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May 14, 2012 | Posted By David Lemberg, M.S., D.C.

Do we really need more drugs? We can gain some insight into this question by posing a qualifying question: “How’s it working out so far?” The answer is rather obvious: “Not all that well.” Despite spending $2.5 trillion in 2009 on health care, representing almost 18% of our gross domestic product, the life expectancy of Americans ranks #36 worldwide. Numerous developing nations enjoy longer lifespans than we do. (Costa Rica, for example, ranks #30.) On the other end of the spectrum, the New York Times recently reported that the U.S. rate of premature births is comparable to that of developing nations. Regarding this impactful public health issue with long-term consequences for society, the U.S. does worse than any Western European country. The U.S. premature birth rate of 12% is comparable with that in Kenya, and Honduras. In other words, on this measure the overweening technological superiority of our notoriously costly health care system fares no better than that of countries with per capita incomes of $2 a day.

How is American health care doing with respect to chronic disease? The statistics regarding American overweight and obesity are now so well-known that presenting them is almost platitudinous, but the numbers are still well worth repeating: 33% of Americans are obese and an additional 33% are overweight. An persistent and apparently worsening epidemic of type II diabetes affects young people. The New York Times editorial page highlighted the problem in No Longer Just ‘Adult-Onset’. Regarding the power of drugs to impact the disease in young persons aged 10–17, the editorial referenced a new study which tested three methods of achieving durable control of serum glucose. The study, published in the New England Journal of Medicine found that neither metformin, metformin plus rosiglitazone (Avandia), nor metformin plus lifestyle modifications was effective. Metformin is the standard drug used to treat type II diabetes in children, and metformin monotherapy failed to be effective in more than half the participants. Metformin plus rosiglitazone reduced the rate of treatment failure, but was not effective in 39%. The addition of lifestyle changes did not substantially improve the performance of metformin.

Cancer mortality has been declining steadily over the past 20 years. Cancer mortality decreased by 15.3% for women and 22.9% for men from 1990 through 2008. Cancer prevention initiatives, such as tobacco-cessation programs, as well as earlier detection through screening and increased awareness are largely responsible for declines in cancer mortality. Improvement in treatment protocols accounts for only a portion of these improvements.

Cardiovascular disease, including heart disease and stroke, is the leading cause of death in the United States, accounting for 2200 deaths per day. Among adults, the prevalence of heart disease and stroke has remained essentially the same from 1997 through 2009. The prevalence of hypertension has increased from 191 cases per 1000 to 249 cases per 1000 over the same interval.

Thus, with respect to chronic disease, it is not unreasonable to assert that medical treatment has obtained equivocal results in the population. Statins are a drug class that has demonstrated proven benefit. For persons who have risk factors for atherosclerotic coronary artery disease, statin use effectively reduces the risk of death due to cardiovascular disease, including stroke. Benefits of statin use increases over time. But drug companies want to extend the statin hegemony to include persons at low cardiovascular risk. In other words, global pharmaceutical corporations want physicians to prescribe statins for prevention in otherwise healthy persons.

There many problems inherent in recommending drug use in healthy persons, problems both ethical and practical. On the practical side, the JUPITER study (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin), the hazard ratio for new cases of diabetes increased by 25% in the rosuvastatin group vs. the placebo group. In contrast, participants previously considered to have low cardiovascular risk had a hazard ratio 44% lower than those in the placebo group for the combined primary endpoint of cardiovascular events including myocardial infarction. Is this an equitable or even appropriate tradeoff? Should a person who is not an actual patient (i.e., one at low risk for the given condition) be given a prescription drug with known serious side effects? How does the physician justify such a prescription to the recipient? A mere discussion of the statistics is not sufficient. Long-term drug use profoundly alters a person’s physiology. What can possibly justify such a course of action when the person is otherwise healthy?

The most cynical answer to this important question is corporate greed and profit-taking. An alternate answer, one which optimistically presumes that the best interests of the person as patient are being considered, proposes that medicine as such has taken a seriously wrong turn when its recommendations favor drug-taking over education and lifestyle modification. But these are topics for another time.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

0 comments | Topics: Bioethics and Public Policy, Bioethics in the Media, Doctor-Patient Relationships, Health Care Policy, Pharmaceuticals


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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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