【备考日志】Economist Debates阅读写作分析-----Health Care BY Rain.

23℃UID: 2708235

October 6th 2009 - October 17th 2009  
Health care

About this debate

As the rich world grows older and sicker and the poor world gets wealthier and fatter, the cost of health care is soaring. Governments and insurers（承保人） the world over are struggling to cope with runaway health inflation. Adding to the demographic（统计学） shift in OECD countries and the wealth effect in the emerging giants is the unprecedented（空前的） wave of technological innovation in new pills, procedures and devices made possible by the ongoing convergence of biology and engineering. The potential health and welfare benefits of this revolution are breathtaking—but who will pay? Are all medical inventions deserving of reimbursement?

Some argue that common-sense tests of economics, ranging from cost-benefit analysis to comparative-effectiveness reviews, are essential to weed out the worthy from the wasteful. But others argue that such tools are crude and anti-innovation at best—and if wielded（vt. 使用,挥舞,运用） by stingy（a. 小气的,吝啬的,缺乏的,有刺的） governments, implements of cruel health-care rationing（n. 定量配给） at worst. What do you think?

The proposer's opening remarks
Oct 6th 2009 | Newt Gingrich

In a recent Wall Street Journal column, I told the story of a three-year-old boy who was diagnosed with a rare, aggressive form of bladder cancer. His parents were told that his chance of survival was 50%.
Their options included radical surgery（根治的手术） to remove his bladder（膀胱）, prostate（前列腺）, and portions of his rectum（直肠）. The side effects included impotence（n.无力,虚弱,无效,阳萎）, a colostomy bag, and having to urinate(vi. 小便,撒尿) through a bag in his abdomen(n. 腹部). Radiation(射线疗法) was also an option, but because he was so young, his pelvic(a.骨盆的) bones and hips would not grow properly, and his bladder would remain the size of a three-year-old's for the rest of his life.
His parents were also told of an "unproven"( a. 未经证明的,未经检验的)option: proton beam therapy(质子射线疗法). Proton beams would target the radiation dose to limit the radiation scatter(辐射散射), which would avoid extensive damage to his body. The targeted beam would also likely be more effective at killing the cancer cells. While the clinical research was insufficient, the physicians' recommendations were unanimous（意见一致的,无异议的）. The boy underwent the treatment. He responded beautifully and is now cancer free, living a normal, healthy life.
Innovation and technology saved his life. Government-imposed comparative effectiveness research did not.
In fact, because there is little science on using proton beam therapy for pediatric
cancers, a strict adherence to comparative effectiveness research would probably have led to the boy's death or certainly his mutilation（n. 切断,毁损）. In most nationalized health systems, his parents would likely have been denied the power to choose this treatment because government-imposed comparative effectiveness research would have deemed（v. 认为,相信） it unproven, investigational, or experimental.
（In general, Comparative Effectiveness Research is defined as: The direct comparison of existing health care interventions（n. 插入,介入,调停） to determine which work best for which patients and which pose the greatest benefits and harms. The core question of comparative effectiveness research (is) which treatment works best, for whom, and under what circumstances. http://www.cmtpnet.org/comparative-effectiveness/comparative-effectiveness-definitions/?searchterm=None）

