THE NEXT NORMAL

Copyright © 2022 by Peter J. Pitts

All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review or scholarly journal.

First Printing: 2022

ISBN 978-1-6781-4459-3

Cognito Press

757 Third Avenue

New York, NY 10017

www.cmpi.org

Graphic design by Mandi Vollmer.

He who wrestles with us strengthens our nerves and sharpens our skill. Our antagonist is our helper. Edmond Burke

Author’s Note

This book is dedicated to all the healthcare professionals, first responders and frontline workers who put their lives at risk for all of us. Banging pots wasn’t enough, but it was a start.

To Sweet Jane, For better or for worse.

To the women and men of the FDA and the biopharmaceutical industry who pulled off a miracle bringing diagnostics, therapeutics and vaccines to market at warp speed, helping issue in a new era of cooperation within and between the broader healthcare ecosystem. It’s amazing what we can accomplish when we work together for the common good.

And to the courageous staff of 54 Riverside Drive who, in the teeth of the pandemic, hunkered down, masked-up and braved the highways, byways, subways, sidewalks, roads and tunnels of New York City, coming to work every day. They have my deepest respect and are forever part of our family.

Peter J. Pitts

New York City

January 2022

Contents

Author’s Note 8

Introduction 12

Chapter One 14

Value Equity 14

Health Literacy: The Common Denominator of Healthcare Progress 16

Comment on Health Literacy: The Common Denominator of Healthcare Progress 23

Authors’ Reply to Ibrahim and Nair’s Comment on: Health Literacy: The Common Denominator of Healthcare Progress 26

A 21st-Century Lexicon of Value 28

Value over Volume: Maximizing Resources by Prioritizing Value: The Dubai Healthcare Experience 31

Government Detailing 36

Chapter Two 48

Reconsidering the 21st-Century FDA 48

Too Fast or Too Slow: Is the FDA Moving at the Right Speed? 51

Should We Rethink the FDA Commissionership? 54

FDA Needs a Competitiveness Czar 57

A Breakthrough for Alzheimer’s Patients — And a Need for More 60

Settling for Second Best? 62

Biosimilars: Strength vs. Potency: Avoiding a Regulatory Hobson’s Choice 65

The Major Healthcare and Cybersecurity Risk of Right-to-Repair Laws 72

Chapter Three 78

Counterfeit Drugs in a Post-Pandemic World 78

The Spreading Cancer of Counterfeit Drugs 79

Chapter Four 100

The Crucial Nature of Intellectual Property 100

Waiving COVID-19 Vaccine Patents: A Bad Idea and a Dangerous Precedent 101

Remdesivir and Federal March-In Rights 110

Chapter Five 116

Science Is Back 116

Understanding CRISPR 117

Implications of CRISPR-Based Germline Engineering for Cancer Survivors 120

The Privacy Delusions of Genetic Testing 141

Chapter Six 146

The Lessons of COVID-19 146

Healthcare Lessons Ignored from Our Fight Against COVID-19 147

Vaccine Hesitancy: When Political Miscommunication Replaces Scientific Benefit/Risk Assessment 151

The Other Vaccine Denial 154

Chapter Seven 158

Speaking to/Through America’s Newspaper of Record 158

Healthcare and Reality 159

Sunday Dialogue: Equitable Healthcare 160

Should We Suspend Patents on COVID Vaccines? 162

Making Sure the Drugs We Take Are Safe 163

What to Do About Drug Shortages? 164

Cost of Living: Who Gets New Drugs? 165

Paths to Stopping Painkiller Overdoses 165

Warnings Labels on Drugs 165

Concluding Thoughts 165

Embracing Opportunity Management 165

About the Author 168

Introduction

Human history becomes more and more a race between education and catastrophe. H.G. Wells

Why The Next Normal? Over the course of the COVID-19 pandemic, during dozens of media interviews, virtual conferences, and Zoom encounters, people asked me what the new normal will look like. I fundamentally disagree with the premise of this question because, when it comes to healthcare, there will never be a new normal. Healthcare will always be in a constant state of change — and that’s a good thing. What will always be just around the corner is the Next Normal. Stasis isn’t always good, especially if you believe in the power of innovation. But the status quo is a harsh mistress. If we have learned nothing else from COVID-19 we should remember and embrace the warning of management guru W. Edwards Deming, who said, It is not necessary to change. Survival is not mandatory.

