This article continues the work started previously, which can be found here.
Here are a few less known facts about “the legal drug industry”, in other words – Big Pharma.
The amount usually claimed to be spent by the industry in order to develop a new drug is 1 billion dollars. Some respectable sources go beyond that: an average of 4 billion and up to 12 billion (for an approved Astra Zeneca drug in 2011). These figures speak for themselves and explain the need to set high prices for new drugs in order to keep profits on an ascending trend. But are these figures accurate?
First of all, all Research & Development figures are graciously provided by the industry, for there is no legal constraint to publish them. It is hard to be unbiased in these circumstances for we might not all have the same definition of what is an R&D-related cost (see more here).
One thing that is easier to check though are profit margins for these companies. In 2014, they averaged 20%, a figure only matched by the banking industry! (source: bbc) And this is not a new trend, for the drug industry has been extraordinarily profitable since 1982, with an average return on revenue three-times the one of other industries in the US (source here). Is manufacturing new drugs a risky business? All these companies are so solidly profitable!
Another thing that we know is that the drug industry spends up to twice as much on marketing drugs than on developing them. The ethics are difficult to grasp in their way of prioritizing resources. Speaking of ethics- drug promotion at any cost is also the reason why drug companies are most often fined. Bribery might be illegal in most Western countries – it is common practice in other parts of the world (see for instance the 490 million dollar fine for GlaxoSmithsKline’s bribery attempt in China in 2014 (bbc)). But this is one tactic among many others worth knowing (especially if you desire to improve your multinational thug skills).
R&D is also subsidized with taxpayer money to an unknown extent (not easy to find using free internet searches). Nevertheless, public subsidies for drug research mean that “taxpayers pay twice, first for research and development, and then they pay high prices at drugstore” (said in 2011 Marcia Angell, former editor of the New England Journal of Medicine).
Finally, R&D is a tax-deductible expenditure. After tax deductions, the actual cost of R&D is a quarter to a third of the initial amount. Drug companies have an effective tax rate way below other industries (source). To this we can add various strategies to avoid paying tax, like piling up money in untaxed locations and using it through elaborate schemes like inversions or by reducing apparent earnings. Earnings can be easily reduced through paying royalties to one’s own subsidiaries. Inversions are a different take on the same tune: they are done by acquiring a smaller company and moving headquarters to the new location, accessing off-shore money in the process (for more see here).
We have assumed all the way that R&D was designed to produce new medicine, with a potential benefit for all mankind in terms of better curing awful diseases like cancer. Less than 1 in 4 new drugs are truly new – the rest are “me-toos” or very modestly active (see here and here).
All these aspects paint a picture of an industry that has more to do with banking (besides the astounding 20% profit margin they share) than with the genuine concern to cure and alleviate pain. It is no coincidence that banks are the main shareholders in this industry. Is this the way we want our health managed? Are we ok with the monsters we feed?
For those interested in more, please google “venture philanthropy” and “pay to keep healthy”. Have a safe journey!
Cancer is the world’s leading cause of premature death.
That being said, let’s cut to the chase: the public is under the impression cancer is routinely cured by evidence-based medicine (aka mainstream, occidental medicine). Is this really the case?
First of all, what does it mean, to cure cancer?
For most of us, it would mean to be free of cancer cells in the body, without any symptom associated to their existence, and stay this way indefinitely, until death occurs from unrelated causes. In reality, current cancer treatments are more about attempting to increase survival together with maintaining quality of life, when compared to patients receiving other drugs. This means that a good treatment for cancer is able to make us get through a few more months than another drug already in use, ideally without taking what’s left of fun out of them.
