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	The Health of Nations By Ken Rabin

The Chairman and CEO of a large international pharmaceutical company recently launched a fascinating and widely publicized attack against a phenomenon he has labeled "medical nationalism."

He basically argues that protectionist impulses in national healthcare policy are the enemy of consumer or patient access to the best available medical care, including the newest medicines.

He is, of course, quite right. But my experience suggests that the quest to subdue the dragon of healthcare nationalism may rival that of Don Quixote.

Over the course of more than two decades in international healthcare communications, I have had the opportunity to analyze and help carry out health policy communications projects in several countries, and have interviewed hundreds of patients and doctors. But what is probably at least as useful is that over the last five years, I have lived at various times in the U.S.A., UK, France, Germany and Poland, and been a generally satisfied if occasionally bemused consumer of healthcare services in each of these countries.

So why does my experience tell me that doing combat against healthcare nationalism so closely resembles the Spanish knight's noble quest to fight the unbeatable foe?

I think that there are two fundamental obstacles to overcome:

1. While one must always be wary of national stereotypes, nations, like individuals, do differ in terms of the ways they look at life and the ways they choose to live it, sometimes superficially but often in very significant ways.
2. Issues of national "personality" aside, some nations have more resources to invest in healthcare than others, and are using the issue of economic resources to reinforce medical nationalism.

Here's my take on these obstacles from professional and personal experience.

The Health of Nations

Back in 1992, I had an opportunity to take part in the preparation of a global assessment of the quality of patient information about prescription medicines, which was done under the auspices of a now-defunct Geneva group called the International Medical Benefit- Risk Foundation.

At one point during the preparation of this report, I found myself in Tokyo trying to understand a number of interesting discrepancies between Japanese, North American and European healthcare.

Why, for example, have Japanese doctors traditionally not disclosed a cancer diagnosis to their patients? And why is it that, unlike their counterparts in America and Europe, doctors in Japan both prescribe medicines and dispense them, thus deriving a large share of their income from their pharmacy business?

The answer to the first question, I was told by Japanese colleagues, has a great deal to do with the innate sense of privacy and decorum that is part of the Japanese character. In fact, it is only over the past few years that Japanese patients have had access to any consumer guides to prescription medicines, and almost none of these guides initially listed any cancer drugs.

The answer to the second question came not from a Japanese source but from a German pharmacologist who was part of our research team. "In Europe the rise of mercantile guilds during the fourteenth and fifteenth centuries led to the separation of physicians and apothecaries," he explained. "Japan did not experience a parallel historical development, so even though there are pharmacies in Japan, the prescribing and dispensing functions never fully separated."

This historical anomaly has, not surprisingly, led today's Japanese pharmaceutical companies to employ huge sales forces to cater to every need and whim of dispensing physicians, roughly one sales representative for every four doctors, the last time I looked. Or, as a young Japanese pharmaceutical executive in Osaka once told me, "Such a small island, so many sales reps."

The work I was doing on comparative access to patient information on prescription medicines also introduced me to one of the finest medical writers I have ever encountered, the late Lynn Payer, who was one of a number of "reactors" invited to review and comment upon our findings.

Payer's 1988 book, Medicine & Culture, which she updated in 1995 a few years before her death, remains a classic in its field. Her astute comparisons focus on medical practices in four of the countries where I have also lived (the U.S., England, France and Germany). Extensive reference to her pioneering work here is both enlightening and inevitable.

Payer argues strongly that despite all scientific charts, apparatus and white coats one might see in a doctor's office, the factors driving medical practice in the countries she studied owe far more to national culture, history and medical educational practice than to hard scientific evidence.

How strong is the force of tradition and culture? Over the past two decades there has been an increasing trend toward "evidencebased medicine," where third-party medical experts formally assess the body of clinical and treatment outcomes research on a particular condition and issue reports or treatment guidelines that are intended to influence the actual delivery of care. Writing halfway through the development of this trend, Payer surmised that perhaps 25 percent of medical decisions are evidence-based, up from 15 percent when she wrote the first edition of her book.

Some recent work I have been doing on the management of hypertension in Europe and North America suggests that the rate of adoption of evidence-based treatment guidelines has not improved all that much over the past decade.

Here are some of the significant cultural variations Payer reported in 1995:

"British, Canadian and American specialists in genitourinary oncology were asked how they personally would want to be treated if they had cancer. For locally advanced bladder cancer, 92 percent of American and Canadian specialists wanted radical surgery, compared to only 30 percent of British specialists. In the case of localized prostate cancer, 79 percent of the American specialists, 61 percent of the Canadian specialists, and only 4 percent of the British specialists wanted radical surgery."

He continued, "Patients and doctors in England and America, while often taking opposite sides on the issue of whether it is better to do something or nothing, tend to see disease as something that comes from the outside. By contrast, continental doctors and patients are more likely to emphasize weakness of particular organs and/or systems. French doctors will diagnose vague symptoms as spasmophilia or something to do with the liver; German doctors will explain it as due to the heart, low blood pressure, or vasovegetative dystonia; the British will see it as a mood order such as depression; and Americans are likely to search for a viral or allergic cause."

