The Virus Strikes

By now it is impossible to be unaware of the presence of a certain coronavirus (SARS-Cov-2, causing COVID-19) that is sweeping around the world. (Wouldn’t it be better if some nit-pickers could stop changing the name and do something more constructive to deal with it?) Unfortunately, the time for containment has passed. It may have been that the only chance was early on in Wuhan because China can do things to stop the personal lack of consideration of others; the possibility of 5 years in a Chinese jail would inhibit most from personal stupidity, but the authorities did not get started quickly enough. This, in turn, may have been because the officials in Wuhan did no alert Beijing until it was impossible for Beijing not to notice. That golden opportunity was missed.

In New Zealand, we started with a law passed by which all people coming into the country had to self-isolate for two weeks. Within about two days a small number had been arrested for breaking that rule. In Wellington here we had someone fly in from Brisbane. He had been tested in Brisbane, but would he wait for the test results? No, he felt he wasn’t sick (so why was he tested?) Did he stay isolated until the test results? Of course not. When you are that self-centred, you do not suddenly become responsible. Wellington now has the second most cases in the country.

There was one woman who arrived in Auckland from overseas and was feeling ill.  At this stage she was advised to self-isolate but the law requiring her to had yet to come into play. So what did she do? She convinced herself she wasn’t so ill after all, so she flew to Palmerston North, where she discovered that maybe she really was sick so she flew back to Auckland. The net result of this is we shall get some idea of how easily this virus really does spread. So far, Palmerston North has three cases, but if there is an inexplicable surge over the next few days, we shall find out something. If, on the other hand, there are no such cases, we may be able to breathe a little easier. (It is not just the people sitting close on the aircraft; recall how people behave prior to boarding, during boarding, collecting luggage, and if using public transport, getting to and from the airport.)

While we were relying on voluntary compliance, the virus was actively spreading. The government has now required a complete lockdown, going out only for essential services. Will that work? In principle, if everyone on the entire planet stayed home for a month, all would be well. Those who had it would have to recover, but the virus would run out of people to transmit to. Simple? The problem there lies in everyone doing it at the same time. In the West, people want freedom of movement. Asking them to give this up seems to be beyond them. In New Zealand this might work. The police and if necessary the military are there to enforce it, and China appears to have shown this can work. We shall see.

As for me, I am self-isolating, only going out for groceries, but in my case, because I am retired it is no big deal. My day-time job used to be to do chemical research on contract for companies wanting to develop new products. That work has dried up completely. When potential clients are having problems staying open and paying their wages, research is the first to be stopped. As it happens, I was approached to write a chapter for an academic book on hydroliquefaction of algae, so writing that will keep me occupied. Searching the scientific literature can be done on-line these days.

The main tactic is not to get close to people. However, there is also the problem that the virus may land on something and you touch it. Staying at home is fine, but you still have to get groceries, and some people have to work.  Hand washing is important, but if you touch something after washing hands, that wash does nothing for what follows. The virus on the hand does no damage, but how often do you touch your face? What I intend to do is make a blocking gel to smear on my hands when visiting the supermarket. Two functions are desirable. One is to kill viruses. The second is to make the virus immobilized on the gel, like flies on flypaper. The coronavirus has a “crown” of protein so something that binds protein is called for. I won’t know for sure it works, but one advantage is that while I cannot get it tested for efficiency, I can back my own theoretical ability for myself.So, keep well, everyone. If all goes will and we all cooperate, this will pass. Finally, good luck all.

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A New Coronavirus

2019-nCoV is having an effect that most will have heard of. It is apparently milder than some related viruses, such as SARS, which had a mortality rate of 10%, but that might be premature because the new virus has caused a very large number of seriously ill people, and nobody knows what will happen to them. So far, the probability of death appears to be around 3%, although a number of those are through people who had poor health anyway. Unfortunately, it appears to spread at a dizzying rate, and so far the number of patients appears to double every six days. It appears to have a period of about 12 days when it is asymptomatic, but it remains contagious. Most people will know about the effects of mild contagious coronaviruses. The common cold is caused by over 90 different viruses, the majority of which belong to the rhinovirus family, but coronaviruses participate in a good percentage.