Big money has been invested and big pharma has delivered a certain number of drugs – chemotherapy – as well as other cancer-breaking strategies (mostly through radiation). The number of FDA-approved anti-cancer drugs went from 69 (between 1965 and 2000) to 153 in 2015 (source Sloan Kettering). These drugs, associated to the improvements in overall diagnosis and patient care, are quite effective in terms of survival – treated cancer patients tend to live longer. There has been an average of 1.6% decrease in cancer death rate in the US between 2002 and 2011 (source). This has to be put into perspective with the astounding 40% of the worldwide population concerned with cancer at some point during their lifetime (source).
Many of these therapies have been used long enough to notice there are not only acute side-effects (the well-known vomiting-diarrhea-hair loss picture we all have in mind) but also long term effects: more cancer. Bitter sweet irony! The world invests colossal sums of money in cancer research, the industry develops the cures which we pay again in order to benefit from them, we go through hell and back, hopefully don’t die in the process, get on with life, only to get vacuumed once more in this death trap because of a new cancer, this time related to the cure of the first one….
The strange life of surrogates
Needless to say – this didn’t look good, so scientists went back to the bench and tried to find something that could predict which patients would most benefit from a particular treatment in order to target them specifically. This is how the search for predictive markers began. We nowadays have a wide variety of them, spanning from easy ones like metastases in lymph nodes to the sophisticated search of specific mutations in the genome of a specific tumor, inside a specific patient (overview here).
Predictably, things got even more complicated: some very accurate predictive markers proved to be difficult to work with. For instance, in order to measure them, one would need to inflict a risky procedure to the patient. So this is how we began searching for surrogate markers of predictability. This is one of the reasons why medical imaging (such as CT scans, MRIs, PET scans) has tremendously developed over recent years.
The compass is broken
There has been a shift in our collective reasoning. Somewhere along the road, we found it is time- and resource-consuming to directly measure the number of days a particular cancer treatment adds to a patient’s life. There are now surrogate markers of survival and of life quality – such as Progression Free Survival. You need to know about this one, for this is what doctors hear about on a daily basis from the industry.
“Progression Free Survival (PFS) rate is the number of people who still have cancer, but their disease isn’t progressing. This includes people who may have had some success with treatment, but the cancer hasn’t disappeared completely” (Source: Mayo Clinic). This might seem a good surrogate marker for survival – if only a high PFS rate were actually linked to a better rate of survival….but it’s not. Why? it is hard to explain since scientists don’t fully understand it. Nevertheless, the shift has been operated and PFS has become the main “end-point” in most clinical trials. New treatments are developed to slow down cancer progression whether this translates into a longer and better survival or not.
One more thing: all these rates are calculated on a 5-year basis. This does not mean that cancer cannot occur afterwards. It is an agreement between medical and industrial worlds to use the 5-year deadline in studies, for it is less expensive to use in trials.
One can only respect and encourage the efforts of the ones engaged in this mind-boggling work. Nevertheless, these people might have lost track of the essential point at the heart of their work. Slowly, we see a shift in the way cancer is measured and referred to – lowering expectations from new anti-cancer drugs in the process. A fairly good drug today, is a drug capable of improving PFS by, let’s say, 4 months, regardless of its effect on actual survival or quality of life (example here). And this drug will soon become part of international guidelines for cancer treatment, which means that oncologists all over the world will be bound to prescribe it to their patients.
In 2009, two brave oncologists published an article that called medical community to embrace an ethical approach and challenge the validity of official guidelines regarding cancer drugs with limited benefits.
If we allow a survival advantage of 1.2 months to be worth $80 000,
and by extrapolation survival of 1 year to be valued at $800 000, we would need $440 billion annually — an amount nearly 100 times the budget of the National Cancer Institute — to extend by 1 year the life of the 550 000 Americans who die of cancer annually. And no one would be cured.
Yes, you’ve read it right: And no one would be cured.
We all agree, children are best taken care of by their parents. We also know that sometimes, rarely, families abuse children. In this case, the victims must be taken away from their parents and placed under someone else’s care and legal authority. This is the reason Child Protection Services (CPS) exist – so that impartial professionals establish what is the nature and intensity of the abuse, who are the perpetrators, who might be the person most likely to give the appropriate care to the victim/child and for how long.
