Sunday, March 18, 2012

Sin taxes and the cost of health

Over the last few days, there were several FULL PAGE advertisements by the tobacco association and distillery companies in the Philippines. As all obvious vested interests go their way, these companies have the money (and temerity) to splurge on full page ads in order to block the passage of additional sin taxes for vice.

Glaringly different is the stand of some government officials (whose brains I don't know where manufactured from) regarding the cost of medicines in the Philippines.

Let's put the facts in order.

The World Health Organization's most recent report on Global Health Risks puts into perspective the reality of health problems in high-, middle-, and low-income countries. The full 70 pages report published in 2009 should serve as an eye-opener and reference material not only to the public, but to every government official who still is confused at what kind of Philippine laws to roll out (if only to grand stand for the upcoming election).

Based on the WHO regional classification, the Philippines falls under the Western Pacific Region and NOT Southeast Asian Region. Countries are grouped by WHO region and income per capita. WHO member states are categorized as low and middle income (LMIC) if their 2004 gross national income per capita is less than USD$10,066.00 and as high income (HIC) if it was greater than this amount based on estimates provided by the World Bank.

In the Western Pacific Region, those considered HIC are: Australia, Brunei, Japan, South Korea, New Zealand and Singapore. Considered LMIC are: Cambodia, China, Cook Islands, Fiji, Kiribati, Lao People's Democratic Republic, Malaysia, Marshall Islands, Micronesia, Mongolia, Nauru, Niue, Palau, Papua New Guinea, Philippines, Samoa, Solomon Islands, Tonga, Tuvalu, Vanuatu, Vietnam.

For the record - NONE of the countries in Southeast Asia region are high income countries.

The technical report's summary is concise and direct to the point in just the first paragraph of the SUMMARY section:

"The leading global risks for mortality in the world are high blood pressure (responsible for 13% of deaths globally), tobacco use (9%), high blood glu- cose (6%), physical inactivity (6%), and overweight and obesity (5%). These risks are responsible for raising the risk of chronic diseases such as heart disease, diabetes and cancers. They affect countries across all income groups: high, middle and low."

To explain in layman's language, let me define two terms:
1. DALY (disability-adjusted life years)
2. Health risk

DALYs measure the burden of disease and quantifies the gap between a population's health and an ideal situation wherein one lives to old age in full health. Ergo, 1 DALY is equivalent to one (1) lost year of "healthy" life.
Health risk is defined as a "factor that raises the probability of adverse health outcomes."

It is in this context that we need to understand and balance the musings and lopsided advertising b*llshit that tobacco and distillery companies pointed out.

Based on the data provided by the WHO technical report, of 19 health risk factors, 15 of them are life style risk factors (regardless of income in the country). Rounding up the top 8 risk factors are: hypertension, tobacco use, high blood sugar, physical inactivity, obesity and overweight, high cholesterol, unsafe sex, and alcohol use.

If you considered the DALY of the 19 health risk factors, based on country income level, the devil in tobacco and alcohol usage would still rank in the top 8. Obesity, high colesterol and inactivity would follow suit.

The technical report summarizes these findings as follows:

"Five leading risk factors identified in this report (childhood underweight, unsafe sex, alcohol use, unsafe water and sanitation, and high blood pressure) are responsible for one quarter of all deaths in the world, and one fifth of all DALYs. Reducing exposure to these risk factors would increase global life expectancy by nearly 5 years."

"Eight risk factors (alcohol use, tobacco use, high blood pressure, high body mass index, high cholesterol, high blood glucose, low fruit and vegetable intake, and physical inactivity) account for 61% of cardiovascular deaths. Combined, these same risk factors account for over three quarters of ischaemic heart disease: the leading cause of death worldwide. Although these major risk factors are usually associated with high-income countries, over 84% of the total global burden of disease they cause occurs in low- and middle-income countries. Reducing expo- sure to these eight risk factors would increase global life expectancy by almost 5 years."

"Nine environmental and behavioural risks, together with seven infectious causes, are responsible for 45% of cancer deaths worldwide. For specific cancers, the proportion is higher: for example, tobacco smoking alone causes 71% of lung cancer deaths worldwide. Tobacco accounted for 18% of deaths in high-income countries."

