None of this is very surprising. Pharmac simply does not have the same philosophy as mainstream medicine. Doctors are thinking “what can I prescribe to my patient that will give the best result?” Pharmac is thinking “What is the cheapest drug I can use for this condition?” Admittedly, doctors are notorious for being lead around by drug reps who are adept at persuading us that their drug is the best, with the lowest side effects and the strongest action. Pharmac is not so easily persuaded, needing hard evidence to convince them.

That last sentence is not quite true. Pharmac seem extremely easy to persuade that a cheaper drug is the exact equivalent of a more expensive one or, worse still, that a cheaper drug does “as good a job” as the more expensive one. Part of the reason for this is the division between itself and Medsafe – the body that approves drugs. Medsafe is only concerned with the safety of drugs, not their bio-equivalence (whether the drug is absorbed in the same way). Consequently, Medsafe will declare a drug “the same” without ever testing whether it is absorbed at all, let alone absorbed at the same rate as another brand. Pharmac will then buy the brand because it is cheaper, without testing its efficacy. Small wonder that sometimes the new drug is simply not bio-equivalent. Small wonder that Mrs. B’s blood pressure suddenly goes through the roof after ten years of stable readings.

Perhaps the most overtly ridiculous example of Pharmac’s idea of equivalence is their steadfast refusal to fund the EpiPen. The Herald today carries two articles – one on a little boy called Finn who carries an EpiPen with him everywhere and one on the renewed call for funding for EpiPens following the death of an 8-year-old boy from an acute allergic reaction to cashew nuts. It is highly likely that an EpiPen could have saved his life. Pharmac believes that providing a patient with a syringe, needle and ampoule of adrenaline is the equivalent of an EpiPen – an auto-injection device that contains the exact amount of adrenaline needed. Adrenaline injected at the earliest opportunity in anaphylaxis (collapse from allergy) is a life-saving action. Pharmac thinks that:

1. carrying around a syringe, needle and glass vial, breaking the vial and drawing up the required dose; then plunging the needle into your leg and pressing the plunger; is the equivalent of
2. carrying around a neat pen, taking the cap off, putting it against your leg and pushing the button.

You might think this madness is purely temporary while Pharmac is struggling a little for funds, but you would be wrong. Pharmac have stuck to this position since 2005. Here is the New Zealand Medical Journal article that pleads for full funding of the EpiPen. Here is the reply from Pharmac in the NZMJ. For those of you who like summaries, the gist of Pharmac’s argument goes ” People don’t know how to use the EpiPen properly and don’t carry it with them – so we will only fund an “equivalent” that is more difficult to use and harder to carry around”.

Yeah. I can’t follow their logic either.

Apparently, it does not occur to Pharmac that the simple solution to the poor use statistics of the EpiPen (which is still 10 times better than the syringe/vial combo) is to ensure that people are trained properly in its use.

• Provide it only to GP practices.
• Fund a nurse consultation to ensure that holders of the EpiPen and parents can use it properly (this does not add a lot to the overall cost of the EpiPen).
• Have a recall system in place so that people come in and replace their Epipen at no charge – and get another “refresher” from the practice nurse.
• Add training in the use of the EpiPen to all the first aid courses.

I am willing to bet within a couple of years at least 50% of all episodes of anaphylaxis will get treated with an EpiPen in the community. And we won’t have 8-year-old boys dying from an eminently treatable condition because Pharmac is too busy funding chocolate flavour condoms.

Related posts:

1. Why Pharmac Does Not Always Work
2. Three Thyroxine Monkeys
3. Mean Medicine

ROTFLMAO

The provision of free condoms (including flavoured and ribbed!) in GP practices has made absolutely no difference to the rates of unplanned pregnancies (the euphemism for abortion) and STDs. Neither has a massive indoctrination education campaign at all levels of the education system. The recent fall in abortion rates appears to be unrelated to these things.