As Thomas Kuhn so powerfully explained in his masterwork The Structure of Scientific Revolutions, new science is always unproven at first. But today's breakthroughs regularly become tomorrow's routine treatments. Just look at Lance Armstrong's triple drug combination for metastatic testicular cancer. Many similar innovations were discovered not through population-based research, such as comparative effectiveness, but through personalized application with specific individuals.
（这一段是说population-based research并不是完全没用的，保证观点的完整性。）That is not to say that population-based research has no role. I have long advocated that knowing whether a treatment, pharmaceutical（配药学的）, or technology actually works will lead to better health and better quality because individuals could get the right treatment at the right time and not pay the opportunity costs associated with pursuing ineffective treatments. This kind of knowledge can give patients and their families important information to make more informed（a. 见多识广的）, individual, and independent decisions with their doctors.
As my friend in this debate, Sir Michael Rawlins, recently said of all the various options to treat prostate cancer, "We're not sure how good any of these treatments are." Sir Rawlins is right that for prostate cancer, and indeed for most treatments, we cannot predict what will work and what will not for specific individuals. However, knowing what works across a large population is not the same as knowing what is best for an individual.(这段从两个方面说明了population-based research很难起到作用，一是很难确定一种treatment有多好，二是同一种treatment就算对大多数人有用也不一定对某个人有用。)
（举例说明，抽象的例子）For example, let's say comparative effectiveness research is used to determine the efficacy of new drug treatments. Population research reveals that drug A works 70 percent of time and drug B works 60 percent of time. A strict adherence to comparative effectiveness would rule drug A the winner. But what if the 30 percent of people who did not respond to drug A did respond to drug B? Or what about the even smaller groups that may have responded best to drug X, Y, or Z? Population-based research is ill-equipped to answer these kinds of questions.
Comparative effectiveness often leads to an even more dangerous outcome. When effectiveness is combined with the pressure to control costs and the power to decide who gets what, innovation will suffer and patients will suffer. That is because many see comparative effectiveness as a way for government to allocate scarce medical resources. Sir Rawlins implied as much when he wrote last year: "Countries do not have infinite sums of money to spend on health… The debate is not about whether - but how - healthcare budgets can be most fairly shared out among a country's citizenry."
Governments, like the United Kingdom, use comparative effectiveness to decide what treatments its citizens can get, from diagnostics（n. 诊断学）, laboratories, and imaging to new innovative drugs and therapies. Go back to the example of drug research. What happens when a drug is more effective than another but costs three times as much? To make this decision, government must weigh the costs it will bear with your quality of life. Do you want government to decide that the more expensive drug isn't worth the cost for you to have less pain and suffering?
（从更深的价值观层面探讨）Government placing a numeric value on an individual's life, such as the quality adjusted life year formula, or placing a value on an individual's quality of life is anathema to the very foundation of the United States. Our Constitution values life as an unalienable（= inalienable） right endowed by our Creator. How can you place a numeric value on an unalienable right?
In addition to the restrictions this imposes on individuals accessing care, this has profound implications for creating or discovering the next breakthrough. What good is a new breakthrough if government decides you can't have it? Take the earlier example of proton beam therapy. There are questions whether it is the most effective way to treat prostate cancer, its most common use. If these questions had led to a wide restriction on using it to treat prostate cancer, would doctors have ever had the opportunity to try it as a treatment for pediatric cancer? New science and innovation would be dramatically reduced if innovators and entrepreneurs have little hope of their products reaching patients.
21st century science and innovation is moving toward personalized, individual-centered medicine, like genetics（n. 遗传学）, and away from population-based research, like comparative effectiveness. We need to embrace and encourage ways to understand how a specific individual will respond to a specific treatment, not try to determine the lowest common denominator（n. 分母,命名者） for everyone. This kind of research will give rise to a rational（理性的,合理的,推理的）—not rationed（定额, 定量, 配给）—healthcare system.
The opposition's opening remarks
Oct 6th 2009 | Sir Michael Rawlins
Over the past 60 years the advances in medicine and public health have been extraordinary. Because of childhood immunisation（n. 免疫）, diseases like diphtheria（n. 白喉） and poliomyelitis（n. 小儿麻痹症,急性骨髓灰白质炎） are now unheard of in developed countries. Modern antimicrobial（抗微生物药） agents are available to treat scores of infectious diseases. Treatments to control high blood pressure and reduce blood lipids have had a substantial impact on strokes（中锋） and heart attacks.
Some of the increase in life expectancy over the period has been due to changes in the environment, such as better housing and reduced atmospheric pollution. Other advances have been the result of eliminating useless or even dangerous diagnostic and therapeutic techniques. And some have unquestionably arisen（a. 兴起的,出现的） from the efforts of the pharmaceutical, device and diagnostic industries.
This motion, though, has to be considered in today's context and must address three questions.（提出中心的三个问题）
What is "innovation" in health care? How might comparative effectiveness reviews "stifle innovation and lead to unacceptable rationing"? And on what basis should nations use their resources to treat ill health in a manner that is fair to all?
Innovation
There are numerous definitions of innovation and their multiplicity suggests an amorphous（a. 无定形的,无组织的） concept. I consider innovation in health care, to be a process or a product that has a positive impact on health. An innovation may be modest (incremental（a. 增加的） innovation), or it may represent a very substantial advance (step-change innovation). Process and product innovation are both equally important.
Past process innovations include the introduction of day-case surgery for cataract extractions and hernia（n. 疝气,脱肠） repairs; the use of home, rather than hospital, dialysis（透析,分离） for people with chronic kidney failure and, recently, pre-operative checklists to increase patients' safety during surgical（a. 外科的,外科医生的,手术上的） operations. Such process innovations have been of considerable value to patients and in most instances have been associated with a reduced financial cost.
Product innovation may be a new medicine, device or diagnostic technique. It may represent a modest albeit useful advance on existing product; or a step change with profound beneficial effects on a particular disease (e.g. Glivec/Gleevec for chronic myeloid leukaemia（n. 白血病）).
Comparative effectiveness reviews
Outside the United States, comparative effectiveness reviews are known as health technology assessments. These involve a close examination of the clinical effectiveness of a particular health technology (such as an individual, or class of, pharmaceutical). And they may, or may not, include some form of economic assessment.
Assessing the clinical value of a particular health technology by means of a formal comparative effectiveness review has become a sophisticated scientific discipline. It seeks to answer two critical questions. Does the particular technology offer benefits in comparison with existing forms of treatment? And if so, by how much?
(举例说明Comparative effectiveness的作用)Comparative effectiveness reviews have played a major role in the evaluation of numerous pharmaceutical(a. 配药学的) (and other) products. For example, our knowledge and confidence in the use of thrombolytic ("clot busting") therapy, for the treatment of acute heart attacks, owes much to the technique. The dangers of giving SSRI ('selective serotonin reuptake inhibitors') anti-depressants to children and adolescents were identified from careful comparativeness effectiveness reviews.（驳斥Comparative effectiveness不能针对特殊人群的论点） Nor are these reviews confined to looking at patients as a whole: they have been particularly powerful in identifying subgroups of patients who are more or less likely to respond. Recognising which patients will benefit from the use of aspirin in preventing heart attacks is a case in point.

