# 反向“喔可释”：药品与椅子

【编注：标题中Voxsplaining一词系作者模仿mansplaining一词而生造，由Vox和explaining拼成，Vox是一家美国主流网络媒体，以评论为主，经常发表以“Something blah blah, explained”为标题的真理在握底气十足的评论文章。】

[Content note: this is pretty much a rehash ofthings I’ve said before, and that other people have addressed much moreeloquently. My only excuse for wasting your time with it again is that SOMEHOWTHE MESSAGE STILL HASN’T SUNK IN. Pitching this as “market” vs. “government” is overly simplistic, but maybe if I am overly simplisticsometimes then it will sink in better.]

[内容说明：这差不多是我之前说过事情的重复，其他人也曾经雄辩得多地阐述过。之所以再一次在此问题上浪费你的时间，是因为不知为何我所说的意思还是没有传达到。把这个问题仅仅定义于“市场”和“政府”是过于简单化，但是也许我的简化会令人更容易理解。]

EpiPens,useful medical devices which reverse potentially fatal allergic reactions, haverecently quadrupled in price, putting pressure on allergy sufferers and thosewho care for them. Vox writes that this “tells us a lot about what’s wrong withAmerican health care” – namely that we don’t regulate it enough:

EpiPens的价格最近涨了四倍，作为一个可以有效逆转潜在致命过敏反应的医疗设备，这个涨价给过敏症患者和那些关心他们的人增添了许多压力。Vox网站评论道：“这说明了许多美国医疗卫生状况的问题”——也即我们对它没有足够的监管：

【Thestory of Mylan’s giant EpiPen price increase is, more fundamentally, a storyabout America’s unique drug pricing policies. We are the only developed nationthat lets drugmakers set their own prices, maximizing profits the same waysellers of chairs, mugs, shoes, or any other manufactured goods would.】

【Mylan 公司大幅提高 Epipens 价格的事情从更本质上讲关乎美国独特的药品定价机制。我们是唯一一个允许制药商自主定价的发达国家，让制药商可以像卖椅子、杯子、鞋子或者其它制成品的商家一样追求利润最大化。】

Let me askVox a question: when was the last time that America’s chair industry hiked theprice of chairs 400% and suddenly nobody in the country could afford to sitdown? When was the last time that the mug industry decided to charge $300 percup, and everyone had to drink coffee straight from the pot or face bankruptcy?When was the last time greedy shoe executives forced most Americans to gobarefoot? And why do you think that is? 对此我有个问题：什么时候美国的椅子产业将椅子价格提高到400%然后突然间所有人都买不起椅子坐不下来了？什么时候杯子产业决定每个杯子售价300美元然后所有人都不得不直接从咖啡壶里喝咖啡不然就要破产了？什么时候贪婪的鞋业高管迫使大部分美国人赤脚走路了？为什么你认为制药业就会发生这样的情况呢? The problemwith the pharmaceutical industry isn’t that they’re unregulated just likechairs and mugs. The problem with the pharmaceutical industry is that they’repart of a highly-regulated cronyist system that works completely differentlyfrom chairs and mugs. 制药业的问题不是他们像椅子或者杯子产业那样不受监管，而是它所处的是一个高度管制的裙带系统。这与椅子和杯子产业完全不同。 If a chaircompany decided to charge$300 for their chairs, somebody else would set up awoodshop, sell their chairs for $250, and make a killing – and so on untilchairs cost normal-chair-prices again. When Mylan decided to sell EpiPens for$300, in any normal system somebody would have made their own EpiPens and soldthem for less. It wouldn’t have been hard. Its active ingredient, epinephrine,is off-patent, was being synthesized as early as 1906, and costs about tencents per EpiPen-load.

Why don’tthey? They keep trying, and the FDA keeps refusing to approve them for humanuse. For example, in 2009, a group called Teva Pharmaceuticals announced a planto sell their own EpiPens in the US. The makers of the original EpiPen suedthem, saying that they had patented the idea epinephrine-injecting devices.Teva successfully fended off the challenge and brought its product to the FDA,which rejected it because of “certain major deficiencies”. As far as I know,nobody has ever publicly said what the problem was – we can only hope they atleast told Teva.

In 2010,another group, Sandoz, asked for permission to sell a generic EpiPen. Onceagain, the original manufacturers sued for patent infringement. According toWikipedia, “as of July 2016 this litigation was ongoing”.

2010年，另一个集团Sandoz请求允许售卖一个通用类EpiPen，最早的制造商再一次以专利侵权告了他们。根据维基百科，“直到2016年7月该诉讼仍在进行”。

In 2011,Sanoji asked for permission to sell a generic EpiPen called e-cue. This gotheld up for a while because the FDA didn’t like the name (really!), buteventually was approved under the name Auvi-Q, (which if I were a giantgovernment agency that rejected things for having dumb names, would be goingstraight into the wastebasket). But after unconfirmed reports of incorrectdosage delivery, they recalled all their products off the market.