Chapter One

Value Equity

You cannot escape the responsibility of tomorrow by evading it today.

Abraham Lincoln

Equity and equality are not synonyms. When it comes to healthcare, equity means similar outcomes across race, gender, socioeconomic conditions, and political borders. One of the key lessons from the COVID-19 experience is that we’re all in this together. We rise or fall together, and redlining healthcare (purposefully, through ignorance or lassitude) is an evil that lurks throughout the healthcare ecosystem. There are many strategies and tactics to consider. And at the top of the list is a reconsideration and renaissance of personal responsibility.

Health Literacy: The Common Denominator of Healthcare Progress

By Peter J. Pitts and Emily Freeman

Originally published in The Patient, July 7, 2021

Introduction: Embracing the Lessons of COVID-19

Perhaps the most important lesson learned from the COVID-19 experience is that American health illiteracy kills. From confusion over the value of wearing protective masks and social distancing (How are viruses transmitted?) to vaccine skepticism (How do vaccines work?), from confusion over the value of hydroxychloroquine (How are data collected and what do they mean?) to doubts about the safety and efficacy of products available through Emergency Use Authorizations (How does the US Food and Drug Administration review process work?), the dearth of health literacy has not only slowed down the US response against COVID-19, it has placed thorny societal problems along the path to victory over the virus. Nature abhors a vacuum — and so does social media.

Health literacy comprises two parts:²

Personal health literacy is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

Organizational health literacy is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.

As we study our national responses to COVID-19 to better plan for the next public health emergency, a key global learning is that health literacy is an integral part of pandemic preparedness and a broader facilitator of positive healthcare behavior and outcomes. Health literacy facilitates public health messages that are not only understandable but motivational and actionable.

According to the US Health Resources and Services Administration, health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.³ Health literacy is capacity building. It is crucial infrastructure development. And it is being ignored.

The Value of Health Literacy

The value of health literacy extends far beyond the boundaries of COVID-19. Education leads to fact-based empowerment and an educated healthcare consumer can be a potent change agent.

Consider medication adherence and compliance. Medication nonadherence is widespread with nonadherence rates that range from 25 to 50 percent.⁴ Every year, 125,000 Americans die from not taking their medications, a staggering number that also costs the US health system some $289 billion annually.⁵ One potent tool for recapturing and redirecting these healthcare resources is health literacy. Safe and effective. Knowledge is power.

Low levels of health literacy are a source of health disparities among disadvantaged communities and minorities. Of the nearly 77 million Americans who struggle with health-related reading tasks, 65 percent are minorities.⁶ The issue of health literacy and minority communities is not new, but it has been rediscovered because of COVID-19, specifically because of the problem of vaccine hesitancy driven by historic distrust of government-sponsored healthcare programs⁷ and a perceived lack of clinical trial diversity.

One reason minorities and communities of color have been hesitant to embrace COVID-19 vaccines is that they do not see people like me in clinical trials.⁸ An easy excuse is that groups are represented proportionally to their ranking in the general population. But that is an excuse. As with many health conditions (e.g., diabetes mellitus, cardiovascular disease, cancer), diverse communities suffer disproportionally. COVID-19 is only the most recent example with death rates and serious manifestations of the virus far outpacing the relative impact on White America. African-American individuals are experiencing COVID-19 death tolls exceeding 1 in 800 nationally, while White Americans are experiencing a death toll at 1 in 3,125 nationally. African-American individuals have COVID-19 death rates of more than 2.7 times those of White Americans.⁹ There are many reasons for this and there is no single magic bullet solution. Health literacy, alone and in combination with other therapies, however, should be considered at or near the top of the list of post-pandemic public health priorities.

