I Approve My Tax Dollars to do that: Bring Back Tetracycline

Attending a conference on small animal dermatology yesterday, one of the veterinarians asked the speaker about what drug to use as a substitute for one that is currently unavailable. To my surprise, the unavailable drug was not some obscure, esoteric medication. It was tetracycline, one of the most common broad-spectrum antibiotics used in human and animal medicine. I was shocked. How can such a drug be unavailable?

The current drug shortage is not a new problem. Since 2007, the number of unavailable drugs has been on the rise, peaking at over 280 as of October 2012. It is unclear as to when the shortage will be resolved. 

Photo credit: http://online.wsj.com/article/SB10001424052748704680604576110613604195324.html

Tetracycline joins the list of over two hundred drugs currently unavailable; a crisis over two years in the making. The entire list of unavailable medications can be accessed here. For the most part, the drugs on the list aren’t your unusual, random, rarely prescribed medications: they are your cancer treatment drugs, nutritional aids, anesthesia drugs, and antibiotics (http://onpoint.wbur.org/2011/10/04/prescription-drugs). The FDA cites manufacturing and quality issues as the main cause of the shortage. These include regulatory violations such as incorrectly printed expiration dates on bottles and sterility issues during production, and shortage of raw materials required to make the drugs. Though companies are required to inform the FDA of an imminent shortage and the estimated duration of the shortage as part of the Food and Drug Safety and Innovation Act passed in July, the FDA cannot force them or other companies to manufacture the drug. (http://www.fda.gov/Drugs/DrugSafety/DrugShortages/ucm050796.htm). The shortage affects a large number of suppliers but the majority of the drugs on the list only have one or two sources of supply (http://www.imshealth.com/portal/site/ims/menuitem.edb2b81823f67dab41d84b903208c22a/?vgnextoid=a6fbcc0f68f73310VgnVCM100000ed152ca2RCRD&vgnextfmt=default&vgnextrefresh=1)

How drug shortages affect patient care. While some drugs can be replaced with near equally-effective substitutes, such as doxycycline for tetracycline, others cannot. Even in the case of replacing tetracycline with doxycycline, increased use of one antibiotic risks creating increased resistance to that particular antibiotic. The last thing we need to do is to create more antibiotic-resistance super bugs such as Merca. 

Photo credit: http://online.wsj.com/article/SB10001424052702304584404576442211187884744.html 

Despite what the FDA claims, the shortage stems from more than manufacturing and quality assurance problems. Like most other shortages, the current drug shortage has as much to do with business as production. As more drugs became available in cheaper generic versions, companies quit producing brand-name versions because they could not earn a profit turning out more expensive drugs that neither hospitals nor insurance companies would pay for. They then switched to the less readily prescribed drugs. The switch ensured protection of their business venture, as financially it made no sense for generic companies to take up production for smaller quantities. Shortages arise when the generic companies producing the drugs experience material shortages or are shut down by the FDA for production violations. No factories, no drugs  (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60414-0/fulltext).

Health care should not follow free-market policies, especially not when people’s lives are at stake (I refer specifically to the availability of cancer drugs). What my body needs should not be at the mercy of companies more interested in making a dollar than my health. It’s absolutely ridiculous to me that such basic drugs are inaccessible to the public. Congress should exercise increased authority over drug manufacturers, holding them to tougher, and more stringent and ethical standards. At least fifteen deaths have been reported as a direct result of the shortage (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60414-0/fulltext). Congress needs to do something. Medicine is not about money: it’s about getting better.

I approve my tax dollars to do that: bring back my tetracycline. 

Some of the more popular drugs currently unavailable and their uses. Uses range from nutritional supplements, such as electrolytes, to cancer treatments. How would you feel if you went to the hospital and were told you couldn't be treated because the drug was not available? This is why we need to improve and increase federal overnight of drug manufacturing. 

Photo credit: http://sfmedicalsociety.wordpress.com/2011/08/22/prescription-drug-shortages-forcing-physicians-and-pharmacists-to-scramble/

Can an Iranian System Really Help Mississippi?

Back to the question from my previous post: Can HealthConnect, an agency based on the primary health care system established in post-revolutionary Iran, really help Mississippi?

According to HealthConnect’s founder Dr. Aaron Shirely, HealthConnect serves two purposes in Mississippi: improve primary care for its rural residents and prove that Medcaid and health insurance will not eradicate all of the state’s health problems.

