Aargh! By AARP

 

 

 

 

 

 

I have several medical journals open on my desk with interesting topics that I thought I might mention in “The Weekly Packet.” By and large, the open journals are now properly aged, like pieces of meat at a fine steakhouse.

Nonetheless, they will have to wait. The most comment-worthy item to come along this week was in the AARP weekly flimsy.  Painful truth: my wife and I joined AARP to get the substantial discount offered by our local optometrist’s shop on new glasses. Even more painful truth: I was pulled in by the headlines about “why do drugs cost so much?”

I did not have high hope for a rigorous exegesis in the AARP journal, but the presentation was actually quite balanced. The writers covered the long timelines from drug discovery through clinical trials and the FDA approval process, and even covered phase 4 studies. They also touched on the vast amount that “big pharma” spends on marketing. In all fairness, they at least mentioned that Medicare cannot, by law, negotiate drug prices and touched on the strange role that “pharmacy benefit managers” play in the US system.

What’s my point? An AARP member who actually spent some time carefully reading the article would have a basic vocabulary, would become familiar with some of the players in the market, and would have been introduced to two key facts: pharmaceutical costs are only about 10% of overall health care costs, and big pharma spends as much on marketing as on basic research. Not bad. Although the authors did not point out to their readers that without this industry, their diabetes, high blood pressure, high cholesterol, and cancers could not be treated.

More importantly, what the AARP reader would NOT know, struck me last week when I attended the Clinical Leader Forum in Philadelphia. The pharmaceutical industry, particularly the clinical research organizations that have proliferated in the past couple of decades, exemplifies the new economy.

Let me try to explain. In one lifetime, mine, pharmacology has gone from a collection of empiric facts about medicinally useful herbs like digitalis or compounds, like sulfa, to an integrative science and technology focused on identifying “drug targets” in pathophysiologic processes.

From this point of view, the new drugs that pharma generates are the physical tokens, the representation of knowledge and of enormous amounts of data. The patients are not really paying for the drugs, they’re paying for the data. I think eventually, we will work out something more functional for drug pricing. But take a step back, and look again.

Kids who under-achieve academically will not find jobs in this industry. What I saw during last week’s meeting was a relentlessly driven technological and sociological wedge splitting the workforce into those who could deal with complexity and those who could not.

And I’m sure that other industries are similar.

There is no going back. No matter how much we would like to idealize the post-WWII economy, it’s gone.

Here’s the really scary thing; there’s good evidence most AARP members don’t understand what this kind of industry means for our society.

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Time Travel is REAL!

This time last week, I was in Havana.

This is not a report from last week. It is a report from the late 1950s or early 1960s. If you don’t want to take my word for it, read Carlos Manuel Alvarez in the New York Times. 

Packet-style breaking news from Cuba: we Americans have been involved in armed conflicts twice there, in the Spanish-American War in 1898 and in the 1961 Bay of Pigs invasion. The count so far looks like one and one. After 1898, Cuba shook off Spanish rule to become a unique and vibrant society, and most Cubans seem to view that intervention positively. Plus, San Juan Hill gave Theodore Roosevelt an enormous boost.

By the mid-1930s, Fulgencio Batista, strongman, dictator, and certainly a friend of the mob, consolidated his hold on Cuba. He eventually brought rampant gambling and widespread corruption to Cuba. Although the US government supported Batista, revolution was in the air by the mid-1950s. A young lawyer, Fidel Castro, and his brother Raoul, along with Che Guevara, led the successful overthrow of the Batista government in 1959.

In April of 1961, a Nicaragua-based, CIA-sponsored, 1400-man anti-Castro “brigade” invaded Cuba at the Bay of Pigs. The invasion was a disaster. Over 1100 of the brigade were captured. “14 were put on trial for crimes allegedly committed before the revolution, while the others were returned to the U.S. in exchange for medicine and food valued at U.S. $25 million. Castro’s victory was a powerful symbol across Latin America, but it also increased internal opposition primarily among the middle-class Cubans who had been detained in the run-up to the invasion. Although most were freed within a few days, many fled to the U.S., establishing themselves in Florida.” https://en.wikipedia.org/wiki/Fidel_Castro

Having seen the terrain around the Bay of Pigs, including the dense Cienaga de Zapata, it’s not hard to understand why the invasion stalled. Most Cubans seem to view the Bay of Pigs for what it was, a fiasco.

After the events of 1961, time stopped. In fact, with the fall of the Soviet Union, from 1990 to about 2000, time went backward. This was Cuba’s “Special Period,” when support from the Soviets ended and the entire country fell into dire straits, short of everything.

Today, what we saw was how Castro’s unrestrained idealism, with the best of intentions, nearly destroyed a country. Cubans have universal education, universal healthcare, and no homelessness. But in this society, the infrastructure has crumbled; housing stock has steadily deteriorated, and the highly educated are vastly under-employed and underpaid.

The current government has reduced restrictions on free enterprise. Independent restaurants, “paladars,” flourish in Havana (see the photos). Some restoration and refurbishing is happening. But the work to be done is daunting!

High points of the trip: the Hemingway museum at Finca Vigia  and the National Museum of Fine Arts in Havana.

If you click on any of the photos in this post, you should get a slide-show view that will have nice size and detail. I have almost 900 photos sitting in Lightroom; more to come.