Health Literacy as a Tool in Achieving Clinical Trial Diversity

In an age of precision medicine,¹⁰ health literacy can be a powerful tool to improve both clinical trial diversity and overall data sensitivity. Addressing diversity in clinical trials is a bellwether issue when it comes to advancing health literacy. We are all learning the nuanced differences between equality and equity. Equality means each individual or group of people is given the same resources or opportunities. Equity recognizes that each person has different circumstances and allocates the exact resources and opportunities needed to reach an equal outcome.¹¹

A recent study of Pfizer-sponsored clinical trials¹² showed that between 2011 and 2020, Black or African-American participants made up 14.3 percent of 212 trials for which data on race were collected. African-American individuals represent about 13.4 percent of the US population. But when broken down by trial, only about half of Pfizer’s studies (56.1 percent) surpassed census levels for Black participants. Only 15.8 percent of Pfizer’s oncology trials reached census levels for Black participants, compared with 78.9 percent for White participants. The percentage of trials overall to exceed census levels for White participants was 51.4 percent.

Asian-American individuals made up 3.1 percent of trials compared with 5.9 percent of the US population. Hispanic or Latinx participants represented 15.9 percent of trials, vs. 18.5 percent of the population. In total, 16 percent of Pfizer’s trials surpassed census levels for Asian participants, compared with 14.2 percent for Native Hawaiian or Pacific Islanders, and just 8.5 percent for American Indian or Alaskan Native individuals.

Those numbers are par for the course in biopharma, where minority groups have historically been left out of clinical trials. Of the 53 drugs approved this past year, Black patients represented about 8 percent of participants in the trials that regulators based their decisions on (and for which data on race were collected).¹³

Why are there not more minorities and people of color recruited for clinical trials in the US? The usual and customary explanation is because of historic distrust of the government (e.g., Tuskegee, Henrietta Lacks).¹⁴ But this is only one of many issues. Participation in clinical trials research is a rigorous and demanding enterprise. Another associated long-term impediment is that physicians and other research professionals have their own cognitive biases concerning who they believe will comply with difficult therapeutic regimens¹⁵ required for proper participation in clinical trials. Many physicians believe African-American individuals are two-thirds as likely to be adherent as are their White patients.¹⁵

We must be aware of and fight against such normative bias (aka racism). Despite these factors, research demonstrates that minorities are, in fact, willing to participate in clinical trials. Minority groups are as willing to participate as White American individuals but are not asked to (literally) sit down and roll up their sleeves.¹⁶ In a health literacy issue brief, the Secretary’s Advisory Committee noted, As health literacy research and practice have accumulated, we now more fully understand that responsibility for health literacy extends beyond individuals to include the organizations and professionals who create and deliver health information and services.¹⁷ Physicians and healthcare professionals must also advance their own health literacy. Perhaps we need continuing medical education for health literacy.

Health Literacy and Pharmacovigilance

Pharmacovigilance traditionally relies on physicians and pharmaceutical manufacturers as the two main pillars of reporting, with the overwhelming volume coming from industry (as well as a small but growing and significant contribution coming directly from patients and healthcare providers).¹⁸ Pharmacovigilance has not been a large experimental ground for patient participation; on the one hand, this is because it has always been perceived as an area where only healthcare professionals have the right competence to deal with adverse events and the associated risks, and on the other hand, because patients have not historically been encouraged to play an active role in this issue. With an increasing number of drugs being approved on shorter trials that involve fewer patients, obtaining timely and accurate reports of adverse events and side effects after approval from all members of the post-marketing ecosystem is more important than ever.¹⁹

In both the US and the European Union, proactive pharmacovigilance efforts by both regulators and pharmaceutical companies have escalated in recent times through (among other efforts) an increased use of real-world data, gathered and validated across