ࡱ> nqs_f{>K[ PNG  IHDR[}7qPLTEI竷ZrŐ엜~go|rJk5@U cmPPJCmp0712HsIDATx^SNǷbAЊxJ?c^ҋ ũu`dz&M }f/Z!~ٳ /9 Ggx|<>O?~<4M,}5 k_gՑn,bEQy˜ i|j{-֠׿ŖfE _`u뻭YՄկt~JőE!,sgg1Wt|Ug|cO(\ϔbP3dV2M!Ϙ)nji=duɧ#%ZgW>T"cgA5n3hgZmI_0yk3FmL\ra=ԄffЖ @}4ix%~5dxfz3.5N/a~,f54ϏNfޏK>'mOj~6/,N]LO"FVf\)>{Ǝrw= {4fjp7zu+on>OY>MgMg98C>QŮRYwVN23ɠ @/ /}_faӺ+Wx3@<ԮH4w.t a=*"ʑ+>Blìnf⚉S>(_#^Tv1~e~mK2Ut}vz^[#DQYt6T79#휣s>ݬXHmnrfUnouݡ.U{>l뻼>L#أGݔc*M̜F|f2!qƴ(~ߴ(m|Zw6ahhM?/*}ߊmĝjH,aW׭gf$W?y@HJ_"j-eƇ# ܙ{T*Rf]fN|1,90uH 'l%|0+GAh7}C\'>oYZ_F"?Rpm<&F?~c 4!lg+>hYwn)OBN|OYSw?"`gL3bncY g> `@u =cyp#q>P')~M2& %;Sʹ<>C|p^:o{cofP< +YяtzS"Oa2Emܠ8=Ħw) mƒB`M˗q~9`\&17-4#ćn' bO6lz]`O|T=$MwPW$7;zq lO|~Q?z)wUh/H,w$ޠv4M?pn@d []֌58_ Ԛeng؋~hGMBaqt6+9'S 4E|}4bh^ Wر2g>h..K)DUqV#=+C%zUx|G%Bb"!&%& 㿬agvWBvq,,$D1Qj%L"gL'.bZi' 6~7dͼɍb!(6unq_^NJ\إ>@eAL6OnVRnMOh%2E޽tg~FU"rujrd'ԻjW,l.!;ShÓᓛل~^!WoDZr(o4!t̄#HgpwGK|5 ኏V=A>  h6B\&SfP^ˮTHZ[R w<!cLXs:? Ј⛓d.V \-q{?|je?j0DcCF@җpBV-tA$yLBD 5Rdy"$sK1CAn&$\òvr&hCrS" S)6*PGra1V8̥jJexxP> YdQJίq\NQ\L? $(AxSH(}GAvJ!sd` plѮl147b Ө5/gb"ԛzm%IF 7Aί@bh5/x{3 Kڣ0 0uؼJ|hCSwNP,(*Q51JJ.wjLO<$f\V so!(G`狒(6tM ceI\'H}yd(LI!|-3iشyXF0T4~>5# hkJZP9TʼnPAG!GAHbO$jNpA2~Nb(T,+?g !,VA3>]gD>>%.DIC;C  ;("(;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;To" }!1AQa"q2#BR$3br %&'()*456789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz w!1AQaq"2B #3Rbr $4%&'()*56789:CDEFGHIJSTUVWXYZcdefghijstuvwxyz ?<3xSHM*affBX$ⴿc\;D|-kTvXcd i@O𭂴ҕj»1o24{GMVJiOj!]?l?›UT$Ֆ2~?LmejVY7aG?G?´ȍ[r;`dFa[^&6Y4:!t:\RӢ٨WYӤ"bhšRݣEJLt'vL:@?H|U5 RixR[V[&t>_4?[赭R+CuZӞHifu4fc֤E2p*"k7W_Lb4dža\Co[&LO'k9W:o'cԼkm}%"l<[ Z]vPo{f,@}NrNk_Y}k;zԷOja$Ň`8+S{xG$T59-dozƹh"xi2gk7.Ŵ׭މ_ӼCi88YBƅczT2!Jep ?f̚k"8«15m(0fݳ(4٥Z|\&5\6=>Џ_赬<\~Q2Hgڃ^iZE_%?u#eVRP{kxoOzq  rlršd[uߛ֡ g6Ka^=9K+G*ts3rx mh,A?0{bpӡZQẂXGq]&-M7"<0-`┴eGTaƳC R$qЊTFs|͵cfōSA< F,wa[\[f2>XV(s.jʅ$Z?G.}c)QMP"!Nq3J6HYFT `I\qV$KR6A*{=㱗6T{ *NjQl}Go֭a;Xq8M@@)6~=+'+3ovoc#ɔgbB#g\DQ;ՏG͚鱚:vkn!K`zwu[ƒ.׵stɶF#kʗ}VۼVJfwOZ[dؿ~a\$ Ӵ6p>\='UKp=}*g6!Zc#?|VW ѷ`Ze[hMqT|qiזGI+0u=5M{fѼ*cnA8ѣx&e?ʱɊ杘8Li."5W"Ql[9ĎNx~Na CSd&mʠ=p)^5Ŧm+:YU[ohVdXɈ}vI&**rL`GH=줵H7^?u+2A$Cf҃I{OoK[ yR$ҝcɛݿH_c y 0AA@8qʚ;ʚ;g4dddd젱 0ppp@ <4dddd8A10lx v0___PPT10 6___PPT9{?  %C;\Using Race to Sell Drugs: Pharmaceutical Marketing and Challenges to Medical Professionalism]](yHoward Brody, MD, PhD Institute for the Medical Humanities University of Texas Medical Branch, Galveston habrody@utmb.eduzZziOverview Critical elements of medical professionalism Aspects of pharmaceutical marketing that challenge professionalism today The BiDil story Lessons for the futurezProfessionalismAn aspect of ethics Specifically, virtue ethics as applied to medicine and other health professions What sort of person ought the good physician to be? What sort of character ought the good physician possess?dm  5  #Professionalism (II) Considerable definitional inconsistency within today s literature Nevertheless, appear to agree on a few key elements Physicians must maintain competence Physicians must serve patients interests primarily (fiduciary relation) Physicians must view practice as public trust McCullough, Am J Bioeth 4(2):13, 2004 Rhodes et al, Am J Bioeth 4(2):20, 2004jvZZNZv   ,""Professionalism (III) A shorthand approach to medical professionalism: Physicians must view medical practice as more than a mere business Professionalism: public trust, fiduciary relation Business:  Let the buyer beware J. CohendtS Z S  Medicine and Pharma Today s relationship between medicine and the pharmaceutical industry challenges all three core aspects of professionalism This is not  industry-bashing Each party can have different concerns without either one being bad& So long