This is an extremely heavy responsibility. The CPS workers must be of sound judgment, psychologically balanced, with solid knowledge of all aspects of childhood – including psychological and medical ones. They must not act alone, but be part of larger teams of social workers, psychologists, physicians, lawyers, judges. These teams have to be able to investigate very thoroughly each case of suspicion of abuse. All parts must have the means to be heard – the children and the parents. This means that a community or a state must provide financial resources and appropriate legal grounds to make this system work.
There are a few countries that have understood the importance of this matter and allocate considerable amounts of money to their CPS. One country stands out among them as THE country where children have indeed rights and are particularly guarded against abuse: Norway. This is part of a larger agenda, Norway’s main stated priority being “strengthening the international human rights system”. Norway is and has been for many years one of the largest financial contributors to the Office of the High Commissioner for Human Rights in Geneva. Norway is the state who selects the winner of the Nobel Prize for Peace each year.
Norway’s CPS is called Barnevernet. The system is organized similarly to other CPS in the Western countries. It has several levels of decision that are independent from classic courts of law. The system is also bound to confidentiality.
A few dozen cases since the beginning of modern Barnevernet in 1992 got the attention of international media. Most of these cases concern immigrants (from Eastern Europe, India, Africa and other). These cases start to paint a certain pattern in the way the system works that should be of concern. There are a few common points to all these stories:
-there is usually an anonymous tip or a concerned teacher at school who alerts the Barnevernet
-the children are always separated from one another and placed in foster families;
-they lose all contact to their native cultural background including their mother tongue;
-the parents have the right to a free legal counsel;
-the parents usually report they do not feel their interests are well represented by the legal counsel;
-the appeal procedures are usually very long;
-diplomatic and international interventions do not usually make the procedure shorter nor appear to change the outcome;
-parents are never prosecuted in a regular court of law for the abuse that led to the separation;
-spending years in procedures claiming their children were unjustly taken away from them does not constitute a proof of innocence for parents;
-even in the cases where the system admits an error has been made, the children are not always returned to their parents – separating the children from their foster family after several years is deemed not in their best interest.
Several points need to be addressed:
First of all, confidentiality issues make it difficult to get a good sense of any of the cases: the media only report the parents’ view on the matter – a highly subjective one by nature. Also, without a public account emanating from the CPS on specific cases, one can only judge of its reliability through general statistics. On one side, we have a mother who claims her daughter was taken away from her because she didn’t have enough toys for the child or because the mother will be soon too small to adequately raise the child – reasons so preposterous they automatically tend to discredit the parent. On the other side, we have a powerful system of a wealthy country whose figures show its efficiency. To sum it up, there is a dark side to confidentiality – the lack of control from the public.
Secondly, it has been argued that although other family members such as aunts and uncles come forward and claim temporary custody of the children, the system widely prefers foster care. Foster care system in Norway is largely private. There are private companies managing state funds for foster families as well as their selection. There are advertisements to become foster parents. Harboring a child grants a substantial increase in income. There are political figures involved in the foster care business. Yes, foster care is a business and, like all businesses, there is a profit to be made out of it. There is also a pressure for the business to continuously grow. How can it grow when the rate of abuse is actually very low and constant over the years?
Third, the best interest of a child is, like good parenting, difficult to define, especially from a legal point of view. There are obvious cases – like sexual abuse with a child directly pointing the finger at the parent and exhibiting injuries – where the best interest of the child is crystal clear. Most of the cases are on the contrary in a gray zone: what about mild physical punishments? What about religion? Where does religious indoctrination start? What about feeding from one’s hand, is it force-feeding? What about having an obese child? Doesn’t that imply improper feeding? What about being poor? Doesn’t that represent a loss in terms of chances to become a healthy, well-educated person? In order to prevent misinterpretation and abuse in the name of the law, all these questions and many more should be clearly explained by the legislator. We have to know where we draw the line of unacceptable. We also have to prepare for unexpected consequences, one being taking away the desire to have children of your own in a world that leaves less and less educational choices to the parent.