Dyson is also incorrect when she states:

It could actually reduce costs to the taxpayer, she said, as making the condoms available in shops would circumvent the need to go to a GP, which incurs a taxpayer subsidy.

You do not actually need to see a GP to get free condoms as you can get them from the practice nurse. In any case, most people pick up condoms at the same time as they visit the GP for some other problem, so there is no saving to be made. The majority of these people use condoms regularly as their main form of contraception, so this is a legitimate funding expense.

Condoms are readily available in the supermarkets, and pharmacies and are relatively cheap. It is not the price of a condom that deters people from using them, it is simply that people do not like using them. Even the chocolate flavoured ones.

I expect to see large numbers of broom handles well-protected by condoms, if this daft policy ever get through the door.

Hat Tip: Chuck Bird

Additional:

David Farrar has made an attempt to cost this silly policy and come up with the figure of $100 million. I think that he has not factored in the enormous discount Pharmac will gouge out of the manufacturers. But even if it is a tenth of that, it is still money wasted on yet another Labour hare-brained scheme that has no medical or epidemiological evidence to back it at all.

Related posts:

1. Hot Chocolate
2. Condemning Condoms
3. There’s got to be a Morning After.

Those who know anything about AIDS in Africa, will know about the success story of Uganda. The promotion of “ABC” of AIDS (Abstinence, Being faithful and Condoms) has dropped the prevalence of HIV in pregnant women from 30% in 1992 down to 6% in 2002, a decade later (PDF). No other nation has experienced a drop of that magnitude, not even the US, with its widespread use of anti-retrovirals. Detractors have said that Uganda’s impressive drop is simply an artifact due to the large number of deaths from AIDS. There is only one problem with this suggestion – it is patent nonsense.

While some have postulated that the prevalence decline was primarily a result of so many people succumbing to the disease that the rate of new infections was simply outweighed by the numbers of AIDS deaths (e.g., Wawer et al., 2005), a number of other African regions have experienced nearly as old—and at least as severe—epidemics as Uganda’s, yet prevalence has yet to decline substantially at the population level. Moreover, the large decline in prevalence among younger age cohorts in Uganda cannot be explained by AIDS mortality, as very few people under age 20 die of AIDS.

Edward C. Green and  Daniel T. Halperin (2006)

And for those who say that only the condom element had any effect and that the abstinence/fidelity message fell on deaf ears they produce this:

The Ugandans have a phrase for this – “zero grazing”. Seems to work for them very well.

So. When do we start teaching our kids abstinence and fidelity along with condom use? New Zealand may not have a large AIDS problem at the moment, but every other sexually transmitted disease is on the rise. There is every evidence that ABC will work on these just as well.

Alternatively, we could just complain about moralising Christians while our young women’s fertility is destroyed by chlamydia infections.

Related posts:

1. And Condoms For All…
2. No Magic Bullet
3. Hot Chocolate

Seriously though, it was interesting to see the range of reactions over the announcement. TV three had Bob McCoskrie saying it was “tragic and a national disgrace”. 

“At a time when Pharmac can’t find funding for sufferers of breast cancer, heart disease, high blood pressure and other serious problems, that they can find funding to subsidise flavoured condoms,” he said.

Bob is full of nonsense, of course. Pharmac already funds condoms, just as it funds oral contraceptives, Depo Provera and the Morning After pill. Apparently, it can get the flavoured condoms ten percent cheaper than the normal ones. And that would be the only thing motivating Pharmac.

From the left, comes the inimitable Standard – Steve Pierson does one of his “here’s the facts” lists which looks almost like one of the Dim-posts satires:

- people have sex, young people have sex, people have sex with people they don’t know well or don’t intend to spend the rest of their lives with, they always have done and always will – you can get as moralistic as you like, it will still happen,
- sex can lead to unwanted pregnancies and STDs,
- unwanted pregnancies and STDs carry a cost to individuals and society,
- the best way to prevent unwanted pregnancies and STDs is by using a condom,

Well, three out of four ain’t bad, Steve. 

