I'll never forget a coworker telling me that in a previous job hunting round he had interviewed with a pharmaceutical group that was tracking the manufacturing process for batches of drugs and comparing the little tolerance mistakes (heated a little too high or held at temp a little too long or not quite long enough) and finding a market where they can sell that batch.
You'd like to think that companies have factories with quality control laws and there are local people trying to ensure that all of their product are up to the local standards. What you don't expect is that they are binning them like Intel CPUs, where they just make a batch and hope for the best, take cream off the top until the priority orders are done and then everyone else gets whatever is left. You might get a slightly better product sometimes but not be so lucky the next time.
If you've taken a prescription over a long enough time you'll know this to be true even if you've never really considered it.
Some time ago I was very frustrated with the massive swings in how well a prescription was working so I started looking into it. Saved a pill from every month, sent 12 of them off for testing.
+/- 30% accuracy on that dosage, and that's within spec for the US. Some months your 20mg pills are 26mg. Others? 14mg. Later repeated this test with a family member's blood pressure medication, which has a dosage of just 0.5mg. Same deal, 0.35-0.65
The same thing happens in food processing. The low quality stuff gets sold under a different, cheaper brand, or reprocessed into another product.
I'm not going to cast stones at this practice because as always the alternative isn't some magical world where all produce is perfect, the real alternative is that it gets thrown in the trash and wasted, and everyone is worse off despite feeling better about themselves.
They only need to be as good as the minimum standard for the category they're sold in. If you have a "good" bin and a "bad" bin, and the good bin easily exceeds the minimum requirements while the bad bin just barely meets them, that's fine, too. Or the good bin can be sold as class I, while the bad bin needs to be labeled as class II. Of course those categories usually aren't about safety-relevant aspects of quality, but things like weight or shape or appearance.
If the product is ineffective you’re stealing from people. And in the case of pharma, probably ruining their lives in the process, since we rarely do more than two care plans at once and if one is busted then they should be doing something else instead.
> the real alternative is that it gets thrown in the trash and wasted
My view is a bit different nowadays, but this is very much an extreme bird's eye view from very high up, looking at only the smaller processes I have no disagreement. So, my point is more like an alternative co-existing higher level view, not a replacement of what you and others say. You will still be right to want to optimize your processes of course.
I view it as different streams. Everything is a circle. There is a significant cost - energy (and time and space and effort). As long as we use ancient sun-energy dug out of the ground it's bad, but if we could power the circles with current sun energy it would not matter much.
You have one overall stream or flow, all materials, and output streams are various sizes of end products. The good stuff stream flows to the customers (and forms bigger circles), the mistakes are instead rerouted into the recycling stream.
In chemical engineering and in manufacturing you have the same. Making food, whether completely natural, or including any kind of processing even if it's just separation and packaging, will have similar properties. Quality varies, and you have additional processing streams for various qualities.
Sure, one would want to optimize the streams, but if we did not have the fossil energy source limitation, and maybe also space, if you have to go back to the growing fields, it would not matter too much.
----
Imaginary picture:
Imagine in the far future somebody set up a fully automated closed system for making food, from growing to putting it in a huge cafeteria buffet, fully stocked all day. But there is no more people. As long as there is energy, food is created, processed, put on the buffet, and then recycled, since there is nobody to actually eat anything.
Is it a waste? Well, yes and no.
The whole of earth is like that!
As long as there is energy the cycles continue. What is "waste"? If you take the very big view, everything just "is".
But again, our actual limitation is the energy source for our food cycles. Using ancient stored sun energy releases the carbon stored underground, and it also slowly depletes those stores. The real problem first of all is where we get the energy for our cycles from, not really if parts of it don't make it to the end customers. Opportunity cost, what we could use the space and general effort for instead of on recycling cycles comes a distant second, I think.
> the real alternative is that it gets thrown in the trash and wasted, and everyone is worse off despite feeling better about themselves
Depending on what's the minimum quality you consider acceptable for the product, you might want to throw away something and have good reasons to feel good about yourself doing it. There is a point where something dips below good ("less effective medication") and even neutral ("it's an empty pill"), into actively harmful ("it will kill you faster"). Discarding it instead of monetizing it is the positive outcome.
Over here in The Netherlands, the milk for all milk products comes out of the same cows and is processed in the same tanks. When you're paying 2x the price for brand name milk, you're getting seriously scammed.
There are a couple cooperatives here that own their own processing facilities. As food businesses got bigger the distance between processing plants has grown and grown and it ends up netting the farmers less and less.
I learned recently that there was a small coop near where I live that got bought up by a larger one, Organic Valley. Which has a semi famous permaculturist as a member (Mark Shepard), and the only reason I knew it to be a coop. They don’t advertise that fact well.
Is this system not preferable over just trashing anything not perfectly made? Sure it would be nice if everyone can have perfectly manufactured medicine, but that's not reality. I would think something that's still likely good is still better than nothing.
A fair number of countries can't do the proper inspections required for this, either due to lack of resources or government corruption (or both). They could put a literal carbon copy of FDA standards into their regulations, but it's meaningless without enforcement.
See the HIV infected blood products scandal with Bayer. The infected blood was pawned off on the third world since they (correctly) figured they'd have much less success suing them.
You can tell what a bunch of assholes Bayer is made up of by the fact they were even willing to entertain purchasing Monsanto. Which they ended up doing. The lawyers are clearly in charge there.
There's a difference between a few percent difference in efficacy which is understandably still marketed (the same kind of thing happens when you leave meds on the shelf a while) and meds that are no longer effective at all to a reasonable level or toxic.
>roughly one in six — were found to have incorrect active ingredient levels
>But some drugs are also counterfeit, and that increases the risk of discrepancies between what's on the product label and the actual medicine within.
If I was desperate, and given a choice between either 1 of "Might have incorrect active ingredient levels" "Might be counterfeit" "Might have been stored improperly" or "No cancer drugs for you" I know which way I would be leaning.
"Defective" is doing a lot of work in this headline.
More accurate to say they should get access to drugs that contain the actual molecules they are advertised to have across markets.
You shouldn't be able to sell what is basically sugar water in Somalia and call it cyclophosphamide. That's fraud if I do it as a private citizen.
In fact it's even fraud for me if I buy actual cyclophosphamide, and cut it with a bio compatible totally non reactive filler compound. How are these people getting away with it without the president and senators being on the take? When they'd run you or I down in less than a month for effectively the same act?
To be clear, I don't believe you or I should be able to do this. But I know what happens to private citizens who try to do things of this nature. So there is no question that this is a crime. The only question is why is it not prosecuted for larger corporations.
Why shouldn't every single person on earth immediately be granted citizenship to America and allowed access to all forms of welfare given to citizens? It's unfair to them
America is weird in that the poorest get significantly more benefits than the merely lower-middle class. And the majority of Americans pay no federal tax after EITC and other refunds.
You can get SNAP (free food), Section 8 (free housing), Medicaid (healthcare, CHIP for kids is easier than adults, but still many people get it), and if you manage to raise smart kids despite poverty they will get college for free as well (most highly-selective universities are free for the poor, but extremely expensive for even the middle class).
I own a lot of rental property and I have a Section 8 tenant who has never worked, completely gamed the system with a subjective disability that renders her unable to ever hold a job (supposedly). A good tenant but is constantly trying to give away tons of food she buys because she always tries to spend the SNAP she gets every month. And she gets free heat, and electricity, and public transportation pass, and on and on.
What a weird take: I'd definitely expect the poorest/sickest to get the most additional benefits of all, the middle to get none and the top to get charged extra to cover up.
If you're middle class, that should be the average and that means you only get things which are the foundation of the system covered by the taxes.
Let me elucidate why this system kind of sucks, as someone else who knows someone personally who lives a "full benefits" poverty life.
These benefits are binary, not tiered, so once you earn a dollar over the incredibly low threshold, they vanish. So the person I know cannot get a job and work, because if they earn over ~$16k in a year all the benefits go away. And where she lives you need about $50k/yr minimum to scrape by. So there is this $34k/yr gap which creates a no-mans land of livelihood.
> So there is this $34k/yr gap which creates a no-mans land of livelihood.
it also creates/necessitates a vast enforcement bureaucracy to make it all "work" which in itself is a huge waste when you could just tax it back from high-earners at the end of the tax year... its almost as if it was designed to suck
In addition to income, there are extremely low "wealth" qualifiers. You cannot save money while on most of these programs to try to improve your situation or build a personal safety net. If you manage to save more than a couple thousand dollars, you become ineligible for benefits.
