people who lack coverage (or who lack good coverage) are included, but the role of the US medical system in determining which TREATMENTS work, is vital.
If something changes in the US to interfere with the new-medicine introduction cycle however, then everything changes everywhere. Where in the world, if not in the US, will new, and likely expensive medications or treatments be offered the chance to demonstrate their effectiveness?
The nightmare scenario would thus be that the US would adopt an 'off the rack' national health care model that would seek out preferential pricing, and which would not allow new drugs into the national formulary until they had a well established record on the market. This scenario would create a sort of 'lockout' with the formulary systems of the world excluding all or most new drug introductions, and preventing new medications from proving themselves.
In fact, a Canadian or British unitary and single-payer system is not required to squelch medical development however. Even if EVERY new drug were allowed, but allowed with a delay, then drugmakers would have less time when they would be able to recoup their costs (which includes costs for drug development that did not pan out) before the opportunity to do so was truncated by patent expiration. A limited trial period when drugs would see a limited introduction would likewise slice into the period when a drugmaker is protected by patent monopoly.
For most national health systems, a delay in introducing a drug to the national formulary causes injury to the extent that such patients as are denied the medication suffer its lack for a few years. This can be lethal to the affected individuals, but their numbers are limited. Due to the crucial role of the US in the global drug market however, the effects of a delay or other market alteration are likely to be more lasting, and could eliminate new treatments altogether.
The Obama administration has put a good deal of emphasis on the creation of an agency that would evaluate the "effectiveness" of particular drugs and treatments, and an agency of this sort could easily provide the justification for excluding new medications, whether it is a government program or private insurance that would actually pull the trigger. If new medical treatments are introduced less and less often, then the costs associated with new medical treatments will drop. It will be hard for people to miss treatments that did not ever exist in the first place.
Showing posts with label medicine. Show all posts
Showing posts with label medicine. Show all posts
Tuesday, June 16, 2009
Friday, November 28, 2008
Could declines in smoking be behind the autism epidemic?
An Autism Epidemic?
One spring day in 1999, a Los Angeles Times newspaper article brought a problem to the attention of the nation. A fiercely disabling, but previously rare childhood developmental disability, autism, was being seen in more and more children throughout California, with a 273% increase in incidence in the previous 10 years. Parents of autistic children, struggling to help them, wanted a cure, prospective parents worried about being in the same position, and this report soared to national attention. Soon many, perhaps even most, Americans had heard of autism.
Bar chart of the number (per 1,000 U.S. resident children aged 6–17) of children aged 6–17 who were served under the Individuals with Disabilities Education Act (IDEA) with a diagnosis of autism, from 1996 through 2007. Vaccines To Blame?
An additional reason for alarm was a 1998 paper published in the prestigious medical journal, the Lancet, with the author, Andrew Wakefield suggesting that the MMR vaccine in some cases induced an adverse autoimmune reaction in the vaccinated children, causing autism and an associated bowel disorder.
Wakefield suggested that instead of the widely used triple vaccine, children should be immunized with separate vaccines for Measles, Mumps and Rubella (German measles) with each vaccine being spaced a year apart, to quote: "If you give three viruses together, three live viruses, then you potentially increase the risk of an adverse event occurring, particularly when one of those viruses influences the immune system in the way that measles does." Such vaccines were not generally available at the time however.
Both the medical establishment, and governments were displeased by this study. Neither trusted the public much, and they feared that parents would simply avoid the vaccinations. Moreover, three separate vaccines would increase costs.
Thus battle lines in Britain (where Wakefield worked) were drawn, and all parties performed as expected. Doctors fell over themselves to dismiss the possibility of vaccine harm, the government refused to provide separate vaccines, and the public kept their children away from the vaccinating needles.
Toxic Vaccines And Heavy Metal Poisoning.
Moreover, a new issue soon sprung to life, raising new concerns even for those who accepted studies and data analysis dismissing the possibility of autoimmune vaccine injury. As it happened, many vaccines were manufactured and dispensed with a mercury based preservative, thimerosal. Mercury is quite neurotoxic, and a handful of noted scientists in the US contended that the thimerosal contributed to the development of autism. The US government and medical establishment were generally dismissive (or at least officially dismissive) of this notion, but with several other nations demanding mercury free vaccines, it was decided that reducing mercury levels would help to ensure that the public would accept vaccination.
Mercury reduction was accordingly implemented, but as of yet, no great reduction in autism prevalence has been noted. Government and establishment sources have settled on this fact as proving the complete safety of the vaccines, but neither camp of vaccine critics is convinced. So far as the immune effects are concerned after all, nothing has much changed, with children still being injected with three weakened, but live and infectious sets of disease germs, although few Americans focus on this factor. So far as the mercury is concerned, any approval of the government's new rules is rather squelched by the fact that the officially permitted description "mercury free" does not mean that mercury is not an ingredient, but rather means simply that there is not enough thimerosal in the vaccine when it is diluted to dosage strength to provide reliable preservation. While the levels of mercury per vaccine have come down, the number of vaccines that children are now supposed to receive have gone up, and many people are thus convinced that the amount of mercury remaining is enough to cause autism.
