17、Big Pharma

　　The benefits of hypertension

　　Dec 4th 2003 From The Economist print edition

　　Growing pressure on pharmaceutical firms is a force for good

　　FIRMS today fall from grace with the alarming ease of wayward bishops，few industries, however, have tumbled as far, as fast and on as many fronts as drugmakers. Only five years ago, big firms were celebrated as the purveyors of exciting new medicines, such as Viagra, and even more stimulating earnings growth.

　　Today, firms are seen by many as more profiteering than profit-making. Companies are castigated for spending billions on research and development, only to deliver too many “me too” drugs and too few genuinely new ones. Comparable sums spent on sales and marketing—particularly on direct-to-consumer advertising in America—are lambasted for corrupting doctors and creating demand on the back of fancy publicity rather than legitimate medical need or product superiority. Efforts to fend off lower-cost competition from manufacturers of generic drugs through patent lawsuits leave companies accused of driving up the drugs bill in rich countries and depriving millions of life-saving medicines in poor ones The shares of most big drug firms now trade at a discount to the market, as promises of bright times ahead are marred by risk.

　　To be sure, pharma companies come in for criticism not just because they are more profitable than those in other sectors but because they are profitable in a field, medicine, where money makes people uneasy. And not only are drug companies profitable, but also visible: in America, rising hospital and physician costs are as much to blame for soaring insurance premiums as pharmaceuticals, but it is drugs which are the most obvious recurring expense and the one that consumers are asked, at least in part, to shoulder directly. Firms are caught between shareholders, who fear drug prices will fall, and consumers, who complain about their rise.

　　Some of the pain which big firms now feel is undoubtedly self-inflicted. Firms were slow to recognise the gathering storm around the lack of access to life-saving drugs in the developing world. Their public relations on most other issues remains pretty clumsy too, and their promises to investors have been overblown.

　　And yet it is also true that producing new drugs today has become a more complicated, costly and risky business than before and many firms now face a couple of years during which they will have relatively few new products coming to market. For example, using the human genome to identify promising new treatments is proving a much more difficult scientific task than many had predicted, and it will be many years before the promised flood of new drugs occurs.

　　Current pressures on pharmaceutical firms are forcing a long-overdue examination of how they organise research and development and these changes could cut the cost, in time and money, of R&D and eventually boost output GlaxoSmithKline, the world's second-largest company, this week showed early signs that such root-and-branch re-engineering is starting to bear fruit. The final step drug firms will need to take is to prove that the drugs they produce really do justify the prices charged, in conferring appreciable benefits compared with existing therapies.

　　18、School meals

　　Eat up your greens

　　Dec 2nd 2004 From The Economist print edition

　　Can school meals be appetising, nutritious and profitable?

　　PUPILS, like soldiers, march on their stomachs. A well-nourished child is more likely to be a studious one. But food has been seen as a cost to be cut, rather than an ingredient of good schooling. That may now be changing: as the government worries about obesity—which is rising fast among children—and urges everyone to eat less salt, fat and sugar, and more fruit and vegetables, the paucity and unhealthiness of most school meals is striking. But cash constraints and rules on public-sector contracts make improvement hard.

　　Since cost-cutting began in the 1980s, quality has fallen along with food budgets. More and more children have chosen to bring packed lunches, spend their dinner money on fast food or skip lunch altogether. Now only half the pupils who could eat school meals do so. As numbers fall, the overheads become more burdensome and the pressure on ingredients greater. Of a typical £1.20-1.30 ($2.30-2.50) charged for a primary-school meal, labour costs account for 55p, equipment another 5p, administration charges up to 15p and profit 8p, according to Paul Kelly of Compass, a leading catering company. That leaves barely 40p for the ingredients. By contrast, a prison would spend 60p (per adult). The Dragon School in Oxford, a top junior school in the private sector, spends 75p per child and a hospital 90p.