This virus almost certainly came from animals, probably a bat, but when and how are uncertain. The genomic sequence of 2019-nCoV is 96.2% that of a bat coronavirus, and 79.5% is identical to sequences found in SARS. The Huanan Seafood Wholesale Market in Wuhan, which also sells animals as well as fish, may be the origin of the outbreak as the earliest patients had visited it, and 33 environmental samples from the Western end of the market, which is where the animals were sold, contained the coronavirus. However, the first patient apparently had no contact with this market, so it is possible it started elsewhere and infected the market. Genomic sequencing, which involves counting mutations since entering the human population, suggests the virus began spreading in mid November, 2019.

So, what can be done? At present, the best approach is containment, but whether this is possible when it takes two weeks for symptoms to appear is another matter. If it works, in a few months everybody will wonder what the fuss was all about. If containment fails, it appears to be as contagious as the common cold, and who hasn’t had one of those? One calculation has suggested there could be up to fifty million dead through it. Most would say that is unduly pessimistic, but is it? If there is any good news, it is that the number of reported cases in Wuhan have had about three days of falling. We hope the decline is real and not a consequence of poor reporting.

For current patients and those over the next year, we need something ready to go, and fully approved for use. That suggests trying drugs with antiviral properties. At this point we do not know whether any will work, but if used on patients with the virus, the argument is it is preferable to attempt to do good. In Wuhan, they are already trying a randomized controlled trial of two drugs that target the protease enzyme used by HIV to copy itself. These drugs apparently gave beneficial results against SARS, which is promising. The drug remdesivir, made by Gilead Pharmaceuticals, is a possibility. It interferes with the viral polymerase enzyme, and it has shown activity against every coronavirus tested so far. When combined with interferon it slowed viral replication in MERS-infected mice. (MERS is another coronavirus.) Another US biotech Regeneron is trying to develop monoclonal antibodies; it has previously managed to develop them that were effective against ebola and MERS. 

The next most obvious approach is to develop a vaccine, but historically there has never been a vaccine developed fast enough to have a significant impact on an emerging virus. Historically, vaccines were based on the concept of injecting dead virus into the body to stimulate the immune system, but this is not the current approach. The Chinese got proceedings started by publishing the genetic code of the virus, which was truly impressive work given how quickly they did it. One approach is to convert viral sequences into messenger RNA, which causes the body to produce a viral protein that triggers immune responses. Another approach, at the University of Queensland, is to try to develop a vaccine made of viral proteins grown in cell cultures. Another approach is to make a string of RNA that corresponds to a section of the coronavirus. Thus there are a variety of approaches, and the question then is, will they work?There is also the question, will they work fast enough? Suppose we developed one? It is inconceivable this could be done in less than three months, at which time there would need to be clinical trials. These would take several weeks, and that would have to be followed by a period of six months where it was determined whether there were any adverse effects. That would have to be followed by an extended period where it was examined whether the vaccine actually works, and the net result of this is that it would take over a year at the very least to decide whether we had a working vaccine. Then it has to be manufactured. A vaccine is our only defence if we cannot contain it and it becomes endemic. In the meantime, the scientific community is working; apparently there are at least 77 scientific papers made public on it since the outbreak became declared.

Cancer: the problem.

I read an interesting blog recently entitled “The War on Cancer” (http://sten.astronomycafe.net/the-war-on-cancer/). Apparently, in the US a little under 600,000 people die of it each year. The author, Dr Sten Odenwald, then set out to illustrate that funding for cancer research is far too low. I think it was President Nixon who coined the phrase, “war on cancer”, and set it as an objective, in the same way Kennedy had set the Moon landing as an objective, but this was doomed to fail, at least in the spectacular way. The reason is the nature of cancer, which, as an aside, is not one disease. We have been trying to cure this for a very long time, but with mixed results. Gaius Plinius Secundus recommended a poultice of broccoli for breast cancer, and asserted it works. There are indeed agents in broccoli that will deal with some breast cancers, but by no means all, and even then, the cancer would need to be near the surface. There are at least twenty different types of breast cancer. Drugs like tamoxifen stop the growth of at least one type, monoclonal antibodies help in some others. So we have made some progress, but there are still severe problems, especially if the tumour metastasizes (dislodges cells to other parts of the body).

