A rapid escalation of the ongoing global power struggle in the US$3 trillion health sector1 is
challenging the status quo between global pharmcos, pharmacy industries and guilds, the all powerful
fiefdoms of clinicians, government agencies, politicians and the health insurance industry.
This perfect storm is due to a unique combination of interconnecting drivers that collectively offer the
winner, in this high stakes game, to take all. This would be achieved by acquiring control of the supply and
cost of all medications and complementary products, as well as controlling the knowledge of what actually
works for each and every patient according to their own genetic profile.
This contest of strength is showing all the characteristics of a dirty war as all sides start to realise the
ramifications of winning and ramp up their efforts to grab the high ground and the knowledge asset
acquired via the new electronic health records (EHR), by harvesting information from the data provided by
the support services associated with it.
The primary driver for this power shift is the inability by Western governments to meet the direct costs
of escalating health bills due to an explosion of modern day non-contagious epidemics with associated
rising costs of products and services, plus the indirect costs to the economy due to loss of income from
decreased productivity (days off work) and future income lost by premature death. For example, the
annual cost of obesity (and its related conditions, diabetes, heart disease and stroke) contributes US$93
billion to the nation’s yearly medical bill,2 while in Britain, the financial impact of obesity is estimated to
reach £45.5 billion per year by 2050.3
When the indirect costs of welfare and income tax reduction are factored into the equation, along with
meeting the costs of a rapidly increasing ageing population (the over 65s are set to comprise 20% of the
population in the USA by 2030), it becomes apparent that all Western governments, whether welfare or
private healthcare orientated, will need to implement dramatic cost saving strategies if they are to survive
the projected rate of increase in chronic disease and stay abreast of the next wave in “predictive and
preventive medicine” – the new designer drugs tailored for genetically distinct groups that will tackle disease
before you get it, ripening the market for long-term drug dependency.
Informed
consumers and
expert patients
are challenging
the existing
industry and
government
power blocs by
taking control of
their own health
and demanding
access to proven
natural foods and
products.
Navigating the Third Healthcare Revolution
According to Sir Muir Gray, Director of Clinical Knowledge of the UK’s National Health Service (NHS), we’re
moving into a 3rd healthcare revolution which will be knowledge-based, where the “knowledge [of what
works] will become the enemy of disease”. 4
The first revolution was the discovery that dirty water produced disease; the second revolution was the
discovery that chemicals could influence the course of disease, and this third revolution will be driven the
new-found ability of knowing what actually works (of today’s medications and procedures) for each and
every individual and, more importantly, which emerging medical breakthroughs could work. Governments
and insurers will take the lead of Sir Muir Gray, who says “the application of the knowledge we already
possess will have a bigger impact on health and disease than any drug or technology likely to be introduced
in the next decade”. 5
In a bid to control the knowledge, governments, insurance companies, clinicians and pharmaceuticals are
building their own electronic health databases to plug in everyone’s medical records (and eventually every
genome) in order to harvest the knowledge of which clinical procedures deliver the best outcome, the risks
and benefits of drugs within given populations, environmental factors and geographic variations in disease
and, most importantly, the cost-saving benefits or revenue generating capacity that this knowledge will
bring.
The capacity to enter information into a database in real-time has far-reaching implications for all involved.
The sharing of data across multiple parties, including general practitioners, specialists, clinics, hospitals and
support services (pathology, radiology), not only provides the clinician with all the information relating to
the medical events of the patient, but the benefits and risks of any new drug, product or procedure will be
realized in a comparatively short time which will release those that pay and those that prescribe from the
bondage of the pharmcos and manufacturers of new technology and enable more cost-effective treatments
that achieve better outcome for patients. The UK government’s expected cost of running the NHS’s new IT
systems could cost £40 billion by 2014, a huge increase on the budgeted cost in 2002 of £6.2 billion.6 Where
are the tangible benefits for patients?
To date most of these repository projects have run into problems due to the resistance of clinicians, who
traditionally collect and effectively “own” patient information, to enter this data and share it with the owners
of the new repository systems or, in many cases, even the patients themselves. However, this is not hindering
the funding of these systems by governments as without access to this type of knowledge they have nothing
to combat spiralling healthcare costs.