　　The easiest way to get more children into the school dining room is to offer fast food, like chips and pizza—but that conflicts with improving nutrition. What is both tasty and good for you is likely to be more expensive. One way round that would be to cut labour costs—which is impossible thanks to a government directive which says that workers in privatised services must have the same terms and conditions as they would have enjoyed in the public sector.

　　All this is no fun for contractors, whose margins are being squeezed. Compass and another big firm, Rentokil Initial, a conglomerate with its roots in rodent control, have complained that they are finding the primary-school business unattractive. “We have decided not to go into that market,” says Mr Pollard of Avenance, an upmarket catering firm which mainly works for state hospitals and independent schools. “We cannot provide the right food to put on a child's plate for 42p. The government has made the effort with hospital food, but has yet do so with schools.”

　　Some local authorities are getting fed up too. Essex County Council has given its 600 schools direct charge of catering. That has been good news for some—chiefly large ones, or those able to form clusters in order to negotiate good deals. But it is bad news for small schools in remote areas, who benefited from a cross-subsidy under the old scheme. Around 75 of them have given up offering hot meals.

　　It is not just about money, says Neil Porter of the Local Authority Caterers' Association, who notes that school meals are only 15% of a child's annual food intake. It is unrealistic, he says, to think that they are the key to delivering better nutrition. “Children live in a processed-food culture with at least two generations of parents who cannot cook and are themselves unfamiliar with certain foods,” he says. “The vast majority of children will not eat in school what they do not recognise and do not eat outside of school.”

　　19、Race and education

　　Black marks

　　Mar 10th 2005 From The Economist print edition

　　It's the natives, not the immigrants, that are the problem Alamy

　　WHITE people tend to be nervous of raising the subject of race and education, but are often voluble on the issue if a black person brings it up. So when Trevor Phillips, chairman of Britain's Commission for Racial Equality, said that there was a particular problem with black boys' performance at school, and that it might be a good idea to educate them apart from other pupils, there was a torrent of comment. Some of it commended his proposal, and some criticised it, but none of it questioned its premise. Everybody accepts that black boys are a problem.

　　On the face of it, it looks as though Mr Phillips is right. Only 27% of Afro-Caribbean boys get five A-C grades at GCSE, the exams taken by 16-year-olds, compared with 47% of boys as a whole and 44% of Afro-Caribbean girls. Since, in some subjects, candidates who score less than 50% get Cs, those who don't reach this threshold have picked up pretty little at school.

　　Mr Phillips's suggestion that black boys should be taught separately implies that ethnicity and gender explain their underachievement. Certainly, maleness seems to be a disadvantage at school. That's true for all ethnic groups: 57% of girls as a whole get five A-Cs, compared with 47% of boys. But it's not so clear that blackness is at the root of the problem.

　　Among children as a whole, Afro-Caribbeans do indeed perform badly. But Afro-Caribbeans tend to be poor. So to get a better idea of whether race, rather than poverty, is the problem, one must control for economic status. The only way to do that, given the limits of British educational statistics, is to separate out the exam results of children who get free school meals: only the poor get free grub.

　　Poor children's results tell a rather different story. Afro-Caribbeans still do remarkably badly, but whites are at the bottom of the pile. All ethnic minority groups do better than them. Even Bangladeshis, a pretty deprived lot, do twice as well as the natives in their exams; Indians and Chinese do better still. And absolute numbers of underperforming whites dwarf those of underperforming Afro-Caribbeans: last year, 131,393 of white boys failed to hit the government's benchmark, compared with 3,151 Afro-Caribbean boys.

　　These figures suggest that, at school at least, black people's problem is not so much race as poverty. And they undermine the idea of teaching black boys separately, for if poor whites are doing worse than poor blacks, there's not much argument for singling out blacks for special measures: whites need help just as badly.

　　It's a nice thought

　　This isn't, however, a message that anybody much wants to hear. Many white people find the idea that there's something fundamentally wrong with black people comforting: it confirms deeply held prejudices and reassures them that a whole complex of social problems—starting with underachievement in schools, but leading on to unemployment, drug addiction and crime—is nothing to do with them.