The first three are indisputable. The fourth is utter crap. The best way to prevent unwanted pregnancies and STDs is by avoiding sex, of course. But, should abstinence not be on your agenda, the best way to avoid unwanted pregnancy is the oral contraceptive, the next best is Depo Provera, the third best is the Morning After pill, and the absolute worst is the condom. The best way to avoid STDs is monogamy, or, at least, as few sexual partners as possible. Condoms are only about 80% effective at preventing STDs. Your chances of the clap rise exponentially when you start counting your lifetime sexual partners on the fingers of more than one hand (or if you use ladies of negotiable affections).

My thought is that the guys at Pharmac may know lots about medicine, but they know diddly-squat about economics. For a saving of about $100,000, Durex has managed to get Pharmac to agree to allow multiple types of condoms to be offered. It should be obvious that, if you are offering multiple types of condoms, all the GPs will want to stock all the types of condoms available. Expect a vast increase in the stocks that GPs wish to hold. Maintaining large stocks is expensive. Bye-bye savings! Expect also that the price of the condoms will go up next year but the choice will remain.

I predict the chocolate ones will be popular…

Related posts:

1. And Condoms For All…
2. There’s got to be a Morning After.
3. The Pen is Mightier Than the Jab

A South Auckland family doctor is worried some women might unintentionally become pregnant because of a shortage of contraceptive injections.

Now I have some issue with the word unintentionally, here. Unintentional implies a lack of knowledge. You can accidentally fall pregnant, if you are one of the unfortunates who regularly take their contraceptive pill, but still fall pregnant. Clearly your intention was not to become pregnant but through no fault of your own, you did. That is an accident. Unintentional.

This article depicts an entirely different scenario. Here the woman is coming for her three monthly injection. The doctor tells her that there is a shortage and recommends an alternative, in this case, condoms. If the woman then ignores the advice and risks the pregnancy, is this an accident or an inevitable consequence of risk? On the one hand, she is probably not trying to get pregnant, but, on the other, she is certainly not taking adequate precautions, even though she knows she should. How unintended is it?

This is not a purely idle question on a slow blogging day ACC have long accepted willfully risky behaviour as still an accident, but that is because it has a “no-fault” policy. Pregnancy is a little different (for one thing, ACC do not consider it an injury and therefore don’t pay for it!). Pregnancy most assuredly has a “fault” side to it. Pregnancy has consequences for both men and women. Should the woman be allowed to have an abortion if she has been intentionally reckless? Should the man have to pay child support if the woman doesn’t tell him she may not be protected against pregnancy? These are ethical questions that arise purely because of the issue of responsibility. Does it belong to Pfizer for making a bad batch of Depo? Pharmac for having inadequate supplies? The GP because his advice wasn’t clear? All of this stems from the word unintentional and it’s implication of non-responsibility of the woman.

A very similar situation occurs when a doctor prescribes an antibiotic to a woman on oral contraceptives. She will be advised to take other precautions while on the course and for a week afterwards. Yet I don’t see headlines saying “Antibiotic use sparks baby-boom worry” with an opening line “A slightly paranoid family doctor is worried some women might unintentionally become pregnant because of the usage of antibiotics.” I suspect we don’t see such headlines because we know that women on the pill are taking responsibility for their own contraception. Are women who take the injection somehow less responsible? I don’t think so – I think they recognise the fact that they are not very organised about taking tablets, and take other precautions instead. So I think the risk of unintentional pregnancy here is zero. There will be one or two women who will play the contraceptive version of russian roulette but, if they become pregnant that will not be an accident – just stupidity.

This Herald article is thus a total beat-up which apparently assumes that large numbers of women are completely irresponsible creatures. [Blokes are advised not to comment on that last statement ] If you want confirmation of the dumbness of this article then check out this quote from the doctor:

Abstinence is not very popular.

Tell me about it…

Related posts:

1. Accidental Baby
2. Accidental Rape?
3. Another Birth Defect