The insurance industry is also taking a keen interest in accessing the knowledge from these harvested
repositories. In the US, health insurers Kaiser Permanente, which has 8.7 million members, employs over
13,700 physicians and runs more than 30 medical centres7, has already established its own repository and
through the harvesting of data can now offer treatment to members whose data indicate that they may be
heading towards an adverse event, such as a heart attack, so producing large savings for the organization.
With the pharmaceuticals taking a keen interest in acquiring the harvested knowledge from these massive
data repositories the battle for control is also touching on a range of issues regarding ownership of individual
and collective data.
Each country seems to be tackling the issue of identity verification along similar lines using either national
identity cards, welfare or tax numbers, whilst, at the same time, arguing for a national ID card or exchanges
that can link multiple existing ID systems together for health and welfare. Much confusion exists around
ownership and privacy where most governments and corporations seem to use privacy legislation as a reason
not to provide information to citizens.
In order to avoid this tricky issue of ownership, a common approach is to allow personal information within
a health record (including the DNA profile) to be sold without permission so long as the person’s name is not
included. This “de-identified” rationale falls down on two points: firstly, it is possible to reconstruct identities
from these databases using new probability software; and secondly, current practices allow de-identified
information to be sold by a third party, without the owner’s permission, to multinational insurance companies,
which, in effect, challenges the whole principle of ownership and legalises theft by corporate bodies.
Unless ownership of individual data and the range of issues surrounding the rights of access and use of
aggregated data are established for the citizen and the common good, then the likely default position will be
a few powerful multinationals controlling the knowledge in collaboration with governments.
In order to put the endpoint of this power game into context it’s necessary to recognize not only the US$3 trillion
industry that’s up for grabs, but also the value of this new knowledge-based commercial asset. Although
no reliable figures have been published of this knowledge asset, it’s easy to estimate what the asset-value
would be, and therefore the share value of a small group of multinationals controlling the very heart of this
knowledge-based revolution.
This asset would contain the majority of individual medical records (including the knowledge of their DNA
profile) within the Western world and, in particular, those individuals who either have the ability to pay for
extended treatment or who can access the appropriate insurance.
The real asset value increases dramatically as it becomes possible to then match these findings with emerging
genomic products. This provides the owner with the ability to offer personalized treatment for the existing
chronic population of the Western world and the targeted market referred to as the “worried well” that would
effectively become drug-dependent for the rest of their lives in the belief that they are taking preventive
medicine.
Power Bloc Dynamics
To gain an understanding of these forces and to work out the implications of what happens if any particular
party wins the high ground we need to understand the politics of power. Only then do the tactics and
strategies of the dirty war become apparent and the darker implications for us all become blatantly obvious.
The three power blocks who currently vie for control are those who control the manufacture and dispensing
of drug-related products, those who are authorised to diagnose and prescribe product-based treatments and
those who pay which, in most western countries, tend to be government and/or insurance companies rather
than consumers.
The fourth emerging force represents the communities of common interest whose concern is to obtain
knowledge of what actually clinically works for them in their specific condition. As the aggregation of this
eco-group occurs it will gain the consumer power to counter the pharmaceutical industries, it will accrue the
knowledge to challenge the diagnostic powers of healthcare providers and it will exert political power to either
dictate policy change or even remove governments.
Most commentators are aware of the general dynamics between the three power blocks, but few have
factored in the destabilising fourth power. Aside from any obvious outcomes of shift in power, such as a rise
in prescription costs and insurance or a tightening of restrictions on the products we buy or the services we
are granted access to, very little is said about the true ramifications for us, and even less thought is given to
the not so passive emerging fourth power. Let’s examine the potential for each group.
Manufacturers and dispensers
The stated goal of these players is absolute control of product supply and, if possible, the extended use of
drug products for all which would include the chronic (33 per cent of Western populations8) and the “worried
well”. The most worrying aspect is that a strategy of dependency usually ends up as being multi-product
based, often using pills to counter the effects of the original treatment.
All’s fair in a corporate orientated world, some may say, where the share value is king, but a “sickness”
industry singularly profits from increased drug-dependency and targets large markets with blockbuster drugs
that generate 40%-45% of their revenue. Traditionally pharmcos ignore any innovative research into drugs that
prevent, treat or cure, instead ploughing funds into a small range of blockbuster drugs which can generate
revenues of over US$20 billion during the life-spans of their patents. 9
As the bubble bursts, it is finally acknowledged by the pharmcos that beneficial outcomes are limited to only
33 per cent of users, and up to 50 per cent may not respond. They focus the blame for this failure on the
variations in genetic make-up of individuals, where some people, for example, may metabolise the drug
before it has time to act.
