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For the record

Are there analogies to be drawn in the US between the cost of drugs and Iraq?

I was rather startled this week; startled by President Bush. Startled in particular, when he was addressing the nation on his future policy in Iraq, by how he looked. All I could think was `who is this Bush impersonator reading from the teleprompter?'

Actually, these are not my words. They are the words of seasoned Republican businessman and friend of 20 years, John Marriotti. He went on: Our President is lost, doubling up on a bet that he has already lost. One definition of insanity is `doing the same thing over and over and expecting a different outcome'.

Marriotti continued: Bush's opponents, whether they are the new Congressional controlling Democrats, or people like me - Republicans who are astounded at his actions - don't have many better ideas. That is the scary part.

The US' staunchest allies, the Brits, don't know what else to do either. The problem is that when things really fall apart, they will look to us, and condemn us if we don't use our massive resources to somehow 'fix it'. Marriotti is a wise and balanced man.

He told me: There are two steps to solving any problem, large or small (and Iraq is a biggie - ignoring that it is largely self-inflicted). The first is to define the problem, the second to solve the problem. However, there is a step that precedes step number one and that is to understand the nature of the problem.

Clearly, we don't. We don't and the Americans don't.

The right questions
Someone who does seem to understand the dilemma is Craig T Trebilcock, a Lieutenant Colonel in the US Army Reserve who served in Iraq during 2003, helping to reconstruct its legal system.

He is also the author of a novel on that experience, One Weekend A Month.

Anyone who delights in the name Trebilcock has to be taken seriously!

He writes: ' ...clearly the stability of Iraq is degrading, insurgent and criminal violence is increasing, and yet, the US continues the same policies of the past, but with a larger force as the primary change.'

Perhaps not quite 'insanity', but close. He goes on: 'Clinging to the belief that more military force is the answer to Iraq's internal political struggles, despite four years of failings, reveals a fundamental weakness in the Administration's understanding of Iraqi politics and culture...

`The wrong questions are being asked in the Administration on how to create stability in Iraq and, thus, the answers will not improve the political outcome there. The policy question most frequently asked is, how can we use military means to stop increasing sectarian violence? Under that narrow view, the logical answer is to increase the amount of force in the unstable areas. However, if the question posed were, how can we attain the strategic goals of political stability and democracy in Iraq?, a different set of answers would be required.'

Trebilcock then goes on to point out that 'many of these answers may be politically undesirable to the civilian leadership, and thus the default is to the US military forces to fix internal Iraqi cultural and political problems.

`In order to have a chance for success, US policies and tactics cannot be based solely on more military force, but must incorporate the understanding of these principles: societal values, loyalty, defending what is valued, historic bedouin origins, conflicting values, time and the concept of En Sh'allah.'

Nicely put.

Price negotiations
However you slice and dye all this, it is a mess. A huge mess and a mess that could have profound implications for the pharmaceutical industry.

The mid-term elections have been a disaster for the Republicans. Bush looks more and more like King Canute. As a result, the Democrats now control both Houses in Washington, and they are not wasting any time.

There are 'real' elections on the horizon and the Democrats are putting down markers. Politico-pharma podcasters FirstWord (see reported in mid-January that Democrats from the US House of Representatives have already introduced legislation that would require the Health and Human Services Secretary to negotiate lower drug prices for Medicare with pharma companies. The House of Representatives is scheduled to vote on the bill on February 12.

Discussing the measure, a spokesman for the House Speaker explained that the Democrats were hoping to get some savings, obviously, from the price negotiation, and then we can try to use some of that money in order to address a coverage gap in the Medicare plan.

The Washington Post reported that the Democrat chairman of the House Energy and Commerce Committee also indicated that the legislation was just a `first step' of planned new measures the party envisions for Medicare.

He noted that he intended to hold hearings in the near future, in order to `identify additional changes needed to improve the Medicare drug programme', the paper highlighted.

Bloomberg reported the comments of CitiGroup analyst Paul Heldman: The legislation is likely to pass the House... but I think right now the odds are against it passing the Senate. Even if supporters are able to get the votes needed in the Senate, I think the President is likely to veto it.

Senior vice president of Pharmaceutical Research and Manufacturers of America (PhRMA), Ken Johnson, noted in a statement that the association was trying to determine the practical implications of the legislation. He added that while PhRMA was supporting the Medicare programme, it remained strongly opposed to any price control scheme which would limit the choice of medicines available.

Comparisons are inescapable. Iraq, Medicare. Bush will send more troops to Iraq; it won't work. Bush will veto any bill that will look like it is trying to reduce the cost of medicines in the US; it won't work.

Is he protecting the oil industry? You bet. Is he protecting big pharma? You bet! There is the mother of all elections coming and the Republicans need all the support (and money) they can get. Please, someone remind him: if you always do what you always do, you'll always get what you've got. In this case, a bloody mess.

The author
Roy Lilley is a healthcare author and broadcaster

12th February 2007


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