as neither party confuses its own core agenda with the other s Pharma: overriding goal is to make a profit for shareholders~ZZ=ZQ o=&7  Competence The competent physician uses reliable sources of information to keep current Sources of information in turn must rely on scientific accuracy of published medical literature Competence: Challenges,Information obtained from drug sales reps is biased so as to sell drugs (marketing, not education) Cooper & Hoffman, Br J Gen Pract 52:168, 2002 Clinical trials funded by industry ~4X more likely to favor company s drug than neutrally-funded study Lexchin et al., 326:1167, 2003Pc.gc.g,~u Fiduciary: Challenges7Physicians who rely on reps and industry for information are prone to prescribe the latest, most expensive drugs At least a good portion of the time, the better treatment is really: An older, generic drug Lifestyle change, not drugs Recent track record: newer often = unanticipated safety problems (e.g., Vioxx)P3Oq=3O1  Public Trust: ChallengeszPublic trust relies on lack of conflicts of interest Medicine, virtually alone among professions, has rationalized routine acceptance of gifts and payments of large value from those who have commercial interest in altering outcomes Cf. law Recent press exposs, calls for new legislation suggest public won t toleratelZZNZ ; Race-Based Pharmaceuticals?Challenges are problematic enough with  ordinary drugs Add issues of race, health disparities, and the new genomics, and issues become greatly complicated The BiDil story Kahn, Yale J Health Policy Law Ethics 4:1, 2004 Bloche, NEJM 351:2035, 2004 Brody & Hunt, Ann Fam Med 4:556, 2006 Bibbins-Domingo, Ann Intern Med 146:52, 2007! :P7(& CHF in African-Americans=African-American patients more likely to die, and at younger ages, from CHF Multiple potential explanations One focuses on bioavailability of nitric oxide and its effect on restructuring of L ventricle Isosorbide dinitrate = nitric oxide donor Hydralazine = antioxidant Therefore, hypothesize possible role in therapy>Z>>   ? V-HeFT 2 Isosorbide/hydralazine vs. enalapril After 2 years, lower mortality in enalapril arm Cohn et al. NEJM 325:303, 1991 Later subgroup analysis: whites disproportionately benefited from ACEI; black subgroup had more benefit from vasodilators Carson et al., J Card Fail 5:178, 1999xUz'U z  6 #  A-HeFTSponsored by NitroMed, owner of patent for use of combination vasodilator for CHF Enrolled only African-Americans ~1000 Ss Randomized to isosorbide/hydralazine tid vs. placebo added to baseline meds 69% on ACEIs 18 mo f/u planned<  b t+  A-HeFT (II)* 3Study stopped at 10 mo 43% relative risk reduction for mortality in active vs. placebo groups (NNT = 25) Overall outcomes (hospitalizations, quality of life) better in active drug group Taylor et al., NEJM 351:2049, 2004 Is vasodilator combo helpful for any or all white patients? Unknown because not testedd#<<From A-HeFT to FDA:NitroMed patented BiDil as drug  for blacks only Extended patent life by 13 years NitroMed sought FDA approval to market BiDil for CHF  for blacks only A-HeFT was designed to use a dose of drugs different from that commonly available generically Accident, science, or marketing ploy?F2!2!&Z <~Subsequent Marketing (6/05)3BiDil marketed at $1.80/pill, approximately 4X cost of generic equivalent Some publicity made veiled threats against generic substitution as off-label and hence risking legal liability Anecdotal evidence: NitroMed recruited African-American historians as consultants to stress parallels with Tuskegee Study 44$_What Happened?