However, the real cause of failure is that the clinical trials, funded by the drug
companies themselves, use only carefully selected individuals that do not reflect the population for whom
these drugs are aimed, such as those suffering from one or more chronic degenerative diseases, or the elderly.
In addition, the studies may inaccurately reflect the true results of findings due to the vested interests of the
authors or to a failure of reporting negative findings. 10
The emerging
fourth force
comprises the
communities of
common interest
whose concern is
to obtain
knowledge of
what actually
clinically works
for them in their
specific condition.
Because scientific proof of effectiveness and safety in the broad community is not required for drug approval,
the testing only truly begins when they enter the market place and are foisted onto a trusting public. With a
meaningless reporting regime of adverse reactions in real-time, which provides absolutely no contribution to
have time to reap many casualties as was seen in the cases of both Thalidomide and Vioxx.
Also under the spotlight is the effectiveness of older, generic drugs (whose patents have expired) against
newer drugs. Approval for a new drug is dependent upon achieving superior results than the drug it is
replacing, or improved clinical outcomes when added to an accepted protocol. Pressure to replenish revenue
streams with new patents as the old patents expire has led to inflated claims, and with no requirement to
test the added-value of a drug in a real-life setting, it is difficult to prove these claims.
However, in 2002 when ALLHAT (Antihypertensive and Lipid Lowering treatment to prevent Heart Attack Trial)
published its findings from a five-year trial involving 30,000 patients, no difference was found in the clinical
outcome between using cheaper diuretics (thiazides) over the more expensive angiotensin converting enzyme
inhibitors (ACEIs) and calcium channel blockers (CCBs).
There was no difference in mortality but a greater
incidence of adverse events was seen with the ACEIs and increased occurrence of heart failure with the CCBs,
while the thiazides reduced the incidence of stroke and had better effects on lowering blood pressure. In spite
of the negatives for the thiazides, such as reduced potassium and increased glucose and cholesterol levels,
these did not lead to any difference in clinical outcomes and they appeared to modestly improve the outcome
for most. As with most generic drugs, the cost for thiazides was only US$0.05 - $0.30 daily, while the other
medications ranged from $1.15 - $1.50 daily. 11
Although future negotiations between health care payers and the pharmcos will likely be based on clinical
outcome, the pharmcos are looking to the emerging market of “predictive and preventive” medicine – the
industry’s definition of the “wellness industry” - where they will be able to predict predisposition through
genetic screening and then prevent the disease with drugs before we become sick (this will also include
mandatory vaccination programs).12 Steve Burrill (of Burrill & Co, biotechnology company), predicts that when
everyone’s genome and medical records are plugged into the system that “in the future babies could be given
a smart card when they are born and we’ll add to that as they go through life.” 13
With new technology that can decode the human genome and identify the key signalling molecules (targets)
linked with disease, and the capacity to make, test and screen 1,000s of new chemical compounds day in,
day out, through building a library of millions of chemicals, it will be possible to match a drug with each new
target as it is identified. By linking genetic variance to drug response, scientists will be able to determine
which drugs will work best with each genetically distinct group. Peter Goodfellow of GlaxoSmithKline (GSK)
says “We’d like to create a drug for every target in the human genome, so you could start with drugs, not
the target.” 14
However, supporting a strategy in the absence of research to understand the full implications of altering gene
expression, that leads us down a route of greater drug-dependency is hardly intelligent, particularly as the
WHO has stated that 80per cent of heart, stroke and diabetes and 40 per cent of cancer is preventable and
that it is cheaper to prevent disease among healthy populations than to treat sick populations. Currently only
3 per cent of health care spending is used for prevention. 15
Global pharmcos are also looking to capture the lucrative alternative health industry to annihilate
competition and control product supply and consumer choice. Dirty tactics have so far involved government
regulatory bodies and the Codex Alimentarius Commission, an international organisation that sets
international standards and codes for foods, establishes upper limits for over the counter (OTC) vitamin
and mineral supplement dosages, and reclassifies all products that have therapeutic action as medicines
regulated under the various drugs acts.
The next stage will involve the patenting of new products based on natural products. Natural products cannot
be patented, but what can be patented is the technology that isolates and measures the bioactivity of each
discovered active compound of a natural health product and then replicates this in a laboratory. Hence we see
the emergence of pharmaceutical versions of herbs (PharmaPrinting), nutritional products (Nutraceuticals)
and functional foods based on a person’s genetic make-up (Nutrigenomics).
