• week 1
• week 2
• week 3
• week 4
• week 5
• week 6

Sept 24 Workshop timetable, notes, and general organisational issues (being updated -check back monday sept 19)

Essay Writing guide

• there is no final exam,
• students get a chance to think on their feet, and listen and critique others thinking on their feet,
• work cooperatively for half the assessment,
• learn some principles of cost benefit analysis, as well as read and critique some actual studeis in health economics using cost benefit principles (mental health, neo natal health, pharmaceuticals...)
• learn how to avoid shonky arguments based on flimsy evidence and use theory to help fill in the gaps where there is little relevant evidence (it's mostly gaps...)
• becasue there is no fianl exam.

• Angell, Marcia Science on Trial: The clash of medical evidence and law in the breast Implant Case
• Avorn, J Powerful medicines: benfits risks and costs of prescription drugs
• Millenson, Michael Demanding Medical Excellence: Doctors and Accountability in the Information Age
• M Goozner The $800 Million Pill : The Truth Behind the Cost of new drugs
• David Dranove What's Your Life Worth? Health Care Rationing: who lives?who dies? who decides?
• Dvid Dranove The ECONOMIC EVOLUTION OF AMERICAN HEALTH CARE: FROM MARCUS WELBY TO MNANAGED CARE
• David Cutler Your Money or Your Life :strong medicine for America's health care system
• Lara Marks Sexual Chemistry: a history of the Contraceptive Pill
• Barron Lerner The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America
• Lois Wingerson Unnatural Selection: the Promise and the Power of Human Genome Research
• Mendel in The Kitchen
• Kip Viscusi Smoke Filled Rooms: A postmortem on the Tobacco Deal
• David T. Courtwright Forces of habit : drugs and the making of the modern world
• Tomas J. Philipson, Richard A. Posner Private Choices and Public Health: The AIDS Epidemic in an Economic Perspective
• Institute of Medicine Saving Lives Buying Time Economics of Malaria Drugs in an Age of Resistance

• David Dranove What's Your Life Worth? Health Care Rationing: who lives?who dies? who decides? Prentice Hall (2003)
  • here's an exceprt from the Introduction : You may not know it, but the people who pay for yourhealth care have decided that enough is enough. They haveplaced a limit on how much they are willing to spend to saveyour life. [They].... have capped spending growth, forcing providers to cut back on care. At the same time, ...employersare getting fed up with rising health insurance costs, and theyare giving managed care organizations the go-ahead to cutback on prescription drug benefits and other services. Suchrestrictions are old news in the rest of the world, where government payers have been limiting access to costly medical technologies for over three decades.

    This is rationing, plain and simple. Rationing is a dirtyword in health care, but it is not necessarily a bad thing, providedthe cost savings are large enough to justify any resulting harm. For the most part, rationing has been ad hoc, withoutcareful weighing of the benefits and costs. But in the last fewyears, a few payers have taken baby steps toward rationalizingrationing—making sure that they get biggest bang out of theirhealth care bucks.

    This book is about the many ways in which health care isrationed, and the transition toward rational rationing. As Chapter 1 details, rational rationing has already been institutionalizedby the British and Australian national health systems.The outcomes have been mixed. Government decisionmakers seem obligated to balance scientific principles withpolitical considerations. The outcomes are not always pretty,and government health officials remain crippled by budge tceilings that force them to place an unrealistically low valueon life. Chapters 2 through 4 provide the theoretical justificationfor rationing health care and demonstrate the disconnectbetween theory and practice in Europe and the United States. At least for now, any careful weighing of lives and dollarsseems to be mere happenstance. Chapters 5 and 6 describerational rationing. Chapter 6 also explains how to numericallyscore different diseases to determine which are most worthcuring. These methods appear to be relatively simple to implement.In fact, they were central to a rationing plan implementeda decade ago in the state of Oregon, as described in Chapter 7. But, as I show, appearances are deceiving. Proponentsof rational rationing have yet to overcome numerousobjections based on methodological, economic, ethical, andpolitical grounds. Even if supporters of rational rationing can overcome themyriad objections to it, their schemes will not fully succeedunless they can grapple with the most challenging obstacle ofall. At some point, payers must decide where to draw the lineand declare that one particular health care service is "worthit" whereas another, slightly less cost-effective service is not.To do this, payers will have to explicitly determine how muchlife is worth. Chapter 8 tackles this question head-on and evenshows you how to compute the value of your own life. One question remains: Who should implement rational rationing? Chapter 9 describes the global imperative to containcosts in the public and private sector. I argue that rationalrationing is better left to the market, where individuals candecide for themselves how much their lives are worth. I concludethat if payers fully embrace rational rationing, they may no longer fear spending money to save lives.

