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Hurrah for a David Leonhardt and his superb article “The Choice: A Longer Life or More Stuff” (New York Times, September 27, 2006).

It’s a very thoughtful and provocative essay about what we, as a society, receive for what many pundit, pols, and MSM savants derisively refer to as “spiraling health care costs.”

Mr. Leonhardt writes, “Living in a society that spends a lot of money on health care creates real problems, but it also has something in common with getting old. It’s better than the alternative.”

As David Cutler (our second favorite health economist) points out in “Your Money or Your Life,” in 1950 the average American spent less than $100 a year ($500 in today’s dollars) on medical care. That number today is $6000.

And, according to Leonhardt, “Most families in the 1950’s paid their bills, but they also didn’t expect much in return. After a century of basic health improvements like indoor plumbing and penicillin, many experts thought that human beings were approaching the limits of longevity.”

Remember what biologist Rene Dubos wrote in the 1960’s, “Modern medicine has little to offer for the prevention or treatment of chronic and degenerative diseases.”

As Walter Wriston famously quipped, “The future isn’t what it used to be.” He was wrong. And so was Monsieur Dubos.

Dan Quayle was more on the mark (kind of) when he said, “The future will be better tomorrow.”
That's turned out to be surprisingly prescient.

Mr. Leonhardt points out that perhaps “spiraling” costs are, well, worth it. “A baby born in the United States this year will live to age 78 on average, a decade longer than the average baby born in 1950 … If you think about this as the return on the investment on medicine, the payoff has been fabulous: Would you prefer spending an extra $5500 on health care every year – or losing ten years of your lifespan?”

And what do you think the proponents of so-called "rational use of medicine" would have to say about that? Ultimately, they say what Leonhardt points out as both true and frightening -- "that the best way to reduce health care spending is to reduce health care itself."

That is not acceptable in our affluent society. In First World societies health care is precisely how we should spend our money. As David Cutler writes, “We have enough of the basics in life. What we really want are the time and the quality of life to enjoy them.”

And to do this we must be able to choose the health care (yes – even the pharmaceuticals) that are best suited to our individual needs. Choosing to support spending on health care means choosing life.

Health care: it's where pro-choice meets pro-life.

Put up your Dukes

  • 09.28.2006
Exciting news from the FDA website ...

FDA and Duke Clinical Research Institute Form Partnership to Collaborate on Cardiac Safety Virtual

'Warehouse' of Electrocardiograms Will Serve as Primary Tool In Cutting-Edge Safety Research
The U.S. Food and Drug Administration (FDA) today announced a partnership, under the agency's Critical Path Initiative, with Duke Clinical Research Institute (DCRI) to develop a new generation of tools to identify, as early as possible, the potential effects that drugs and devices may have on the heart -- one of the more ominous side effects associated with such products.

The research will be conducted using a virtual electronic database of more than 200,000 electrocardiograms (ECGs) amassed by the agency from the clinical trial data submitted as part of new drug applications.

"For years we have received generally low-quality copies of ECGs on paper, and we were limited in our ability to use the information to understand why some treatments affected a patient’s heart," said Andrew C. von Eschenbach, M.D., Acting Commissioner of Food and Drugs. "Through the development of digital ECG data standards in 2004, the development of the ECG warehouse in 2005, and this partnership in 2006, we hope to identify patterns that will help to predict which patients are at an increased risk for cardiovascular side effects. This knowledge can guide the development of safer treatments."

FDA and the Duke Clinical Research Institute are developing a consortium with members of academia, patient advocacy groups, other government and non-profit organizations and industry to coordinate and support a variety of research projects involving ECGs obtained in clinical trials. Through the consortium, FDA and DCRI will identify gaps in cardiac biomarkers and prioritize projects based on those needs.

Research shows that women are at higher risk of arrhythmias (abnormal heart beats), but it is not known whether this difference in susceptibility is related to different responses to drugs. Among the first applied projects the consortium will address is a review of gender differences in the effects of drugs on the ECG. A second research project will evaluate the four current methods of measuring ECGs and develop criteria to determine the best method to be used in a particular research study.

"By selecting the most appropriate method for measuring ECGs, we can better assess the impact of a drug or device on patients," said Norman Stockbridge, M.D., Director for CDER's Division of Cardio-Renal Drug Products.