The US has a weird class stratification system, that some people think has been embedded into society dating back to the Calvinist New England and slaveholding days.
It's developed since then in interesting ways and shows up everywhere. The biggest thing is that each cohort looks down on those "beneath" them. This manifests in different ways... people living in public housing, getting housing and typically SNAP benefits, will often scoff at people collecting temporary assistance (cash) as loafers.
If you're looking at families, the prevailing rent in Onondaga County, NY (Syracuse) is $1475 for a two-bedroom apartment. "Prevailing" rent is the metric used for Section 8 is essentially the price floor for an adequate apartment. The median household income in the county is $74,000, which is 23% rent to income ratio, so pretty good, right? (Keep in mind, this is from a not so great apartment that passes Section 8 inspection, but little else) Eh, not really, the well-off suburbs skew the statistic... if you look at the City of Syracuse, more representative of the blue collar working class and poor, the median income is $45,500 -- 39% rent to income. The median household in the city requires some support to live -- in Syracuse that's like 70,000 people
As you see purchasing power decline for working people, traditional "middle class" respectable jobs are falling off the ladder in terms of livability. A parent in a 90% of retail and semi-skilled labor jobs is making $80-90k max, and is basically a car disaster away from financial ruin. Many, many of these people are stuck with non-dischargeable student debt for life as well.
The problem with these discussions is the errant use of poor/middle/upper/top as class identifiers.
The more useful identifiers would be roughly young and/or working, and old and/or non working. The latter category also covers the beneficiaries of wealthy people (who are among the old and/or non working).
The USA (and many countries, especially democracies) has a situation where your expected quality of life is lower (or not sufficiently higher) for the young and working than the young and non working for those not lucky enough to be born to the right families or prudent enough to make the right choices in school, etc.
The incentives should always be such that expected quality of life is always greater for those working than non working.
Note that this is a different topic than whatever the floor for quality of life should be.
You are saying this with completely forgetting that the vast majority of the people who are old and non working are in fact, retired, sick, on medicaid, and generally just not that great at working in the first place because they already (most of the time) spent 40+ years working.
Why would the person who spent 40+ years working have a worse quality of life than someone whose spent 10 years working? The incentives you put up basically say "as soon as you are done we're sending you to the glue factory."
The whole point of retirement saving is so that you can still support yourself after your mind and body can. Just about everyone is aware of this, yet many still save nothing because "society will deal with it" when they get older.
When I was younger I had an easy time buying into "everything is too expensive to save money", now that I am older, past the "you must start saving now" age, I know way way too many people who don't save for retirement and live stupidly beyond their means.
"We don't have any retirement savings because how could we give up eating out 1-2 times a week, $250 monthly beauty appointments, $90 gym membership (they have clean warm towels!), and our annual Disney vacation and our family Lake Tahoe trip. And no way will you catch me in a 5 yr old used car, sorry I cannot sacrifice my new car leases!"
I know so many more people who recklessly spend money than people who honestly are trying but cannot make it.
> The incentives you put up basically say "as soon as you are done we're sending you to the glue factory."
Those are the incentives nature puts up.
>Why would the person who spent 40+ years working have a worse quality of life than someone whose spent 10 years working?
Depends how much they earned and saved. Current workers (proxy for young) know they will not have a quality of life as good as those that have already worked decades past, so where is their incentive?
>because they already (most of the time) spent 40+ years working.
But they (at least these first few generations) are receiving healthcare worth far more than the work they did, tenable only due to the higher total fertility rates of many decades ago.
At its root, these deferred benefit schemes were either never sustainable for modern lifespans and healthcare consumption, or they depended on unrealistically high total fertility rates. One could even say they played a role in causing lower total fertility rates, as society de-coupled raising one's own productive children and having a good quality of life post working age, since you could now depend on others' productive children.
Money, savings, and other wealth abstractions that legislators can easily bring about don't materialize the goods and services one might want to buy.
through my eyes i see a similar implication to disproprortionate judicial punishment - aspects of a hegemonic system designed to suppress individual voices. for example, pirates in the UK being handed jail terms of greater duration than those given to individuals having killed other humans - people daring to go against the powerful have their lives taken away from them, whereas infighting within the working class is almost encouraged by miniscule sentencing.
or in this case, why bother putting any effort into life when doing nothing provides a greater reward? why attempt to make something of oneself at the risk of losing everything forever?
all in all, whether or not intentionally curated, these societal facets serve to foment an atmosphere of fear - individuals are forced to exist either in ignorance, or otherwise must live with the knowledge that minor infractions may end one's dreams, while concurrently one's dreams may be ended at any time for no reason but the whim of another.
such a dichotomy between ignorance and fear effectively suppresses societal change, which if it were to happen anyway, would be instantly detected by automated surveillance, and promptly quashed under fully legal pretences. but that's not even necessary. the populace is already addicted to living vicariously through screens (now from birth thanks to parents being forced to devote energy to work instead of their children).
The say you write about it, being poor in America is easy and great. And then you look at powerty in America and see hopeless desperate people with no access to justice,lite chances in life, little access to healthcare and raising homelessness on top of it.
And funny enough, the poor are just about to loose their healthcare and food stamps via big beautiful bill. Which is official name of that bill.
You're so programmed to knee-jerk about some political bullshit that you're not thinking.
These companies are making defective drugs and shipping them to people. The only thing preventing that from happening in the United States is the regulatory system, which we are in the process of smashing.
To elaborate on this, if the individual in Somalia didn't want to die from said cancer and preferred better regulation, they would readily move to Ohio.
hope all you want i think understanding what this site reveals about the world view of investor/dev types is a kind of sociological? shock.
its like everyone learning during covid their neighbors would kill every service worker to avoid the inconvenience of making their own coffee. it leaves a mark.
see what happened to the poor n-gate.com fellow, burned him out
As Matt Levine would say: inefficacious cancer drugs sold in the American market would be egregious securities fraud[1] if the shareholders are not informed by company offices ahead of time. The resulting shareholder lawsuit may cost some managers their jobs. There is also the (minute) risk of getting Luigi'd by someone a state over, whose loved one they suspected to have gotten a bad batch and didn't get better.
1. "Everything is securities fraud" is a running series showing the breadth and depth of how shareholders exercise their rights in creative ways.
They will both die. Cancer treatment is largely useless (this is an editorial statement) Survival statistics are largely dependent on early detection. Detect the cancer early, you live longer after treatment.
Cancer treatment effectiveness has improved substantially, with many treatments now achieving high cure rates or significantly extending survival.
Highly effective treatments:
Surgery remains the most curative treatment when cancer is localized and can be completely removed. Complete surgical resection often leads to cure for early-stage solid tumors.
Chemotherapy can be curative for several cancers, particularly blood cancers like leukemias and lymphomas. Some testicular cancers and certain pediatric cancers also respond extremely well to chemotherapy alone.
Radiation therapy achieves excellent local control and can be curative, especially when combined with surgery or chemotherapy. It’s particularly effective for head and neck cancers, early-stage lung cancers, and certain brain tumors.
Revolutionary newer treatments:
Immunotherapy has transformed outcomes for melanoma, lung cancer, kidney cancer, and others. Some patients with advanced disease achieve long-term remissions that were previously impossible.
Targeted therapies work exceptionally well when tumors have specific genetic mutations. Examples include imatinib for chronic myeloid leukemia (transforming a fatal disease into a manageable condition) and HER2-targeted drugs for breast cancer.
CAR-T cell therapy has achieved remarkable results in certain blood cancers that failed other treatments, with some patients achieving complete remissions.
Combination approaches:
Modern treatment often combines multiple modalities - surgery plus chemotherapy plus radiation, or immunotherapy plus targeted therapy. These combinations frequently outperform single treatments.
Current limitations:
Some cancers like glioblastoma and pancreatic cancer still have limited treatment options, though research continues. Metastatic disease remains challenging, though increasingly manageable as a chronic condition rather than immediately fatal.
This is an oft-refuted trope that does harm to patients. Numerous randomized phase 3 studies show meaningful survival advantages for modern treatments.
If the treatment were useless, early detection wouldn't help. Or are you saying, the extended lifespan is just the difference in time between "early" and "late" detection?
Yes. I'm not saying all treatments are useless. Surgical removal of an isolated tumor or melanoma for example. But medical/chemo/radiation in all cases I've seen the person died anyway and spent many of their remaining days feeling awful from the side-effects.
Thanks for this comment - I didn’t read the article and might have taken away a largely incorrect belief based on the parent. And you handled it so politely too!
