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From: Steve Harris <>
Subject: Re: diseases of rich deprive poor of drugs
Date: 13 Sep 2005 16:03:26 -0700
Message-ID: <>

Mark & Steven Bornfeld wrote:
> fresh~horses wrote:
> > Jim Chinnis wrote:
> >
> >>"fresh~horses" <> wrote in part:
> >>
> >>
> >>>The reason drugs cost so much is graft. Plain and simple. Far more is
> >>>spent on marketing than on research.
> >>
> >>Just passing through for a sec, but:
> >>
> >>Marketing tends to decrease prices, not increase them. Businesses market in
> >>order to increase sales. The increased sales have to more than offset the
> >>marketing cost, or marketing isn't done the next time or is reduced. The
> >>increased sales spread fixed costs (such as drug development and testing and
> >>FDA submissions etc.) over a larger number of sales, bringing the cost down
> >>and allowing a drug to compete in the marketplace at a lower price.
> >>--
> >>Jim Chinnis   Warrenton, Virginia, USA
> >
> >
> >
> >
> >
> > "When it comes to accepting gifts from the marketing reps of
> > pharmaceutical firms, the American College of Physicians-American
> > Society of Internal Medicine suggests that its members apply a simple
> > litmus test: "What would the public or [our] patients think of this
> > arrangement?"
> >
> > Most patients never find out. If they did, they'd probably go into
> > shock over the goodies doctors accept, like meals, travel, gift
> > certificates or parties. The pharmaceutical industry estimates that it
> > spends about $5.7 billion a year on marketing directly to physicians,
> > which works out to about $6,000 to $7,000 per doctor."
> ...and all I've got is this damned coffee mug...
> Steve


Well, that's because that $5.7 billion is a total cost of the
opperation. Most of it goes to pay salaries of the drug reps which go
to see doctors in their offices, AND I suspect it counts also cost of
free samples of drugs given out by those reps, which is the only reason
most doctors put up with the drug reps (so they can get the samples,
and have something to give to their indigent patients).

The "$6000 to $7000" per doctor is a completely misleading statistic.
The doctor never sees usually anything more of that gross advertising
cost for his personal use other THAN a coffee mug, a pen, and some
reprints. Which is why these stories sound so weird to most of us. It
ain't being used to fly us to Aruba (or even Bonaire, where the better
diving is). Yes, some few physicians really work the system giving drug
lectures, and that CAN pay well. But your own doc (however he or she
was) is probabaly not one of them. I could have done it for Fosamax and
some other drugs, but turned all that down. Didn't feel like science.

I think the biggest things I've ever accepted from drug companies were
some very nice host-bar caffeteria-style soiree/dances, after a few
scientific conventions. I remember one at the Wriggley mansion above
Phoenix, which the company had rented for the evening. Given by the
Plavix people, I think. Or maybe it was the Aggrenox people. Anyway,
when it came to strokes, they were against them. Had a fine time.

Came back and gave out so many of these drugs that all my patients bled
out of their eyes, eyes, noses, and some even developed the stigmata of


From: Steve Harris <>
Subject: Re: diseases of rich deprive poor of drugs
Date: 13 Sep 2005 14:13:57 -0700
Message-ID: <>

Jim Chinnis wrote:

> Marketing tends to decrease prices, not increase them. Businesses market in
> order to increase sales. The increased sales have to more than offset the
> marketing cost, or marketing isn't done the next time or is reduced. The
> increased sales spread fixed costs (such as drug development and testing and
> FDA submissions etc.) over a larger number of sales, bringing the cost down
> and allowing a drug to compete in the marketplace at a lower price.


Just so. That's pretty obvious in selling novels or magazines, so why
do people's mental circuit breakers trip out when it comes to
pharmaceuticals? A pill is a piece of physically instantiated
information, like a newspaper. It should be obvious that the more
subscribers you can find for your newspaper, say the New York Times,
the better the quality of the paper you can produce for the
subscription price. So, does subscriber advertising really tend to
*raise* the price of a subscription to the TIMES, or decrease it?