It is the nature of cancer that is the problem. Cells grow around nucleic acid, and nucleic acids reproduce by base pairing, then splitting, each strand now being the frame for the production of more nucleic acid. Thus after splitting, when a new double helix is finished being assembled, the amount of nucleic acid has doubled, so a new pair of cells is possible, the old cell having been destroyed. So what can go wrong? You will usually read that copying is not correct, or something is added to the double helix, but I don’t believe that. It is the peculiar nature of the hydrogen bonding that either the correct nucleic acid goes onto the growing strand or nothing does. That is why reproduction is so accurate. In the double helix, the reactive sites are protected, as they are in the interior of the helix, and the outside is the phosphate. A further substitution on the phosphate to make a tri-ester would be a nuisance, but it would not be very stable, and it would repair itself. Further, it would require a highly reactive reagent to do this, as it is exceedingly difficult to make phosphate esters in cold water other than through enzymatic catalysis. No, I think the problem probably arises during the splitting stage when the reactive sites become exposed. If something happens to the nitrogen functions, then that will block the formation of the next double helix at that point.

At that stage, the body will attack the nucleic acid at that point, and the next usual outcome will be that the various parts of the strand will be degraded, and the bits reused or excreted. But if the problem occurred in certain places, it may be that what is left can start reproducing. If that happens you have something growing that has no function for you, BUT it looks like it is part of your body, because up to a point it is. The growth just keeps growing, and reproducing itself. The reason there are so many different cancers is there are so many places where a nucleic acid could go wrong, and each different place that can reproduce will lead to a growth that is slightly different from any others. Because it looks like part of your body, your natural defences ignore it.

So far, we have largely relied on surgery, radiation or drugs. So, how is progress? In some cases, such as leukemia, progress is good, and it is often curable. In other cases, life can be extended, but according to Wikipedia, since Nixon declared war on cancer, the US alone has spent $200 billion on research. Between 1950 and 2005, the death rate, adjusted for population size and age has declined by five per cent. On the other hand, while in remission many patients have had life extended.

However, we should ask, are we doing anything wrong? I think we are, and one problem relates to intellectual property rights. Here is an example of what I mean. In the 1980s I was involved in a project to extract an active material from a marine sponge. My company developed some scale-up technology and made a few grams of this material, which, from reports I received, if the odd microgram was introduced to a solid tumour, the tumour blistered and died, leaving a well-repaired skin outside wherever the organ was. This property was limited to studies on rats, probably with external carcinoma. Anyway, the company that hired us ran into difficulty with its source of funds and went bankrupt, however, somehow ownership of the intellectual property lived on. At the time, there was no known technique of introducing a material as reactive as this to internal tumours, nor did we know whether that would even be beneficial. Essentially, the project was in an early stage, and maybe the material would not be beneficial. Who knows? The problem is, now we don’t know and nobody is likely to work further because the patents have expired. Any company working on that will have all the expense, and then somebody else can come in and take the benefits. In my opinion, this is not a desirable outcome. We should not have a situation where promising knowledge simply gets lost because of formal procedure.

Equally, we should not have the situation where drugs become ridiculously expensive. Why should the unfortunates who get a rather rare cancer have to pay the huge prices of drug companies? I am not saying drug companies should not get a fair return, but I think society should pay for this. Think of it as compulsory insurance. The alternative is a family might have to decide whether to bankrupt themselves, kill the grandchildren’s education prospects to buy a year or so for grandmother, or whether to just let her die. What sort of society is it that allows this?

Cancer is one of those diseases that everybody comes into contact with one way or another. In my case, my father died of pancreatic cancer, and I am a widower because of cancer. Yes, these things happen, but isn’t it in everybody’s interest to try and do what we can to at least minimize the harsh effects?