• Millenson, Michael Demanding Medical Excellence: Doctors and Accountability in the Information Age (1997) [UC Library RA 395 .A3 .M646]
  • Click to see New England Journal of medicine Review here or go to Amazon to see what other readers have said
  • here's an exceprt from NEJM review " His engaging account of the development of information science and quality assurance in medicine is enlivened by clinical vignettes and brief biographies of key actors. The first of his principal theses -- that doctors, unsupervised and unaccountable throughout most of this century, committed a myriad of sins -- is surely correct. The second -- that medicine's new masters, having gained leverage through access to medical information, will make beneficent use of their power -- is surely questionable."
• David T. Courtwright Forces of habit : drugs and the making of the modern world Harvard Press 2001 [UC Library HV 4997 .C866 2001] see reviews in Amazon or read New England Journal of medicine review here
  • Table of Contents: Introduction: The psychoactive revolution -- The big three: alcohol, tobacco, and caffeine -- The little three: opium, cannabis, and coca -- The puzzle of distribution -- The sorcerer's apprentices -- A trap baited with pleasure -- Escape from commodity hell -- Opiates of the people -- Taxes and smuggling -- About-face: restriction and prohibition -- Licit and illicit drugs.
• M Goozner The $800 Million Pill : The Truth Behind the Cost of new drugs
  • An excerpt from Amazon's book drescription full description click here:: "Why do life-saving prescription drugs cost so much?......Goozner demonstrates that almost all the important new drugs of the past quarter-century actually originated from research at taxpayer-funded universities and at the National Institutes of Health. He reports that once the innovative work is over, the pharmaceutical industry often steps in to reap the profit. .....The $800 Million Pill suggests ways that the government's role in testing new medicines could be expanded to eliminate the private sector waste driving up the cost of existing drugs. .....essential reading for everyone concerned about the politically charged topics of drug pricing, [health insurance] coverage, national health care, and the role of pharmaceutical companies in developing countries"
• Jerry Avorn Powerful Medicines : The Benefits, Risks, and Costs of Prescription Drugs 2004
  • Amazon.com : Profiteeering pharmaceutical companies and the FDA have met their match in Dr. Jerry Avorn, a Harvard Medical school researcher and clinician. In Powerful Medicines, he brilliantly combines patient vignettes, scientific critique, and statistics to create a risk/benefit balance for prescription drugs. His premise: "Every drug is a triangle with three faces--representing the healing it can bring, the hazards it can inflict and the economic impact of each." Avorn's gifts as a writer are apparent in the prologue, an edgy account of the mismanaged medications of several stroke patients. He then details the intellectual history of drug assessment and benefits, including the biblical food police in the Book of Daniel, the deer in the headlights Estrogen debacle and the current infatuation with Ginseng and other alternative medicines. Turning from benefits to risks, Avorn examines diet pills, Viagra, cold medicines and diabetes drugs with comparisons the decisions of Dr. Fautus--who makes life-changing bargains between safety and effectiveness. Other insightful chapters offer views of prescription drug economies, and comparative healthcare around the globe. The final chapters create an insightful template for emerging public policy. Throughout, Avorn pulls at common threads: the line between personal and public responsibility, the perils of drug promotion, and the marketplace that usurps the role of scientific evidence in selecting treatments. Anyone looking for a quick muckraking read will be disappointed. But Avorn's views, literate and complex, will frame the debate on prescription drugs for years to come. more reviews at amazon
• John Abramson Overdosed America 2005