The irony is that the regulatory burden on the the pharm industry is so
high right now, mostly due to activists like Zee, that they really are
forced into the kinds of economies of scale which only large scale
advertising CAN deliver. Zee wants a small limited edition art-journal
kind of world, while demanding the kind of monster potective regulatory
infrastructure that, were it to be imposed on the publishing industry,
only formulaic best-sellers could support. And wonders why my heart
doesn't bleed for her position.

A story, reported by a nutritionist and MD I once read. Once upon a
time, there was a wonderful new anitbiotic for TB (panacea!), which
caused blindness in lab animals (plaugue!). But such were the horrors
of TB at the time, that they decided to do limited trials on humans
anyway, since our retinas differ somewhat from the average animal (as
you can see at night with a flashlight). They ran the tests, warning
the sanitarium patients to report the slightest problems with vision.
After some time, a walk through the wards produced one fellow who was
"reading" his magazine upside down.  Turned out he couldn't see at all.
They asked why he'd said nothing. He replied that he'd seen too many of
his friends go out the back door over the years, and he was determined
to go out the front, even if if with a cane and dark glasses. He knew
if he complained, they'd stop the drug (They cut his dose, his vision
came back, and he was later able to re-start).

That research world described above, is gone. The drug never would have
gone to human trials in THIS world, and *everybody* in the hospital
would figuratively have gone out the back to the body removal lift, in
the politically correct way. Say "Tuskeegee," and remember them in your

And TB, meanwhile, is winning. New drugs are more and more too
expensive to develop, and when we try it in Africa to cut costs, there
are political objections and more muttering about Tuskeegee. Corporate
greed is blamed for the spiggot running dry. So TB continues to rank
with the top killers of people every year in the world.  That's our
unintended consequences of limiting individual choice, and interfering
with research. That's our brave new world of best-sellers or nothing.


PS. The drug in the story, however, survived its trials and is still
used for TB, albeit with careful vision testing. All doctors know
ethambutal. Now no longer panacea or plague, but just a perfectly
pedestrian pharmaceutical. Albeit an older one.


From: Steve Harris <>
Subject: Re: diseases of rich deprive poor of drugs
Date: 13 Sep 2005 13:25:40 -0700
Message-ID: <>

fresh~horses wrote:

> > The reason the drug doesn't cost pennies is usually government
> > regulation.
> The reason drugs cost so much is graft. Plain and simple. Far more is
> spent on marketing than on research.

Not "far more." The figures are roughly comparable, and much depends on
what you count as "marketing" and what as "research."  Is dealing with
the FDA on how to present the data for those package inserts
"marketing" or "research"? How about publication costs and conference
travel?  How MUCH conference travel? Research isn't done in the rest of
science until the paperwork is done. If you go to "pure" academic
research conferences, you'll find that self-promotion, and promotion of
results, is hardly limited to results that stand to make any kind of

What is this "graft?" You think advertising is "graft"?

Complaining that you pay for "marketing" when you pay for a product
(including a medical product) is like complaining that you pay for
"transportation" from the field when you buy strawberries. It's part of
the business. If it's not done, most of the fruit stays in the field,
where it rots. What YOU want, is for somebody to go out and pick it for
you, select and sort it for you, and bring it to you, all for free.
Well, that's not the way the universe works. It's not even the way
Canada works (though this may not be immediately apparent).

It would be nice if somebody picked the nicest strawberries and brought
them to your door as a public taxpayer funded service, I suppose. And
dipped them in chocolate, too.  But I don't think that's going to

>> It is only "callous" to
> > expect adults to learn, if you are thinking of adults as children in
> > the first place.
> Or, master and student?

BIG difference. Master and student can trade places in an instant,
depending on the game (How do you beat Bobby Fisher?  Play him at
anything but chess..).  But parent and child is more permanent, and
more pernicious.  Especially when government is involved.

> Oh it all sounds so noble Steve. But really it all just boils down to
> don't restrict Steve. The restrictions imposed upon a person who has
> been injured by undertested, overmarketed drugs doesn't enter into it
> for you.