Happenings!

Since my last post, things have been happening and there has been material for several posts. I have been in hospital getting a hip replacement, but that is of little importance, other than to me. The United States elected a new President, after what I thought was one of the most bizarre campaigns, and then there was . . . But more of that below.

The surgery and the follow-up care were carried out with professionalism, skill and commitment, and I can assure anyone wondering that New Zealand does have good skilled medical care. One can argue about the politicians’ involvement with health care (and many of us Kiwis do), but I could not have asked for more. While recovering, the election results were coming in, and I had nurses pausing and discussing. Many Americans probably do not appreciate the importance many ordinary people in other countries attribute to their political scene. Of course there is no personal involvement, so we could make our comments in a detached sort of way. I am sure all who are following my blog, or other writings, will have seen enough comments on the actual result, so I shall leave it at that, other than to add that only too many of such comments show some ugly aspects of the writer that probably should not have been shown.

Then it was time to come home. My daughter thought I was being silly coming home because I have some fairly steep steps to climb, but no problem. The hospital had the rule, if you cannot climb up and down steps, you cannot come home, and I had practised. A lot of people commented on how well I was doing, bearing in mind . . . I put that down to three things. First, for weeks before going in I had been doing exercises to strengthen hip muscles. You cannot do anything about what is to be cut, but with bad hips, the muscles around them tend to atrophy through lack of use. You can do something about that. The second, I was determined to do what had to be done, and I think attitude helps. Finally, I had some long-term goals. Simple goals, like being able to walk down the beach in our up-coming summer. Be that as it may, I mention it just in case anybody else is to face such surgery. One can imagine all sorts of things, but it helps if you can focus on the desirable.

So, the day I came home we had, in a 24 hr period, the total average rainfall for November, and here was me hobbling up towards the house. Any moss on concrete, when wet, tends to get slippery, and you need slipperiness under crutches like you need the plague. So, the end of the bad luck?

Nope. I came home on a Saturday, and had a quiet Sunday, but then shortly after midnight, the house started shaking: a 7.8 earthquake. (Equivalent, I have been told, to 5.35 Mt of tnt.) This was centred at Waiau, which is about 40 % of the way between Christchurch and Wellington. This has apparently got international attention, especially “cow island” – three cows stranded on a pillar where the rest of the land had subsided. In one sense it was good this happened at Sunday/Monday midnight because many of the high-rise buildings in the Wellington commercial district lost sheets of glass, and there would have been serious casualties had there been people wandering about down below. Meanwhile, the electricity to the house went out. For me, there was worse to come – just as I was getting back to sleep, the sirens for a tsunami warning started up. No real likelihood of a tsunami where I live, because I am about 70 meters up a hill. But these sirens went on and on.

Then on Tuesday I had to go back and get dressings changed. No problems, except there was a serious storm going on, a number of roads were closed, and I had to hobble both down and up my path to my house. Of course my inconvenience is nothing compared to others’. Apparently, the whole town of Kaikoura has to be evacuated by sea because all land routes to and from it are blocked by huge rock slips. These road closures are all over the country. Earthquake/storms have closed at least 7 roads in the Lower Hutt area where I live, and a good number of houses have had to be evacuated. Then, of course, the aftershocks; 2000 of them. These have ranged as far north as Taupo, (half-way up the north Island) and a number directly under Wellington. A number of high-rise buildings there are under suspicion.

Yes, this has been a period where things have been happening. I just wish they would slow down, or happen somewhere else. I know that is hardly fair to someone else, but I have felt that a quiet spell for recovery would be good.

A disastrous example of free market economics

Do we see crises coming, and if so, are we in the habit of preventing their arrival? Is our free market system of economics capable of preventing their arrival? In answer to the first question, I think some of us do. As the second, no, especially if it means we do not make so much money so fast. Climate change is an example. The scientific community has made it fairly clear that our addition of infrared absorbing molecules into the atmosphere is causing the planet to warm. The politicians, or at least some of them, wave their arms and say we have to burn less carbon, but who says we have to stop using spray cans? A device that led to air creating the spray would be fine, but hydrocarbons, fluorocarbons, etc are not. How about stopping the manufacture of sulphur hexafluoride? Or reducing the level of application of nitrates to the soil?