Other Possible Causes.
Going beyond vaccines, while the geneticists are pressing the idea that the condition is almost completely inherited, people have looked to other environmental influences as well.
Studies have lately linked high rates of autism to high rainfall, suggesting a possible autism connection to vitamin D deficiency, indoor pollution exposure, or even increased juvenile television watching. The situation is further confused by questions about just how much of an epidemic there is in the first place. Autism would not be the first disease to have many of its sufferers misdiagnosed, and more widespread awareness might lead to a specific diagnosis where before a generic label like "retardation" might have been applied. Further, autism is now generally held to be a "spectrum" with several related conditions of varying severity but a common mechanism or cause. This understanding and concept might easily lead to children being diagnosed as autistic where before, despite their problems, the designation would not have been held to be appropriate.
Of course, whether or not there are more autism cases then previously, does not change the needs of the autistic kids one whit, but this question is very important if we are to catch any environmental or non-genetic provocation that will push a child towards autism.
The Latest.
Now a new study has emerged, which just might suggest an environmental cause of an entirely different sort.
As many a public health warning has pointed out, cigarette smoking by a pregnant woman affects her unborn child, and a smoker's baby is born with a brain that developed in a nicotine tainted environment. Some of the milder manifestations of autism like Asperger syndrome seem to manifest themselves as almost a hyper-nerdiness. Is it possible that an autistic child born to a chain smoker would be born weak, sickly, and undersized due to the harmful effects of smoking, just as the public health announcements tell us, but also be a notable but functional nerd, rather than be a child completely disabled by autism?
Of course there is also the possibility that the brain changes causing autism manifest primarily postnatally, and I have never seen a two year old light up! However, children are exposed to secondhand smoke. Is secondhand smoke enough to provide a dose of nicotine? Well a number of studies claim so. Even allowing for exaggeration, (it is easy to become enthusiastic when fighting so dangerous a habit) it seems reasonable, or at least not impossible to suppose that there might be enough nicotine to "shake loose" malfunctioning neural cells. If secondhand smoke would "do the job" then this is very important as well because of the truly massive historical exposure. A great many women throughout the 20'th century who did not smoke, had a spouse who did.
The smoking rate has been dropping steadily and consistently however (note that the above chart goes back only to 1965, when smoking had already been declining for many years), and the decline in prenatal and childhood exposure to nicotine has been much greater because habitually smoking parents have increasingly taken steps to avoid smoking around children, having been (correctly) told that secondhand smoke is a hazard to them. Such a precaution would have been quite alien 60 or 70 years ago.
Summing Up
Overall of course, eliminating tobacco use is of enormous benefit to everyone, and the harmful effects of secondhand smoke or prenatal exposure are very well established. Even if nicotine helped to prevent autism, smoking around children would make ill more children than it would cure.
This being said however, there are exceptions and caveats to most rules or truths in the world, and it is interesting to consider the possibility of HARMFUL side effects to the reduction of the generally harmful habit of smoking. This theory, or the research that prompted it, may turn out to be incorrect, and certainly I am going to keep an open mind on the subject, but at the same time it would be a mistake to simply dismiss the study as a fluke. Until recently, the actual mechanisms behind autism were almost entirely unknown, and the new study shines some light into this dark corner of medicine. It is generally harmful to inhale significant amounts of smoke, no matter what is burning, but nicotine has its addictive and stimulant qualities because it is a near analogue to a substance naturally found in the brain and nervous system. Native Americans used tobacco in medicine, and when tobacco was introduced to Europe, well before the development of a giant industry, it was used as a medicine as well. Both tobacco and cannabis are most commonly used for recreational purposes, but both contain chemicals that naturally regulate significant portions of the human nervous system. It has been unfortunate that disapproval of recreational use has prevented cannabis from being used fully in medicine, and we should not toss the medicine out with the cigarette butt.
[FULL DISCLOSURE: I do NOT smoke tobacco (or anything else for that matter), and NEVER DID. I did NOT grow up in a family of smokers, etc. etc. I do NOT work for a tobacco company, own tobacco company stock, benefit from cigarette advertisements, or even work for a shop that sells cigarettes. I have NO CONFLICT OF INTEREST here. My opinions stand on their own intellectual merits, not some hidden agenda, and of course, implicit in the use of a blog, I certainly understand and appreciate that you, the reader might disagree. If you have a point to make, I welcome comments. ]
Of course, whether or not there are more autism cases then previously, does not change the needs of the autistic kids one whit, but this question is very important if we are to catch any environmental or non-genetic provocation that will push a child towards autism.
