Overdosed on therapy! We are when you consider traditional medicine with its overstated benefits and overwhelming costs; watch the television ads for medications and “health aids,” consider the overabundance of “non-traditional” approaches, health hucksters and such, therapists of every ilk almost with limited to no basis in science and no proven health benefit. We’re spinning our wheels to the tune of over 15% of our GNP.

Cancer, like all other medical problems is treated best and most cost-effectively with prevention. Therefore, it is great news that a vaccine to prevent HPV (Human Papilloma Virus) infection, a cause of cervical cancer, has been recommended for approval by the Food and Drug Administrations’s (FDA) expert panel—the FDA usually but not always follows these recommendation. A decision to allow marketing is expected by June.

This Guttmacher report outlines the world situation with cervical cancer. There are about a half million new cases each year with half dying of the disease.

In the U.S. there are 12,000 new cases each year with about 1/3 dying of the disease. However, each year there are “approximately 5.5 million new genital HPV transmissions representing about one-third of all new sexually transmitted infections” with an estimated 20 million men and women thought to have genital HPV at any given time. Access to PAP smear early diagnosis technology is successful in limiting the number of those developing the invasive dangerous disease.

The cost of this vaccine , $300 and $500 per patient, is prohibitive for people living in third world locales where yearly expenditures per capita for health may be as low as $5.00/year. As this drug moves to market the question will be how to provide it in the places where it is needed most.

The broader question here and most notably with HIV treatment, is how to bring modern medical technology to people who need it most. Our system of government sanctioned monopoly, i.e. patents, is not up to the task.

Darksyde at the daily Kos reviews the Christianist right’s changing view of this vaccine.

A significant decrease in transmission of HIV in Kenya has been reported.

It’s not clear what is actually working. But combining prevention strategies of abstinence education, condom use and testing, with treatment available makes sense to me.

However, the U.S. funded program limits those under 15 year old to abstinence education alone –unless they ask. In a culture where HIV is highly prevalent and early sexuality is common and in some situations expected, we need to provide the full gamut of HIV prevention information.

The PSI policy statement doesn’t own up to it’s limitations.

There may be problems with this medication and careful monitoring and study of it’s effects are essential. Perhaps at some point there will be enough adverse data to remove it from the market. (Washington Post 5/17)

The groups opposing it in the Post article today, however, lack credibility. They believe that contraception of any kind encourages promiscuity and that all types must be opposed. Many of them believe that the only acceptable contraception is the rhythm method which was rejected as ineffective two generations ago.
Hopefully the FDA will objectively evaluate and use the evidence not preconceived notions to guide their decisions.

Wikipedia: The elephant in the room (also elephant in the living room, elephant in the corner, elephant on the dinner table, etc.) is an English idiom for a question or problem that very obviously stands, but which is ignored for the convenience of one or other party. It derives its symbolic meaning from the fact that an elephant would indeed be conspicuous and remarkable in a small room; thus the idiom also implies a value judgment that the issue should be discussed openly.

In 1988 while visiting Uganda I met a missionary physician from a fundamentalist, I believe, Baptist group. We talked about the emerging AIDS epidemic there. Thousands had already died; village populations were decimated; innumerable orphans were evident. His view, and that of his brethren was that those with AIDS had behaved badly and essentially got what they deserved. The problem would take care of itself with their suffering and deaths. He offered sympathy but was not inclined to intervene medically.

Sadly that was the defining characteristic of the fundamentalist religious community (with some exceptions) during the Reagan era and for many years after—you recall that Reagan couldn’t bring himself to utter the words AIDS during most of his presidency. Clinton as president offered sympathy and concern but little in the way of material aid, though he was hampered by a republican socially conservative congress for much of his administration.

It wasn’t until the new millennium that these fundamentalist groups fully acknowledged the epidemic and decided to offer interventions, this after 20 million deaths and many more new infections. With their “clearance” President Bush in his 2003 State of the Union called for funding of treatment and prevention initiatives. While emotionally calling attention to $300/year medications in his address, his subsequent program has sanctioned use only of FDA approved, read that patented expensive medications. So rather than using $140/year (current pricing of generic HIV triple therapy) we pay several times more for similar drugs offered by the pharmaceutical industry. Adding insult to injury the program’s prevention philosophy is guided by the the religious right, the same people, as noted above, who early on opposed any intervention in the AIDS epidemic.

Meanwhile millions are infected and continue to die. Only 1.3 million are under treatment and unless we get our act together our funding will continue to be ineffective and mostly wasted—consider the impact of tripling those treated for the same money we currently spend!

In the next few weeks the elephant will be evident again as the FDA takes up the new vaccine for papilloma virus—thought to be a cause of cancer of the cervix. It’s being opposed by the social conservatives because it’s felt an effective vaccine will increase promiscuity by removing the risk of cervical cancer.

More on this as the FDA takes this up.

Refs: http://www.msnbc.msn.com/id/12665678/site/newsweek/
http://www.zmag.org/content/showarticle.cfm?ItemID=2964
http://www.au.af.mil/au/awc/awcgate/crs/ib10050.pdf
http://www.thenation.com/doc/20040426/editors2
http://www.newscientist.com/channel/sex/mg18624954.500

I’m a retired internist with specialties in Hematology and Oncology and a degree in Public Health. I’ve worked for the government and been in private practice, both overseas in the third world as well as in the U.S.

In the U.S. patient care is under attack from meddling lawmakers, intrusive religion, the financial interests of insurers, big pharma, equipment manufacturers and providers. We have created a monster where the needs and desires of patients as well as the quality of care for medical problems are of secondary import to other interests. It is no accident that in the U.S. we spend far more than any other country per capita on health care and yet by standard health care indicators have a very mediocre quality of care.

The purpose of this blog will be to discuss these influences on the state of the medical art, critically (and skeptically) analyze medical advances, and look into the real cost effectiveness of medical innovation. We’ll try to cut through the publicity and analyze the often inflated rhetoric and spin.

Hopefully as we wade through the froth and bull we’ll find significant evidence-based advances.