For those that are ignorant of how heart disease and these other risk factors play a role in health risk, the causal chain below illustrates the pathway on how there is interaction in increasing the risk. (You can read the full report in the link if you're interested in understanding this further)

"Health risks are in transition: populations are aging owing to successes against infectious diseases; at the same time, patterns of physical activity and food, alcohol and tobacco consumption are changing. Low- and middle-income countries now face a double burden of increasing chronic, noncommunicable conditions, as well as the communicable diseases that traditionally affect the poor. Understanding the role of these risk factors is important for developing clear and effective strategies for improving global health."

Worldwide, there are more deaths due to being overweight or obese than being underweight. Diet-related risk factors and physical inactivity in LMIC is similar to being burdened with HIV/AIDs and TB. The 6 risk factors in this category include: high blood pressure, high cholesterol, high blood glucose, overweight and obesity, low fruit and vegetable intake, and physical inactivity.

The bottom line for this technical report is revealing. It shows us that in order to address health care, we need to address the root cause of the disease. We cannot be a culture where we discover a pill for every ill, when there are non-pharmacologic (no need to use drugs) treatment plans.

Making tobacco and alcohol inaccessible to those who consume it more (the poor consume this more than those who have money and ironically, spend more for vices than for putting the right food on the table); putting into perspective a healthier life style by shunning fast food chains (read - McDonalds, Mang Inasal, Red Ribbon, Jollibee, KFC, etc) and encouraging our children and people to eat healthier meals (feeding is a habit that is learned); engage in sports activities and move around (instead of simply sitting down with an iPad or texting in wild abandon)...these are the simplest solutions to the increasing chronic problems that plague our people.

We cannot allow a culture where people simply learn to mortify their bodies by taking a "pill for every ill". It does disservice to the public if the government does not have the "balls" to reign in the vices that use "economic displacement" of a country as the prime mover and shaker for something that is altogether wrong. If the line of reasoning of the tobacco and distillery industry is that "putting additional taxes on tobacco and liquor will make this less accessible to the buying public and will displace hundreds of thousands of workers" and hence the law on additional sin taxes should be blocked, then it is a stupid line of reasoning provided only by those with selfish interests to stay in the Forbes list of billionaires. I would go to the extent of arguing with them that if this were the case, then let's let all the shabu and marijuana producers and dealers and sellers be made legal because they only push drugs as a source of livelihood.

Finally, I'd like to take a jab on how pathetic some law makers are on making the cost of drugs a major issue. For the record, we have one of the most number of generically equivalent drugs in the world. How we have over 50 brands of each drug is a puzzle even to me. With so many of them in the market, I even doubt the quality assurance of many of them. Making them dirt cheap is not the solution at curbing the problem of inaccessibility of every Juan to medicines. No matter how cheap you sold the drug, as long as each Juan does not change his outlook on lifestyle diseases, the idea of decreasing health risk through a more cost-effective government program is not achievable. Cheaper medicines is NOT the solution to accessing health care.

Health care requires politicians to think out of the box.

There's a saying that if you give a man fish, you feed him for the day. Teach him how to fish, and you feed him for a lifetime.

It is time we teach every Juan to fish for his life.

Sunday, March 11, 2012

Is the party over?

Jessica Soho's 'State of the Nation' TV news show had editorialized the age-old dilemma of the relationship between the physician and the pharmaceutical company.

The following day, several newspapers had featured the press release of the PHAP (Pharmaceutical and Healthcare Association of the Philippines) on this entanglement between the industry and the doctors.

The press release, which I think should NOT have been released and was done in very bad taste by PHAP through its President, Mr. Reinier Gloor (a former executive of Zuellig Pharma Corporation - a distributor for pharmaceutical products) focused on two evils - the DOCTOR and the INDUSTRY.

First, let me point out that I have nothing against policing entanglements between the physicians and the pharmaceutical industry, I just think that the PHAP is not the proper organization to trump the say-so in having to police the rank of the industry. Fine, so the 44 pharma companies under the PHAP umbrella are banding together to rid the industry of the so-called "corrupt practices' of bribery and influence in prescribing habits by peddling under the guise of junkets and free gifts or rebates to doctors.

What I am peeved about is that the doctors who are the recipients of this are made to look like crooks. Well, yes, so there are some of us in the medical profession who have sold their souls to the devil and have no ethical boundaries. That's a given. What's strange is that the same people who have formed PHAP and bounded together in the fight against this abusive practice are the same idiots who created the problem in the first place!

It's not a chicken and egg scenario. The early years of the pharmaceutical industry saw a boom in business via prescription peddling through backdoor channels - a trip to the Swiss Alps here, a tour of Honolulu there...a gift basket here, payment for convention registration there...