Under the framework of this consortium, Duke and FDA researchers, together with other industry and academic consortium partners, will use the database to identify early indicators for potentially life-threatening cardiac arrhythmias. Strategies will range from the systematic comparison of variants of existing risk-evaluation techniques (to select the most efficient methods) to searching for novel ECG waveform features capable of detecting small adverse drug effects.

"Through its academic mission, the DCRI is committed to identifying and developing more accurate measures of cardiac safety. We will continue to advance the science supporting safety in drug development," said Dr. Robert Califf, Director of DCRI / Vice Chancellor for Clinical Research of the Duke University Medical Center. "This goal is shared with the FDA, and we are proud to be an integral member during the process that will bring a priority area of the Critical Path Initiative from concept to reality."

In October 2005, FDA and the Duke Clinical Research Institute co-sponsored the first in a series of meetings on improving the evaluation of cardiac safety during product development, a high priority under FDA's Critical Path Initiative. The Cardiac Safety and Critical Path Initiative Think Tank brought together representatives of academic research institutions, industry, professional societies, patient advocacy groups, and government agencies as part of a long-term effort to foster the development of tools needed to improve cardiac safety. Another meeting of the group is scheduled for November 3, 2006 at Duke University.

The ECG Warehouse
Following the establishment of an ECG waveform and annotation standard, the FDA partnered with Mortara Instrument Inc., to develop a digital ECG warehouse to support the storage and review of the submitted data. Under the terms and conditions of a Cooperative Research and Development Agreement (CRADA), the FDA's ECG Warehouse was designed and built and contains ECGs submitted as part of submissions to the agency, separated from any personal patient information.

The data standards that enabled this step were a product of Clinical Data Interchange Standards Consortium (CDISC) and Health Level 7 (HL-7), organizations in which FDA and industry are cooperating to develop a comprehensive set of standards for clinical trial data. Through such efforts, the agency expects to enable other similar research opportunities across the full range of data collected in clinical trials of new drugs. Proprietary and nonpublic information will only be disclosed in accordance with FDA regulations and appropriate confidentiality agreements.
Was it something we said? We hope so. In any event, let me second Peter's sentiments and thank everyone for their words of support and humor in the wake of this attack.

So much to catch up on ...

I see that Families USA released a study showing that many kids without health insurance have parents that work. Lots of these kids are eligible for SCHIP and haven't signed up ten years after the program was initiated by the Clinton administration...Families USA Godfather Ron Pollack never attacked President Clinton in the first two weeks of the program rollout about lack of enrollment as he ceaselessly assaulted President Bush during the Medicare part D rollout about poor enrollment. Partisan. Hypocrite. You pick your terms... And by the way...lots of those parents could afford to insure their kids but are too cheap. Sorry, but that's a fact.

Novartis released promising results about a MS drug. According to an AP report
"80 percent of patients taking the drug were found not to have active inflammation according to medical imaging scans. The company also said that patients who had been given a placebo for the first six months of the study showed a marked improvement after they were switched to the treatment, an improvement that was sustained out to the 24th month of the study."

Now let's see, if we follow the IOM recommendations there would be no advertising about the product and its results for five years, there would be an onerous daisy chain of product handling, patient enrollment criteria and bans on off-label prescribing and any expert in MS who had anything to do with Novartis in the past would be excluded from advising them even if they had a Nobel Prize... And that benefits patients how?

Seems to me that since the IOM panel was full of HMO types who do nothing but write guidelines and make formulary decisions all day -- instead of actually conducting clinical trials and seeing patients -- that perhaps, just perhaps its conclusions were a bit biased, narrow and self serving? What about THAT conflict of interest. The IOM recommendations will definitely keep new medicines off HMO formularies. Anyone in the media think of that when writing their articles slamming the FDA?

Feels good to be back.

Go Yankees and L Shana Tova to everyone!
Late Sunday the website was hacked by someone none too keen on what we've been saying. But we're back.

As you can see we are still in the process of making the site pretty. Soon enough. But first things first, right?

A few of the comments we received relative to the hacking incident (names have been omitted to protect the guilty):

"You must really piss people off."

"Somewhere Sid Wolfe is smiling."

And my favorite ...

"Sorry to hear it. Also, congratulations."

I suppose that says it all.

