The economics of life-saving research

By Marshall Scott

I’m paying attention to the thimerosal trial that began last week. The issue is the alleged causative relation between thimerosal, a mercury-based preservative once used in vaccines, and autism in children. Some parents of autistic children believe profoundly that their children’s symptoms began with and were caused by childhood vaccinations.

This has come, after some years in process, to the U. S. Vaccine Court. If you’re like me, you didn’t know there even was a Vaccine Court. It is, it turns out, a division of the U. S. Court of Federal Claims.Congress established the Vaccine Program “as a no-fault compensation scheme whereby persons allegedly suffering injury or death as a result of the administration of certain compulsory childhood vaccines may petition the federal government for monetary damages.” Congress intended that the Vaccine Program provide individuals a swift, flexible, and less adversarial alternative to the often costly and lengthy civil arena of traditional tort litigation.” Of course, in addition to offering possible victims monetary damages in “a swift, flexible, and less adversarial” context, the Vaccine Program also offers some protection to the pharmaceutical companies by virtue of being “not fault.”

For the families involved, of course, this case and the issue of alleged harm caused by a vaccine preservative is very important in and of itself. However, it also brings up a corollary issue: whether a health care system based primarily in private industry can adequately provide for us.

My point is not a general condemnation of free market capitalism. But we need to recognize the limits of the free market in providing for general welfare. While no company or corporation can survive unscathed by knowingly mistreating customers, the first responsibility of the company or corporation is to the owners and investors. We acknowledge that in a meaningful way when we distinguish in law and ethics between for-profit and not-for-profit organizations. The not-for-profit needs to come out ahead at the end of the year just as badly as the for-profit; but we allow some tax benefits and social approval for a not-for-profit because it reinvests all of its surplus in maintaining and perhaps expanding the work of the organization. The for-profit organization will return some surplus to reinvestment, but a significant portion is distributed to the owner or owners. That’s not a bad thing; but we need to remember that it’s integral to their nature.

And in health care that can be a problem. The pharmaceutical industry is a case in point. There are a number of areas in which we would benefit from more pharmaceutical research. New and safer vaccines, and new processes for delivering them faster is one. We have yet to see a vaccine for HIV, for example; and public health officials around the world worry about how long it would take to develop a vaccine for a rising pandemic influenza. Another area is development of new antibiotics. The recent story of the American traveler with extreme drug resistant tuberculosis (XDRTB) has raised again that concern. Finally, there are orphan drugs for orphan diseases. Orphan diseases are those that affect statistically small numbers of people. Orphan drugs are those that might treat them, but aren’t available, or are only available at very high prices, to treat those diseases.

These are all areas where many if not most of us face real risks, and where some experience severe suffering. However, they are not the major areas of research for pharmaceutical companies because they won’t be major sources of profit. Orphan drugs serve too few people to be financially viable. Vaccines prevent disease, and it’s been well documented that preventing disease is much cheaper than treating disease – the flip side of which is, of course, that is also generates much less cash flow. Antibiotics are prescribed ad hoc, as needed for a specific infection and only for a limited period of time. All of those are, if you will, natural limiters of profitability.

On the other hand, we all know some drugs can be quite profitable. They tend to have two characteristics. First, they are chronic medications for chronic concerns. For example, while you might take an antibiotic for a week or two, if you’re on cholesterol medication you’ll probably be on it for the rest of your life. Some folks will successfully change their lives sufficiently to eliminate the need for blood pressure medicine, but probably not that many. A company can make a lot for a long time, or at least for the life of the patent, with a drug taken daily for life.

The second characteristic is that the medications treat concerns that affect a lot of us, or that we fear will affect a lot of us. As we age as a society, that becomes even more of an issue. We baby boomers, wanting to fight off our own perception of our age as long as possible, are driving a lot of that. It’s no accident that there are so many advertisements these days for medications, both prescription, and “natural” (over-the-counter) for “erectile dysfunction.” Many of us men aren’t aging well, at least in our own minds, and we’re willing to pay a lot for the drugs that will help us, and for the research that will produce them.

Unfortunately, that leaves the small but significant gaps – and how small they are depends on whether or not you’re in one of them – that I’ve described. The benefits of new and safer vaccines, and new antibiotics, and specialized drugs are clear. The economic feasibility of the research to produce them is not clear at all.

Again, this is not to say that corporations, including pharmaceutical corporations, are evil for needing to make a profit. However, it is to raise a question for us as consumers (and investors), and as members of the body politic, and as Christians. Jesus has called us to be in the world but not of the world (as in John 17); and to be “wise as serpents and innocent at doves” (Matthew 10:16). As Episcopalians and as Anglicans we have long understood that to mean being engaged in the world, actively participating in God’s compassion (as in Matthew 25). The Millennium Development Goals are one expression of this. Our own advocacy as individuals and as a Church for a health care system, including pharmaceuticals, that serves all people is another.

That’s why, you know, the Episcopal Church maintains the Office of Government Relations. It is, to put it simply, a lobbying office, working to bring the moral statements of the General Convention to the attention of our elected and appointed officials. By lobbying themselves, and by involving individual Episcopalians through the Episcopal Public Policy Network , they make known the positions that we have taken in Convention on social concerns.

General Convention has not spoken to these specific pharmaceutical concerns. We have, however, spoken repeatedly of a need for “appropriate levels of cost-effective health care for all persons,” (1988-D108) and of “the right of all persons to medically necessary health care… to include… prescription drugs” (1991-A010). We have called for a system for universal access to health care (1991-A099), and have articulated principles for “quality health care” (1994-A057). In our last General Convention we adopted a Comprehensive Children’s Policy that includes the assertion that “Every child and family has a right to guaranteed quality, comprehensive health care” (2006-B018). All of these are based in the Baptismal Covenant, where we commit to seek and serve Christ in all persons, loving neighbor as self.

So, while we have not spoken explicitly about vaccines or antibiotics or orphan drugs, we have spoken consistently about appropriate health care, including pharmaceutical care, for all, including those who won’t generate a profit. For us as Episcopalians, these are opportunities for us to show our faith in the world in concrete ways. What do we expect of the officials we vote for, both in terms of programs like Medicare and Medicaid, and in terms of paying for basic research? With most health insurance provided through employers, what do we call for in the health plans of the companies we work for – of the companies we lead? How do we support health care institutions, whether with money or volunteer hours? All of these are ways that can directly or indirectly affect the availability and affordability of health care, including appropriate drugs, for all people.

And they’re all ways that are in our hands. Our free market, for-profit health care and pharmaceutical industries have indeed brought us significant benefits, but we can’t consider them sufficient to meet all needs. We have to act ourselves, both as individuals and as active, voting citizens, if we want a health care system that serves “the least of these” – including those who will never generate a profit.

The Rev. Marshall Scott is a past president of the Assembly of Episcopal Healthcare Chaplains. He keeps the blog Episcopal Chaplain at the Bedside.

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