The comment you replied to also paints an incorrect picture. The real quote from the article regarding the origin of the poor quality is:
>[...] Those causes can include faults in the manufacturing process or product decay due to poor storage conditions. But some drugs are also counterfeit, and that increases the risk of discrepancies between what's on the product label and the actual medicine within.
So this is actually pretty in line with the top level comment, since no mention of the actual ratio among reasons is made. It certainly doesn't say that counterfeiting and after production storage are the main reasons.
here in Canada the active ingredient must be identical in identical quantity but the binding agents, excipient, and propellant are proprietary. The generics have to have the same bioavailability +-20%.In some drugs it doesn't matter, in others there is a world of difference.
I pay the 2$ it cost for brand name ventolin (my insurance cover the cost generic and I pay the difference) as the generic give asthma attack. But I would not pay one cent more for the brand name Vyvaanse. Effect wise the generic is indistinguishable (but damm the pills colors make them looks like a cheap gray market knock-off).
My wife has a paper from her oncologist for original femara because the generic made her faint a few times ( the insurance cover the whole cost because of that paper)
I’ve known people who claim up one side and down the other that Advil is more effective than generic ibuprofen and it’s thought to be down to the other ingredients. I had at one point convinced myself of this as well, but these days even Advil doesn’t always help. Bummer is that only a couple of CBD products do anything for me either. May be why I’m so grumpy.
As a layman who fortunately has never had to deal with any "serious" medicine, how would I know which drug is good-enough is generic form, and which should be the brand name? To someone not in the know, +/-20% bioavailability sounds like a lot. Hopefully, the doctor will account for that when prescribing it, and know which way the 20% goes.
You also make it sound like 2$ isn't much to go from the generic to brand-name Ventolin. How much is too much? And is there a difference between generics of the same drug (I assume multiple manufacturers can actually produce generics) and how do you know which is better?
It’s a huge amount. I have a seizure disorder and I have to carefully increase my dosage by as much as 50% to compensate for the difference between generics and brand-name. The 20% is an average: one of the big differences between the two is absorption before/after you’ve eaten, so taking the medicine on an even slightly full stomach dramatically reduces absorption. The brand-name manufacturer now charges $300/mo for an off-patent drug you can buy generic for less than $25 (without insurance) which illustrates their view of the perceived value.
> the doctor will account for that when prescribing it
Sadly they do not. I got prescribed 12.5 mg tianeptine to take three times a day, except that amount is minuscule for my brain & body. You would think they take into account that I have fast metabolism, have many brain lesions, and so forth, but no, they do not, and there are no legal frameworks either to do so. They would have to account for these lesions in my brain for many reasons, but they do not.
Well you try the generic first, if it's does what it says on the tin, you continue the generic! Antibiotics, pain killer, antidepressants are usually not problematic.
Hopefully, the doctor will account for that when prescribin...
I never saw a doctor or pharmacist do that. Probably because you cannot predict the difference in a specific individual.
is there a difference between generics of the same drug ?
Sometimes the generic are better and yes there is a variation between manufacturers, when the pharmacy change my clonazepam supplier, I feel it. Sometimes I feel drugged out, sometime I am sleepless, but it take a few nights and then I feel the same. When that happen, I check the letter before clonazepam on bottle and systematically they changed, ex: apo-clonazepam to pms-clonazepam (the first three letters indicate the manufacturers, and I couldn't tell you which is better, just that there is a subtle difference when you switch) .
For stuff like that works on the hormonal system the difference between them is more pronounced. Like the femara, an aromatase inhibitors the block estrogen production, the brand name was significantly better for my wife but reading MBC survivors forums it's not the case for everyone. And reading those forums, it's a problem in place like the UK where the only things available is the brand NHS choosed for you.
How much is too much ?
Now about how much is too much, well it's an hard question. It depends mostly on the alternative available, there are a lot of asthma drugs so switching from generic ventolin to something else like xopenex is easy so it limits the pricing power of the original manufacturer. Thing like anticancer with a specific mechanism where no direct alternative exists, the price is significantly higher, something like 300$ a month instead of 60-80$. But for my insurance it's relatively nothing compared to the Kisquali that cost 5700$/month. They have to reauthorized it every 6 months (it's a bureaucratic formality but they don't want to pay for it if the cancer has reappear because it's useless to continue the treatment)
Note that I have something my pharmacist call a gold-plated drugs insurance. If we were only covered by Québec's public regime, my wife would probably be dead by now as they still do not reimburse Kisquali, it's suppose to change soon but I am not that informed on that because of my gold-plated insurance. (which is fucking stupid because the alternative was weekly in hospital chemotherapy that cost a lot more than 5700 a month, but then people with that treatment doesn't usually live that long so cynically it probably cost less to the system that way even)
Edit:
Why do I know that
A friend of my parents is a pharmacist and I used to ask him a lot's of questions when I was a child. Two of my female cousin (cousines in French) are pharmacists and I ask them questions on every new year day since at least the last 25 years. One practice in a drugstore, the other negotiate with the federal government for a big company that I won't name. Let's says they have a quite complementary vantage point. And I had quite the motivation to ramps up my knowledge of oncology to be the best advocate I can be for my wife.
Unfortunately pharma has the US patent office in their pocket and they release most drugs in a default form and then when the patent is running out they make a slow release version and get a new patent on it. It doesn’t take them a dozen years to figure out how to make a slow release version, and another ten to come up with an extended release version.
I’m on an extended release generic only because it’s older than dirt.
In my experience as a medically complicated person, generics generally work, but may have different side effects, both in scale and style. One of the worst was a duloxetine generic that came on so hard and strong that I felt serontoninised.
My friend the John the Pharmacist explained that the binders etc can accelerate absorption. His advice was be careful the first two days of a new generic formulation.
I would assume the NHS (like the TGA here in Oz) looks _very_ carefully at the side-affect profile before they buy any particular generic. Government agencies tend to try not to poison voters.
I take dimethyl-fumarate, which is a serious medication for MS, but sadly ever since "Tecfidera" got withdrawn for some reason, I can only get a "shittier" generic. That said, side-effect profile appears to be the same, thankfully. All in all, I think they are "almost" identical, if not identical.
I’ve had decent luck with slow release generics, but they go out of their way to make SR generics take a quarter of a human lifetime to come out after the original is available.
I have sent in drug samples for testing, in my case they were name brand.
Variance per dose is about plus/minus 15% across the board. You might get 9mg one day, and 11.5mg another for a drug with a nominal 10mg label. Injectables are typically better than oral tablets it seems but not by a lot.
Purity was pretty good though, it was mostly a dosing variance I saw.
The political uncertainties of western countries where "there is no truth" and "facts don't matter" could easily bring this level of systemic corruption to them as well. People love to rage bait and say how bad it is now, but that seems to have largely led to groups giving up on enforcing norms, and bodes poorly for the future.
There's a lot of money for the few in systematic corruption! This is something that has to be constantly fought against. R have embraced it entirely, but it's also prevalent on the D side especially in machine-politics cities. Which is why everyone's really so upset about the NY Mayor primary. People have gone on record in the papers about being annoyed that the bribes - sorry, donations - they prepaid to Cuomo are now invalid.
Leo Szilard (he's credited with theorising purposeful fission and patenting core ideas long before the Manhattan project got off the ground) wrote a long time ago about a (dys/u)topia where technocrats made the decisions. He had this idea "the bund" would fix politics by moving decision making to pure evidence based rational methods.
It wouldn't work, but when I see appeals to authority (FDA) enter the room, it's usually to feel superior because its a logical fallacy in argument but the place it actually fits (which btw, is here, in this thread) is that compliance to standards and policing them, is not "argument" it's the "you only had one job" part of the gig.
"yes Mr Kennedy, these friends of yours are very nice at parties, but unfortunately they are neither qualified, nor actually capable of fulfilling their role and so no, you won't be appointing them" is what the Bund would do.
Being able to take a compliance body oversight function and leverage it to remove adjuvents because of one paper, despite overwhelming evidence to the contrary, is precisely whats wrong in the current politicised situation.
If people making generic cancer drugs for use in africa had to be held to the standards in the west, we'd all be better off. I have said elsewhere that if the US rejects flu vaccines because of the mercury, they should be checked for other compliance and standards, and subject to cold chain integrity shipped to economies who usually can't afford them, and can use them.
>"yes Mr Kennedy, these friends of yours are very nice at parties, but unfortunately they are neither qualified, nor actually capable of fulfilling their role and so no, you won't be appointing them" is what the Bund would do.
