Alan Richards and docross asked us to list pharmaceuticals, biologics, and devices that could genuinely be worth investing in and benefit society. Real ones, not Zum Zum products. Instead of giving a comprehensive list, here is our strategy.
First, we look for systemic reviews that show high-quality evidence that makes a difference to patients. For example, we previously wanted to identify medications that affect emergency hospital admissions. To do this, we did an overview of systematic reviews identifying 11 medications supported by sound evidence and backed up by clinical guidelines that could help reduce emergency hospital admission.
Second, to identify promising treatments whose effects are uncertain, we would examine NICE guidance and mine its research recommendations. As NICE develops guidance, it identifies gaps and uncertainties in the evidence base that could benefit from further research.
Third, for many interventions of public health importance currently used in practice, we would perform systematic reviews using clinical study reports - as we did for tamiflu - to better inform decisions about their use.
Finally, we would review the WHO’s essential medicine list and overhaul its approach to adding new treatments using evidence-based methods. Be warned; the vital medicine lists should come with a warning. We previously identified 137 national lists of essential medicines that included 2068 unique medicines. The reason why the medicines are on the lists is unclear, and differences between national lists are only partly explained by differences in country characteristics and often aren't related to priority needs.
You may have noticed that we do not list our new wonder mega-blockbuster ZumZum items, as Boyd Brogan remarked. Recent history is littered with them, and their longer-term effects will be evaluated later.
For instance, if you are a great believer in the use of medication for obesity, then history (and the evidence) tells you these drugs are littered with problems. We did a systematic review of the post-marketing withdrawal of anti-obesity medicinal products because of adverse drug reactions. We found that most of the drugs over the past 65 years have been withdrawn because of adverse reactions. Furthermore, while oral centrally acting antiobesity products generate modest weight losses, they also increase adverse events and discontinuations because of adverse events. When we looked at the Clinical study reports (item 3 on our list), we saw that Naltrexone-bupropion (Mysimba) significantly reduces body weight by a small amount but significantly increases the risk of adverse events.
In the long run, the evidence will show the problems. As we’ve pointed out several times, a rigorous process for postmarketing surveillance is needed. The problem is—there isn't one.
But how many will be harmed before we get the proper evidence?
The Darzi post drew a lot of comments.
James Jones wondered whether we are moving out of the traditional funding model of health services inspired by the experience of two world wars. Helen McArdle reminds us that the current actors are members of the lockthemdownharder party. God save us.
There’s certainly something going on. At the very least, if HMG wants to go down the prevention route, the first job will be finding what works and what produces more harm than benefits. The trouble is, who is going to do that? UKHSA? They could not finish their mask review because they lacked funds and expertise. Or perhaps Cochrane so we can be subjected to influencers’ views, wokery and “measured gambles based on circumstantial evidence”?
Talking of Cochrane and its history, the Canadian Journalist Alan Cassels was commissioned by the then-Cochrane Collaboration to write a history to celebrate its 20th anniversary. He wrote it, but Cochrane bounced it, so he had to find other publishers.
What follows is a copy of part of early draft of the Introduction to “The Cochrane Collaboration: Medicine's Best-Kept Secret”, copied here with Alan’s permission:
Back to why this book almost never happened. Over the two years I spent researching and writing this book, I traveled to Madrid, Oxford, Paris and Quebec City carrying out more than 160 interviews with people both inside and outside the collaboration. Those interviews were video-recorded and made part of the 20-year Cochrane Anniversary and viewable at: http://www.cochrane.org/multimedia/video
I talked to those critical of the Collaboration, those who lead it, and many of those who are part of the 30,000 or so volunteers who work to make health care more evidence-based, more rational and more lifesaving.