One of the major problems in Mississippi is the routine use of the emergency room for primary care. Patients who arrive in the ER and cannot afford treatment are still treated at taxpayer expense. While such practice is unfair to taxpayers, cutting of taxes appropriated toward this purpose will not prevent the arrival of unpaying patients to the ER. About 550,000 out of three million Mississippi residents lack health insurance. The state only has 176 doctors per 100,000, the lowest ratio in the country. Those numbers piggyback on Mississippi’s rank as “the country’s poorest and most racially divided state.”  That is where HealthConnect fits in. 

Mississippi is not the only state with a high percentage of its population lacking health insurance. This graph shows how it compares to nearby states and to the proportion of uninsured in the country as a whole. Note: these percentages reflect 2012 numbers. 

Photo credit: http://mepconline.com/blog/healthcare/building-toward-economic-mobility-in-mississippi-health-care/

This map shows the population density and the location/size of hospitals. Clearly there are fewer and smaller hospitals compared to the number and size in urban areas. No wonder such a large proportion of the population goes untreated simply because they do not have easy access to health care. 

Photo credit: http://archive.ahrq.gov/prep/nursinghomes/atlas/atlas_ms.gif

Unlike emergency C-sections, quadruple bypasses and ventilators, HealthConnect does not go after the final stage eruption of a health problem; it combats the part of the cause. While home-health agencies will dispatch nurses to conduct work in the patients’ homes, their care requires insurance and they often work for unregulated, lucrative for-profit agencies. Shirley’s approach, on the other hand, argues that the health care provider must be in it solely for the benefit of the patient. Without that sense of responsibility and loyally, the profit, rather than the best interests of the patient, is the foundation of treatment options.

Furthermore, the caregiver “must come from the patients world.” Black patients often do not trust white caregivers and will fabricate answers to pacify nurses or prevent them from asking more questions. As the daughter of a health care provider, one of the most important aspects of proper diagnosis and treatment is honesty with your doctor about symptoms, conditions and what you are experiencing. If a doctor does not know what is wrong, how can she or he effectively treat a patient?

Clearly, poverty in Mississippi is still very much a racial issue. As a result, it is imperative that an adequate proportion of Mississippi health care providers are African American who can actually see which health care problems stem from racism and mistrust on both sides. 

Photo credit: http://mepconline.com/blog/wp-content/uploads/2012/06/Child-Poverty-Rate-by-Race-Mississippi.jpg

Part of Shirley’s goal is to “get into homes and alter the course of future generations before obesity…or diabetes sets in.” He wants to make it so that the patients will trust their health care providers and in turn take measures to improve their health. To achieve this goal, Shirley opened health care houses in the schools. The location gave him access to both growing kids, to whom he can provide the most long-term benefit by teaching them good health practices early on, and their families. He also fills a much-needed gap, as many Mississippi public schools lack full-time nurses.

The workers of HealthConnect do not work 9-5. They are always trying to help, whether it take the form of allowing people who do not have electricity to stay a night in their home, making an unscheduled stop to check up on a patient and her new baby, or extending an appointment by an extra fifteen minutes to admire the patient’s family photos on the wall. In a way, they fulfill a particular void in many poor Mississippians’ lives: they act as family.

Many people shy away from making this kind of commitment. You sacrifice much of your time, energy and life to taking care of other people at a much higher cost than simply the financial expense. I am reminded of this every time I come home from college and my mom has to go do an emergency within five minutes of my arrival. But in the case of the poverty-stricken Mississippi Delta where all other attempts to improve health care have failed, such commitment is imperative. And I believe that it will work. Only proactive prevention of the most common killers of Mississippi residents, HIV/AIDS, diabetes, congestive heart failure, hypertension and asthma, will stop them from appearing in the ER when it is too late to treat them.

Obesity is one of the many faces of poverty in the United States. Left unaddressed, it condemns the child to an early death before he or she even becomes a teenager. As the cause of other conditions, Type II diabetes and high blood pressure for example, it proves to be more expensive to treat later than to prevent with a healthy diet and exercise now. Basic exercise (walking, running, push ups, crunches, etc) is free. Emergency room care is not. 

Photo credit: http://www.nourishinteractive.com/system/assets/general/images/nutrition-facts/childhood-obesity-rates-US-2011.gif 

I was appalled to read that some Mississippians have to shop for food at a gas station because a fully stocked grocery store is thirty miles away. That should not be the case in the twenty-first century United States. Insurance or Medicaid will not change that. But agencies like HealthConnect, who promote the well being of the patient and go after things like availability of healthy food and accessibility of medication, can.

Source: http://www.nytimes.com/2012/07/29/magazine/what-can-mississippis-health-care-system-learn-from-iran.html?pagewanted=1&_r=4&hp