The irony here being that the degree to which Kennedy and Johnson bungled 'nam was in large part a doing of the professionals with their academic attitudes about how foreign policy and war ought to be conducted. Obviously you don't get do-overs with history but it's very possible that Kennedy's preferred cabal of self serving frat bros would have concluded "the Vietnamese are screwed either way but we come out looking better not escalating, dominoes be damned".
>If people making generic cancer drugs for use in africa had to be held to the standards in the west, we'd all be better off.
How can you say that without an understanding of how much it would shrink the market in Africa?
$600 "perfect" insulin vs $50 "good enough" insulin. Metaphorically speaking.
Because of concerns how toxic ammonia was, and how common leaks. Turned out to be useful many decades later when they were designing the cold chain for the H Bomb before solid duterium/lithium came along.
Ah yes because technocrats are never prone to groupthink or missing the forest because of the trees, et cetera.
There was a fascinating article I read years back about how much of China’s top leadership had engineering degrees, unlike in western countries. Then the article pointed out how that led to things like the one-child act based on research in the 1970s predicting mass starvation. That one child policy is now leading to possible demographic collapse after causing decades of social strife.
Be careful what you wish for, as you’re possibly a variable which could optimized out.
Alternatively consider the long term ramifications of leaving pandemic responses purely in the hands of unelected epidemiologists whose primary focus is a virus and not the overall welfare of a population. Those are not the same thing after all, even if they seem like it at first glance.
IMHO, alternative means of thinking are needed in a governmental system for the best overall outcomes.
hence (dys/u)topia above. I think Szilard was off his rocker when he proposed this, it was before he had much to do with Teller. I suspect after the events of the bomb, he might have changed his mind.
(he wrote rather bad scifi about talking to dolphins. Somebody else, Pierre Boule wrote it much more sexy/exciting, that became "the day of the dolphin")
Ah it wasn’t quite clear if you were for or against the notion.
Bad dolphin sci-fi sounds a bit too much for my tastes. Though it’s often the border line crazy folks who give us some of the best ideas or stories. Though they also often need refinement by, uh, more standard people. I say that as an ADHDer who sometimes benefits from the same.
There is a punchline to the one child policy and all of the problems and suffering it caused. They could have just encouraged having kids later in life like at 25 instead of ar 18 and reduced it with fae fewer side effects. With exponentials compounding over time, delay is as good as reducing the count and far less invasive - scientests and engineers should have known that! Not a funny punchline but one all the same. But China chose a path of maximum violence and minimal personal choice.
Really the biggest problem with a technocracy is that power corrupts, and that people already refuse to admit when they were wrong because it would be detrimental to themselves. Make the metrics of what is right the key to power, especially with no objective arbiter and you'll see shit pretty much indistinguishable from Lysenkoism. As seen with the Great Leap Forward and its 'immovations' in agriculture, it is a road towards madness, not an accelerated path to progress.
Might makes right and war in general have many, many, many things wrong with them and should not be looked towards as some sort of ideal. But such conflicts forces objective verification of the technologies, tactics, and strategies and force science to be real to succeed. You cannot rely upon Lysenkoism to feed your armies because it is not real. If you insist that bullets cannot harm you because of your breathing techniques even if you convinced others of your bullshit it won't save you from a gun. But conversely if you insist you are protected from bullets by the right ceramics and kevlar even those who sneer at you for "using pottery for armor" if it blocks bullets and absorbs kinetic force it is right and thus "scientific" in a way.
american right-libertarianism is a thought-terminating ideology. "government bad, only private sector good" presupposes that we can't collectively provide services to residents/citizens, even when that's proven very effective in other countries.
The FDA has been approving generics from factories known to have repeatedly failed prior audits or had products recalled for quality issues without re-inspecting the factories or inspecting the drugs on import. And they're doing it via a special process that bypasses the ordinary review process and over the objections of many of the inspectors.
Was just reading about this one a few weeks ago, I couldn't find the article again but I believe it was based around the book Bottle of Lies. Basically the political pressure to keep drugs available and costs down has them looking the other way. And it has been going on since at least the Obama administration IIRC.
Not after the opioid crisis in the US. That was the job of the FDA to prevent that exact scenario. They approved Purdue Pharma opioids for non-chronic usage when European/Canadian regulators did not. Hence why the crisis was largely contained to the United States.
In both cases, the FDA was generally run and staffed by non-political people who were at least vaguely competent. I have plenty of issues with how the FDA operated, but it didn’t matter much who was president.
Today, most of the Cabinet positions are held by people who love to talk, who are generally extremely wealthy and/or well connected, and who are generally unqualified for their jobs. And, even more relevantly, they have been very heavily interfering in the operation of their respective departments.
Australia doesn’t allow most USDA beef because of strict biosecurity rules.
Australia’s one of the world’s biggest beef exporters. There’s not much incentive for them to open the door to a competitor unless the protocols align perfectly.
Africa and China are awash with fake meds - perhaps even in India. Large amounts of fake drugs are common in Africa/China = deaths are common. Pharmacies are very aware of this and watch their sources. The big problem is very good copies of the container, box and printed insert that mimic exactly the true drugs are everywhere. A copied box/insert/vial/tablet that costs $1 can hold drugs worth $200 or more. There are gangs that buy them from China and try to insert them in the supply chain.
I was with Sanofi-Pasteur(before I retired) and we had strict QC controls on every batch(every single ingredient). Every ingredient was sampled and tested locally and a sample sent to various head offices in USA/Canada/UK/etc. Batch ingredients were kept in locked areas and only allowed out in a weighed batch amount. The whole area was a clean and watched area with limited access badges on each person working there. You could only enter your zone and use your lunch/toilet area.
Some ingredients are active and can have high values. Some are inert fillers. 1 milligram of fentanyl is minuscule = it ends up in a 25 or 50 milligram pressed tablet for ease of patient/pharmacy handling. Even adding the inert is complex as the active and the inert must mix with no settling or gravity segregation. Often the active is mixed with an intermediate diluent and a fluid that will not dissolve either and mixed in wiped surface mixer to make a very uniform paste which was then dried and granulated and this was added to the final diluent and a 'binder'. The binder is a material that will glue the tablet together in a high speed press. Some tablets get an enteric coating that resists acid but dissolves in the lower gut alkaline state = breaks and dissolves.
Fentanyl and other strong opioids are killers in small amounts, so extreme precautions are taken to ensure correct doses.
You are going to rue the day. Enjoy your temporary comforts. You got so used to speaking of other people that are not in your demographic (especially Africans) as almost human that Africa will also not shed a tear should America be gone tomorrow And yes, we will survive your abscence, like we had since the beginning of time Tick tock (Or Tik Tok:-), more aptly)
I'll never forget a coworker telling me that in a previous job hunting round he had interviewed with a pharmaceutical group that was tracking the manufacturing process for batches of drugs and comparing the little tolerance mistakes (heated a little too high or held at temp a little too long or not quite long enough) and finding a market where they can sell that batch.
You'd like to think that companies have factories with quality control laws and there are local people trying to ensure that all of their product are up to the local standards. What you don't expect is that they are binning them like Intel CPUs, where they just make a batch and hope for the best, take cream off the top until the priority orders are done and then everyone else gets whatever is left. You might get a slightly better product sometimes but not be so lucky the next time.
If you've taken a prescription over a long enough time you'll know this to be true even if you've never really considered it.
Some time ago I was very frustrated with the massive swings in how well a prescription was working so I started looking into it. Saved a pill from every month, sent 12 of them off for testing.
+/- 30% accuracy on that dosage, and that's within spec for the US. Some months your 20mg pills are 26mg. Others? 14mg. Later repeated this test with a family member's blood pressure medication, which has a dosage of just 0.5mg. Same deal, 0.35-0.65
There are labs where you can just send prescription pills for testing as an end user?
For something like amphetamine, could get it tested at Energy Control lab in Spain. Valisure used to offer this kind of service for most pharmaceuticals in the USA but faced lawsuits and pushback: https://www.bloomberg.com/news/features/2023-12-05/pentagon-... [ https://archive.md/eyWSn ]
Generic amp huh? Thought I was going crazy. Who does name brand? Shire sold to Teva?
The same thing happens in food processing. The low quality stuff gets sold under a different, cheaper brand, or reprocessed into another product.
I'm not going to cast stones at this practice because as always the alternative isn't some magical world where all produce is perfect, the real alternative is that it gets thrown in the trash and wasted, and everyone is worse off despite feeling better about themselves.
Happy to live in a country with very strong food control. Yes we have the alternative labels yet it must be at least as good as the original.
