October 28, 2006

Prescriptions for Profit

After four days of bravely battling an attack of bronchitis with milagu rasamMulligatawny Soup for the non-Tamil speaking masses — threatened with divorce, and worse, I went to the clinic. With my primary physician on vacation, I was attended to by his team-mate. Because it was a day of "continuing education" for most of the doctors at the clinic, she was one of the two who were attending to the patients, some of whom were double and triple booked. For the first time, I learnt that it's not just the airlines that practiced this sleight of virtual capacity expansion.

After the usual rituals of the nurse taking my weight, height, blood pressure, etc., she left me waiting for the doctor for what seemed like an eternity. Eventually, the doctor came in, and we exchanged a couple of pleasantries about how much she liked Indian food, the virus that has been going around (setting the stage for her inability to diagnose my ailment), yada yada. She then got down to business. After checking my ear, throat, and chest, she declared that I had bronchitis, and as if to console me, she added, "I have seen a few cases of this today. And, my husband, too! It's the virus that I told you about." But, of course! "I am prescribing for you the same antibiotic that I gave to my husband. Please make sure that you complete the 10-day course. If the symptoms did not disappear, please see you primary physician." She led me out after spending a total of five minutes with me!

Mulligatawny Soup
Once upon a time, I was on the faculty of the Administrative Staff College of India (ASCI for short), Hyderabad. ASCI had a cafeteria then, that would compare quite well with the restaurants in five-star hotels. We used to have free lunch there, served by smartly dressed waiters, who behaved as if they were trained at ASCI's sister institution at Henley, U.K. The chef, let's call him Tony, was a thoroughly anglicised and "proper" Tamilian. It was my first afternoon there for lunch, and I asked Tony what the soup of the day was. "Mulligatawny soup, sir", he replied smartly, obviously trying to impress the newcomer. "Good, I'll have a bowl of soup for starters", I said. Tony, not knowing that I spoke Tamil, turned towards the kitchen and bellowed, "Déy! Saarukku oru cup rasam kondada! (You there! Bring a cup of Rasam for sir!)" Mulligatawny, translated literally into Tamil, is "Pepper Water", and Mulligatawny soup, is milagu rasam, an excellent home remedy for cold, imho. Ah, what would we have done without such legacies of British Colonialism!

When I went to the next door pharmacy to fill the prescription, I was shell-shocked by the amount, $40, that I had to co-pay. The full cost, I was told, was $100 for the 10-day course. My insurance company paid the balance of $60. It was $10 for each 400mg Avelox pill that I was prescribed! When I googled Avelox, this is what I found from WebMD on its uses:

Moxifloxacin is used to treat a variety of bacterial infections. This medication belongs to a class of drugs called quinolone antibiotics. It works by stopping the growth of bacteria. This antibiotic only treats bacterial infections. It will not work for viral infections (e.g., common cold, flu). Unnecessary use or overuse of any antibiotic can lead to its decreased effectiveness. [emphasis mine]

How did the doctor decide on Avelox? Clearly, the drug is effective only against bacteria and not against viruses. As I recall, it used to be that the doctor would take a swab of my throat fluids and test it for the presence of streptococcus or some other bacteria. My doctor did not. How did she determine that I have a bacterial infection?

Another expedition to the web yielded a plethora of information on treatment courses for antibiotics and their implications. The recommended course for Moxifloxacin varied from 5 to 21 days depending on the condition. A recent article here contends that a 3-day antibiotics course is as effective as the full course, even in the case of pneumonia. How did the doctor determine the length of my treatment course? What made her decide that I needed a 10-day course, and not a shorter course of 5 days? Longer treatment than necessary, I surmised from what I read, would reduce the risk of re-infection but increase the risk of resistant bacteria and side effects. How does a doctor balance these risks? Notwithstanding that the field of medicine has made incredible advances over the last century, the diagnosis, identification, and treatment of many diseases remain pretty much a black art. We are mostly dependent on the physician's experience and intuition.

The economic incentives are, however, clearer. Disease mongering is now a multi-billion dollar industry. In a hard-hitting article in BMJ (British Medical Journal, before it became fashionable to use abbreviation), the co-authors — a journalist, a general practitioner, and a professor of clinical pharmacology — contend that,

There's a lot of money to be made from telling healthy people they're sick. Some forms of medicalising ordinary life may now be better described as disease mongering: widening the boundaries of treatable illness in order to expand markets for those who sell and deliver treatments. Pharmaceutical companies are actively involved in sponsoring the definition of diseases and promoting them to both prescribers and consumers. The social construction of illness is being replaced by the corporate construction of disease.

Minor, self-limiting ailments are now made over to serious diseases by interested drug manufactures, doctors, and patient groups with help from a willing media searching for viewership.

Even social fads are increasingly touted as treatable mental illnesses. A case in point is the so-called internet addiction. A story from the New ScientistTech, reporting the results of a study of 2513 adults in the US, leads off with a dire warning that the "US could be rife with 'internet addicts', who are as clinically ill as alcoholics, according to psychiatrists involved in a nationwide study." The lead author of the study, Elias Aboujaoude, compares the compulsive drive (sic) to check email, post blog entries, and other internet activities to substance abuse. "The issue is starting to be recognised as a legitimate object of clinical attention, as well as an economic problem, given that a great deal of non-essential internet use takes place at work," Aboujaoude says.

As if taking a cue from the study, the Chinese government today announced measures, ostensibly designed to prevent internet addiction among minor children. The Xinhua News Agency reported that the measures would also "ban minors from Internet cafes, bars and commercial dance halls." Will someone please commission a study to look into the politicians' addiction to dipping their fingers into the cookie jar of the personal lives of the rest of us?

Friday, November 17, 2006

Update

Writing in the New England Journal of Medicine, Dr. Richard P. Wenzel and Dr. Alpha A. Fowler from the department of internal medicine at Virginia Commonwealth, note that the widespread use of anti-biotics to treat common bronchitis is unwarranted. According to Dr. Wenzel, one reason for this is convenience:

"Think of all the patients we have to move through the office," he said. "I could take 15 minutes to explain why an antibiotic is not needed or write a prescription in 30 seconds."
1 comment :
  1. Scary.We do seem to be swallowing much more pills than earlier generations even though health conditions are supposed to be improving with every generation. Must be a multi billion dollar scam that we are all victims of.

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