So, we are at best a quarter hearted about climate change, but what about other impending problems? It is here I think the answer to my third question is no, and in fact the free market is more than just a part of the problem. One such problem that I think needs more thought is the question of antibiotic resistance. How does this come about? Basically because when antibiotics are used, the surviving bacteria are more likely to be resistant, after all, how else did they survive? This is evolution at work; the survival of the adequate, and being adequate to survive in the presence of antibiotics is to develop resistance to the antibiotic. And the problem is, the resistance can be transferred to further bacteria.

So, how does that come about? The most obvious example comes from agriculture, where antibiotics at low levels are used to promote growth. This helps the farmer’s and the drug company’s profits. The object is not to kill off all the bacteria, but rather to reduce their number, hence the low levels. (If you kill off the lot, digestion is impeded.) So, we have a little fermentation pot where resistant strains can develop, and then be transferred to the general environment. Why is this permitted? Because there is more money to be made by the companies, and a bit more by the farmers. Up to 80% of the antibiotic usage in the US has apparently gone into agriculture, and the big pharmaceutical companies are not going to give away that market. The chances of the farming sector turning down the quicker bringing of stock to the market are somewhat slight. Some do not use them, but only because they can then sell meat that can be advertised as “grown antibiotic-free”. So, maybe the consumer is at fault. Are we prepared to pay a bit more to prevent antibiotics being used this way?

Does it matter? I think so. If antibiotics no longer work, or if there is a reasonable risk they will not work, then medicine goes back a hundred years. The more advanced surgery developed during that period may well have to be abandoned. Surgery in the late 19th century was not something many would want to see their family undertake, let alone themselves. Additionally, many cancer treatments seriously suppress the immune system, and antibiotics are needed to deal with adventitious infection.

Now, for the moment we still have a slate of antibiotics, and while resistance is growing, it is rare to get superbugs resistant to just about all of them. Accordingly, our society is responding to this problem in its usual way: we ignore it, and assume we can find a way around it. The way around it is to have a “last resort” antibiotic, or preferably, more than one. The problem is, what used to be the antibiotics reserved for the most serious problems are now being used loosely and widely. But we can discover more, can’t we? Well, probably not. The first problem is, who is going to do the discovering?

The usual answer would be, big pharma. Nevertheless, success there is somewhat unlikely because by and large big pharma is not looking. The problem is, drug discovery has become hideously expensive, and suppose one was discovered and put away as a drug of last resort, usage would be incredibly small compared with the costs of getting it. The reason, of course, is that to prevent getting resistance to this, it too would be used very rarely. The company would never get its money back. Big pharma wants drugs to treat chromic conditions.

There is another problem. One drug that has had a dramatic increase of sales to the agricultural sector is tylosin, and it, by and large has little use in human medicine, but it is in the class known as macrolides, and if resistance is developed to tylosin, it is quite plausible that resistance will be developed to all those in the macrolide class. The use of third and fourth generation cephalosporins in animals has jumped seriously, and these are essential to human medicine. Why are they used? Almost certainly because of direct marketing. These drugs are convenient to use, but they are by no means the most suitable. There have been large increases in the use of tetracyclines and aminoglycosides in the agricultural sector, the latter class includes streptomycin. This report shocks me because of direct experience. When she was about 40, my wife got severe brucellosis, and the only cure then was serious doses of both tetracyclines and streptomycin. At the time it was a close call what would die first: Claire or the bacteria. Fortunately the bacteria did, but brucella live in animals, and I would hate to see that become resistant.