They only need to be as good as the minimum standard for the category they're sold in. If you have a "good" bin and a "bad" bin, and the good bin easily exceeds the minimum requirements while the bad bin just barely meets them, that's fine, too. Or the good bin can be sold as class I, while the bad bin needs to be labeled as class II. Of course those categories usually aren't about safety-relevant aspects of quality, but things like weight or shape or appearance.
I want more good regulations, and less bad regulations, so I am not necessarily against anything you said here.
If the product is ineffective you’re stealing from people. And in the case of pharma, probably ruining their lives in the process, since we rarely do more than two care plans at once and if one is busted then they should be doing something else instead.
> the real alternative is that it gets thrown in the trash and wasted
My view is a bit different nowadays, but this is very much an extreme bird's eye view from very high up, looking at only the smaller processes I have no disagreement. So, my point is more like an alternative co-existing higher level view, not a replacement of what you and others say. You will still be right to want to optimize your processes of course.
I view it as different streams. Everything is a circle. There is a significant cost - energy (and time and space and effort). As long as we use ancient sun-energy dug out of the ground it's bad, but if we could power the circles with current sun energy it would not matter much.
You have one overall stream or flow, all materials, and output streams are various sizes of end products. The good stuff stream flows to the customers (and forms bigger circles), the mistakes are instead rerouted into the recycling stream.
In chemical engineering and in manufacturing you have the same. Making food, whether completely natural, or including any kind of processing even if it's just separation and packaging, will have similar properties. Quality varies, and you have additional processing streams for various qualities.
Sure, one would want to optimize the streams, but if we did not have the fossil energy source limitation, and maybe also space, if you have to go back to the growing fields, it would not matter too much.
----
Imaginary picture:
Imagine in the far future somebody set up a fully automated closed system for making food, from growing to putting it in a huge cafeteria buffet, fully stocked all day. But there is no more people. As long as there is energy, food is created, processed, put on the buffet, and then recycled, since there is nobody to actually eat anything.
Is it a waste? Well, yes and no.
The whole of earth is like that!
As long as there is energy the cycles continue. What is "waste"? If you take the very big view, everything just "is".
But again, our actual limitation is the energy source for our food cycles. Using ancient stored sun energy releases the carbon stored underground, and it also slowly depletes those stores. The real problem first of all is where we get the energy for our cycles from, not really if parts of it don't make it to the end customers. Opportunity cost, what we could use the space and general effort for instead of on recycling cycles comes a distant second, I think.
> the real alternative is that it gets thrown in the trash and wasted, and everyone is worse off despite feeling better about themselves
Depending on what's the minimum quality you consider acceptable for the product, you might want to throw away something and have good reasons to feel good about yourself doing it. There is a point where something dips below good ("less effective medication") and even neutral ("it's an empty pill"), into actively harmful ("it will kill you faster"). Discarding it instead of monetizing it is the positive outcome.
The alternate also happens though.
Over here in The Netherlands, the milk for all milk products comes out of the same cows and is processed in the same tanks. When you're paying 2x the price for brand name milk, you're getting seriously scammed.
There are a couple cooperatives here that own their own processing facilities. As food businesses got bigger the distance between processing plants has grown and grown and it ends up netting the farmers less and less.
I learned recently that there was a small coop near where I live that got bought up by a larger one, Organic Valley. Which has a semi famous permaculturist as a member (Mark Shepard), and the only reason I knew it to be a coop. They don’t advertise that fact well.
A quality increase does not mean "perfection" and so "magical" turns into "more expensive".
Id like to live in that world.
Is this system not preferable over just trashing anything not perfectly made? Sure it would be nice if everyone can have perfectly manufactured medicine, but that's not reality. I would think something that's still likely good is still better than nothing.
How do we assess that it's "still likely good" and "still better than nothing"? If they are defective it also means that they might make things worse.
Hopefully that's up to the laws of where the incorrectly processed stuff was allowed to be sold.
Hopefully those countries don't reduce standards due to lobbying.
A fair number of countries can't do the proper inspections required for this, either due to lack of resources or government corruption (or both). They could put a literal carbon copy of FDA standards into their regulations, but it's meaningless without enforcement.
>They could put a literal carbon copy of FDA standards into their regulations, but it's meaningless without enforcement.
This is funny because the USA itself doesn't do proper inspections.
https://en.wikipedia.org/wiki/Katherine_Eban
See the book "Bottle of Lies".
I believe we have a long history of companies selling toxic or non working stuff to countries not able to test or make sure its safe themselves.
See the HIV infected blood products scandal with Bayer. The infected blood was pawned off on the third world since they (correctly) figured they'd have much less success suing them.
You can tell what a bunch of assholes Bayer is made up of by the fact they were even willing to entertain purchasing Monsanto. Which they ended up doing. The lawyers are clearly in charge there.
Including the article we are all responding to.
And this is victim blaming. It’s not the government that suffers it’s billions of people.
This is literally a post about bad drugs being sold to brown people because they can.
There's a difference between a few percent difference in efficacy which is understandably still marketed (the same kind of thing happens when you leave meds on the shelf a while) and meds that are no longer effective at all to a reasonable level or toxic.
Why should a person in Somalia suffer and die from cancer while a person in Ohio, lives, soley on the basis of where they live?
Why should they not get access to drugs because the drugs would fail some bogus test made up by an american senator?
Do you remember what thread yours responding to?
Here I’ll remind you: nearly 20% of cancer drugs defective in four African nations.
That’s the context. What on earth are you talking about?
Did you read tfa?
>roughly one in six — were found to have incorrect active ingredient levels
>But some drugs are also counterfeit, and that increases the risk of discrepancies between what's on the product label and the actual medicine within.
If I was desperate, and given a choice between either 1 of "Might have incorrect active ingredient levels" "Might be counterfeit" "Might have been stored improperly" or "No cancer drugs for you" I know which way I would be leaning.
"Defective" is doing a lot of work in this headline.
More accurate to say they should get access to drugs that contain the actual molecules they are advertised to have across markets.
You shouldn't be able to sell what is basically sugar water in Somalia and call it cyclophosphamide. That's fraud if I do it as a private citizen.
In fact it's even fraud for me if I buy actual cyclophosphamide, and cut it with a bio compatible totally non reactive filler compound. How are these people getting away with it without the president and senators being on the take? When they'd run you or I down in less than a month for effectively the same act?
To be clear, I don't believe you or I should be able to do this. But I know what happens to private citizens who try to do things of this nature. So there is no question that this is a crime. The only question is why is it not prosecuted for larger corporations.
How do you know they would advertise it as unmodified cyclophosphamide (identical to the US product) in Somalia?
The point of the article was that counterfeit drugs are ineffective or killing people, bro.
Who is going to pay for the replacement drug?
[dead]
Why shouldn't every single person on earth immediately be granted citizenship to America and allowed access to all forms of welfare given to citizens? It's unfair to them
Speaking as a non-American, the dysfunction of US healthcare was one of the reasons I decided against the USA when considering an international move.
Not the primary reason, but it was part of it.
America is weird in that the poorest get significantly more benefits than the merely lower-middle class. And the majority of Americans pay no federal tax after EITC and other refunds.
You can get SNAP (free food), Section 8 (free housing), Medicaid (healthcare, CHIP for kids is easier than adults, but still many people get it), and if you manage to raise smart kids despite poverty they will get college for free as well (most highly-selective universities are free for the poor, but extremely expensive for even the middle class).
I own a lot of rental property and I have a Section 8 tenant who has never worked, completely gamed the system with a subjective disability that renders her unable to ever hold a job (supposedly). A good tenant but is constantly trying to give away tons of food she buys because she always tries to spend the SNAP she gets every month. And she gets free heat, and electricity, and public transportation pass, and on and on.
What a weird take: I'd definitely expect the poorest/sickest to get the most additional benefits of all, the middle to get none and the top to get charged extra to cover up.
If you're middle class, that should be the average and that means you only get things which are the foundation of the system covered by the taxes.
Let me elucidate why this system kind of sucks, as someone else who knows someone personally who lives a "full benefits" poverty life.
These benefits are binary, not tiered, so once you earn a dollar over the incredibly low threshold, they vanish. So the person I know cannot get a job and work, because if they earn over ~$16k in a year all the benefits go away. And where she lives you need about $50k/yr minimum to scrape by. So there is this $34k/yr gap which creates a no-mans land of livelihood.
> So there is this $34k/yr gap which creates a no-mans land of livelihood.
it also creates/necessitates a vast enforcement bureaucracy to make it all "work" which in itself is a huge waste when you could just tax it back from high-earners at the end of the tax year... its almost as if it was designed to suck
In addition to income, there are extremely low "wealth" qualifiers. You cannot save money while on most of these programs to try to improve your situation or build a personal safety net. If you manage to save more than a couple thousand dollars, you become ineligible for benefits.