.......it will be
possible to match
a drug with each
new target as it
is identified. By
linking genetic
variance to
drug response,
scientists will be
able to determine
which drugs will
work best with
each genetically
distinct group.
For investors to invest, market exclusivity must be assured. We are already beginning to witness the banning of natural health products
under the guise of consumer protection, and there are already indications that we are heading towards a
situation where it would be illegal to grow herbs in your own back yard on the basis that they are dangerous.
The endpoint for the pharmcos is to capture all the indigenous markets (Chinese, Ayurvedic, South American,
African etc.) who have used traditional herbs for centuries and convert them to patented products that have
passed all the testing, standardization and scientific proof required for all drugs. 16
Clinicians and prescribers
Often referred to as the priesthood, this highly fragmented group of clinicians seek to control the ownership
of the relationship with the patient, the prescribing of drugs, the procedures that are used and the
acquired knowledge of their application. Their collective stance of non-collaboration (although not shared by all
clinicians) in government health initiatives to establish an EHR not only reflects this desire to control the
ownership or copyright of patient records, but also an unwillingness to be accountable for decisions made on
the patient’s behalf. EHRs will enable the auditing of all decisions and trace major mistakes in general practice
and hospital management.
An additional pressure will come from patients who will expect to have access to, or be advised on, the latest
clinical evidence when making choices in treatment. Sir Muir Gray states that whereas “the clinician was the
driving force in the 20th century, the patient will be the driving force in the 21st century.” 17
At this turning point, clinicians can either submit and become glorified pill dispensers (as described by the
then British Prime minister, Mrs Thatcher) or they can take up the challenge and use what’s left of their
credibility and trust to help patients as advocates and assist them in harvesting the knowledge of what
works. As attitudes to the profession change, the intimidating paternalistic stance that was once their hallmark
will no longer be acceptable as patients demand the respect they deserve when making critical health
decisions.
Governments and insurers
With health insurance costs set to rise by 6.5 per cent annually (an estimated US$1.00 of every US$5.00 spent
in the US on healthcare), with statistics indicating that more people in the USA per annum are dying from
medical errors (approx. 195,000 in 2000-200218) than from breast cancer, AIDS or motor vehicle accidents, 19 and
with the predicted rise in chronic disease set to affect 50 per cent of populations in developed countries,20
governments and insurance companies are looking to drive the costs down, increase their profits and get
better patient outcome.
Reducing costs means extricating the industry from the stranglehold of those that control prescribing - the
pharmocs and clinicians. A rapid deviation from the scientifically-based model of healthcare to one that is
clinically-based will demote the “scientific evidence” mantra that governed healthcare policy in favour of what
actually works, whether scientifically proven or not. With the EHR initiative, governments and insurers will be
able to accelerate the diffusion of clinical research information to sponsors, researchers, regulatory bodies
and the medical community at large, systemise healthcare by defining and controlling procedures including
the rules on what can be prescribed for any condition, and control what products can be used accordingly.
They will then be able to aggregate the demand and negotiate cheaper prices.
The UK government has also tapped into the frequent flyer market of patients with chronic conditions who
make the most visits to GPs and hospitals. The Expert Patient Programme 21, an NHS health initiative where
a certificate of competence is issued after a 6-week course of 2.5 hours per week, simply replicates the
self-management advice that self-help or support groups have been offering for decades, but through the
formalisation and adoption of the program (20,000 people have already taken part) has been able to show
measurable benefits both on improved quality of life and cost-savings for the health budget. Tangible results
demonstrate a reduction in visits to GPs and other health professionals by 44-80 per cent by various groups,
and a 31 per cent reduction in hospitalisation for asthma sufferers. 22
The expert patient - Pandora’s box
Although there are short-term benefits of shifting management of chronic conditions back to the consumer,
the long-term implications of endorsing groups of highly motivated people have not been factored into the
health equation.
Under the government and pharmco model, the “expert patient” is drug-compliant and therefore more cost
effective and profitable. However, virtual community groups in increasing numbers are communicating their
views and their own knowledge of what works for them over the Internet, and with the availability of the
new, free, open source software and tools, these groups will be able to gather, store, harvest and share
knowledge themselves, and become better informed and more responsible for their health – a threat to the
system, indeed. With the new emphasis on clinical outcome, as opposed to scientific evidence, comparison
studies between mainstream and complementary medicine may be published and present new challenges to
conventional healthcare.
