Sunday, November 28, 2004

Vioxx: What would Gandhi do?

An interesting report from AP (here via CNN) tells how 12 states have by-passed FDA judgment and decided for themselves which drugs are safe and effective and therefore which they are willing to shell out their portion of the billions of dollars spent on prescription drugs by federal and state governments. Using information from the scientific literature the twelve state cooperative venture, called the Drug Effectiveness Review Project, recommended to its members that Vioxx be considered for reimbursement removal two years ago. Washington and Oregon did so in early 2002. Missouri took another tack:
Missouri applied the Vioxx warning to a computer program that in fewer than three seconds judges whether the state should pay for prescriptions, said George Oestreich, the program director.

After that, when a pharmacist tapped in prescription information, the computer program knew to block payment for Vioxx if the patient had a history of cardiovascular disease or if the prescribed dose was higher than 25 milligrams and was to be taken longer than five days.

In those cases, an electronic message would flash the answer back to the pharmacy: Missouri won't pay.
Seems like a constructive program. Which brings me to Gandhi.

Many people think of Gandhi as the exemplar of passive resistance. But as Jonathan Schell writes in a book I strongly recommend, The Unconquerable World: Power, Nonviolence, and the Will of the People (Metropolitan/Owl, 2003 and available on Amazon here), Gandhi was anything but passive. His philosophy was quintessentially one of action. In addition to his better known strategy of active non-cooperation, he was an ardent advocate of what he called "the constructive program." If the goal is the betterment of India, why not proceed to it directly? As Schell writes,
Why not pick up a broom and sweep a latrine--as Gandhi in fact did at the first Congress [Party] meeting he attended, in 1915....He frequently suggested, indeed, that the constructive program was as effective a path to political power as noncooperation. Political power, he wrote, would in fact increase in "exact proportion" to success in the constructive effort. (pp 140-141).
Gandhi's goal was not seizure of political power per se but the objectives that political power can help achieve: ending untouchability, cleaning latrines, improving the diet of Indian villagers, improving the lot of Indian women, making peace between Muslims and Hindus (as summarized by Schell, p. 142).

It is something to think about. Obsessing about the recent election loss should not obscure the possibility that in many areas of public health we can advance our own "constructive program" without waiting for the Messiah of 2008 and his/her Congressional Apostles. There is much interesting discussion about "framing" issues. Fine. Probably important, maybe essential. But let's not forget that we can sweep some latrines now and provide support for those who have been doing so for a long time. Since the latrines have been filling with crap faster than we have been removing it, perhaps it's time to start thinking and implementing new and better ways to sweep, whether it be the state, local or neighborhood levels.