The US has a weird class stratification system, that some people think has been embedded into society dating back to the Calvinist New England and slaveholding days.
It's developed since then in interesting ways and shows up everywhere. The biggest thing is that each cohort looks down on those "beneath" them. This manifests in different ways... people living in public housing, getting housing and typically SNAP benefits, will often scoff at people collecting temporary assistance (cash) as loafers.
If you're looking at families, the prevailing rent in Onondaga County, NY (Syracuse) is $1475 for a two-bedroom apartment. "Prevailing" rent is the metric used for Section 8 is essentially the price floor for an adequate apartment. The median household income in the county is $74,000, which is 23% rent to income ratio, so pretty good, right? (Keep in mind, this is from a not so great apartment that passes Section 8 inspection, but little else) Eh, not really, the well-off suburbs skew the statistic... if you look at the City of Syracuse, more representative of the blue collar working class and poor, the median income is $45,500 -- 39% rent to income. The median household in the city requires some support to live -- in Syracuse that's like 70,000 people
As you see purchasing power decline for working people, traditional "middle class" respectable jobs are falling off the ladder in terms of livability. A parent in a 90% of retail and semi-skilled labor jobs is making $80-90k max, and is basically a car disaster away from financial ruin. Many, many of these people are stuck with non-dischargeable student debt for life as well.
The problem with these discussions is the errant use of poor/middle/upper/top as class identifiers.
The more useful identifiers would be roughly young and/or working, and old and/or non working. The latter category also covers the beneficiaries of wealthy people (who are among the old and/or non working).
The USA (and many countries, especially democracies) has a situation where your expected quality of life is lower (or not sufficiently higher) for the young and working than the young and non working for those not lucky enough to be born to the right families or prudent enough to make the right choices in school, etc.
The incentives should always be such that expected quality of life is always greater for those working than non working.
Note that this is a different topic than whatever the floor for quality of life should be.
You are saying this with completely forgetting that the vast majority of the people who are old and non working are in fact, retired, sick, on medicaid, and generally just not that great at working in the first place because they already (most of the time) spent 40+ years working.
Why would the person who spent 40+ years working have a worse quality of life than someone whose spent 10 years working? The incentives you put up basically say "as soon as you are done we're sending you to the glue factory."
The whole point of retirement saving is so that you can still support yourself after your mind and body can. Just about everyone is aware of this, yet many still save nothing because "society will deal with it" when they get older.
When I was younger I had an easy time buying into "everything is too expensive to save money", now that I am older, past the "you must start saving now" age, I know way way too many people who don't save for retirement and live stupidly beyond their means.
"We don't have any retirement savings because how could we give up eating out 1-2 times a week, $250 monthly beauty appointments, $90 gym membership (they have clean warm towels!), and our annual Disney vacation and our family Lake Tahoe trip. And no way will you catch me in a 5 yr old used car, sorry I cannot sacrifice my new car leases!"
I know so many more people who recklessly spend money than people who honestly are trying but cannot make it.
Cool anecdote.
> The incentives you put up basically say "as soon as you are done we're sending you to the glue factory."
Those are the incentives nature puts up.
>Why would the person who spent 40+ years working have a worse quality of life than someone whose spent 10 years working?
Depends how much they earned and saved. Current workers (proxy for young) know they will not have a quality of life as good as those that have already worked decades past, so where is their incentive?
>because they already (most of the time) spent 40+ years working.
But they (at least these first few generations) are receiving healthcare worth far more than the work they did, tenable only due to the higher total fertility rates of many decades ago.
At its root, these deferred benefit schemes were either never sustainable for modern lifespans and healthcare consumption, or they depended on unrealistically high total fertility rates. One could even say they played a role in causing lower total fertility rates, as society de-coupled raising one's own productive children and having a good quality of life post working age, since you could now depend on others' productive children.
Money, savings, and other wealth abstractions that legislators can easily bring about don't materialize the goods and services one might want to buy.
through my eyes i see a similar implication to disproprortionate judicial punishment - aspects of a hegemonic system designed to suppress individual voices. for example, pirates in the UK being handed jail terms of greater duration than those given to individuals having killed other humans - people daring to go against the powerful have their lives taken away from them, whereas infighting within the working class is almost encouraged by miniscule sentencing.
or in this case, why bother putting any effort into life when doing nothing provides a greater reward? why attempt to make something of oneself at the risk of losing everything forever?
all in all, whether or not intentionally curated, these societal facets serve to foment an atmosphere of fear - individuals are forced to exist either in ignorance, or otherwise must live with the knowledge that minor infractions may end one's dreams, while concurrently one's dreams may be ended at any time for no reason but the whim of another.
such a dichotomy between ignorance and fear effectively suppresses societal change, which if it were to happen anyway, would be instantly detected by automated surveillance, and promptly quashed under fully legal pretences. but that's not even necessary. the populace is already addicted to living vicariously through screens (now from birth thanks to parents being forced to devote energy to work instead of their children).
yet the world keeps turning
The say you write about it, being poor in America is easy and great. And then you look at powerty in America and see hopeless desperate people with no access to justice,lite chances in life, little access to healthcare and raising homelessness on top of it.
And funny enough, the poor are just about to loose their healthcare and food stamps via big beautiful bill. Which is official name of that bill.
You're so programmed to knee-jerk about some political bullshit that you're not thinking.
These companies are making defective drugs and shipping them to people. The only thing preventing that from happening in the United States is the regulatory system, which we are in the process of smashing.
the person in somalia likely has a different cost/effectiveness preference vs the american, which is expressed through the lack of regulation.
To elaborate on this, if the individual in Somalia didn't want to die from said cancer and preferred better regulation, they would readily move to Ohio.
I sincerely hope both of you are just trying to make a joke. I don't think a web forum like this one is the right place for it, though.
hope all you want i think understanding what this site reveals about the world view of investor/dev types is a kind of sociological? shock.
its like everyone learning during covid their neighbors would kill every service worker to avoid the inconvenience of making their own coffee. it leaves a mark.
see what happened to the poor n-gate.com fellow, burned him out
Larry Summers is that you?
The person in somalia doesn't live in a country where the managers of the pharmaceutical company live and can be arrested.
Can the managers of the pharmaceutical company really be arrested in the US? Arrests are for poor people.
As Matt Levine would say: inefficacious cancer drugs sold in the American market would be egregious securities fraud[1] if the shareholders are not informed by company offices ahead of time. The resulting shareholder lawsuit may cost some managers their jobs. There is also the (minute) risk of getting Luigi'd by someone a state over, whose loved one they suspected to have gotten a bad batch and didn't get better.
1. "Everything is securities fraud" is a running series showing the breadth and depth of how shareholders exercise their rights in creative ways.
They will both die. Cancer treatment is largely useless (this is an editorial statement) Survival statistics are largely dependent on early detection. Detect the cancer early, you live longer after treatment.
> Cancer treatment is largely useless
Cancer treatment effectiveness has improved substantially, with many treatments now achieving high cure rates or significantly extending survival.
Highly effective treatments:
Surgery remains the most curative treatment when cancer is localized and can be completely removed. Complete surgical resection often leads to cure for early-stage solid tumors.
Chemotherapy can be curative for several cancers, particularly blood cancers like leukemias and lymphomas. Some testicular cancers and certain pediatric cancers also respond extremely well to chemotherapy alone.
Radiation therapy achieves excellent local control and can be curative, especially when combined with surgery or chemotherapy. It’s particularly effective for head and neck cancers, early-stage lung cancers, and certain brain tumors.
Revolutionary newer treatments:
Immunotherapy has transformed outcomes for melanoma, lung cancer, kidney cancer, and others. Some patients with advanced disease achieve long-term remissions that were previously impossible.
Targeted therapies work exceptionally well when tumors have specific genetic mutations. Examples include imatinib for chronic myeloid leukemia (transforming a fatal disease into a manageable condition) and HER2-targeted drugs for breast cancer.
CAR-T cell therapy has achieved remarkable results in certain blood cancers that failed other treatments, with some patients achieving complete remissions.
Combination approaches:
Modern treatment often combines multiple modalities - surgery plus chemotherapy plus radiation, or immunotherapy plus targeted therapy. These combinations frequently outperform single treatments.
Current limitations:
Some cancers like glioblastoma and pancreatic cancer still have limited treatment options, though research continues. Metastatic disease remains challenging, though increasingly manageable as a chronic condition rather than immediately fatal.
This is an oft-refuted trope that does harm to patients. Numerous randomized phase 3 studies show meaningful survival advantages for modern treatments.