  • From Publishers Weekly: According to Abramson, Americans are overmedicated and overmedicalized as a result of the commercialization of health care. Falling prey to marketing campaigns, we demand unnecessary and expensive drugs and procedures, believing they constitute the best possible medical care. Wrong, says Abramson: though more post–heart attack procedures are performed in the U.S. than in Canada, one-year survival rates are the same. Similarly, notes Abramson, a former family practitioner who teaches at Harvard Medical School, we spend more on high-tech neonatology than other Western countries but have a higher infant-mortality rate because of inattention to low-tech prenatal care. Abramson deconstructs the scientific sleight of hand in presenting clinical trial results that leads to the routine prescription of pricey cholesterol-lowering drugs even when their effectiveness has not been proven; he examines what he calls "supply-sensitive medical services"—the near-automatic use of medical technologies, such as cardiac catheterization, less because they are needed than because they are available. Abramson's bottom line: "More care doesn't necessarily mean better care." Arguing firmly that doctors should focus more on lifestyle changes to improve health, Abramson seems less credible when he writes off depression as "exercise-deficiency disease" and disposes of cancer in little more than a page. Still, he makes a powerful and coherent case that American medicine has gone badly astray and needs a new paradigm—one untainted by profits
• John Calfee Prices Markets and the Pharmaceutical Revolution (2000)
  • Are price controls called for on pharamceuticals? Do drug companies charge exorbitantly high prices? Do they spend unusually high amounts on advertising to promote their products to doctors and ill informed consumers? Should direct to consumer advertising be banned? Is more spending on pharmaceuticals a cause for concern, and more quantitative rationing? Read Calfee if you are interested in etting sensible answers to these questions. If you read this (short) book I'd also expect you to read his " Public Policy Issues in Direct-to-Consumer Advertising of Prescription Drugs" Journal of Public Policy and Marketing! 2002 and to engage on the debate in NZ about banning direct advertising to consumers. Click here to see a pdf of table of contents
• Angell, Marcia Science on Trial: The clash of medical evidence and law in the breast Implant Case Norton 1997 (& pdf file book review...)
  • Amazon.com review.."Introduced in 1962, silicone breast implants had been used by between one and two million women by the time they were virtually banned in 1992 by David A. Kessler of the Food and Drug Administration. While the ban came about because manufacturers had failed to demonstrate the safety of the devices, Marcia Angell, executive editor of The New England Journal of Medicine, argues that there actually was no medical consensus to support the contention that implants could cause widespread illness. Science on Trial examines the silicone debate and argues for the reliance on scientific evidence "to curb the greed, fear and self-indulgence" of such disputes." See Publisher's Weekly review below, other reviews on Amazon.com
• Nina Fedoroff, Nancy Marie Brown Mendel in the Kitchen: A Scientist's View of Genetically Modified Foods
  • From Publishers Weekly
    Is genetically engineered Golden Rice (enriched with vitamin A) a dangerous "Frankenfood" or a safe, nutritionally enhanced food that could fill a major vitamin deficiency in the Third World? Fedoroff, a molecular biologist and member of the prestigious National Academy of Sciences, and science writer Brown (A Good Horse Has No Color) argue forcefully for the latter view, saying we should embrace most of the advances genetic engineering has made in the agricultural arena. In an extremely accessible style, they take readers through the basics of genetics and genetic engineering to demonstrate why they believe that the risks associated with this technology are trivial. They also contend that the use of modern molecular technology to insert genes from one species into another isn't very different from the hybrid crosses that agriculturalists have been doing for millennia. Taking on concerns voiced by environmentalists, the authors articulate how genetically modified crops could reduce the amount of pesticides and fertilizers used and increase the yield of crop plants to keep up with a growing world population that could reach eight or nine billion in this century. Though likely to be controversial, the authors' clear and rational presentation could well change the opinions of some readers.
    