My own experience in France suggests that when French people suffer a vague pain, they really do say "Mon foie!" (My liver!), while an American might exclaim, "My heart!"

This really does follow through in medical practice. America remains the great center of cardiovascular medicine and surgery, even going back to the battles between the pioneering Houston coronary bypass surgeons, Doctors Denton Cooley and Michael DeBakey. American and international heart patients still routinely trek to Houston for a bypass procedure that could almost surely be performed as successfully much closer to their homes.

But if I had an operable liver tumor and wanted to be sure I got the most aggressive treatment and successful outcome, I would head for Paris. I would go straight to the Hôpital Paul Brousse in Villejuif for a consult with Professor Rene Adam, whose five-year survival results using aggressive liver resections to treat primary and metastatic liver tumors are astounding.

Lynn Payer found that the Germans have a far more complex relationship with their hearts than their livers, and that it is also a more subtle and mysterious relationship with that organ than is found in hi-tech America.

Writing before German reunification, she observed that, "West Germans use about six times the amount of heart drugs, per capita, as do the French and English.

"Herzinsuffizienz really has no translation into English because it would not be considered a disease in England, France or America. German doctors often translate it as 'cardiac insufficiency'...The German physician considers any heart more than thirty years old to be defective by definition, and he may well prescribe a cardiovascular product for all patients above a certain age...Taking digitalis for Herzinsuffizienz is something of a status symbol."

For a doctor in America or Britain (where Dr. William Withering discovered the medicinal properties of the purple foxglove in the 1680s), digitalis is used to treat something whose name is far less benign and far more clear-cut than cardiac insufficiency. In the English-speaking countries, digitalis, along with diuretics, drugs that interrupt the reninangiotensin- aldosterone system, and in some cases beta-blockers, are used to treat heart failure, a well-defined and staged condition that is usually fatal within five years.

For Payer, the American impulse to form a national heart association, develop a clearcut set of diagnostic stages of heart failure, and conduct massive clinical trials to test aggressive treatments to delay morbidity and mortality is bred into our culture.

"The aggressive approach that has characterized American medicine was evident even before the American revolution. Dr. Benjamin Rush [a signatory of the Declaration of Independence] believed that one of the hindrances to the development of medicine had been an 'undue reliance upon the powers of nature in curing disease.'

"Rush's success in promulgating his thesis meant that for many years to come massive purging and bloodletting were to characterize American medical practice. Rush promoted his therapies in part by convincing practitioners and patients alike that they were heroic, bold, courageous, manly and patriotic...

"This 'can-do' attitude is as much a characteristic of American medicine as it is of the American character in general."

It is a great sadness that Lynn Payer did not live long enough to carry out the next stage of her studies in a unified Germany, or elsewhere in Central Europe, where doctors and patients are now caught up in a very difficult struggle to adapt from state-controlled healthcare monopolies to more pluralistic and free-enterprise based systems of care.

Four years ago, I had an opportunity to conduct a qualitative survey of German patient attitudes towards their healthcare system and the pharmaceutical industry. We talked to almost 100 patients across the country.

Among other findings, we fully confirmed the continued validity of Payer's assertion about the German love for alternative medical treatment: "Still another legacy of romanticism to German medicine is the healing powers accorded to nature, whether it be in the form of long walks in the forests, mud baths or herbal medicine."

In fact, we found that a substantial number of Germans, East or West, would rather see their Krankenkassen (Sick Fund) reduce prescription drug benefits than their access to health spas and herbal medicines.

We also found that for all the financial investment that has poured into the eastern part of Germany, a great many former citizens of the DDR preferred the healthcare system they had under a communist state.

As one patient we talked to in Leipzig said, "We could go visit the doctor whenever we wanted. The doctor would spend time with us and even if we did not get the newest treatment, we felt that we were being taken care of by someone who cared about us."

I have found this to be true in Poland as well. People in my new home country visit doctors far more frequently than they do in the U.S. And they are willing to wait long hours in long lines to have this frequent access.

Some cultural variations in medicine and health are nothing more than interesting anomalies, of course. In America, when my kids or I complained of feeling feverish, my late wife took our temperatures orally. In France, when I was confronted with the need to manage the effects of a bad choice in seafood, the doctor took my temperature rectally and also prescribed a startling array of suppositories to treat the problem. In Poland, the first time I complained of feeling hot and feverish, my new wife startled me by inserting a thermometer into my armpit.

These are just a few snapshots of the doctor and patient behavior differences that help sustain medical nationalism. National variations in the ability to pay for healthcare services also serve as powerful incentives to medical nationalism, but may be a bit more amenable to change.

The Health of Nations and the Wealth of Nations

Economics can be a powerful force to sustain medical nationalism, especially in countries with government-financed national health systems.

Poland, a very large nation with welltrained doctors, spends a lower proportion of its GDP on healthcare than all but the poorest of the new EU member states.

The first time I accompanied my new wife to her annual checkup at a large medical center, she had to undergo routine blood work. As we stood in line waiting for her to have her blood drawn, I noticed that all of the people coming out of the phlebotomist's Gabinet had their left arms raised and were pressing small slips of white paper onto the site of the blood draw with their right hands.