　　The race-relations industry also has an interest in explaining educational underachievement in terms of ethnicity. A whole raft of committees, commissions and task forces has been set up on the assumption that racial differences are a fundamental cause of social problems. If that's wrong, then all those worthies might as well pack up and go home.

　　Trying to explain educational underachievement away as a racial issue may be comforting and convenient, but it is also dangerous, for it distracts attention from the real problem—that the school system fails the poor. That's not a black problem or a white problem: it's a British problem.

　　20、Restoring hearing

　　Hair tonic

　　Feb 17th 2005 From The Economist print edition

　　Gene therapy may restore lost hearing and balance

　　EVOLUTION has provided people with an exquisitely sensitive system of hearing and balance—the inner ear. But that sensitivity comes at a price, for the inner ear is also the sensory system most susceptible to damage. Nearly one child in 1,000 is born profoundly deaf, and if you are lucky enough to live to be 80, you have a 50% chance of losing enough of your hearing on the way for normal conversation to be troublesome without a hearing aid.

　　Often, the reason is damage to specialised sensory cells known as hair cells. The hair-like cilia that give these cells their name act as transducers. They convert the vibrations of sound into electrical impulses that the nervous system can handle. But cilia are fragile. Loud noises, such as those produced by machinery and booming stereos, can knock them away. So can some infections, such as meningitis. And so can some antibiotics. This damage is, at the moment, irreversible. But if Yehoash Raphael of the University of Michigan and his colleagues have their way, that will not be true for much longer.

　　Over the past two decades, many of the genes required for ear development have been identified. One of the most important is called Math1. But it is active only in embryos. Dr Raphael wondered, therefore, whether it would be possible to turn it on in adults, and thus generate new cilia.

　　The adults in question were guinea pigs—both literally and metaphorically. (Despite the colloquial use of the name, experiments involving rodents more often use mice or rats.) They were treated with antibiotics, to kill their hair cells. This made them completely deaf. Then, after four days, their left ears were infected with an adenovirus (one of the sorts of virus that cause colds). Half the infections were with viruses that had had a Math1 gene engineered into them. Half used viruses that had had a dummy DNA sequence engineered in instead. The hope was that the Math1 gene would be activated in the infected cells, which would then grow cilia, thus becoming hair cells. And it worked. As Dr Raphael reports in Nature Medicine, eight weeks later the animals treated with Math1-carrying adenovirus had regenerated their hair cells and were able to hear.

　　Their hearing was not restored completely. Although they were able to perceive sounds in the range of 40-50 decibels—similar to the volume of a typical conversation—Dr Raphael suspects that what they heard was rather fuzzy. That is because the treatment only caused the regrowth of a group of cells called the inner hair cells. These determine the threshold of hearing. A second group, the outer hair cells, did not reappear. The outer cells are responsible for amplifying sound, and for modulating its quality. Dr Raphael suspects that a second gene will need to be added to the viral package to stimulate the outer cells' regrowth.

　　Meanwhile, at the University of Maryland, Hinrich Staecker has been doing similar experiments designed to restore balance in mice. In these experiments, which have yet to be published, he uses an antibiotic injection to knock out the hair cells devoted to balance. (These cells work by detecting movements in the fluid that fills the canals of the inner ear.) Forty-eight hours later, he injects the animals with adenoviruses containing Math1 genes. A month after the injection, the animals have regained their sense of balance.

　　Both groups of researchers think this is the beginning of a new approach to treating inner-ear problems. Dr Staecker predicts that the first Math1 gene-therapy trials will happen in people who have lost their sense of balance. If those work, hair cell-regeneration treatments for deafness may follow. There is still a long way to go. Trials of any kind are probably five years away. But it looks as if science is having more luck restoring the hairs of the ears to youthful vigour than it is with the hairs of the head.