Killing the geese that lay the golden eggs 2 March 2003
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Richard G Fiddian-Green,
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Re: Killing the geese that lay the golden eggs

Parties within the medical profession and the environmental movements are, through ignorance, guilty of being party to killing the geese that lay the golden eggs (1,2,3).

The primary objective for the medical profession should be to do anything legitimate within their power to maximize longevity and especially disability-adjusted longevity for their patients and their descendents. As we cannot always have what we want and have to bow to economic realities we have, therefore, to choose what is the most cost- effective. That means we have first to be able to define what is meant by effective. Agreement upon this definition appeared to have been reached but only very recently. We need to measure the effectiveness of outcomes in terms of life-years and disability-adjusted life-years saved.

Whatever the cause or causes of premature death and disability the sooner one is able intervene effectively the more cost-effective the intervention is likely to be It should be appreciated that unless a given treatment has been shown, by appropriate statistical means when the therapeutic benefit is not obvious, to be effective it can never be considered cost-effective. This eliminates an embarrisingly large number of therapeutic interventions especially in medical as opposed to invasive practices. Once a treatment is shown to be effective its cost-effectiveness can be determined. For both medical treatments and measures devised to address environmental causes this may be best expressed in terms of dollars spent per incremental life-year or disability-adjusted life-year saved (4,5,6). Only when these steps have been taken is it possible for us to make rational decisions.

From the outcry they provoke it is clear that rational choices do not necessarily equate with popular choices even amongst the medical profession and basic scientists whom one would have assumed were most capable of making rational judgements (1,3,7,8,9). Part of the problem may ralate to a lack of appreciation for what it is that really causes diseases that cause disabilities and death (10). Part of the problem may be the failure to appreciate that whilst many drugs and environmental pollutants may clearly be harmful exposure to low doses may often be beneficial potentially even in the case of the environmental pollutants(11,12). Part of the problem may be the unreliability of much of the data that have been gathered even by WHO (13). Hidden and highly provocative political agendas may account in part for inaccuracies in the data.

The therapeutic activity of plants or drugs reside in descrete chemicals within them. Furthermore the potency and safety of different products differs widely even when manufacturing controls insure uniformity in the composition of the products. Given this scenario who in their right minds would want to be given a drug manufactured in some third world sweat shop or herb even if genetic engineering insured that it concealed pharmaceutical products with established efficacy? There is a real danger of political forces supported by covert activities undermining the established free market practices of established and highly credible pharmaceutical companies. The attacks against the pricing of AIDS medications in lesser developed countries is one manifestation of these political forces.

The attacks against intellectual property rights is another manifestation of these contraversial and possibly hidden political initiatives. Having worked on both sides of the fence and in both developed and lesser developed countries I have little doubt that free market practices, with some improvements, are by far the best means of keepingall patients supplied with the most effective and theerefopre cost- effective treatments even in lesser developed countries (14,15,16,17). The reality is, as President Mbeki appreciates, that the determinants of cost -effectiveness and hence the ranking of cost-effective interventions be they public health, medical or surgical differ greatly between developed and lesser developed countries.

1. Drug companies face pressure on profits Deborah Josefson BMJ 2002; 324: 65.

2. Thought control The scourge of the greens is accused of dishonesty (From The Economist print edition) Jan 11th 2003

3. Howls from greens The appointment of an eco-sceptic may mark a big change in policy (From The Economist print edition) Mar 2nd 2002

4. Fiddian-Green RG. Tonometry: part 2 clinical use and cost implications. Intensive Care World. 1992 Sep;9(3):130-5. Review.

5. The truth about the environment (From The Economist print edition) Aug 4th 2001

6. Doomsday postponed (From The Economist print edition) Sep 8th 2001

7. Defending science (From The Economist print edition) Feb 2nd 2002

8. Never the twain shall meet (From The Economist print edition) Feb 2nd 2002

9. The litany and the heretic (From The Economist print edition) Feb 2nd 2002

10. Determining the cause of death Richard G Fiddian-Green bmj.com/cgi/eletters/324/7328/41#29384, 3 Feb 2003

11. Dual Effect of energy deficit on hippocampal neurogenesis Richard G Fiddian-Green bmj.com/cgi/eletters/325/7370/934#26556, 28 Oct 2002

12. D'Arcangelo D, Facchiano F, Barlucchi LM, Melillo G, Illi B, Testolin L, Gaetano C, Capogrossi MC. Acidosis inhibits endothelial cell apoptosis and function and induces basic fibroblast growth factor and vascular endothelial growth factor expression. Circ Res. 2000 Feb 18;86(3):312-8.

13. Should WHO confine its activities to monitoring?? Richard G Fiddian- Green bmj.com/cgi/eletters/325/7375/1294#27726, 10 Dec 2002

14. Has the FDA served its function? Richard G Fiddian-Green bmj.com/cgi/eletters/325/7364/592#25700, 20 Sep 2002

15. Patents and their commercial value are essential Richard G Fiddian-Green bmj.com/cgi/eletters/325/7364/562/a#25646, 19 Sep 2002

16. The need to protect intellectual property rights Richard G Fiddian-Green bmj.com/cgi/eletters/325/7363/519#25347, 9 Sep 2002

17. Preparing for the coming healthcare revolution Richard G Fiddian-Green bmj.com/cgi/eletters/325/7375/1290#27463, 29 Nov 2002

Competing interests:   None declared