The driver for this wave in consumer power is the cost of treatment, the reduction of disposable income,
a loss of confidence and trust in the medical industry and, more importantly, the realisation that health is
spiralling downwards and not a cent is being spent on addressing the causes. This group does not want to
be drug-dependent, does not want to see their children suffering chronic conditions: they want to own the
right to be healthy and any move by governments or pharmcos to inhibit access to natural food and health
products or therapies that have proven benefit will be met with fierce and co-ordinated opposition. Likewise,
this group will strongly resist and fight for the power to deny consent to any group – government, pharmco
or clinician - or even any IT company such as Microsoft or Google which stores health records to data-mine or
de-identify these records for the on-selling to corporations who seek to control and influence the market.
With a growing consensus that failure to address the key causes of our decline - environmental pollution
and nutritional depletion - will drive us deeper into a cul-de-sac, this fourth consumer power will succeed in
destabilising the current balance of power. When the core message from the three power blocks – “We think
we can help you manage and take responsibility for your condition that we created and, if able, to have you
pay for it” - finally dawns on the majority then the wave towards true preventive medicine, to manage your
own health before you become sick, will become the new mantra.
An additional
pressure will
come from patients
who will
expect to have
access to, or be
advised on, the
latest clinical
evidence when
making choices
about treatment.
Transparency International: Corruption and Health http://www.transparency.org/global_priorities/health
IT Facts Employment; Obesity Costs US Companies $13 billion a Year http://www.itfacts.biz/index.
php?id=P7657
UK Government Office for Science; Foresight Tackling obesities: Future Choices – Summary of Key
Messages http://s3.amazonaws.com/foresight/20.pdf
Brice, A. and Gray, M., Knowledge is the enemy of disease, Update, March 2003, http://www.cilip.org.uk/
publications/updatemagazine/archive/archive2003/march/update0303b.htm
ibid.
Carvel, John Confusion in Whitehall as IT budget for NHS balloons, The Guardian, 14 October 2004,
http://www.guardian.co.uk/technology/2004/oct/14/internet.politics
Department of Health, UK; The expert patient: a new approach to chronic disease management for the
21st century. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/
dh_4018578.pdf
Coghlan, A.; New Scientist: Blockbuster Challenge; June 2004 http://www.sciencejobs.com/insider/article.
action?article.id=insider105&focusId=uk
Etheredge, L.M., A Rapid-Learning Health System Health Affairs 2007;26(2)
The Answer: Thiazides First-line for Hypertension; Therapeutics Letter, Issue 47; January - March 2003
http://www.ti.ubc.ca/pages/letter47.htm
PriceWaterhouseCoopers: Pharma 2020: The Vision - Which Path Will You Take? June 2007
Coghlan, op. cit
ibid
PriceWaterhouseCoopers, op. cit
Alexander, K., Natural Health Products: Guilty until Proven Innocent? www.getalife.net.au/file_folder/nhp.
pdf
http://useu.usmission.gov/Dossiers/Public_Health/eHealth_Workshop_Presentations_May2007/Muir_Gray.
pdf
Kolodner, K., MD., (National Coordinator for Health Information Technology, USA) The United States National
Health Information Technology Agenda: MEDINFO conference; Brisbane, Australia, August 2007
Conversation with Stephen Alexander, e-health strategist, August 2007
http://www.expertpatients.co.uk/
UK Department of Health, op. cit.
This article first appeared in Nexus New Times Magazine, Vol 15, No 1; Dec 2007-Jan 2008
Kathryn Alexander, D.Th.D, Adv. Dip. Nat; Gerson Therapist, is an internationally acknowledged author and
expert in the field of detoxification and dietary healing, having lectured widely in the UK, USA and Australia.
She served on the Board of Directors of the Gerson Institute and produced its practitioner training manual.
Following the success of her current publication Dietary Healing: the Complete Detox Program she will be
publishing her expert patient series to help those with chronic disease take control of their journey, navigate
the medical system and choose treatment options that will deliver them the best outcomes.
Kathryn can be contacted by post at PO Box 259, Maleny, Qld 4552, Australia, by email at kathryn@getalife.net.
au and also via her website http://dietaryhealing.com