/By all accounts, sales of BiDil have been disappointing Despite promise from NitroMed of financial assistance for indigent patients Not known if this is due to generic drugs being used, or simply physicians not using this combination Given its potential according to A-HeFT, non-use would be unfortunate<8L8L>.Race and MedicinezObviously, racial differences: Exist Have a biological basis Are inherited The remaining question: do racial differences  go down deep enough to explain very much of true medical interest?P,s,.0Racial Medicine: Con & There is no basis in the genetic code for race. Craig Venter (quoted in Kahn 2004) Racial (geographic) differences in genome occur mostly in  junk DNA, not in active genes Lee, Hastings Cent Rep 35(4), 2005d4#Z#4#Z Genes vs. Environment$Conceptual trap: assuming that if we find a difference in disease incidence or characteristics among racial groups, this must be due to genes and cannot represent social or environmental influences Also wrong to assume that larger effects must be biological Sankar et al., JAMA 291:2985, 2004#yHAddressing Health DisparitiesSeems clear that African-Americans have a serious problem with CHF at younger ages Probably related to HTN Precise cause may not be clear Any treatment that appears to narrow this gap a cause for celebration<SeSe"Association of Black Cardiologists##&Between rock and hard place Trying to get adequate funding to study CHF in blacks Trying to avoid endorsing inappropriate uses of  race in therapeutics In general, statements made were cautious and scientifically valid<}C}CLessonsRacial and ethnic health disparities deserve aggressive attention Should be very cautious regarding claims of: Race-specific medications Race-specific genes Medical professionalism is threatened when  race and  health disparities are hijacked by corporate marketing<o.oo.oG  0` 3Wo+ff3̙` 33f33̙3` ! <yxG`wglZff` yE[AQpff3k` 31m̙3f` 3333̙3` O~̙Zƺ` ffff̙` ǵfZƺ` fff3fZ̙>?" dd@*?nZd@`K `7@d` n?" dd@   @@``PR    @ ` `0p>> ph ((  (T `  ( "`  ( 6ϱ"  20\ }` ( "}` ( 6ӱ"}` 20B ( s *DjJ"`,$D 0 ( 6ձ "@`  T Click to edit Master title style! !$ ( 0ر "@`  RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  ( 0ޱ #" `b@   >*   ( 0  #" ``@   @*   ( 0 "``  @* `B  ( s *D"  H ( 0޽h ? 3333̙3___PPT10i. 3l+D='  = @B +  Layers  0 !  , (  ,,T  , " , 6\"P  20L\  , " , <tv"p 20 , <a "0 `s 20hB , s *Dp" p \ Pp , "Pp  , 6e"pPp 20B  , s *D"p,$0  , 64h "`@  T Click to edit Master title style! !  , 6j " `@   W#Click to edit Master subtitle style$ $  , 0\o #" `b?  >*  , 0t #" ``Aa   @*  , 0Xy #" ```  @* H , 0޽h ? 3333̙380___PPT10. 3l P((    NTY4 y˼y˼ .  4  \* a00aa  N[4 y˼y˼ 2 . 4  ^* a00aa  TL4 y˼y˼ q  4  \* a00aa  TR4 y˼y˼ q2  4  ^* a00aaH  0ηo~ ? 3380___PPT10.N`JS;c0 zr  (  x  c $ ,p`  x  c $4 ,0 `@     <WAE >AA Grand Rounds Memphis 4/9/082 0 T  C ,Autmb logo 0 P  C (Aold red` `]H  0޽h ? 33___PPT10i.B +D='  = @B +$ 0 4$(  4r 4 S է(@`   r 4 S (ڧ(@`  H 4 0޽h ? 3333̙380___PPT10.D`4;$ 0 8$(  8r 8 S "(@`   r 8 S "(@`  H 8 0޽h ? 3333̙380___PPT10.DPZk$ 0 <$(  <r < S )(@`   r < S x*(@`  H < 0޽h ? 3333̙380___PPT10.Dз.$ 0 @$(  @r @ S 7(@`   r @ S |8(@`  H @ 0޽h ? 3333̙380___PPT10.E$ 0 D$(  Dr D S A(@`   r D S A(@`  H D 0޽h ? 3333̙380___PPT10.Fpf$ 0  H$(  Hr H S D(@`   r H S 0E(@`  H H 0޽h ? 3333̙380___PPT10.F|$ 0 0L$(  Lr L S $a(@`   r L S a(@`  H L 0޽h ? 3333̙380___PPT10.F`aʷ$ 0 @P$(  Pr P S i(@`   r P S xj(@`  H P 0޽h ? 3333̙380___PPT10.Gm$ 0 PT$(  Tr T S ?@ABCDEFGHIJKLMNOPQRSTUVWXY[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root EntrydO)Pictures(Current UserSummaryInformation(ZLUPowerPoint Document(DocumentSummaryInformation8