Seriously? My early formative years in medical school and then in residency training made me realize that the pharmaceutical companies were willing to bend over, and yes, even dance on their heads - in exchange for a prescription. I saw this most blatant display of commitment by the pharma players in the milk companies! Talk about milking a cow dry - the Philippines should make it a capital punishment to be even endorsing milk products (but hey, Kris Aquino is an endorser so I doubt if PNoy would even blink before considering this).

I cringe at the fact that I have colleagues that literally ask OR beg the industry for trips and gifts. Mind you that this was not only in the Philippines but in the United States as well! But the carrot was put in front of the rabbit a long time ago. Cognitive psychological impact on the behavior of doctors was altered the day the doctor stepped out of medical school and began his medical practice. The dilemma of the pharmaceutical companies coercing the physician on entanglements was NEVER taught in med school. It became an intricate web that the physician had to fight over (like good and evil in the Garden of Eden) in his heart and soul with the pharma devil placing the temptuous apple in front of the doctor.

Finally, is the fact that this statement of policing itself is only true for pharma companies under the banner of PHAP. There are several key players in the local pharma business that are NOT under the PHAP organization. Which means that the PHAP members are simply restricting themselves and it's really not an all out effort to curb the ethical conflicts of interest between the doctor and the industry.

In short, as long as this is not a government initiative there will still be sponsors for the merry making to continue. Whether it is without Astra Zeneca or GSK or MSD or other big name companies - it's not going to matter. The party will continue until government steps into the bigger picture to ban the parties forever!

In the meantime, Jessica Soho can eat her shorts for all I care!

Tuesday, March 6, 2012

The iconic wonder of Majestic Mayon

The GSK Vaccine Congress this year was held in Legazpi City.

The province of Albay is home to the world's most perfect-coned active volcano, Mount Mayon. Getting to Legazpi is a "challenge" to say the least. The landmark and hallmark of the flights landing from Manila to Legazpi is dictated by the weather. Which means that when you can't see Mt. Mayon, you don't land.

And that was what almost happened. As we approached 13 miles to Legazpi City, we made two circles in the air before the captain finally announced that because the visibility is zero, he will attempt to go around a few more times and if the weather does not let up, we would go back to Manila. And you could hear the groan of all the passengers.

After two more attempts, the clouds suddenly opened up the skies and you could see the beauty of majestic Mt. Mayon. Flaps down. Wheels came whirling down and we landed almost 40 minutes off schedule in Legazpi.

I needed to give two lectures in the congress. The first was 90 minutes after we arrived. The second was the following morning. The congress was a successful one. But I am not blogging about the meeting. I am blogging about how beautiful Legazpi City has turned out to be.

It had been more than 10 years since I went to Legazpi. Aside from the weather being unpredictable, Legazpi was such a laid back city that the most you'd get with accommodations is a lackey hotel.

I was booked at the Oriental Hotel. One look at the place left me in awe! I mean, really jaw dropping awe. The picture of Mt. Mayon was taken at the foot of the Oriental Hotel. It gives you a spectacular view of Mt. Mayon in all its splendor.

The all white, all glass majestic Oriental Hotel isn't only fabulous from the outside, but the lobby itself was symmetrically modern and encompassing the senses.

The digital touch elevator panel was mind-blowing considering that even the most posh hotels in Manila do not have this.

Then there's the room. Mind you that this isn't a suite room, but a standard room. All rooms on the east wing face Mt. Mayon and all have a glass encased veranda overlooking not only the volcano (they say it's a beautiful view at night time during an eruption where you see the fiery lava cascading the perfect cone of Mayon), but the infinity pool as well.

The queen size beds are divine and the bath

The queen size beds are a sprawl and a perfect sleep and the bathroom has a rain shower with amenities that of a 5 star hotel.

And even if I stayed overnight only, Legazpi City has made an impression on me as the next tourist destination to go to. Only an hour away from Sorsogon where you can do whale watching and ride and swim with the "butandings", or explore the Embarcadero mall and the strip of the well lighted boulevard, or go on a trip to explore Mt. Mayon itself...this is one city that will surely leave an impression of having more fun in the Philippines.

By the way, did I forget to mention that there's a spa and gym at the Oriental Hotel?

I had a 75 minute massage at the spa (60 minutes of Swedish massage and 15 minutes of foot massage) for only P600 ($13.00)!!! Now who says that bliss has to be expensive?

Come visit Legazpi City. It will definitely change the way you look at our country.