• OTA : US Office of Technology Assessment "Adverse Reactions to HIV Vaccines: Medical, Ethical, and Legal Issues" September 1995 OTA-BP-H-163 (pdf 1Mb).
• Temin, Peter Taking your medicine : drug regulation in the United States (1980) [UCCentral Library level 11 HD 9666 .T279]
• Institute of Medicine Crossing the Quality Chasm
• Joseph Newhouse Pricing the priceless: A Health Care Conundrum 2002 MIT Press
• Lara Marks Sexual Chemistry: a history of the Contraceptive Pill Yale Univ Press 2001
• Barron Lerner The Breast Cancer Wars: Hope, Fear, and the Pursuit of a Cure in Twentieth-Century America Oxford Press 2003
• Edward Shorter From Paralysis to Fatigue: A History of psychosomatic ilnness in the modern era Free Press 1992
• Robert Weinberg Racing to the Beginning of the Road The Search for theOrigin of Breast Cancer 1998
• Lois Wingerson Unnatural Selection: the Promise and the Power of Human Genome Research(1998)
• David Cutler Your Money or your life: strong medicine for America's Health Care system Oxford 2004
• David Dranove The Economic Evolution of American health Care From Marcus Welby to Managed Care Princeton 2000
• Lee Silver Remaking Eden
• Peter Skranbeck The Death of Humane Medicine and the Rise of Coercive healthcare
• Lois Wingerson Unnatural Selection 1998
  • Approaching her subject with a journalist's objective eye, Wingerson (Mapping Our Genes) takes a comprehensive look at the issues swirling around the rapidly developing field of human genetics. She is at her best early on, discussing the personal decisions faced by couples who discover that their fetuses are likely to be born with Tay-Sachs, cystic fibrosis or any of a growing number of diseases for which prenatal genetic testing has become available. Equally moving is her account of the dilemmas faced by genetic counselors in their attempts to be caring and informative while remaining nondirective. Less successful is the book's middle section, which provides a brief history of the early eugenics movement and a discussion of the genetic effects of nuclear radiation. Wrapping up, Wingerson returns to the issues raised in her early chapters, though now focusing on social and ethical rather than personal considerations. Possible abuses of genetic information acquired by employers and insurers are covered in detail, as are the ramifications, potentially positive and negative, of the Human Genome Project. Wingerson, perhaps taking her lead from genetic counselors, raises provocative philosophical, moral and political questions but provides few answers, or even personal opinions. Throughout, numerous short, boxed features furnish background material that enables even readers with minimal scientific knowledge to gain a solid grasp of the complex issues broached. review from Amazon
• Kip Viscusi Smoke Filled Rooms: A postmortem on the Tobacco Deal 2002
  • From Library Journal
    Harvard law professor and tobacco industry expert witness Viscusi turns the tables on the 1998 tobacco settlement, arguing that tobacco companies made a colossal blunder in settling with the states. The book's underlying thesis is that tobacco is a consumer product whose risks are well known to those who choose to use it. He expertly dissects the settlement and its supporters, using charts, statistics, and medical studies to claim that smoking is not as dangerous or costly to society as believed. The settlement was politically driven, he submits, amounting to an excise tax on the poor. He believes that the government should have helped the tobacco industry develop a "safer" cigarette, since a total ban on smoking would fail. The book is well argued and worth reading, regardless of the reader's personal views on the subject. There is also an interesting longer review from the new england journal of medicine at amazon
• Peter Temin Taking Your Medicine Drug Regulation in the United States Harvard 1990
• Glenn A. Gaesser Big Fat Lies: The Truth about Your Weight and Your Health 2002
  • Amazon.com
    If you've ever looked at height-weight tables in your doctor's office or calculated your body-mass index from a formula in a fitness magazine, and realized that you're technically overweight, this book is for you. Not only does it expose the highly flawed methodology used to calculate those ideals, it also argues that you can be fit at any weight. In fact, the author asserts, being heavier is actually better for you in some ways: statistically, you have a better chance of living a longer life if you're both active and on the heavy side. But there's the rub: being heavy in itself is no virtue. Exercise and healthful eating are still the keys to vitality and longevity. It's just that weight control has been unrealistically foisted upon us by the insurance and fashion industries, making us miserably concerned with girth when there's often no need for worry. see other reviews at Amazon
• Tomas J. Philipson, Richard A. Posner Private Choices and Public Health: The AIDS Epidemic in an Economic Perspective (1993)
  • Editorial Reviews From Book News, Inc.
    An economics professor and a federal judge point out that engaging in unprotected sex is a dangerous but pleasurable activity, like downhill skiing and mountain climbing, and that people weigh the risks and benefits when deciding whether or not to do it. The people setting up public health measures to combat the spread of AIDS, they say, are not taking this informed and often rational decision-making into account. Therefore, their predictions are off and their information campaigns are not only in effective, but may well be encouraging the disease's spread. They also look at the cost and benefits of research and education for the society as a whole. The book is bound to be controversial.