The Big Shill

  • 09.25.2006

It would be easy enough to let Senator David Vitter (R, LA) et al. claim victory and go home claiming that we have dodged a public health bullet.

But it would be wrong.

Codifying the “personal exemption rule” comes with a container-full of unintended consequences.

It’s important to get one thing out of the way right away. If you walk into a pharmacy in Windsor, Ontario and have your prescription filled by a real pharmacist — the drugs you receive will be both safe and effective. That being said, there are problems.

A Canadian pharmacy cannot fill a prescription written by an American physician unless it is co-signed by a Canadian doctor. Senator Vitter may see this as an added safe-guard — but he would be mistaken.

Most Canadian provinces (including Ontario and Quebec where most of the cross-border drug trafficking takes place) have a provision called the “Touch Law.” An American prescription cannot be co-signed by a Canadian doctor unless that doctor actually examines (“touches”) the patient. But this rarely happens. Most Canadian pharmacies situated near the American border employ physicians who do nothing more than blithely sign their names without even bothering to see what the prescriptions are for or who they are for.

Bad medicine? You bet — and ripe for abuse. Consider this — last year a doctor in Toronto was indicted for co-signing 24,212 prescriptions for American patients he had never seen — at $10 a pop.

Nice work if you can get it.

Mr. Vitter’s amendment, already passed by both House and Senate, would let Americans carry up to a 90-day supply of medication back to the U.S. from Canada without being stopped by Customs agents — codifying this YOYO (“You’re On Your Own”) policy.

So what’s the problem? It very clearly does not allow importation via the Internet or even tacitly approve any of the failed bone-headed schemes introduced by the likes of Pandering Tim Pawlenty or Wrong-Way Rod Blagojevich.

In fact, the truth of the matter is that the 90-day supply “personal exemption” has been the de facto rule since, well, forever.

So why worry about it? Why not just let Senator Vitter get away with what is really nothing more than a Big Shill? Two reasons.

First — it’s already a proven fact that terrorists are playing in this game and this legislation shines a bright light on how they can further exploit a weakened chain of pharmaceutical custody and, second, it sends the dangerous message that full-blown global importation is okay — and the next logical step.

And that you can take that directly from the horse’s mouth.

According to Senator Vitter, this agreement “proves that we have significant majorities in favor of reimporting.” And, “This really breaks the dam, and it shows that it’s only a matter of time before we pass a full-blown reimportation bill.”

All this at the same time the European Union is moving in the opposite direction, trying to design ways to limit cross-border pharmaceutical shipments because of increased safety concerns and a growing problem of counterfeiting.

Senator Vitter’s amendment is more than just a Big Shill; it’s a dangerous and slippery slope.


  • 09.24.2006

I predict the following verbiage from the just released IOM report on FDA reform will NOT appear in any mainstream media reporting:

Some observers believe that drug withdrawals (which are only one potential indicator of drug safety) represent de facto failures of the drug safety regulatory system, or that newly identified unusual and serious adverse events indicate that someone made a mistake in approving the drug. This is not so.”

Thank you, IOM, for that very honest, bold, timely, and necessary statement. Sorry Senator Grassley. Can we now assign David Graham to the dustbin of history?

The IOM report makes many comments and suggestions. Herewith a few of my own (ps/ I have added the appropriate report notation for easy referral):

* Needless to say, the single most important recommendation (and the one that must happen if any of the other ones stand a chance of success) is the very last one — “substantially increased resources in both funds and personnel for the FDA.” (7.1)

* I am glad the that IOM has included in their recommendations my idea of a standing FDA advisory committee on communications. I suggested just such a committee at the November 4, 2005 FDA Part 15 hearing. (6.1)

* A comprehensive review of agency-wide risk communication plans? Absolutely. Lack of centralization has led to overlap, inconsistencies and gaps. Paul Seligman should lead such a program — and immediately. (6.2)

* Similarly, a systematic review of adverse event reporting systems. Yup. When it comes to AERS, we cannot and must not allow miscommunication to lead to health-related unintended consequences. (4.1)

* I certainly agree with the IOM that, when it comes to DTC advertising, the FDA must draw bright lines. But I do not see how a “first five years” moratorium on DTC advertising advances public safety, public health, or public knowledge. Same goes for the black triangle. All that does is triangulate on fear and give trial lawyers a wonderful new weapon in their continued quest for greed. (5.1, 5.3)