Will the worst-case scenario actually happen? I don’t know, and hopefully it won’t. Nevertheless, from a strategic point of view, don’t we want to optimize our chances of avoiding disaster? And it is here that the problem is most apparent, because the sufferers of the disaster scenario are not the current beneficiaries. We have an economic model that is almost designed to maximize the chances of disaster. It is not time to panic, but equally, it is also not the time to continue being stupid. If we want to insure our medicine does not descend into the state where serious surgery is to be avoided, should we not be cautious and defend what we have? Or do we say, let the corporations make what they can now, and not worry, and hope we never need the antibiotics?

The day after first posting this, the Huffington Post reported: ‘THE END OF THE ROAD FOR ANTIBIOTICS’

A Role for Government

What with a an election in the USA at the end of the year, and the possibility of Bernie Sanders, described by some as a rabid socialist (although in parts of Europe he would probably be regarded as right of centre) we see a lot on the web from people who seem to say government is the problem, and basically they could spend their money much more efficiently than the government. No comment about what on. This raises the question, what should a government do? The classic minimalist response is to organize defence and to maintain and defend the value of the currency. Ever since Imperial Rome, the latter responsibility has withered, and debasing the currency has continued ever since. Now Central Banks seem to want to maintain a controlled inflation, so that long term government debts become easier to pay.

However, currency is for some other time. The question really is, do you want to reward uncontrolled greed, or do you think society should provide some sort of fairness? I personally think society should be organized to give all its young a fair chance at making the best of their lives and also to make up for the rough cast of the dice for some. I do not believe that private enterprise cares sufficiently for the common good. A couple of medical examples follow.

I suspect most of my readers have never heard of Sumatriptan. Do not feel bad about this; neither had I until I read Wednesday morning’s newspaper. Apparently there is a health problem called “cluster headaches” which for a very few people cause excruciating pain, and the only reliable way of relieving these is an injection of an appropriate dose of Sumitriptan. The relevance of this to the issue of governance is that Sumitriptan recently came out of patent protection and the pharmaceutical company that made it stopped making it and handed over (for unknown financial benefit) the formulae, etc, to a generic drugs manufacturer in India. The problem is, nobody thought to work out what would happen during the transition. You do not learn to make a drug overnight, and the pharmaceutical company probably decided it did not want unsold product on its books. The net result is there is a period of a few months during which world supplies have effectively dried up, and none will be available for a few weeks or months. So we have a period of unnecessary torture for those who drew the short straw of life and suffered this condition. Much better to maximize shareholder profit than make a little too much drug and let a few who depend on it have a normal life.

Have you ever heard of colistin? Again, probably not. This, according to “Chemistry World”, published by the Royal Society of Chemistry, is the most common antibiotic of last resort, and it has now discovered bacteria resistant to it. What this means is that unless we discover further antibiotics of significantly different chemical structure, we are going to have surgery revert to 19th century failure rates. You may protest that surgery has advanced well since then, and it has, but equally we have many more procedures that are much longer and much more difficult. What has gone wrong is that with the search for profit, antibiotics, which were an exceptional discovery that saved countless lives have also been grossly misused. There was probably not much that could have been done to prevent the silly from not completing courses, but nevertheless if usage was better controlled and with the large choice available, we probably could have got through, particularly if the special ones were reserved for special cases. The idea of having antibiotics in stock feed to accelerate growth was just silly, and greed and convenience got in the road of thinking, including thinking about what happens next. When antibiotics persisted into animal effluent, there was a spread of increasingly dilute antibiotics, at just the low concentration needed for local bacteria to have to develop immunity to it. On top of that, the use of various antibiotics in some parts of the world as prophylactics was just plain irresponsible.

But, you say, science will find more. Maybe, but who will find more? The major pharmaceutical companies probably will not, other than by accident, because it makes no financial sense to look for them. That may seem a strange comment, but think. Suppose it searches, and spends millions of dollars, and then maybe hundreds of millions of dollars getting the drug through the clinical trials and approval processes. What happens next is it does not sell very well. Why not? Because it then becomes the drug of last resort, to be used only under the most extreme circumstances. And this is where the issue of the commons is so important. Society as a whole needs a drug the bacteria have not seen often enough to develop resistance, but that means it has not been used very much. The pharmaceutical company needs massive sales to recover its costs and make a profit.