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• data/evidence issues: what data is (and is not) collected, how such data us measured , analysed and contested in health evaluations
• the measurement and assessment of health risk, uncertainty and information relevant for major participants in the health sector (consumers, providers, managers, regulators)
• contemporary practices for measuring and interpreting the many non priced and non-competitively priced costs and benefits in the health sector
• Have gained practice and experience in expressing their critical reasoning skills as economists
• through oral presentations in small group situations and in organised workshop formats,
• through written essays
• through short oral and written discussions and evaluations that focus on ascertaining key issues/facts/ideas, posing relevant and insightful questions, and justifying their reasoning on appropriate grounds

Notes on Structure and Assessment

The weekly meetings will combine lecture and interactive discussion formats. Generally I will distribute articles to read which we will use as a basis for critical discussion in class. Students are expected to have completed all readings in advance of each class and to actively participate in class discussion. You will be asked to engage in small group discussions, impromptu thinking and reasoning out loud in your group and in the class, organized written and oral presentations of your own, critical listening to and interacting with the ideas and opinions of others in the class as well as learning in conventional lecture mode. You will be surprised how much you can learn from one another, not just from the lecturer.

Critical reasoning skills will form the basis for the 10% "participation" grade. I will keep a daybook and record the individual efforts you demonstrate at critical thinking within the class. The participation grade is not an attendance grade. If you don't say anything all year you guarantee yourself 0 for this piece of assessment. If you regularly , and especially progressively, throughout the course showing good critical reasoning skills you'll receive 10%. I will regularly communicate my assessment of your participation grades to you. If you have any disagreement with the accumulating record of your participation grade please arrange to see me to discuss the matter.

The presentation/discussion/participation component of your grade in Econ 338 will probably be new to you. You will be given clear guidance and feedback on how to do develop and apply critical reasoning skills in your presentations early in term I, following ideas in a handout based on Richard Paul and Jane Willsen's Critical Thinking, From an Ideal Involves an Imperative . You will find that with a little practice in our tutorials and in class that your critical listening and thinking skills will improve dramatically , which is the whole point of the exercise . Once you leave University you will have to work, think and communicate in cooperative social situations , presenting your own ideas and listening to the ideas of others. Helping others in the class through cooperative, critical feedback in a modern form of Socratic dialogue will not injure your own grade: grades assignments in this course are not a zero sum game

Each student, working in a syndicate of 2-3 (preferably in pairs but this depends on class numbers and identified interests) , will be required to write a major essay and present their essay in a workshop format in term 4. Syndicates will be organized early by early August. Essay topics should selected from readings as maintained on the Econ 338 website listed at the end of this outline. All specific essay projects must be approved in advance by the instructor of the course. There is no problem with more than one syndicate developing their essay topic from the same basic set of readings. Topic areas can consist of either books from the list below OR a set of related readingsa from the journal Health Affairs HA) and/or from the webcasts and transcripts of the Kaiser family foundation . Many of the books are not written by health economists, but they contain important information, insights and arguments about many interesting and challenging social and economic issues in health today. I want you (you and others in your syndicate) to select a book and or set of approved articles/webcasts to read, read it thoroughly, present the key ideas and arguments from the book to the class in the workshop and in your essay , and critically interact with selections of material or arguments from the book as an economist.

The essay topics and syndicate groups need to be decided as early as possible so that you can begin working on your term papers. Each syndicate should arrange to meet with me during term 3 to discuss progress on the essay. You have the responsibility to distribute an electronic copy of your essay a week before your workshop. After receiving feedback from discussants and others in the workshops you have a week to revise your essay and submit the final version. Depending on how many people are in the class there may need to be two Saturdays devoted to workshops. These Saturday workshops are fixed in concrete (SATURDAYS 25/9/04) and all students are expected to attend all workshops as a necessary (but not sufficient) condition to receive a passing grade for the course.