I asked Anna, who happens to be medical nuclear physicist, "Don't they give absorbent cotton balls or Band-aids to people after a blood draw here?"

She looked at me as if I were from another planet and said, "Band-aids cost too much."

The same cost-cutting mentality applies to the availability of new medicines in Poland as well. While some innovative medicines for rare cancers are available to some patients in Poland, I learned that the Polish Health Ministry had not approved reimbursement for any new medicines for chronic conditions like high blood pressure, diabetes, high cholesterol or asthma for more than six years.

Not unsurprisingly, cardiovascular disease, diabetes and asthma are much more serious public health problems in Poland than in North America or Western Europe.

Worse still for Polish patients, and perhaps the clearest example of the dangers of medical nationalism, is the commitment the Polish government has made to sustain a domestic pharmaceutical industry whose major products are branded versions of offpatent medicines. This policy decision has created a situation in which Polish patients, with average incomes around $5,000 per year, currently pay higher co-payments for older medicines than their peers in Western Europe and North America pay for the newest available drug therapies.

In addition, the one truly significant resource of the Polish healthcare system, its doctors, dentists and nurses, are underpaid and overworked.

The last time Anna and I visited her surgeon, a charming, forceful and brilliant man in his late fifties, he told us that he would soon be off to Kuwait, where he had been offered a hospital staff position at perhaps twenty times his base salary in Warsaw.

Anna herself regularly accepts three- to six-month appointments to do radiological treatment planning at the Deutsche Krebsforschungzeitung (the DKFZ, or German National Cancer Research Institute) in Heidelberg, because she can work with state-of-the-art technology and make approximately eight times her monthly salary in Poland.

If any nation is using centralized financial levers as a mechanism to shift medical practice away from behavioral quirkiness and toward "evidence- based medicine," however, it is undoubtedly England.

The British have had a National Health Service since the end of World War II. Everyone complains about the NHS, the long waits for appointments and surgeries, the crowding and lack of cleanliness in hospitals, and the centralized bureaucracy (despite several interesting attempts to devolve budgets and decision-making authority to local primary care trusts and hospitals).

But the fact of the matter is that I have not met very many Britons who would swap the NHS for anyone else's system, and the UK spends only about 7.7 percent of its GDP to deliver healthcare services with decent outcomes by any standards of care. By comparison, the U.S. spends twice as large a percentage of GDP on healthcare with general health outcomes that are often not as good as those in the UK.

One reason that the NHS has been able to hold the line on healthcare costs is that over the past several years it has developed a very authoritative capacity to assess healthcare technologies and issue evidence-based treatment guidelines. This process is institutionalized in the National Institute for Clinical Excellence (NICE, for short).

NICE is by no means perfect, and often seems to be interested in delaying access to new medicines and technologies on economic rather than scientific grounds, but it has gained assurance and respect for its overall approach. And NICE does operate under traditional British rules of fair play. If the sponsor of a new medicine or technology feels that NICE has ruled on too narrow an evidence base, the sponsor can bring new data, medical and patient testimony, and media attentionto bear on the issue. If the arguments are compelling ones made within the context of the rules of its appeals processes, NICE will revise its guidance accordingly.

Other nations are looking carefully at the NICE process. Its treatment guidelines are already considered authoritative references in many countries, and politicians in several countries (including the U.S.) have called for establishment of similar bodies. But it is hard to imagine NICE existing in a healthcare system that is not as centralized or driven by the desire to truly rationalize its policies as is the case in the UK, or flourishing in an environment where debate and protest over its recommendations can be so fundamentally civil.

As a health communicator, I frequently encounter the obstacles some national healthcare systems employ to block patient access to health information generally, and information about prescription medicines in particular.

In the U.S., consistent with what Lynn Payer would have called our national character, every health agency and hospital engages in active communication of health information to consumers. While the FDA regulates the flow of medical product information between companies and consumers, it does not ban the transmission of such messages.

In Europe, regulatory authorities and national governments, fearful of anything that might drive patient demand for healthcare products and services, go out of their way to control the transmission of consumer health information.

In today's environment of borderless communications, such restrictions are proving to be both inefficient and dangerous.

Countless surveys have shown that European consumers want to know more about health and medicines, and those who have Internet access and understand English in particular will not hesitate to go to American websites to fill their information gaps.

But this situation discriminates against non-English speakers and does not provide information that is appropriate to the specific healthcare setting in which the European consumer lives.

That is why Ruder Finn is collaborating with a number of international pharmaceutical companies and third-party experts in health communications and patient advocacy to develop a model health communications network proposal for Europe, which will soon be available for demonstration to EU and national health policy makers.

Because the research-based pharmaceutical industry is vitally committed to advancing the use of new medicines to both prevent and treat disease, it has a powerful incentive to be a partner in advancing the cause of evidence-based medicine, improve the flow of appropriate consumer information about health and medicines, and help perfect health and pharmaceutical policy development and implementation in countries as diverse as the UK and Poland, as well as in the U.S.

This may be the most fruitful approach industry can take to help reduce the deleterious effects of medical nationalism.