The public has to make a choice. Either it needs to take responsibility and pay to develop such drugs that are in the public interest, or it has to hope that a major company behaves out of the goodness of its heart. What do you choose?

Excessive pharmaceutical costs.

A recent item in a local newspaper on the price of pharmaceuticals caught my attention. The question is, are the drug companies price gouging? Thus in the 1960s, Thalidomide was sold as an “over the counter” drug as a sedative, and to help with morning sickness, so that was relatively cheap. It got into trouble, however, because there were birth deformities associated with its use. Notwithstanding that, it has had a resurgence and is of value for certain form of blood cancer, and prolongs life by a few months to a year. In New Zealand, however, and using $NZ, in 2002, a month’s course cost $360 (or so the news item quoted). Now we expect a higher price when a drug has only a specialist use, and there has to be allowance for inflation, but this seems grossly excessive.

However, there is worse. Lenalidomide is a very similar drug (for those with any chemical knowledge the phthalic anhydride part that is converted to a substituted imide is replaced by phthalide, with the equivalent substitution, except the substitution is to the amide rather than the imide). Now phthalic anhydride is extremely cheap, phthalide not seriously more expensive, and the more difficult part, the substitution, is the same. Lenalidomide apparently costs $8350 per month, while Wikipedia quotes it as $US163,000 per annum per patient. What justifies this price? More to the point, what justifies and annual difference of over $US 80,000 between two countries? Now, all prices here are list prices, and apparently negotiation can often lower this, but the point remains. Further, studies have shown no significant benefit in survival rates between these two. There is another drug that does the same job: bortezomib, which costs a little under $10,000 per month, and while its starting materials are arguably a little more expensive, they are not that much more.

According to the World Health Organization, over half the expenditure on health is on medicines. Here is another example. There is a drug called Sovaldi, which treats Hepatitis C with about a 90% success rate. Note that patients can survive with the disease for decades, but eventually they have a high probability of liver failure of one sort or another. The prices for a twelve-week course are of interest. In New Zealand, the cost was quoted in this article as $NZ 239,000 (~ $US 180,000). According to Wikipedia, the cost in the US is $84,000, in the UK about 2/3 of that, in Germany, about $US 46,000, and in India, $US 300. Now, these are listed prices, there are probably discounts around, but persuade me this is not price gouging. The company is getting what it thinks it can get from each country. One can argue for charity for India, but the other countries have prices depending on who knows what, other than greed?

The issue for me is the effect of this corporate greed on families of those affected. Thus if we look at this Solvadi, in New Zealand it would cost 1 billion dollars more than the total annual health spending to treat all those with the virus. It is simply not practical to send that sort of money on one subset of patients, yet by not treating them, do they die of liver cancer at some later date? In fairness, there are alternative treatments, and I have no idea what the real situation is. However, I understand the problems. My wife recently died of metastatic cancer, and as it happened, she died before the oncologists could sort out what, if anything, to do. But what would I have felt had I been left with an option that would require all my money to buy a few months more life for my wife? That is a terrible situation for both to be in. The patient will probably not want to beggar the survivors, while the spouse does not want to not take every chance for more life for the patient.

You will hear various justifications for such expense, such as the need to develop new drugs. This is true, up to a point, but if the drug companies can just charge what they like later, there is not much incentive to be efficient, is there? There is also the issue of the cost of getting approvals. Yes, this is expensive, but persuade me it is not in the interests of the drug companies to make this as expensive as possible. The point is, they can price what they like, and the higher the costs, the easier it is to keep upstart competition at bay.

The issue for me is simple. The provision of best medicine is a public good. There is an element of pure luck whether someone suffers cancer, and whether it is aggressive or not. Certainly you can help yourself by not smoking, and by taking care in the sun, but there is no guarantee, and the same goes for many other diseases. So the question then is, should your future, if you are unlucky, depend on the loading of your wallet? Would it not be better for the state to at least keep some check on the approvals process, and remove waste? What do you think?