Forth, there is the question of the acceptable margin of error from a child protection service. When does it stop being a service? If child abuse detection were anything like cancer detection, one would want to set up a system capable of accurately detecting all cancers with the risk of an acceptable amount of false positive results. Cancer is a big deal, like child abuse, so one would want all actual cases to be detected. Unnecessary cancer treatment can lead to very serious side effects. These effects are nonetheless outweighed by the seriousness of leaving cancer untreated. Whereas having even one child’s life unjustly destroyed as a collateral damage in a system that accurately detects all abused children is or should be unacceptable. Statistically speaking, this will only add to the absolute number of damaged children.
Which leads us to the fifth point: what are the outcomes of abused children? What are the outcomes of children in foster or institutional care? There is growing social and scientific evidence that children are best taken care by their biological parents. Unbelievably, the children are sometimes better off with parents who abuse them than in the hands of strangers. Institutionalized kids are a complete mess. In the case of foster care, many children present traumatic disorders which are difficult to link to the abuse in their biologic family or to their new life in foster care. We do know that difficult children are more readily abused by caregivers. It is a spiral of violence that could be ended with immense love and dedication, two things hard to find in “prepaid parents”.
Finally, in all cases where the children are irrevocably separated from their parents there should be a full trial leading to the conviction of the guilty parent. The abuse justifying such a drastic decision must be very damaging and should be illegal.
Most of us have never been in contact with CPS in any country, just like most of us have never been in contact with mental disorder facilities. But they exist and evolve with time. Norway’s Barnevernet is something we all have to question. Is this what we want?
One might say this is just a way for some farmers to promote the fruits they produce. One might say these peasants have a great sense of humor. One might say they were victims of a joke done by a clever advertiser with an even bigger sense of humor. One might find it hilarious and post it on 9gag.
But look closely at the clip below.
What do you see? You see a very rich land where everything grows with ease. For many reasons, the people living on it are poor. In fact, Moldova is the poorest region in Europe, on both sides of the border but especially in the ex-USSR half.
So, look closer. You see worn out people who have been blessed with a beautiful land. You see people who cannot buy themselves what they produce. You see people forced to watch their hard work go rotten because no one wants to buy their very cheap fruit.
You see despair.
Why? Is this the way it is supposed to be? Is there no market for them?
If you would like to have a bite in one of Moldova’s organic apples, wave your hands!
In the rich part of the world, we know water is a major concern for many people, but we’ve never been in that situation ourselves. Some of us suspect our children might have to face the problem. What exactly is the problem? Here are the key facts to grasp a complex situation, insufficiently covered by the media, with direct impact on all of our lives.
Of the world’s total water supply, over 96 % is saltwater. Of total freshwater, over 68% is locked up in ice and glaciers. Another 30% of freshwater is in the ground and is increasingly used by humans. The rest is in rivers and lakes. Most lakes are in very inhospitable regions such as the glacial lakes of Canada, Lake Baikal in Russia or the African Great Lakes. The North American Great Lakes, which contain 21% of the world’s freshwater by volume, are the exception (1). Rivers are the source of most of the fresh surface water people use, but they only constitute about 1/10,000th of one percent of total water (2).
River water and groundwater are the main sources for human use.
Water is never sitting still: our planet’s water supply is constantly moving from one place to another and from one form to another in what we call the water cycle (2). Here are some simple notions you have to keep in mind: Precipitation creates runoff that travels over the ground surface and helps to fill lakes and rivers. It also percolates or moves downward through the soil to replenish aquifers under the ground (3).
It is estimated an additional 1.5 to 11 times the amount of water in the oceans is contained in the Earth’s interior, and some scientists have hypothesized that the water in the mantle is part of a “whole-Earth water cycle” (1).
