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Renegade Quebec Doctor Warns of 'Ethical Bankruptcy' of Health-Care System

From Canadian Press DataFile (February 22, 2011)


MONTREAL -- Dr. Fernand Turcotte had not been retired long from his job in the faculty of medicine at the University of Laval when he came to an unsettling conclusion.

``I realized that the things I had been teaching my students for 35 years were not true,'' says the silver-haired former Quebec City professor.

``What I thought were the contributions of my specialty to the health and well-being of humanity in fact served to further poison people's lives.''

It is a stunning admission from one of Quebec's most prominent public health specialists. Turcotte was among the co-founders of Laval's faculty of public health and was a visible supporter of the province's ban on smoking in public spaces.

But he joins a growing number of experts, policymakers and medical practitioners who are expressing concerns about the creeping medicalization of natural health processes and the growing cost this represents for the health-care system.

At the heart of Turcotte's disaffection is a belief that prescription drugs are being prescribed inefficiently, and in some cases needlessly.

``To do our job, doctors need the pharmaceutical industry, but we treat it like a 300-pound gorilla and try not to bother it too much,'' Turcotte says.

``Except that the gorilla is no longer 300 pounds, it has become a brontosaurus.''

In 2009, prescription and non-prescription drug spending in Canada amounted to $30 billion -- 16 per cent of the country's $183-billion health-care budget, according to figures compiled by the Canadian Institute for Health Information.

That figure has jumped radically over the last decade, and drugs are now the health-care system's biggest expense after the $50 billion spent on hospitals.

Quebec's medicare board, for instance, has seen its prescription drug spending increase by 30 per cent since 2005.

The problem was illustrated neatly in a recent article that appeared in the Canadian Medical Association Journal, in which researchers probed prescription practices of Quebec doctors for cardiovascular drugs.

They found doctors were overwhelmingly prescribing a newer, more expensive class of drugs, even though it appeared to offer no health advantage to most patients compared to the older drugs.

In 2006 alone, the study estimated the health-care system could have saved $77 million by relying on the older ACE inhibitors, rather than newer drugs known as angiotensin-receptor blockers, or ARBs.

Sales representatives of pharmaceutical companies are often the ones telling doctors about these newer drugs, which unlike older off-patent drugs yield significant profits for the industry.

``The representatives that we interact with will be representing on-patent drugs,'' says Dr. Stephane Rinfret, one of the study's co-authors. ``Therefore, over time, it may have some influence on the prescription habits of physicians.''

For Rinfret, this tension is a natural product of having a pocket of private-sector interests operating inside the health-care system.

``We're dealing with business forces within the public system,'' he says.

Canada's patented-drug makers deny their sales practices are responsible for driving up health-care costs. Russell Williams, president of industry association Rx&D, says new medicines account for less than 10 per cent of the total health-care bill.

Generic drug makers must shoulder a good deal of the blame for expensive medicines, he said.

``In the last 20 years we have over-paid for generics in a way that I cannot explain,'' Williams told The Canadian Press.

``It's a failed public policy.''

But over-reliance on ``me-too drugs'' -- new medications that differ little from older ones that are losing their patents -- only scratches the surface of Turcotte's worries about how doctors are plying their trade.

He is alarmed by the consensus opinions being formed around medical issues that, at least scientifically, are far from settled.

Turcotte points to changes made in blood-pressure norms in 2003 by the U.S. National Institutes of Health that instantly created 45 million new patients deemed to have hypertension.

Older people, however, were under-represented in the sample that established the new norm, Turcotte says.

Higher blood pressure is natural in seniors, he adds, but getting it down to a level more prevalent in a younger population means taking a cocktail of medications that could have ill-effects.

``As there are more of us living longer, more of us become eligible for chronic illnesses, so there is a temptation to medicalize the signs of aging,'' he says.

``We're creating illnesses from normal manifestations of aging.''

Popular drugs such as Viagra or Cialis have helped manufacture the notion of erectile dysfunction when there is no scientific consensus on what a ``normal'' number of erections would be, says Turcotte. ``Illnesses are being created by marketing departments.''

Williams flatly rejected the notion that pharmaceutical advertising was driving demand for certain prescription drugs.

``Tell that to the patients,'' he said of Turcotte's assertion about marketing departments.

But Turcotte maintains the medical industry is suffering from an ``ethical bankruptcy,'' in which well-meaning doctors don't have the time to synthesize all the information coming at them from pharmaceutical companies.

Studies suggest a doctor would have to spend roughly 600 hours per month reading academic journal articles just to stay up to date with the latest findings.

``The average doctor feels guilty about falling behind on his reading, and this creates a fear of incompetence,'' Turcotte says. ``This makes them more welcoming of whatever suggestions, no matter how ridiculous, that come from consensus conferences.''

He charges that many of these conferences, where medical consensuses are formed, are tainted by conflicts of interest.

In some cases, papers presented at these conferences -- and related articles published in leading medical journals -- were found to have been written by ghostwriters paid for by pharmaceutical companies.

A recent lawsuit against drug giant Wyeth Pharmaceuticals revealed the company financed the writing of some 26 articles espousing the benefits of hormone replacement therapy in women.

The treatment has since been shown to increase the risk of invasive breast cancer, heart disease and stroke.

Williams acknowledged that the pharmaceutical industry is responsible for much of the information that doctors receive about prescription drugs. But he added that the industry has set up strict ethical guidelines about clinical trials and ghostwriting.

At the same time, he noted that he could only speak for the 50 companies that are members of his association, and that ethical lapses do occur occasionally.

``Some companies do not necessarily follow the same guidelines as us,'' he said.

But despite numerous examples of the influence of big pharma, Turcotte refuses to place blame solely on the drug industry.

``The problem is much bigger than finding a bad guy,'' he says. ``The problem is structural.''

Turcotte believes the solution is making patients, and their doctors, more aware of the pressures facing the health-care system.

Towards that end, he has taken it upon himself to translate into French the works of influential American rheumatologist Nortin Hadler.

Hadler's latest book, ``Worried Sick: A Prescription for Health in an Overtreated America,'' caused a stir for questioning a series of conventional treatments.

``Hadler warns about the impending implosion of the health-care system,'' Turcotte says. ``That's something we should keep in mind even here.''


Posted: February 2011