If the treatment were useless, early detection wouldn't help. Or are you saying, the extended lifespan is just the difference in time between "early" and "late" detection?
Yes. I'm not saying all treatments are useless. Surgical removal of an isolated tumor or melanoma for example. But medical/chemo/radiation in all cases I've seen the person died anyway and spent many of their remaining days feeling awful from the side-effects.
"Cancer treatment is largely useless" is an objectively false statement.
This anecdote is interesting, but the article cites poor storage and counterfeiting as the main causes of the issue.
Thanks for this comment - I didn’t read the article and might have taken away a largely incorrect belief based on the parent. And you handled it so politely too!
The comment you replied to also paints an incorrect picture. The real quote from the article regarding the origin of the poor quality is:
>[...] Those causes can include faults in the manufacturing process or product decay due to poor storage conditions. But some drugs are also counterfeit, and that increases the risk of discrepancies between what's on the product label and the actual medicine within.
So this is actually pretty in line with the top level comment, since no mention of the actual ratio among reasons is made. It certainly doesn't say that counterfeiting and after production storage are the main reasons.
Does that mean that generics really are worse than the brand pharmaceuticals. Or are they binned the same way?
In the UK I know the NHS buys generics, which implies they are effective, but I wonder.
here in Canada the active ingredient must be identical in identical quantity but the binding agents, excipient, and propellant are proprietary. The generics have to have the same bioavailability +-20%.In some drugs it doesn't matter, in others there is a world of difference.
I pay the 2$ it cost for brand name ventolin (my insurance cover the cost generic and I pay the difference) as the generic give asthma attack. But I would not pay one cent more for the brand name Vyvaanse. Effect wise the generic is indistinguishable (but damm the pills colors make them looks like a cheap gray market knock-off).
My wife has a paper from her oncologist for original femara because the generic made her faint a few times ( the insurance cover the whole cost because of that paper)
I’ve known people who claim up one side and down the other that Advil is more effective than generic ibuprofen and it’s thought to be down to the other ingredients. I had at one point convinced myself of this as well, but these days even Advil doesn’t always help. Bummer is that only a couple of CBD products do anything for me either. May be why I’m so grumpy.
As a layman who fortunately has never had to deal with any "serious" medicine, how would I know which drug is good-enough is generic form, and which should be the brand name? To someone not in the know, +/-20% bioavailability sounds like a lot. Hopefully, the doctor will account for that when prescribing it, and know which way the 20% goes.
You also make it sound like 2$ isn't much to go from the generic to brand-name Ventolin. How much is too much? And is there a difference between generics of the same drug (I assume multiple manufacturers can actually produce generics) and how do you know which is better?
It’s a huge amount. I have a seizure disorder and I have to carefully increase my dosage by as much as 50% to compensate for the difference between generics and brand-name. The 20% is an average: one of the big differences between the two is absorption before/after you’ve eaten, so taking the medicine on an even slightly full stomach dramatically reduces absorption. The brand-name manufacturer now charges $300/mo for an off-patent drug you can buy generic for less than $25 (without insurance) which illustrates their view of the perceived value.
> the doctor will account for that when prescribing it
Sadly they do not. I got prescribed 12.5 mg tianeptine to take three times a day, except that amount is minuscule for my brain & body. You would think they take into account that I have fast metabolism, have many brain lesions, and so forth, but no, they do not, and there are no legal frameworks either to do so. They would have to account for these lesions in my brain for many reasons, but they do not.
For stuff like that works on the hormonal system the difference between them is more pronounced. Like the femara, an aromatase inhibitors the block estrogen production, the brand name was significantly better for my wife but reading MBC survivors forums it's not the case for everyone. And reading those forums, it's a problem in place like the UK where the only things available is the brand NHS choosed for you.
Now about how much is too much, well it's an hard question. It depends mostly on the alternative available, there are a lot of asthma drugs so switching from generic ventolin to something else like xopenex is easy so it limits the pricing power of the original manufacturer. Thing like anticancer with a specific mechanism where no direct alternative exists, the price is significantly higher, something like 300$ a month instead of 60-80$. But for my insurance it's relatively nothing compared to the Kisquali that cost 5700$/month. They have to reauthorized it every 6 months (it's a bureaucratic formality but they don't want to pay for it if the cancer has reappear because it's useless to continue the treatment)Note that I have something my pharmacist call a gold-plated drugs insurance. If we were only covered by Québec's public regime, my wife would probably be dead by now as they still do not reimburse Kisquali, it's suppose to change soon but I am not that informed on that because of my gold-plated insurance. (which is fucking stupid because the alternative was weekly in hospital chemotherapy that cost a lot more than 5700 a month, but then people with that treatment doesn't usually live that long so cynically it probably cost less to the system that way even)
Edit:
A friend of my parents is a pharmacist and I used to ask him a lot's of questions when I was a child. Two of my female cousin (cousines in French) are pharmacists and I ask them questions on every new year day since at least the last 25 years. One practice in a drugstore, the other negotiate with the federal government for a big company that I won't name. Let's says they have a quite complementary vantage point. And I had quite the motivation to ramps up my knowledge of oncology to be the best advocate I can be for my wife.Unfortunately pharma has the US patent office in their pocket and they release most drugs in a default form and then when the patent is running out they make a slow release version and get a new patent on it. It doesn’t take them a dozen years to figure out how to make a slow release version, and another ten to come up with an extended release version.
I’m on an extended release generic only because it’s older than dirt.
Generally it’s different companies manufacturing generics.
Instead this mostly comes down to how effective each countries regulations are.
This is also my understanding, but perhaps I am meant to understand that to be the case.
Generics are not supposed to be worse. They are supposed to have the exact same active ingredient. The binders or fillers may differ.
In my experience as a medically complicated person, generics generally work, but may have different side effects, both in scale and style. One of the worst was a duloxetine generic that came on so hard and strong that I felt serontoninised.
My friend the John the Pharmacist explained that the binders etc can accelerate absorption. His advice was be careful the first two days of a new generic formulation.
I would assume the NHS (like the TGA here in Oz) looks _very_ carefully at the side-affect profile before they buy any particular generic. Government agencies tend to try not to poison voters.
I take dimethyl-fumarate, which is a serious medication for MS, but sadly ever since "Tecfidera" got withdrawn for some reason, I can only get a "shittier" generic. That said, side-effect profile appears to be the same, thankfully. All in all, I think they are "almost" identical, if not identical.
I’ve had decent luck with slow release generics, but they go out of their way to make SR generics take a quarter of a human lifetime to come out after the original is available.
I have sent in drug samples for testing, in my case they were name brand.
Variance per dose is about plus/minus 15% across the board. You might get 9mg one day, and 11.5mg another for a drug with a nominal 10mg label. Injectables are typically better than oral tablets it seems but not by a lot.
Purity was pretty good though, it was mostly a dosing variance I saw.
Generics lack the ownership of the intellectual property, but that’s about it
Generics are effective
There can be variances. I’ve measured it with my blood pressure a few times when the pharmacy swaps manufacturers.
Generics tends to be different companies altogether.
The political uncertainties of western countries where "there is no truth" and "facts don't matter" could easily bring this level of systemic corruption to them as well. People love to rage bait and say how bad it is now, but that seems to have largely led to groups giving up on enforcing norms, and bodes poorly for the future.
There's a lot of money for the few in systematic corruption! This is something that has to be constantly fought against. R have embraced it entirely, but it's also prevalent on the D side especially in machine-politics cities. Which is why everyone's really so upset about the NY Mayor primary. People have gone on record in the papers about being annoyed that the bribes - sorry, donations - they prepaid to Cuomo are now invalid.
Leo Szilard (he's credited with theorising purposeful fission and patenting core ideas long before the Manhattan project got off the ground) wrote a long time ago about a (dys/u)topia where technocrats made the decisions. He had this idea "the bund" would fix politics by moving decision making to pure evidence based rational methods.
It wouldn't work, but when I see appeals to authority (FDA) enter the room, it's usually to feel superior because its a logical fallacy in argument but the place it actually fits (which btw, is here, in this thread) is that compliance to standards and policing them, is not "argument" it's the "you only had one job" part of the gig.
"yes Mr Kennedy, these friends of yours are very nice at parties, but unfortunately they are neither qualified, nor actually capable of fulfilling their role and so no, you won't be appointing them" is what the Bund would do.
Being able to take a compliance body oversight function and leverage it to remove adjuvents because of one paper, despite overwhelming evidence to the contrary, is precisely whats wrong in the current politicised situation.
