More Push, Less Nudge.
Ignoring medical science isn't a legitimate choice. Doctors and their patients need to think about risk in a way that benefits
the rest of us. In pharma, we have become conditioned to saying that we are not trying to push people into using medicines.
In part, this is because risk is brushed under the carpet So it goes: If individuals are not asked to make decisions about
their own risk, we have to go softly when they make decisions that put others at risk. Instead, we should be telling the truth
The most shocking of our collective embrace of the "softy, softly" lie is immunization. Last year, official notices in Yiddish
cropped up all over New York and New Jersey. Hasidic Jews in the US were the innocent victims of negligence and irresponsibility
in Europe. The Hasidim have vaccination rates that are very respectable, but, of course, no vaccine is 100 percent effective.
Because of this, the MMR vaccine needs about 85 percent of children in a community to be covered to be sure that no mumps
outbreaks will occur. The Hasidim were just below that and are very sociable. A Hasidic child went to Europe on a family visit
and came home with mumps. Soon there were thousands of cases all over the tristate area.
Everyone made the right noises about emergency vaccination and a quick public health response. But...
- Where were the disciplinary hearings for doctors who had left children vulnerable to a deadly disease?
- Where was the tearful on-screen apology and subsequent mandatory trip to a rehab clinic from the distraught editor of The Lancet, a weekly peer-reviewed general medical journal, one of the oldest and most respected? (It had published the fraudulent "research"
that originally cast doubt over the safety of the MMR vaccine—a conspiracy that it later transpired was funded by lawyers
fishing for evidence against pharma companies.)
- Where were the TV interviews on the doorsteps of the Swiss parents responsible for this public health crisis in America?
(All over Europe, immunization rates have dropped—sometimes as low as 60 percent.)
A Midwestern couple have become vocal advocates of immunization after they and their chiropractor had decided to leave the
couple's child unprotected. The child subsequently contracted and miraculously survived a Hib infection unscathed, and the
parents saw the error of their ways. If they had become road safety advocates after letting their child play on 1-95, they
would be on probation—at least. It's time to get tough on medicine deniers.
As the Hasidim found out to their cost, individual decisions have community repercussions. And yet, we do almost nothing to
push individuals into acting in the community interest on medicine despite the move to the "nudge society" generally. Professor
Richard Thaler, an economist at The University of Chicago and the father of Nudge theory (http://nudges.org/), writes about everything from selling ice creams to stopping global warming, but if he has written about encouraging socially
responsible behavior in medicine, I've missed it.
Because of the impact on herd immunity, vaccines are the obvious example of reckless individuals endangering the rest of us.
But identifying and shaming also could extend into misuse of antibiotics, or even tolerance of childhood obesity.
The theories of making it easier to do the right thing mean that those who refuse to treat heart disease (thus running up
future bills that the rest of us have to pay, directly or indirectly) and those who fail to prevent infections should find
life more complicated.
No "safe" treatments.
The whole truth about medicine safety needs to be told: just as no trip to the mall is completely safe, neither is any treatment.
Most medicines licensed for sale are, though, much safer than going to the mall, especially to the food court.
Safety is often talked about in a way that worked in the 1950s: "people better educated than you know what you should do.
Do it." This may still work well for simple things and unlettered people. For example, in my village (in an old industrial
area with very poor levels of educational achievement), we have great immunization coverage precisely because most of my neighbors
lack the skills to argue with the doctor. This top-down route also helps improve reported compliance amongst the elderly (although
a Stanford study of the medicine cabinets of the recently deceased suggests that it may do rather less to improve actual compliance).
The doctor-in-the-white-coat-knows-best approach doesn't, however, work for the Google generation or as medicine becomes more
about choices than answers. There is a wide variation between patients in how they respond to disease: Psychologists sometimes
speak about repressers and sensitizers. The repressers want to pretend it is not happening while the sensitizers want to know
everything. In the Internet age, the repressers find online quacks while the sensitizers find Wikipedia.
This approach stops us from requiring both groups to treat risk as grown-ups. Pharma companies are forced to use tortuous
legally acceptable language saying that products are "safe." The opponents of pharma and the lawyers who often fund them have
far snappier language to talk about products being "evidently dangerous." Let's forget for a moment the Avandias and Vioxxes
of the world: this tussle goes on with a vast range of products from proton pump inhibitors to skin creams. Consumers look
at mystifying lists of reported adverse events for every advertised drug and try to decide whether common flatulence is better
than rare headaches. GPs see the news story of the month and bounce from prescribing NSAIDs for acute pain (which seem to
raise the stroke risk) to opiates (which seem to be creating a new cadre of middle-class addicts) to acetaminophen (which
is lethal and disabling in remarkably low levels of overdose).
This is just the rehearsal. If you could hire Lao Tze as a management consultant, he would tell you to forget the journey
starting with one step and get walking. As medicine becomes more personal and more focused on prevention, the need to develop
individual responsibility for risk decisions will grow.
Elsewhere in this section advertising gurus talk about how they would approach a vaccine that could stop any recipient from
enjoying nicotine. Several are in trials. The chances are that all will have rare adverse events. How rare? Well, I guarantee
that the risks of any harm will be much, much lower than the risk of smokers getting lung cancer.
Many of those who have sabotaged the effort to protect adolescent girls from cervical cancer (by using HPV vaccines) will,
no doubt, see an anti-nicotine vaccine for teenagers as an even greater opportunity to decry the designs of pharma.
An unlikely coalition of conservative and radical groups has already persuaded many US parents to abandon routine infant circumcision
even though we know that circumcision will protect their boys from threats as diverse as HIV (circumcised men are probably
at a 60% lower risk of contracting HIV through heterosexual sex) and penile cancer.
There will be other vaccines that states and insurers are unlikely to fund for most of us: a vaccine to reduce the risk of
nosocomial infection should we be rushed to a hospital, for example (insurers probably will pay for it in some people with
scheduled hospital stays), or a vaccine to reduce the likelihood of TB infection (which is very low for people in the industrialized
world but which many of us who often sit in airplanes would like to reduce still further). If pharma is selling these vaccines
unreimbursed, it will need a way of engaging in a quite sophisticated discussion about the risks that the patient is paying
to avoid and the tiny risks that the patient may be incurring in reducing the likelihood of MRSA or TB. It cannot expect GPs
or pharmacists to do the hard work on its behalf.
Dr. Paul Janssen, one of the towering figures of the pharma industry in the twentieth century, once proclaimed that his genes
protected him from his 60-a-day cigarette habit. On that occasion, he was probably just deluded and lucky (he was rarely deluded
but often lucky). In the future, though, more and more will be known about our individual genetic profiles, and about the
diseases that threaten us as individuals more than others. Insurers and governments will make some tough health-economic decisions
about which to pay for; we are all likely to want to make different decisions for ourselves. After all, a 15 percent reduction
in the risk of developing breast cancer may not seem a worthwhile investment for a politician balancing this year's books
or an insurance CEO reporting to the market on this quarter; it might look like a good deal, however, to a woman planning
on another 60 years in the same body.
Some European governments and a recent article in The NY Review of Books are tut-tutting over how much government spending was "wasted" on stockpiling vaccines and drugs against H1N1. I wasn't eligible
for a free vaccine, but I think that the $101 paid for one was one of my best bargains of 2010. And I still carry my Tamiflu
around—even if the reports about hallucinations are accurate, I'd prefer a few hours of confusion to life-threatening pneumonia.