The Latest.
Now a new study has emerged, which just might suggest an environmental cause of an entirely different sort.
COLUMBUS, Ohio – Scientists have identified a relationship between two proteins in the brain that has links to both nicotine addiction and autism............Now all this is very important on its own terms, as there is the possibility of a treatment, or even cure for autism. The study begs the question however, if drugs that "mimic the actions of nicotine" might cause a brain predisposed toward autism to develop properly, then would not nicotine itself do the same thing? It would be ridiculous of course to hand a small child a cigarette "for their health", but what if someone effectively did?
The discovery identified a defining role for a protein made by the neurexin-1 gene, which is located in brain cells and assists in connecting neurons as part of the brain’s chemical communication system. The neurexin-1 beta protein’s job is to lure another protein, a specific type of nicotinic acetylcholine receptor, to the synapses, where the receptor then has a role in helping neurons communicate signals among themselves and to the rest of the body.
“If we were to use drugs that mimic the actions of nicotine at an early time in human brain development, would we begin to help those and other circuits develop properly and thus significantly mitigate the deficits in autism? This is a novel way of thinking about how we might be able to use drugs to approach autism treatment,” said Rene Anand, associate professor of pharmacology in Ohio State University’s College of Medicine and principal investigator of the research.
As many a public health warning has pointed out, cigarette smoking by a pregnant woman affects her unborn child, and a smoker's baby is born with a brain that developed in a nicotine tainted environment. Some of the milder manifestations of autism like Asperger syndrome seem to manifest themselves as almost a hyper-nerdiness. Is it possible that an autistic child born to a chain smoker would be born weak, sickly, and undersized due to the harmful effects of smoking, just as the public health announcements tell us, but also be a notable but functional nerd, rather than be a child completely disabled by autism?
Of course there is also the possibility that the brain changes causing autism manifest primarily postnatally, and I have never seen a two year old light up! However, children are exposed to secondhand smoke. Is secondhand smoke enough to provide a dose of nicotine? Well a number of studies claim so. Even allowing for exaggeration, (it is easy to become enthusiastic when fighting so dangerous a habit) it seems reasonable, or at least not impossible to suppose that there might be enough nicotine to "shake loose" malfunctioning neural cells. If secondhand smoke would "do the job" then this is very important as well because of the truly massive historical exposure. A great many women throughout the 20'th century who did not smoke, had a spouse who did.
The smoking rate has been dropping steadily and consistently however (note that the above chart goes back only to 1965, when smoking had already been declining for many years), and the decline in prenatal and childhood exposure to nicotine has been much greater because habitually smoking parents have increasingly taken steps to avoid smoking around children, having been (correctly) told that secondhand smoke is a hazard to them. Such a precaution would have been quite alien 60 or 70 years ago.Summing Up
Overall of course, eliminating tobacco use is of enormous benefit to everyone, and the harmful effects of secondhand smoke or prenatal exposure are very well established. Even if nicotine helped to prevent autism, smoking around children would make ill more children than it would cure.
This being said however, there are exceptions and caveats to most rules or truths in the world, and it is interesting to consider the possibility of HARMFUL side effects to the reduction of the generally harmful habit of smoking. This theory, or the research that prompted it, may turn out to be incorrect, and certainly I am going to keep an open mind on the subject, but at the same time it would be a mistake to simply dismiss the study as a fluke. Until recently, the actual mechanisms behind autism were almost entirely unknown, and the new study shines some light into this dark corner of medicine. It is generally harmful to inhale significant amounts of smoke, no matter what is burning, but nicotine has its addictive and stimulant qualities because it is a near analogue to a substance naturally found in the brain and nervous system. Native Americans used tobacco in medicine, and when tobacco was introduced to Europe, well before the development of a giant industry, it was used as a medicine as well. Both tobacco and cannabis are most commonly used for recreational purposes, but both contain chemicals that naturally regulate significant portions of the human nervous system. It has been unfortunate that disapproval of recreational use has prevented cannabis from being used fully in medicine, and we should not toss the medicine out with the cigarette butt.
[FULL DISCLOSURE: I do NOT smoke tobacco (or anything else for that matter), and NEVER DID. I did NOT grow up in a family of smokers, etc. etc. I do NOT work for a tobacco company, own tobacco company stock, benefit from cigarette advertisements, or even work for a shop that sells cigarettes. I have NO CONFLICT OF INTEREST here. My opinions stand on their own intellectual merits, not some hidden agenda, and of course, implicit in the use of a blog, I certainly understand and appreciate that you, the reader might disagree. If you have a point to make, I welcome comments. ]
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