The first 11 months of 2015, the world consumed over 4500000 billion of liters (4500 km3) (4), mostly on agriculture. Without the water cycle, the water in the rivers would be totally used by humans in less than 50 years.
Asia is the largest consumer. In the years to come, the regions that will see the most important increase in water withdrawal are Africa and South America (5). Here are some trends for the future, that can be sum up in a word:
The highway to hell
The water cycle was thought to be as permanent as sunrise and sunset. There is unquestionable evidence that several human actions disrupt this natural phenomenon:
intense urbanization, with less and less “green soil” out in the open, prevents water from percolating and renewing aquifers. It also changes the runoff pattern, the water never reaching the rivers or the lakes and ending up in the ocean.
massive pollution rendering water unusable for long periods. One of the latest and most dramatic such cases is the dam rupture and pollution of Rio Doce in Brazil (6). There are also intentional types of pollution – the most important of all being agrochemicals.
over-pumping aquifers and lakes to the point where the refill is no longer possible
virtual water trade: using water to produce something that will be exported. In the U.S., about one-third of the water is sent out of watersheds through this mechanism (7)
climate change – the one we are all familiar with – causes loss of glaciers and modifies the pattern of rainfall
In order to complete the horror show, did you know that drying out aquifers might have a terrifying effect? (7) You may have heard of a seemingly natural phenomenon – sinkholes. Several factors converge in order to form them. Urbanization and massive water pumping are frequently noted among them. See below a dramatic image of a Chinese sinkhole in 2013. Others can be seen in Mexico City and Florida.
Is there a contingency plan?
The short answer is no. There is no public plan for it and mainstream media is generally silent on the question. Why?
Some might say this is proof all this is exaggerated, the threat is in reality milder. It is true, water is still a bargain for the West: the average price of water in the U. S. is about $1.50 for 1,000 gallons (around 3785 liters) (3). You be the judge.
There is a general law of the planet Earth – all things are delicately intricate. This means that when something is imbalanced, a countless series of other elements become imbalanced. The opposite is fortunately also true. Putting our collective efforts into rethinking these roads for mankind will provide the spark that will eventually create a chain-reaction and solve much more than we would have hoped to in the beginning. By doing so, we will also trade our global-warming-triggered depression for an invigorating feeling of hope. This is no small thing.
Acknowledging the existence of the 4 causes – urbanization – pollution – over-pumping and export-based economies – besides the well-known global warming – is essential in order to begin the search for the right solution. Global warming is becoming a convenient excuse world governments lean on. Instead of trading carbon chips, we might as well try resetting our priorities (i.e. ensuring an above-all-access to clean water), rethinking our cities, putting to use incredibly efficient ideas already existing in alternative agriculture (8) (Monsanto is already one step ahead), scaling down economies to the local level.
We can do more than what we are told to do – check for household leaks, water the lawn in the morning and take 5 minute-long showers (3).
A corporate love affair
In a world where water – especially clean water – becomes scarce, the main question is who will own and who will use the water from the rivers and from the ground. The question of the ownership of lakes, glaciers and even oceans will at some point become even more important.
Remote sources once too difficult to exploit will suddenly become very appealing and technology will always follow in.
A partnership between IBM and a Saudi Arabian research center has been underway since 2010. The project relies on combining two previously unrelated areas of IBM’s knowhow, microprocessor technology (in a new kind of solar panel) and nanotechnology (in a new kind of desalination filter), in the service of a third: making clean water, a business that IBM wasn’t in 8 years ago (9). The world’s largest solar-powered seawater desalination plant incorporating this groundbreaking technology is due to be commissioned in 2017 (10).
