Physicians' conviction of perfection

I added this back in December, but I saved the draft since I had some reservations about so simplistically maligning physicians. My goal certainly isn't to denounce medicine, but rather I do think conversations like this one highlight some of the worst of medical practice. I've already written on my affection for Atul Gawande's perspectives on medicine, and I have immense respect for the practice of medicine. What I don't understand (in any field, really) is the arrogance that one's understanding and insights are impeccable.

From one of our transcripts:
"M: Do you think it influences your assessment if the results are more consistent along what you would expect?
DR: Oh, absolutely.
M: If it had been reversed and we saw higher response rates in that XX group?
DR: The data is actually very believable. Obviously every one of us forms our own hypothesis as we read these, and if it doesn't come out the way we thought then we know that we don't have any errors in our judgement so it has to be the data. I learned that in medical school.
M: That you have perfect judgement?
DR: Yes, and if not you gave me the wrong data.
M: It's good for you to be confident. You're making important decisions.
DR: There you go."

in other news of confronting my own philosophical inconsistencies

Public Citizen notes that pharma is the biggest defrauder of the U.S. government. Worse than the defense industry, and well, we all know how ethical they are. Deeply unsurprised.

I will write more about this later...but figured I wanted to remember to come back to it, and in the meantime, perhaps interest others in this topic.


something about anthropology

As my previous post, a mere 12 hours or so ago, indicated, I don't really do anthropology lately. As much as one is ever "doing" it. Tonight, after a long day at work, I stopped at a nearby tiny sushi place (one of the best I think in SF). I'd done this once before, showing up alone, sitting at the bar, and just eating. Not reading, not looking at my phone, not worrying about work, not planning the future (escape). I used to get to do this all the time. Sitting. Observing. Listening. Thinking. Not rushing. I miss all those things. In doing them, I started remembering what I like about fieldwork, about actively engaging with anthropology. My back was to most of the tables, and so I could only hear conversations among the diners, without seeing expressions or what they were eating.

It reminded me how much I love the observational part of anthropology, how it's a skill and a superpower simultaneously. I like having to pay attention to nuances to read and to absorb the information around me. Having my back to people forced me to do that. It also provided the pleasure of tacit voyeurism. I know I forget in restaurants that the confessional moments with friends can be heard by anyone around me. The assumption that the public space creates anonymity is pretty naïve, but the frequent public cell phone conversations that we all engage in suggests that we all believe it -- or don't care if we forgo privacy and anonymity. I like how much I can read from conversations, little interpersonal dynamics that get lost when it's happening to me, seem so transparent and poignant when I'm listening to or watching others' interactions.

Long overdue

My new(ish) job has eaten up my life. I can't actually remember much about the last six and a half months, which I find disturbing. It seems to be a traumatic-coping mechanism. It's unfortunate, though, that I haven't been writing throughout the experience. Its challenges though probably not worth the "growth" that it's provided are still going to be rich and long-lasting material for understanding healthcare in the U.S.

I am (somewhat bafflingly) working in the pharma/biotech consulting field. I am helping pharma to better market products for metastatic oncology. Except that I don't really believe in their mission nor do I believe in our methods for collecting and analyzing market research. I don't know if I believe in "market research," at least not in its purely market-driven form. It's been frustrating both finding our research methods mechanized and rote and at the same time being highly skeptical of the purpose and goals attached to what we do. Kind of contradictory -- I suppose.

Last summer, I read Atul Gawande's article in The New Yorker, and I cried. It's resonated deeply with me, and I'm posting it here to share. I was reminded of it by this thoughtful post on Arthur Kleinman on Somatosphere, a great collaborative blog on anthropology + science. One of my great frustrations with my work is that we ask doctors whether they would use a product that has a small improvement in survival for patients who are going to die. They are going to die soon. Pharma Company X comes in and asks whether if you could give your patients Product X with these benefits for a few more months, would you do it? Even in our "probes" to explore whether the very unpleasant side effects or the outrageous costs would be prohibitive, the implication always is, well, how could you not offer your patients two, three, 1.5 more months? Not many American doctors would say, 'huh, no. No, I recognize that [as Gawande suggests] a less invasive death is actually better for my patients and their families.'

At the core of the metastatic cancer market is the denial of death. One product I've been working on is with a small biotech company that has a pretty remarkable drug -- an immunotherapy product for a cancer with limited treatment options. The drug costs nearly $100,000. The company's capacity for production is highly limited, even if everyone could pay the exorbitant fee...and yet....aren't we supposed to celebrate and embrace this product for its novel mechanisms and extension of life? Isn't that for what we are all striving?

Underneath all these products and the highly competitive and strategic pharmaceutical marketplace is really the question of whether putting technology in the service of life-extension for any cost is really worth it. Death is everywhere in this work, and no one talks about it.


NPR covers the HPV vaccine debate and fails to mention key data

I just responded to NPR's story about the HPV vaccine for boys. I'm re-posting here because I have to do other things, but I'll work on elaborating my argument a little better soon...

I think it's unfortunate that nowhere in this story did Ms. Wilson mention how highly successful Pap smears have been in the U.S. in reducing cervical cancer rates. Since their institution as a standard of care in the 1970s, Pap smears have reduced cervical cancer deaths dramatically in the U.S. Guttmacher Institute recently published data, as well, that showed the decrease in cervical cancer rates partly due to the Pap smear.

I think it's irresponsible to cover this vaccine and fail to mention this. It's a critical omission in Merck's promotion of the vaccine. It has value in countries where women do not regularly get gynecological care, but we have much cheaper interventions for reducing cervical cancer. Now, if Merck would honestly acknowledge that their vaccine protects against an STI that has high costs in morbidity, it would be a different promise and a different and more reasonable claim. I am disappointed that NPR did not fully report this information.