A more timely and comprehensive posting of clinical trials on Yes. But as to early stage results — that still needs more debate. (4.11)

* More robust and public discussion of post-market study results. Absolutely. (4.13)

* Adcomm members should be as free of professional conflicts as possible? Duh. But we mustn’t scare away the best and the brightest — as would happen under the proposed Enzi/Kennedy legislation. (4.10)

* Adcomm review of all new NMEs? Shouldn’t that be the decision of the professionals at the FDA? Not all NMEs are alike, so why treat them so? Bad idea. A knee-jerk, Grassley-like suggestion. (4.8)

* Include research capacity in the agency’ s mission statement. This would be a terrific idea if the agency had research capacity — which at present it does not. it should. Fund the Critical Path and then amend the mission statement. (4.7)

* Build a CDER informatics capacity? Totally. (4.6)

* Have the agency work with government partners (such as the VA and DoD), drug companies, public and private insurers, health care provider organizations, and consumer groups to plan, organize and fund confirmatory drug safety and efficacy studies of public health importance. A good idea in theory, but the wording is very vague and could easily lead to a fascist regime of so-called “evidence-based medicine.” Do we really want the editors of Consumers Report telling us which dugs are safe and effective? More debate and clarity needed here. (4.3)

* A 6-year term for the Commissioner of the FDA. Yes. Let the person chosen as Commissioner of the FDA serve as free of the political current as possible. (3.1)

The IOM report has good and bad. But a good next step is to carefully consider them all and expeditiously move forward by taking to heart the words of Goethe that appear on the frontpiece of the report:

“Knowing is not enough; we must apply. Willing is not enough; we must do.”

The IOM report on drug safety is a pompous and inaccurate reshash developed by people who know nothing about drug development and it shows….It ignores the past 4 years of science and the efforts to integrate it and the panel was stacked with managed care and anti-industry types who believe that one size fits all drugs are all that people need and that companies are capable of producing… Ultimately, it is the report that is the real danger to the public health.

To suggest, as the report does, that when a drug is at the FDA, it’s safety profile is uncertain, is to suggest that it can ever be certain or that by piling on mountains of data post market you can ferret out rare safety events or that even if you can you can thereafter determine which people should get the drugs relative to benefits based on the data. The report and the committeee never provide examples of “how-to”. Rather, it is a knee-jerk reaction to headlines that themselves are based on fear, not science. The identification of ALLHAT as an example is the sort of throwaway and play to the crowd comment that has nothing to do with drug safety evaluation in the first place and secondly reflects a bias towards the findings of ALLHAT which themselves are subject to considerable controversy. What’s more the recommendation that Congress require such large science projects as the model for Phase 4 studies is ominous and troubling. And it contradicts the reports own findings that Bayesian type analysis and observation studies can be used with more sophisticated databases. But then again, the IOM report is more interested in sticking it to drug companies than in getting them to share data and develop measures to make drug safety a continuous part of the drug evaluation and development process.

Restrictions on access to medicines the committee recommends would make getting new drugs onerous and place new burdens on doctors and patients alike. Banning any member with any financial invovlement with companies solves the saftey problem exactly how? And, PS, it drives away the best talent.

I will blog on this at greater length later but if you really want to score the US health system compared to others in the world, here’s a list of questions to ask:

f your child had a rare form of cancer and needed an MRI…where would he or she wait the longest and which country would you want to be in?

If you need emergency bypass surgery where would you want to be?

If you wanted access to Humira, early stage treatment with Sutent, Revlimid or Gleevec, where would you want to be?

If your baby weighed 500 grams in which country would it have the best chance of living (hint: even though it would have the highest infant mortality rate for trying? )

Which country has the fewest seniors in nursing homes and most receiving prescription drug coverage?

Is there any difference in the rate at which any industrialized nation spends health care?

I could go on but you get the drift…

Comomwealth uses incidence of medical debt as a quality indicator? Medical debt? Are they kidding? There isn’t one accurate study in the US and then to make international comparisons is close to impossible. How about tax burden as a percentage of income? Try 15-20 percent around the world on top of income and social security taxes…and that is for health care your wait months and years for. But I digress.