And then in January of 2013 shortly after I handed in a 100,000 word manuscript to the publisher, I got some bad news. The leadership of the Collaboration and Wiley, the publisher based in London, UK rejected my manuscript. Apparently they too were thinking of Groucho, not wanting to have a club that would have me as a member. I was disillusioned but hardly suicidal. I feed on rejection like a hungry fruit bat sucks on an overripe mango. That which wasn’t going to kill me was going to make me more obstinate. After all, things kinda start to make sense if you look deeply enough. There are more layers of politics to this organization than one can ever contemplate. And the bigwigs in the Collaboration are skilled politicians, steeped in the myriad power struggles that make up modern healthcare, where the organization’s every snort or wheeze about medical evidence holds huge consequences for someone’s employment out in the real world.
I get it that the Cochrane Collaboration used to be a renegade band of misfits that would, with glee and fervor, attack the establishment, but now it is part of the establishment. You can’t have some crank journalist tarnishing “the brand.” I have no strong theories as to the rejection except one fact. What had happened between me writing the book and the Collaboration rejecting it was a big, lucrative contract. Wiley had just won a juicy, extensive multi-year, multimillion dollar contract to keep publishing the Cochrane Library. It was clear that with the Collaboration as their gravy train, why would they want the headache posed by some pesky book exposing the warts and peccadilloes of the characters in the Collaboration? Explanations from the leadership were cordial but vague. Some said they were truly sorry for what happened and sounded like they meant it. Others? Well, let’s just say it was clear there is something in this manuscript that someone, somewhere, didn’t want published. To me, that’s encouraging. That’s almost the definition of ‘news.’ So that’s why I shook off the rejection and sought another publisher. If you are holding a paper book in your hands, I have been successful.
I invite you to listen to the stories of the people in this book who have created something remarkable. I can’t promise the world, but I can promise that in this book you’ll meet some of the finest healthcare champions in the world, many still toiling against the greatest of odds, under the banner of “Cochrane.”
Although a bit dated, the book provides an interesting background to the first 20 years of something revolutionary. It’s available here.
M Dowrick remarks that we all can help prevent our own ailments reminds Tom of the lesson his Colour Sergeant taught him at Sandhurst: “if you want to see who is going to help you first when wounded on the battlefield, sir, look in the mirror when you shave”.
Dan Shaw wrily commented that the brain amyloid deposition hypothesis as a base forAD (the rationale for the Zum Zum MAB Lecanemab) is falling apart: So what are we targeting and what the XX@#¶¶ is the media screeching about? If the target is doubtful, should we use a very expensive and toxic biologic to fight amyloid plaques when we cannot tell the difference between an act of God and amyloid in AD patients? May we remind you that one of the effects of wonderMAB is the creation of microhemorrhages around the amyloid, which is, unfortunately, in our brain. Here’s an excellent background showing that the original images of the plaques and their deposition in the 2006 paper that launched the theory were fakes.
How many more of these fakes that made it past the infallible quality filter called editorial peer review infest the literature? And how many more will distort the priorities for spending on health services?
The post reminding readers of Dr Tedros’s urge to TEST TEST TEST prompted one of our readers to look up some background on Tedros. Here are some posts: in this one, the bit from the “Ethiopian angle” onwards is interesting. At the same time, this one, written by one of David Cameron’s former speechwriters, reasonably explains the origins of lockdown and its murky politics.
Our mini-series on Zum Zum fountain waters drew many comments.
including a private, unladylike response from Caroline Driver. We were a bit scandalised as old married men at John Jackson’s request for a list of scientific prostitutes. We are not moralists, it’s just that in the very long list, we would have difficulty in separating the fools from the social climbers or those genuinely on the take. We are only sure that Matt Hancock would be our number one on the narcissist list (if he has not drowned in the jungle yet).
Keep the comments coming to keep the old geezers alive. Go, go, go.
I think I have an idea for a thrilling new Netappleux series 'Slow Geezers' starring two down at heel epidemiological medical sleuths determined to root out corruption and dastardly fibbing! A surefire hit!! Now,who to publish the book version , Wiley perhaps??
There are 3 guarantees in this life - death, taxes and TTE readers comments 😆