The bright side of the market is that companies become extremely efficient in reducing the amounts of water they use because they have discovered it comes with cost cuts in electricity, energy and water treatment. These cuts amount to much more than the direct save from water. If we add to the equation the analytic capability of a company like IBM, we actually come close to perfection: their microchip plant in Burlington, Vermont. It is a factory where the company makes ultrapure water – necessary to produce semiconductors but harmful to living beings. They have managed to cut water use by 29% by doing some unbelievable things which won’t be detailed here. The key was to find out where the biggest costs related to water were. The act of measuring alone created an imperative for changing behavior (9). This is how IBM discovered the economic potential of water. In a world where more and more networks are highly monitored, water networks had long been overlooked. Not anymore:
IBM is introducing the world to the era of smart water (11).
Other giant corporations have developed a recent appetite for water, including:
GE – in 2014, GE was named Water Company of the Year by Global Water Intelligence: “GE Water has transformed itself from a bundle of overpriced acquisitions into the most formidable industrial water company in the world, positioned at the center of the water-energy nexus. In 2013, it was arguably the most successful water company in the business, advancing its activities on all fronts, while many of its competitors struggled” (12)
Dow Chemical is “Purifying the essentials of life” through its Water and Process Solutions (13).
Procter & Gamble manufactures a mystery powder that restores water to safe-to-drink levels and commits “to Save One Life Every Hour by 2020” (14)
Nestlé – Nestlé Waters is the world leader of the bottled water industry with a 11.7 % market share (15). In 2011, Nestlé’s CEO, Peter Brabeck-Letmathe, said the only way for the world to manage water distribution properly was to make it something for which we actually had to pay out of pocket (16).
As water becomes scarce, these companies sense the profit-making opportunity: a market develops. There is pressure for water to become a mere commodity. Letting the market manage water may reduce its waste, but not all companies are as efficient as the IBM Burlington water plant. In France, municipal water resources have been managed privately, then reclaimed by the government – with an actual distribution cost cut (16). Other voices claim that water is too precious to be mismanaged by governments (17).
Behind the marketing smokescreen, one has to recognize that the same companies responsible for very serious and long-term water pollution (18) are the ones that promise to adequately manage all aspects of water, including reuse and recycling. If they massively invest in recycling, what is the financial incentive to stop polluting?
Do we rely on recycling water or do we protect the sources we use? Can corporations do both without a conflict of interest?
Protecting the abused
Water is omnipresent on the planet and in our bodies, to the point that it has no color nor smell to us. For a long time, water was just there, within our grasp, not worth to mention.
We need to remember that water and life are inseparable. No known living thing can function without water, and there is life wherever there is water on Earth (19).
We need to remember that people can survive weeks without food and only days without water (3).
In 2006, the UN released a Human Development Report with an eloquent title: Beyond Scarcity: Power, Poverty and the Global Water Crisis (20). The whole report is worth reading, but 2 figures are mind-numbing and probably haven’t improved since:
1.1 billion people don’t have access to drinking water.
1.8 million children die annually from water-related disease.
How do we protect the children, the poor, water and ultimately all Life? Some say we need laws and regulations, but to what extent? What kinds of water should be concerned – drinking, domestic, industrial? Should laws concern water – who owns it, uses it, distributes it, cleans it – or all the other aspects that imply access to clean water, such as food, health and hygiene? Should laws transform housing and education in order to protect this right to water? Should laws regulate the biggest polluters – the industry – energy – agriculture? How?
To this day, two nations have included a right to water in their Constitution: South Africa (21) and Uruguay (22). The amendment to Uruguay’s Constitution was initiated through popular referendum. The amendment states that access to piped water and sanitation are fundamental human rights, and that social considerations take priority over economic considerations in water policies. This type of initiative should be acclaimed, studied and improved. The stakes regarding water are so high, unprecedented measures should be taken. Our political system should be remodeled around this core of rights. Exceptional care should be taken to protect Constitutional Courts from political and lobbyist influences that could weaken the implementation of constitutional law (23). The people in power – the governments – should be personally held responsible for failing to protect these rights and punished accordingly.
The ones that control water control life on Earth. Acknowledge it and talk about it.