The conundrum of the female condom

The female condom initially received approval in the U.S. in the early 1990s, shortly after its approval in Europe. It's been tenacious, though not a wide-spread success. I remember the earlier advertisements with Drew Barrymore as one of its spokepeople, and I think she had a college tour through which my sexual health counselors' group tried to get her to come visit our campus. (Thank you, wayback!!)

In public health school, my group decided to focus our communications' class project on the vaguely outré device. During the health promotion project, it became clear to me that though conceptually interesting (female-control of sexually transmitted infections is difficult, nay impossible to find), the device did not really fill the more pragmatic side of motivating people to protect themselves during sex (awkward + noisy object does not really trump the protests of uncomfortable male condoms). Among safer sex promoters, their message often frames the female condom as an excellent and important alternative to the male condom. Even better, the female condom can be used for anal sex, as well as vaginal sex, making it as unisex as the male condom...maybe even more so. It also covers part of the external genitalia, possibly better protecting against STIs (HPV!!).

The female condom's manufacturers have gone back to the drawing board multiple times, improving the material of the condom (previously criticized as "too crinkly"). A number of major U.S. cities are promoting the condom as part of their safer sex campaigns. Consistently over the years, no one really addresses one of the most significant obstacles of using the female condom: it blocks female lubrication.

The female condom requires extra lubrication to be applied inside the condom before inserting the condom. From men's perspectives, the lack of a condom on their penis is supposed to be motivating and exciting. From a female perspective....well, I'm unclear how one's arousal patterns get taken into account. No one really knows what's going on, since there's a very large sheath covering the vaginal walls. This seems to me a rather significant impediment to female empowerment. How can one feel in charge of her own sexuality and sexual activity when there's no means to prioritize one's own sexual response? Most of the commentary about the female condom (see the CNN article linked above) make vague references to its awkward and large shape (it is supposed to dangle outside of the vagina, a very sexy prospect if I've ever heard one), but no one states the obvious: no natural lubrication.

While many people may use lubrication regardless of the absence or presence of a female condom sheath, shouldn't we be promoting more awareness of the importance of female sexual response?


Government requirement for vaccine insurance

Under the new health plan, insurers are required to pay for government recommended Advisory Committee on Immunization Practices (ACIP) vaccines. As the Vaccine Ethics blog points out, this increases the influence of the ACIP even further.

This also presents a couple of interesting problems. In 2008 the U.S. Citizenship and Immigration Services (USCIS) incorporated the ACIP recommendations on the HPV vaccine for women seeking to become citizens in the U.S. This decision led to a lot of resistance because the vaccine is not a requirement for women who are already citizens, it's not a vaccine that protects against any airborne contagion, and it's an extremely expensive vaccine. It was also discriminatory. The National Organization for Women (NOW) has a good synopsis of the problem. After much resistance, the requirements were eventually removed, but it shows the danger of giving too much power to the ACIP. After all, these are recommendations, not requirements. On the flipside, insurers are not eager to cover preventive health care, so issuing a federal requirement is not such a terrible thing.

In other countries, such as the Netherlands, research around vaccines has been a government-driven project, rather than a private industry responsibility. Corporations are disinclined to spend money on vaccines because they are not a moneymaker, and ostensibly (though increasingly less often in today's vaccine market) once one's customer gets vaccinated, he or she does not come back for another vaccine. (This is less true with vaccines such as the chickenpox vaccine, which appears to have waning immunity just in time for one to be at risk for shingles. There is now also a shingles vaccine, conveniently preserving or at least extending the market for the manufacturer's vaccine...Chickenpox is an example of an expansion of a market that seems unnecessary.) So the government requirement of insurers is a great way for pharma to insure their vaccines get funded. The U.S. is an important market for pharmaceutical companies and provides the incentive to develop vaccines, since companies can charge a lot for the vaccines here (as long as insurance companies will pay for them), making the vaccines more affordable in countries where there is less opportunity to make money, though often a greater need for the vaccines. There is also the Advanced Market Commitment (AMC) for certain vaccines, which has structured the pricing of vaccines so that countries that have a robust market can help subsidize certain vaccines (including the HPV vaccine) for countries that cannot easily afford the market price.

The new requirement poses an interesting conundrum with the HPV vaccine, as it's recommended for women but does not have recommendations for men, in spite of being FDA approved for men. In this instance, an FDA approval does not actually mean insurers will have to cover it. As has been the case with all sorts of attempts to require the HPV vaccine or to slot it into government regulation, the uncertainty about male vaccination pokes holes at the HPV vaccine's great promise, further revealing its status as a commodity instead of a necessary health intervention.


Moments of chagrin and remorse

I'm coming back. I miss writing. I miss thinking. I'm now misanthropic anthropologist, phd, and having grown weary of academia, I launched myself into the world of the private sector. It's been a month, and I mourn the loss of my old life all the time. I think I suffer from the grass-is-always-greener syndrome of being a malcontent. Paycheck=awesome. No free time and tedium=not awesome.

Lest my honed-skillz of writing atrophy while at a fairly unchallenging job, I think I need to re-visit this blog. I've been posting tons of links to facebook about sexual health and women's health developments, and I even got a piece published about the vaccine on a health-oriented website. But writing was so hard, and I realized I need to overcome this paralysis. And maybe need to figure out a long-term career that lets me be my curmudgeonly, cynical self, while impressing people with my insights. We'll see....for now, I'll enjoy the cash in the pocket, the student loans paid off, the ability to indulge in bourgeois bohemianism. And maybe it'll work itself out. At the very least, I'll finally have nice underwear and hot shoes.