If people making generic cancer drugs for use in africa had to be held to the standards in the west, we'd all be better off. I have said elsewhere that if the US rejects flu vaccines because of the mercury, they should be checked for other compliance and standards, and subject to cold chain integrity shipped to economies who usually can't afford them, and can use them.
>"yes Mr Kennedy, these friends of yours are very nice at parties, but unfortunately they are neither qualified, nor actually capable of fulfilling their role and so no, you won't be appointing them" is what the Bund would do.
The irony here being that the degree to which Kennedy and Johnson bungled 'nam was in large part a doing of the professionals with their academic attitudes about how foreign policy and war ought to be conducted. Obviously you don't get do-overs with history but it's very possible that Kennedy's preferred cabal of self serving frat bros would have concluded "the Vietnamese are screwed either way but we come out looking better not escalating, dominoes be damned".
>If people making generic cancer drugs for use in africa had to be held to the standards in the west, we'd all be better off.
How can you say that without an understanding of how much it would shrink the market in Africa?
$600 "perfect" insulin vs $50 "good enough" insulin. Metaphorically speaking.
Too mind-fogged to help you out here..
just wanted to point ou his most famous patent, the Einstein-Szilard fridge
(considerably less famous than the Einstein-Szilard letter, so I feel there's another argument for or against technocracy right there)
Because of concerns how toxic ammonia was, and how common leaks. Turned out to be useful many decades later when they were designing the cold chain for the H Bomb before solid duterium/lithium came along.
Ah yes because technocrats are never prone to groupthink or missing the forest because of the trees, et cetera.
There was a fascinating article I read years back about how much of China’s top leadership had engineering degrees, unlike in western countries. Then the article pointed out how that led to things like the one-child act based on research in the 1970s predicting mass starvation. That one child policy is now leading to possible demographic collapse after causing decades of social strife.
Be careful what you wish for, as you’re possibly a variable which could optimized out.
Alternatively consider the long term ramifications of leaving pandemic responses purely in the hands of unelected epidemiologists whose primary focus is a virus and not the overall welfare of a population. Those are not the same thing after all, even if they seem like it at first glance.
IMHO, alternative means of thinking are needed in a governmental system for the best overall outcomes.
hence (dys/u)topia above. I think Szilard was off his rocker when he proposed this, it was before he had much to do with Teller. I suspect after the events of the bomb, he might have changed his mind.
(he wrote rather bad scifi about talking to dolphins. Somebody else, Pierre Boule wrote it much more sexy/exciting, that became "the day of the dolphin")
He didn't change his mind, he was defeated by other (better socialized) technocrats
https://www.palladiummag.com/2021/03/16/leo-szilards-failed-...
Technocracies tend to be more accountable than cults of personality and even nontechnical intellects (Kissingers) there's that
Ah it wasn’t quite clear if you were for or against the notion.
Bad dolphin sci-fi sounds a bit too much for my tastes. Though it’s often the border line crazy folks who give us some of the best ideas or stories. Though they also often need refinement by, uh, more standard people. I say that as an ADHDer who sometimes benefits from the same.
See more rational for needing mixed viewpoints!
There is a punchline to the one child policy and all of the problems and suffering it caused. They could have just encouraged having kids later in life like at 25 instead of ar 18 and reduced it with fae fewer side effects. With exponentials compounding over time, delay is as good as reducing the count and far less invasive - scientests and engineers should have known that! Not a funny punchline but one all the same. But China chose a path of maximum violence and minimal personal choice.
Really the biggest problem with a technocracy is that power corrupts, and that people already refuse to admit when they were wrong because it would be detrimental to themselves. Make the metrics of what is right the key to power, especially with no objective arbiter and you'll see shit pretty much indistinguishable from Lysenkoism. As seen with the Great Leap Forward and its 'immovations' in agriculture, it is a road towards madness, not an accelerated path to progress.
Might makes right and war in general have many, many, many things wrong with them and should not be looked towards as some sort of ideal. But such conflicts forces objective verification of the technologies, tactics, and strategies and force science to be real to succeed. You cannot rely upon Lysenkoism to feed your armies because it is not real. If you insist that bullets cannot harm you because of your breathing techniques even if you convinced others of your bullshit it won't save you from a gun. But conversely if you insist you are protected from bullets by the right ceramics and kevlar even those who sneer at you for "using pottery for armor" if it blocks bullets and absorbs kinetic force it is right and thus "scientific" in a way.
american right-libertarianism is a thought-terminating ideology. "government bad, only private sector good" presupposes that we can't collectively provide services to residents/citizens, even when that's proven very effective in other countries.
I don’t see how. FDA is widely respected.
The FDA has been approving generics from factories known to have repeatedly failed prior audits or had products recalled for quality issues without re-inspecting the factories or inspecting the drugs on import. And they're doing it via a special process that bypasses the ordinary review process and over the objections of many of the inspectors.
Was just reading about this one a few weeks ago, I couldn't find the article again but I believe it was based around the book Bottle of Lies. Basically the political pressure to keep drugs available and costs down has them looking the other way. And it has been going on since at least the Obama administration IIRC.
Not after the opioid crisis in the US. That was the job of the FDA to prevent that exact scenario. They approved Purdue Pharma opioids for non-chronic usage when European/Canadian regulators did not. Hence why the crisis was largely contained to the United States.
Canada has had many opioid-related overdoses and deaths: https://health-infobase.canada.ca/substance-related-harms/op...
The numbers seems roughly proportional to US opioid deaths (though I haven’t taken a detailed look, and there may be differences in the way deaths are categorized): https://nida.nih.gov/research-topics/trends-statistics/overd...
15 years ago the president was widely respected.
16 years ago not so much.
In both cases, the FDA was generally run and staffed by non-political people who were at least vaguely competent. I have plenty of issues with how the FDA operated, but it didn’t matter much who was president.
Today, most of the Cabinet positions are held by people who love to talk, who are generally extremely wealthy and/or well connected, and who are generally unqualified for their jobs. And, even more relevantly, they have been very heavily interfering in the operation of their respective departments.
Is it?
Australia wont import FDA certified beef. For great reason.
I think you mean USDA.
Australia doesn’t allow most USDA beef because of strict biosecurity rules.
Australia’s one of the world’s biggest beef exporters. There’s not much incentive for them to open the door to a competitor unless the protocols align perfectly.
So the FDA has no hand in Beef?
To my knowledge no
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Oh man did rfk jr actually do something with flouride, like directly out of the movie? I haven't been paying a ton of attention to rfk's actions.
A lot of low-quality and addictive generic drugs has created an opioid crisis in Africa too [1].
[1] https://www.bbc.com/news/articles/cwyew21yyjzo
Africa and China are awash with fake meds - perhaps even in India. Large amounts of fake drugs are common in Africa/China = deaths are common. Pharmacies are very aware of this and watch their sources. The big problem is very good copies of the container, box and printed insert that mimic exactly the true drugs are everywhere. A copied box/insert/vial/tablet that costs $1 can hold drugs worth $200 or more. There are gangs that buy them from China and try to insert them in the supply chain. I was with Sanofi-Pasteur(before I retired) and we had strict QC controls on every batch(every single ingredient). Every ingredient was sampled and tested locally and a sample sent to various head offices in USA/Canada/UK/etc. Batch ingredients were kept in locked areas and only allowed out in a weighed batch amount. The whole area was a clean and watched area with limited access badges on each person working there. You could only enter your zone and use your lunch/toilet area. Some ingredients are active and can have high values. Some are inert fillers. 1 milligram of fentanyl is minuscule = it ends up in a 25 or 50 milligram pressed tablet for ease of patient/pharmacy handling. Even adding the inert is complex as the active and the inert must mix with no settling or gravity segregation. Often the active is mixed with an intermediate diluent and a fluid that will not dissolve either and mixed in wiped surface mixer to make a very uniform paste which was then dried and granulated and this was added to the final diluent and a 'binder'. The binder is a material that will glue the tablet together in a high speed press. Some tablets get an enteric coating that resists acid but dissolves in the lower gut alkaline state = breaks and dissolves. Fentanyl and other strong opioids are killers in small amounts, so extreme precautions are taken to ensure correct doses.
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I actually read the actual study on Lancet. unfortunately for you, your vile prejudice can not be justified by this study.
India isn’t even mentioned in the article.
You are going to rue the day. Enjoy your temporary comforts. You got so used to speaking of other people that are not in your demographic (especially Africans) as almost human that Africa will also not shed a tear should America be gone tomorrow And yes, we will survive your abscence, like we had since the beginning of time Tick tock (Or Tik Tok:-), more aptly)