The 40% assessment for the "Major written paper" is for the final written version only, not for the draft version you distribute electronically or for the version you present. The length of the paper should fall between 10 to 15 pages, double-spaced with 1 inch margins. Syndicate members will receive the same grades for the essay they submit. If for some reason (your reason, not mine)  you or other members of your syndicate cannot submit an essay together you may/will submit one on your own - even if you decide to do a presentation together. The 10% for presentation in the workshop will be based on the critical reasoning skills you demonstrate as a presenter of your own paper (5%) and in your role(s) as a discussant (5%)..

USeful Readings

Recommended reading

Drummond MF, O'Brien B, Stoddart GL, Torrance GW. Methods for Economic Evaluation of Health Care Programmes. Second Edition. (Oxford: Oxford University Press, 1997).This is an excellent (but "verbose") practical text on economic evaluations in health economics, but as we use only portions of chapters 4-7 , you are not required to purchase it. It will be on reserve in the library. 

A handbook of readings will be available at the beginning of the course for an approximate cost of $20

Useful reading

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Book Reviews

Courtwright: Forces of Habit

Review from the New England Journal of Medicine, August 9, 2001
Set on a world stage, this book is about the ``psychoactive revolution'' of the past 500 years. Courtwright, well known for his work concerning the history of drug addiction and, more generally, social history, observes that in wealthy societies in the 20th century a cornucopia of drugs, illicit and licit, became available and popular. How did this situation arise, he asks, and how have societies and governments coped with it, and especially, why have some drugs posed more of a problem than others? The main story relates to the expansion of European oceangoing commerce in early modern times and the resulting discoveries of new commercial opportunities. In the drug trade, the three big items eventually became alcohol, tobacco, and caffeine, to the exclusion of other possibilities derived from the plant world. These three drugs remain abundant and profitable commodities, eliciting various responses in different societies.
Thus, this book is not about medicine itself or about the changing practices of physicians over the centuries. Although the author mentions those practices from time to time, he is concerned with the broader story of the sweeping changes in the markets, and thereby in the uses, of a range of substances. And he explains how governments have responded differently in different ages to the growing commodification and popularity of psychoactive substances. Alcohol and caffeine were, of course, Old World products whose spread became enormously wider as a result of European expansion and European technology. Tobacco was a New World plant that conquered the Old World after Europeans discovered its psychoactive (and addictive) properties. At about the same time, advances in distilling techniques and the spread of information about them through the printed word created opportunities for making and selling alcohol. After their conquest of South America, some Europeans began cultivating coffee on that continent, while elsewhere other Europeans were expanding the tea trade. Alcohol, tobacco, and caffeine soon became important trade commodities, the taxation of which was a mainstay of government finances.
Courtwright does not confine his story to the big three in the drug world. He also writes about cannabis, opium, coca and cocaine, and synthetic products. None of these substances or their derivatives became commodified in quite the same way as did the big three, although there were important regional exceptions, such as the infamous opium dens of the Chinese. Part of the story of the lesser-used drugs is the relative absence of their commercialization. For example, until well into the 20th century, smoking marijuana was a practice of particular -- and relatively small -- populations in certain regions. Nor is Courtwright's analysis entirely commercial. To the Christian Europeans, the Amerindians' use of plant hallucinogens such as peyote was reprehensible.
One essential difference with respect to alcohol, tobacco, and caffeine was the skill of entrepreneurs and their resulting profits and power in promoting these products. Courtwright's approach is to paint a large picture, while occasionally delving in some depth into particulars. He writes about James Duke and the growth of the cigarette trade after the late 19th century. The industry that Duke's ingenuity and acumen fostered became very powerful, and it remains so today, able to fight off efforts to restrict it severely or even to eradicate it, however steep is the mountain of evidence about the ill effects of tobacco use.
Herein lies the story of a sea change in social approaches to drug use and the drug trades. With the advance of industrialized societies, concern mounted about the effects of psychoactive substances. Altered states of consciousness do not mix well with the needs of a technologically complex civilization. Europeans sometimes tolerated altered states of consciousness among peasants and workers as a means of easing the pain of their often miserable lives, especially in early modern times. Views changed with advancing industrialization in the 19th century, however. Even so, efforts to control the use of tobacco and alcohol detract from their potential as objects of taxation (and contradict the realities of their use). The enormous power of the tobacco and alcohol industries has overcome efforts to ban or restrict their products. When the United States, for instance, prohibited the liquor trades in 1920, wealthy Americans eventually engineered the law's repeal by arguing that it would promote an economic revival (repeal occurred in 1933, the nadir of the Great Depression) and pointing out the benefits of having alcohol taxes.
In the case of other drugs that were declared illicit during the industrial age in some places, there are ongoing efforts to eradicate their use. Courtwright is known for his use of historical knowledge to argue against the legalization of ``drugs,'' and he does so again in a concluding chapter dealing with dangerous psychoactive substances in the 21st century.
Courtwright writes with felicity, gracefully constructing his narrative in a clearly organized fashion, eschewing jargon and technical language. This is an engaging book that deserves a wide audience among general readers.
K. Austin Kerr, Ph.D.
Copyright © 2001 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Goozner's The $800 Million Pill