And why do you think so?  Because it can't happen to me, or because you
don't think it CAN happen to me?  And if not, why not?  This is not a
rhetorical question. It relates to the cost of information (or rather,
wisdom) and who's going to pay it.

> > Why don't you go back and read my ADHD oeurve, posted nicely on the net
> > already, and get back with us. I think you might profit by thinking it
> > out again. I already have. It took me a long time to do it, and I'm not
> > going to repeat it.
> >
> > SBH
> I have Steve. Apparently I'm in a minority.

Too bad.


From: "Howard McCollister" <>
Subject: Re: online cash for docs
Date: 22 Sep 2005 19:52:10 -0500
Message-ID: <43335154$0$6857$>

"fresh~horses" <> wrote in message
> Howard McCollister wrote:
>> "fresh~horses" <> wrote in message
>> >
>> > Howard McCollister wrote:
>> >> "fresh~horses" <> wrote in message
>> >>
>> >> >
>> >> >
>> >> > Check the "Honors" box on the left.
>> >> >
>> >>
>> >> epocrates is generally small potatoes for honoraria, as are most of
>> >> the
>> >> online offers. I, and most doctors I know, get such invitations by
>> >> email
>> >> and
>> >> regular mail at least a couple of times every week - fill out a survey
>> >> by
>> >> phone or mail and get $100. Drug companies mostly, but some equipment
>> >> manufacturers and some marketing firms. Then, there are various other
>> >> consulting agreements, usually involving money plus travel expenses,
>> >> honoraria for speaking engagements....stuff like that. It's nothing
>> >> new...been going on for many years now.
>> >>
>> >> HMc
>> >
>> >
>> > It's nothing new been going on for years now...
>> >
>> > That makes it ok?
>> >
>> No, that doesn't make it OK. I think it's intrinsically OK, all by
>> itself.
>> HMc
> A couple questions related to a comment in your post to Harris ie)
> "early adopters".
> What does that mean?
> And preceptorships...what does that mean?
> And when you say teach ... do you mean teach for the pharma device
> manufacturing company? Or teach for your surgery colleageus at Cayuna?

Surgery these days is increasingly technology-driven. In many cases, a
particular operation can't be done using minimally invasive techniques until
someone invents a tool make if safer, or to make it possible at all. The
days of being able to do modern surgery using the same tools that
Halsted/Halstead used are long gone, as of  1989, the day that Eddie Joe
Reddick did the first laparoscopic cholecystectomy in the US. There are all
kinds of technologies being invented, studied, FDA-approved, and then they
make their way into the medical market. Those companies then have to sell
the technology to surgeons.

My partners and I are committed laparoendoscopic surgeons. We tend to stay
at the leading edge of advanced laparoendoscopic technique and as such,
there are a number of operations we do that very few other surgeons around
our part of the country are doing. We evaluate the technologies that are out
there in order to find a better or safer way for us to do a particular
operation, and in some cases we participate in the development of those
technologies with a variety of different companies. We get paid for sharing
our expertise with those design teams. In cases where we have greater
experience with a particular operation than other surgeons, those surgeons
may come to our hospital and we will teach them (preceptorship). Most of
these companies have several other such teaching arrangements. In other
cases, we may be invited to speakand/or teach at other such training
courses. As I type this, I have my feet up on the balcony of a very nice
hotel overlooking the Hollywood hills in LA. I drove up this morning from
San Diego. Dinner at Spago tomorrow night.

Bear in mind that these companies with whom we have consulting agreements
have sought us out because we are already using their equipment - we didn't
start using their equipment because they gave us money. As an example, we
have a consulting agreement with one particular device company that makes
surgical staplers, and we teach surgeons how to do advanced laparoscopic
operations using those staplers. That same company makes an ultrasonic
scalpel and they would dearly love for us to buy it and use it in those
teaching courses. We don't, and use a competing company's ultrasonic scalpel
because we think it's better. It's a sore point with the first company, and
it creates a fair amount of friction in our relationship.


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