Ultimately once you control for obesity and violence the US system does spectacularly well in delivering what we demand from our care…better quality of life as well as longer lives…Europe and Canada do a great job ensuring that the vast majority of healthy people get lots of primary care and do it by limiting access to speciality care when they get sick,

The GOP in the House and Senate will bar Customs agents from inspecting packages of prescription drugs purchased in Canada and brought back into the United States. Can you say “drug runner?” Just how will Customs agents be able to stop the flow of fake drugs or narcotics into the US now that our Congress has given criminals a free trade zone for their trafficking operations? We are building a fence down south and opening a hole up north…it makes no sense at all.

Drug imports from Canada set to be eased
By LARA JAKES JORDAN, Associated Press Writer 5 minutes ago
House Republicans tentatively agreed Thursday to prohibit Customs agents from seizing prescription drugs that Americans buy in Canada and bring back into the United States.

The deal would let Americans carry up to a 90-day supply of medication back to the U.S. from Canada without being stopped by Customs agents, House and Senate Republicans said. But it would not let Americans purchase cheaper prescriptions over the Internet or by mail-order, officials said.

“This really breaks the dam, and it shows that it’s only a matter of time before we pass a full-blown reimportation bill,” said Sen. David Vitter, R-La., who led the fight in the Senate to prohibit the Homeland Security Department from seizing prescription drugs being carried over the border. U.S. Customs and Border Protection is an arm of the Homeland Security Department.

Vitter acknowledged that sales of drugs though mail order or through the Internet is significant. But, he added, “I think support for that is going to continue, and going to continue to grow, no matter what this bill says or doesn’t say.”

Both Presidents Bush and Clinton have rejected repeated congressional efforts to lift the ban on prescription imports. Medications are generally cheaper in Canada because of government price controls.

While importing drugs into the United States is illegal, the Food and Drug Administration generally has not stopped small amounts of medicine purchased for personal use. But Customs officials began intercepting imported controlled substances two years ago and prescription drugs since last November. Since then, Customs and Border Protection agents have seized more than 34,000 packages of drugs coming into the country.

The pre-election controversy over the new rule threatened to split House GOP leadership who oppose lifting the import ban and rank-and-file Republican lawmakers who want to help elderly voters buy cheaper drugs.

However, many Customs agents already allow prescription drugs into the U.S. from Canada because they don’t rigorously search people and cars for them.

Democrats who pushed for broader access to imported drugs accused Republicans of trying to “blow smoke to the voters about cheaper prescription prices when it really doesn’t do much of anything,” said Dan McLaughlin, spokesman for Sen. Bill Nelson (news, bio, voting record), D-Fla. Earlier this year, Nelson sponsored legislation to prevent Customs agents from seizing mailed medication after he began getting complaints from seniors in his state.

“I think you could call this agreement in the House a very small advance and certainly we’ll take it, but it’s no place that we can stop and certainly isn’t enough to be satisfied with,” McLaughlin said. “It really doesn’t help very many people.”

Opponents said importing drugs that do not have FDA approval could be unsafe for consumers. The FDA says it cannot guarantee the safety of imported drugs.

Representatives for the pharmaceutical industry said Canadian Internet pharmacies, for example, have been known to sell fake and potentially unsafe medicines to unknowing American consumers through other countries.

“Americans should look at much safer alternatives that already exist and are proving to be incredibly effective here at home,” said Ken Johnson, senior vice president for the Pharmaceutical Research and Manufacturers of America, or PhRMA.

According to the Congressional Budget Office, brand-name drugs cost, on average, 35 to 55 percent less in other industrialized nations than they do in the United States. Supporters of importing drugs contend that the U.S. is subsidizing the cost of medicine for the rest of the world.

The prescription drug policy shift would be included in a $33.7 billion bill to fund the Homeland Security Department next year. Lawmakers who control the department’s spending levels will meet Monday to debate other last-minute changes to the legislation, which has also been stymied by proposals to give Homeland Security regulatory oversight of security measures at chemical plants.

Lawmakers were negotiating whether to let the department require some high-risk chemical facilities to use nontoxic materials that would be more expensive but safer to the public if there is a release. The chemical industry strongly opposes such a requirement, and environmentalists have been pushing for it just as vociferously.