Amazon Book Description: "Why do life-saving prescription drugs cost so much? Drug companies insist that prices reflect the millions they invest in research and development. In this gripping exposé, Merrill Goozner contends that American taxpayers are in fact footing the bill twice: once by supporting government-funded research and again by paying astronomically high prices for prescription drugs. Goozner demonstrates that almost all the important new drugs of the past quarter-century actually originated from research at taxpayer-funded universities and at the National Institutes of Health. He reports that once the innovative work is over, the pharmaceutical industry often steps in to reap the profit. Goozner shows how drug innovation is driven by dedicated scientists intent on finding cures for diseases, not by pharmaceutical firms whose bottom line often takes precedence over the advance of medicine. A university biochemist who spent twenty years searching for a single blood protein that later became the best-selling biotech drug in the world, a government employee who discovered the causes for dozens of crippling genetic disorders, and the Department of Energy-funded research that made the Human Genome Project possible--these engrossing accounts illustrate how medical breakthroughs actually take place. The $800 Million Pill suggests ways that the government's role in testing new medicines could be expanded to eliminate the private sector waste driving up the cost of existing drugs. Pharmaceutical firms should be compelled to refocus their human and financial resources on true medical innovation, Goozner insists. This book is essential reading for everyone concerned about the politically charged topics of drug pricing, Medicare coverage, national health care, and the role of pharmaceutical companies in developing countries"

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Millenson Demanding medical Excellence:

Review from The New England Journal of Medicine, March 19, 1998
Information is power, and perhaps a seed of corruption. In Michael Millenson's paean to medicine in the information age, once corporations have confiscated power from clinicians it absolutely does not corrupt.
Millenson, a Chicago-based health reporter turned consultant, is a true believer in the virtue of the information revolution. His engaging account of the development of information science and quality assurance in medicine is enlivened by clinical vignettes and brief biographies of key actors. The first of his principal theses -- that doctors, unsupervised and unaccountable throughout most of this century, committed a myriad of sins -- is surely correct. The second -- that medicine's new masters, having gained leverage through access to medical information, will make beneficent use of their power -- is surely questionable.
Millenson is at his best when describing the early, rebel, period of medical information science -- when it was largely the province of insurgent academics and liberal reformers. His account of the Food and Drug Administration's role in improving pharmaceutical quality is superb. He gives a nice glimpse of Archie Cochrane's seminal observations on effectiveness and efficiency, though he gives short shrift to Cochrane's insistence that all effective treatments must be free. He offers an accessible review of the pioneering work of Bunker, Wennberg, Barnes, Gittelson, and Mosteller on variations in practice patterns and of W. Edward Deming, the American engineer whose statistical quality-control techniques were first operationalized in Japan and were instrumental in transforming Japan's manufacturing from merely cheap to high-quality. Millenson nicely narrates the adoption of Deming's precepts by Ford Motors and Donald Berwick's elaboration of these ideas in medicine, spreading the gospel of Continuous Quality Improvement.
Millenson's rosy portrayal of today's corporation-dominated medical accountability, and his "celebration" of medicine's future (he assumes that we will continue on the current trajectory) are less convincing. He trusts employers to monitor their workers' care, ignoring the potential for conflicts of interest in such arrangements. Sometimes care that helps an employee hurts the firm -- expensive mental health services that might keep a marginally performing worker on the job may fall into this category, as well as employer-funded care for retirees or the aggressive diagnosis of workplace-induced illness.
Moreover, even if purchasers of care genuinely seek quality, the tools currently or foreseeably available cannot reliably detect market-driven cheating. In most instances, clinicians and health maintenance organizations (HMOs) literally create the data that must be used to monitor them. When such data are used as the basis for reimbursement they may have the accuracy of a tax return. Rewarding physicians for good outcomes in hypertension, among other things, rewards overdiagnosis. White-coated doctors who screen for hypertension using too-small cuffs in harried surroundings will label many patients "hypertensive," garnering a higher capitation fee based on risk adjustment, while virtually ensuring that most of these "hypertensives" will suffer few bad outcomes.
Millenson also ignores the distortion of medical care that may result when financial incentives are tied to quantitative measures of quality. Quality monitoring -- e.g., with HEDIS (the Health Plan Employer Data Information Set) often gives undue weight to the few items that are readily measurable. Listening, learning, and caring are difficult to quantify, and as one HMO executive put it, "It doesn't count unless you can count it." Counting Pap smears is a fine idea, but scarcely an adequate measure of primary care. When financial reward for performance on such counts is combined with pressures to increase productivity, too many women spend much of their visits in the lithotomy position.
Millenson seems unaware that the current corporate context may sabotage quality initiatives. Instead of a uniform formulary to inform prescribing, we labor with five different formulary lists, each embodying the deals cut between an insurance plan and drug manufacturers.
The book is also marred by occasional inaccuracies and important omissions. Hepatic failure is misdefined as diseased kidneys. A patient is said to suffer from "high blood gases." The pioneering work of Howard Bleich and Warner Slack in clinical computing, decision support, and improving access to medical literature receives no mention, and the Regenstreif Institute's groundbreaking and meticulously evaluated system of computerized medical records and feedback are ignored. Millenson's readiness to trumpet implausible non-peer-reviewed accounts of spectacular quality improvements is also disturbing (isn't this the mirror image of doctors' shoddy use of anecdotal evidence, which Millenson condemns?); hospitals' claims to have reduced transfusion reactions to zero and drug reactions to nine per year are uncritically reported.
Millenson's portrait of medicine in the information age is detailed and artful, but it omits the shadows that would give it depth.
Reviewed by Steffie Woolhandler, M.D., M.P.H.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS. --This text refers to the Hardcover edition.

Angell, Marcia Science on Trial

Amazon.com
Introduced in 1962, silicone breast implants had been used by between one and two million women by the time they were virtually banned in 1992 by David A. Kessler of the Food and Drug Administration. While the ban came about because manufacturers had failed to demonstrate the safety of the devices, Marcia Angell, executive editor of The New England Journal of Medicine, argues that there actually was no medical consensus to support the contention that implants could cause widespread illness. Science on Trial examines the silicone debate and argues for the reliance on scientific evidence "to curb the greed, fear and self-indulgence" of such disputes.

From Publishers Weekly
Angell, executive editor of the New England Journal of Medicine, explores here a preposterous situation: an industrial giant, Dow Corning, forced into Chapter 11 bankruptcy by numerous lawsuits filed on behalf of recipients of Dow's silicone breast implants?despite the fact that medical evidence to date shows no link between implants and autoimmune disorders, cancer or any other disease. In a style that ranges from gently didactic to plodding, Angell describes the events leading up to the FDA's ban on implants, the torrent of lawsuits that followed and the implications of the verdicts?overwhelmingly favorable to the plaintiffs and often carrying cash awards in the millions of dollars?for science and industry. Manufacturers have threatened to stop producing heart valves, shunts and other vital medical devices because of the threat of liability; further, suppliers of raw materials for these devices often refuse to sell to American companies for fear of ending up in an American courtroom. The author gives a clear explanation of the way science calculates risk (by considering populations, not individuals) and ably contrasts this with our judicial system, where the focus is on the individual seeking restitution. Angell is an effective champion of the scientific method and does a good job of exposing the chaos caused by a runaway tort system, but she offers no resolution to the state of affairs she describes.
Copyright 1996 Reed Business Information, Inc.

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