‘‘A major difficulty with Mr. McKinnell’s proposals is that they are probably workable in relatively affluent societies…’

TWO months ago, this column reviewed a book by Marcia Angell, former editor-in-chief of the prestigious New England Journal of Medicine. The book, titled "The Truth about Drug Companies: How They Deceive Us and What to Do About It", severely criticized the behavior of the big pharmaceutical companies. It recounted how these giant firms have strayed from their original mission of discovering and manufacturing useful medicines and instead have become vast marketing machines making unconscionable profits from the sick and the dying.

Last month, this writer received a book entitled "A Call to Action: Taking Back Healthcare for Future Generations" by Hank McKinnell, chairman and CEO of the world’s biggest drug company, Pfizer, Inc. The book attempts to justify the drug industry’s huge profits as being of great benefit to mankind by enabling the development of new medicines for the ever-expanding health needs of present and future generations of human beings.

Just like Marcia Angell’s book, the Pfizer chairman’s book should be required reading for all who are involved in health and medical care especially those in the business of policy formulation and the regulation of health services both in practice and in the academe. Both books are well written and make for easy reading. One book, Dr. Angell’s, is heavy on data and facts and figures but quite understandable even to the lay reader. The other, Mr. McKinnell’s, is long on assertions of conservative faith in the power of unfettered market forces to inspire good deeds but very earnest in arguing for radical changes in the way things are done in the world’s health systems.

"A Call to Action" correctly identifies many of the major causes of dysfunction in most health systems. While his arguments are made within the setting of the American system (hardly a model for developing countries aspiring to have equitable systems) they are recognizably applicable to the Philippines which hasunfortunatelyadopted most of the worst in American health care practices.

One of McKinnell’s basic observations is that the disproportionate disease-orientation of health systems has contributed to an obsessive focus on cost and its containment as the solution to the health problems of humanity. This has diverted attention from the need to develop more effective and efficient ways of promoting health and wellness to prevent ill-health or sickness from occurring in the first place. In agreement with many health systems thinkers of the last two decades, McKinnell proposes that more health resources be allocated to health promotion and disease prevention interventions that would in fact reduce the need for maintaining those hugely expensive sickness palaces called hospitals or medical centers.

As head of a giant for-profit organization, the author of "A Call to Action" is understandably biased in favor of free-market concepts such as financial incentives and disincentives to influence health behavior. This is why he is attracted to the notion of "Health Savings Accounts" (HSA) as one way of promoting health and curbing unnecessary utilization of sickness facilities. The concept in fact is probably best developed in Singapore where "Medisave", a form of HSA, has been in place for years. The idea is that the equivalent of premiums are "deposited" in individual accounts instead of paid into a pool. The account can be used to pay for sickness expenses not covered by insurance but can accumulate for future use if the person stays healthy.

A major difficulty with Mr. McKinnell’s proposals is that they are probably workable in relatively affluent societies with no great disparities in wealth distribution. HSA appears to be working well in Singapore and should work in the United States . In the Philippines with its problem of mass poverty, such a scheme would have to be largely subsidized and is unlikely to be sufficiently protective of health and well-being to induce significant health behavior change. In any case, third party funders of health care (especially PhilHealth) should consider trying out small-scale versions of this idea.

One of the major blind spots in the McKinney book is its obviously self-serving protectiveness of the pharmaceutical industry. The book reiterates the position that protecting profits with patents is essential to continuing development of new, life-saving medicines by "research-based" companies. With this the author exonerates the industry from any blame for the poor state of the American health system and by extension for some unfortunate developing country systems like the Philippines ’. All of the faults are attributable to governments, hospitals, doctors, nurses, academic institutions, and professional organizations. In short all the health system players except the big drug companies like Pfizer which not only are saviors of the sick by bringing them newer and better medicines but are also good corporate world citizens who donate funds to poor benighted countries like Uganda .

Mr. McKinnell unfortunately glosses over many of the documented allegations of Marcia Angell. His book ignores the fact that big drug companies may actually be responsible for most high blood pressure deaths among poor individuals who could have afforded the cheap diuretic medications used until the late 1980s. These inexpensive but effective medicines (costing less than $37 per year) have become scarce in the market and replaced by expensive and actually less effective products like ACE inhibitors of which an example is Norvasc, a product of Pfizer (costing costs over $700 a year).

Throughout the book, Mr. McKinnell repeatedly reiterates that good drug companies can and should be part of the solution to the problem of an unhealthy health care system. Most of the stakeholders in health, including those in poor countries like the Philippines , probably agree with this. However, the pharmaceutical industry cannot become an effective partner in health sector reform unless it acknowledges that to this day and for so many years past it has been a major part of the problem itself.