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An insider's take on revamping US health policy

Dr. Jerry Avorn brings convincing data and sharp analysis to ''Powerful Medicines," his timely, challenging appraisal of health policy.

It is not easy to read, despite Avorn's clever, occasionally risqu style and talent for simplifying complex medical and pharmaceutical procedures. The discussions of statistical methodology and risk-benefit balance will interest primarily Avorn's fellow epidemiologists.

''Powerful Medicines" tries to speak to the layman but often detours into territory most interesting to medical technologists and statisticians. A book of populist intent and, presumably, popular appeal, it is definitely challenging.

Nevertheless, ''Powerful Medicines" does more than preach to the medical choir. While its prescriptions may not appeal to all, many, particularly politicians, should pay attention.

An associate professor of medicine at Harvard Medical School and chief of the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham and Women's Hospital in Boston, Avorn analyzes medications and tracks their effects.

Too often, he suggests, the glass is half empty, not half full. Among his examples are the potentially dangerous prescriptions of hormone replacement products, or pharmaceutical estrogen, to prevent Alzheimer's disease, as well as heart attacks in post-menopausal women; the disastrous effects acne medication Accutane can have on pregnant women; and the unregulated spread of ''natural" remedies ''to replace or supplement officially sanctioned medications."

People in the United States pay more than $200 billion a year for prescription drugs, the fastest-growing part of American healthcare costs, which will soon reach $2 trillion a year, Avorn says. Passage of prescription drug coverage under Medicare isn't likely to help because it doesn't challenge the ''silo mentality" that keeps the various parts of the health industry from working together.

Avorn deplores that the new Medicare law prohibits the government from seeking better drug prices for enrollees and speculates that it will encourage heavier promotion of the costliest products by marketing-driven physicians. He cites a study finding that sales, marketing and administration consume 31 percent of the total revenues in the nine largest drug companies; research and development, meanwhile, account for a mere 13 percent.

Avorn methodically battles the ''marketplace model" of drug prescription that he suggests is part and parcel of the Bush administration's ''fervent belief in commerce-as-panacea." Avorn wants the Food and Drug Administration to have the authority to prosecute manufacturers that make unfounded claims about the medicinal properties of a drug, supplement or herbal remedy and proposes a ''pharmaceutical extension service" deploying medical educators to doctors' offices to counter the blandishments of drug company sales reps.

He touches on Viagra, which successfully treats erectile dysfunction but might also lower blood pressure, and Lotronex, an irritable bowel syndrome treatment that in some cases can starve the intestine of blood. Viagra is popular and highly promoted, though warnings against mixing it with nitrates are discouraged. Lotronex, withdrawn from the market until its fans persuaded the FDA to consider restoring it after a careful risk-management program could be implemented, now is available by prescription at a new, lower dosage.

Avorn also calls for revamping patent law to spur pharmaceutical innovation and allow generic drugs to enter the marketplace in a more timely fashion; and establishment of nonprofit, regulated healthcare organizations to deliver ''core benefits" medical services. Consumers could enroll in them by using a tax-funded voucher.

He concedes that the inexorable privatization of American medicine makes implementation of such proposals unlikely. It's not for lack of trying. Avorn's book is expressive, well-documented testimony to that effort.

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