There has been a lot of mis-reporting about which think tanks take what position on Wal-Mart policies…Here is one position we support..Wal-Mart’s program to make generic drugs even cheaper for millions of Americans and for most of its associates. As for Wal-Mart itself, can’t beat the prices on most items and now that goes for a lot of medicines. The Wal-Mart press release is below:

BENTONVILLE, Ark. â Sept. 21, 2006 â As part of its ongoing commitment to providing more affordable healthcare for Americaâs working families, Wal-Mart Stores, Inc. (NYSE: WMT) today announced that it will make nearly 300 generic drugs available for only $4 per prescription for up to a 30-day supply at commonly prescribed dosages. The program, to be launched on Friday, will be available to customers and associates of the 65 Wal-Mart, Neighborhood Market and Samâs Club pharmacies in Tampa Bay , Fla. area, and will be expanded to the entire state in January 2007.

âEach day in our pharmacies we see customers struggle with the cost of prescription drugs,â said Wal-Mart CEO H. Lee Scott, Jr. âBy cutting the cost of many generics to $4, we are helping to ensure that our customers and associates get the medicines they need at a price they can afford. Thatâs a real solution for our nationâs working families.â

Key components of the program include:

* The $4 pricing will be available to all pharmacy customers with a prescription from a doctor that can be filled with a covered generic medicine.

* This program will be available to the uninsured.

* Insurance will be accepted.

* The program presently covers 291 generic medications from many of the most common therapeutic categories.

* The medicines represented are used to treat and manage conditions including allergies, cholesterol, high blood pressure and diabetes. Some antibiotics, antidepressants, antipsychotics and prescription vitamins are also included.

* The program will be available statewide in Florida in January 2007.

* Wal-Mart intends to take the program to as many states as possible next year.

âCompetition and market forces have been absent from our healthcare system, and that has hurt working families tremendously,â Scott said. âWe are excited to take the lead in doing what we do best â driving costs out of the system â and passing those savings to our customers and associates.â

The program will help alleviate a major challenge for seniors who have fallen into the âdoughnut holeâ coverage gap in their Medicare Part D prescription drug plans and now find themselves responsible for paying 100 percent of their prescription medicine costs.

âThis act of good corporate citizenship will help consumers manage healthcare costs, while benefiting Florida âs growing population,â said Florida Governor Jeb Bush. âIn addition to providing a great service, Wal-Mart is encouraging important conversations between patients and their doctors about the cost savings associated with generic prescriptions. I am pleased Wal-Mart chose Florida to launch this initiative where our large population of seniors will greatly benefit.â

âFifty-bucks for a yearâs supply of prescription drugs is a pretty darn good deal for consumers,â said U.S. Senator Bill Nelson (D-FL), an outspoken proponent of giving people access to lower-cost prescriptions. âBecause Wal-Mart has the ability to shape the market, maybe other retailers will follow suit.â

In addition, the program provides a solution for the nearly 2.7 million uninsured Floridians who may also avoid filling prescriptions and remain untreated. Wal-Mart estimates that the program will save the stateâs Medicaid program hundreds of thousands of dollars annually.

In announcing the program, Bill Simon, executive vice president of the Professional Services Division for Wal-Mart, noted that purchasing a 30-day supply of the popular diabetes drug, Metformin, for $4 represents a nearly 50 percent savings from the cost of the brand name version of the drug. In addition, purchasing a 30-day supply of the brand name blood-pressure drug typically costs $12. Getting the generic, Lisinopril, for $4 saves customers nearly $100 annually.

âThese are medicines for diabetes, cardiovascular disease, asthma, colds and infections â the kinds of medicines that working families need so they can treat illness, manage conditions and stay well,â said Simon. âRising healthcare costs are eating up more and more of familiesâ budgets, so this program brings a lot of value to our customers, associates and communities.â

Generic medications contain the same active ingredients as their âbrand-nameâ counterparts and are equally effective, but cost significantly less. Consumers interested in saving money on prescriptions through the program should ask their doctor if a generic is available for their prescription and is right for them. At this time, the $4 prescriptions are not available by mail order and are available on-line only for in-person pickup in the Tampa Bay, Fla. area. Not all generics in each therapeutic category are included.


Center for Medicine in the Public Interest is a nonprofit, non-partisan organization promoting innovative solutions that advance medical progress, reduce health disparities, extend life and make health care more affordable, preventive and patient-centered. CMPI also provides the public, policymakers and the media a reliable source of independent scientific analysis on issues ranging from personalized medicine, food and drug safety, health care reform and comparative effectiveness.

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