2011年，Sanoji请求允许售卖一个称作e-cue的通用类EpiPen，它一开始被阻挡了一段时间，原因是FDA不喜欢这个名字（千真万确！），但是最终该产品以Auvi-Q的名字被批准了（如果我是一个因其名字愚蠢就拒绝某事物的大型政府机构，那么Auvi-Q会直接进入废纸篓）。但是经过一些未经证实的说他们给药剂量不正确的报道之后，Sanoji从市场上召回了所有产品。

This year, acompany called Adamis decided that in order to get around the patent on devicesthat inject epinephrine, they would just sell pre-filled epinephrine syringesand let patients inject themselves. The FDA rejected it, noting that thecompany involved had done several studies but demanding that they do some more.

Also,throughout all of this a bunch of companies are merging and getting bought outby other companies and making secret deals with each other to retract theirproducts and it’s all really complicated.

None of thisis because EpiPens are just too hard to make correctly. Europe has eightcompeting versions. But aside from the EpiPen itself, only one competitor hasever made it past the FDA and onto the pharmacy shelf – a system calledAdrenaclick.

And of coursethere’s a catch. With ordinary medications, pharmacists are allowed tointerpret prescriptions for a brand name as prescriptions for the genericunless doctors ask them not to. For example, if I write a prescription for“Prozac”, a pharmacist knows that I mean anything containing fluoxetine, the chemicalingredient sold under the Prozac brand. They don’t have to buy it directly fromProzac trademark-holder Eli Lilly. It’s like if someone asks for a Kleenex andyou give them a regular tissue, or if you suggest putting something in aTupperware but actually use a plastic container made by someone other than theTupperware Corporation.

EpiPens areprotected from this substitution. If a doctor writes a prescription for“EpiPen”, the pharmacist must give an EpiPen-brand EpiPen, not anAdrenaclick-brand EpiPen. This is apparently so that children who have learnedhow to use an EpiPen don’t have to relearn how to use an entirely differentdevice (hint: jam the pointy end into your body).

If you knowanything at all about doctors, you know that they have way too muchinstitutional inertia to change from writing one word on a prescription pad towriting a totally different word on a prescription pad, especially if thesecond word is almost twice as long, and especially especially if it’s just todo something silly like save a patient money. I have an attending who, wheneverwe are dealing with anything other than a life-or-death matter, just dismissesit with “Nobody ever died from X”, and I can totally hear him saying “Nobodyever died from paying extra for an adrenaline injector”. So Adrenaclickcontinues to languish in obscurity.

So why is thegovernment having so much trouble permitting a usable form of a commonmedication.

There are alot of different factors, but let me focus on the most annoying one. EpiPenmanufacturer Mylan Inc spends about a million dollars on lobbying per year. OpenSecrets.orgtells us what bills got all that money. They seem to have given the most todefeat S.214, the “Preserve Access to Affordable Generics Act”. The bill wouldban pharmaceutical companies from bribing generic companies not to creategeneric drugs.

Did they win?Yup. In fact, various versions of this bill have apparently failed so manytimes that FDA Law Blog notes that “insanity is doing the same thing over andover again and expecting different result”.

So let me tryto make this easier to understand.

Imagine thatthe government creates the Furniture and Desk Association, an agency whichdeclares that only IKEA is allowed to sell chairs. IKEA responds by charging\$300 per chair. Other companies try to sell stools or sofas, but get boggeddown for years in litigation over whether these technically count as “chairs”.When a few of them win their court cases, the FDA shoots them down anyway forvague reasons it refuses to share, or because they haven’t done studies showingthat their chairs will not break, or because the studies that showed theirchairs will not break didn’t include a high enough number of morbidly obesepeople so we can’t be sure they won’t break. Finally, Target spends tens ofmillions of dollars on lawyers and gets the okay to compete with IKEA, butpeople can only get Target chairs if they have a note signed by a professionalinterior designer saying that their room needs a “comfort-producing seatingimplement” and which absolutely definitely does not mention “chairs” anywhere,because otherwise a child who was used to sitting on IKEA chairs might sit downon a Target chair the wrong way, get confused, fall off, and break her head.

(You’re goingto say this is an unfair comparison because drugs are potentially dangerous andchairs aren’t – but 50 people die each year from falling off chairs in Britainalone and as far as I know nobody has ever died from an EpiPen malfunction.)

（你可能会说这个比喻并不恰当，因为药物潜在里具有危险性但是椅子并没有——但是单单在英国每年就有50人因为跌落椅子而死，而据我所知，还没有人曾因为EpiPen故障而死亡。）

Imagine thatthis whole system is going on at the same time that IKEA spends millions ofdollars lobbying senators about chair-related issues, and that these samesenators vote down a bill preventing IKEA from paying off other companies tostay out of the chair industry. Also, suppose that a bunch of people are dyingeach year of exhaustion from having to stand up all the time because chairs aretoo expensive unless you’ve got really good furniture insurance, which istotally a thing and which everybody is legally required to have.

And nowimagine that a news site responds with an article saying the government doesn’tregulate chairs enough.