It is inconceivable（a. 不能想像的,想不到的,难信的） that any rational person would either object to, or want to stand in the way of, comparative effectiveness reviews. They form the cornerstone（n. 奠基石,基础） of modern evidence-based medicine. Equally, I cannot conceive how these reviews "stifle innovation and lead to inappropriate rationing of health care". On the contrary, they promote rational health care.
Rationing
The amount that a country spends on health care is closely aligned（对齐的） to its gross domestic product. Richer countries can spend more on health care on a per head basis than poorer ones; but all have finite resources and expenditure on one costly component will inevitably deprive other people, with other conditions, of cost-effective care. This is an unavoidable and undeniable fact of life; and some form of rationing is inevitable in every health-care system that operates within finite resources (as most do). The issue is how, not whether, to ration health care.（说明rationing是不可避免的，说明这并不是comparative effectiveness的错）
Some countries ration on the basis of individual wealth, or income, with the rich having access to health care that is denied to the poor. In Europe our health care is based on compassion（n. 同情,怜悯）. We pool（vt. 合伙经营,共享,采掘） our risks; and we try the best we can to look after each other when we are sick. In other words, our health-care systems try to provide services—not, as in America, just to the wealthy or those able to buy health insurance—but to rich and poor alike. By contrast, in Europe, no citizens are denied access to basic health care merely because they are poor.
Whether or not a particular health-care system can afford a specific innovation depends on two factors. What additional benefit does it bring over and above current care? And at what additional cost? The greater the benefit the more likely it is that an innovation will command a higher price. But there are limits to what health-care systems can afford to pay without depriving other people with other diseases of cost-effective care. Hence the necessity of cost-effectiveness analysis in the deployment（n. 部署;配置;展开） of health-care resources.
To meet the needs of patients and the public, innovators must therefore provide their products at an affordable cost. If they cannot do so, it is a failure of the innovative process rather than a failure of the need to examine the cost-effectiveness of innovations themselves. Putting it another way, unaffordable innovation is not an innovation.
The innovative process, particularly for pharmaceuticals, has become outrageously（ad. 残暴地;蛮横地） and unnecessarily expensive. We live in a time of unparalleled（a. 无比的,优良无比的,空前的） knowledge and understanding about the biological basis of many diseases. It is essential that these discoveries benefit the entire human race rather than just the rich and the powerful. We need affordable innovation.

23℃UID: 2708235

The moderator's opening remarks
Oct 6th 2009 | Mr Vijay V. Vaitheeswaran
As the rich world grows older and sicker and the poor world gets wealthier and fatter, the cost of health care is soaring. Governments and insurers the world over are struggling to cope with runaway health inflation. Adding to the demographic shift in OECD countries and the wealth effect in the emerging giants is the unprecedented wave of technological innovation in new pills, procedures and devices made possible by the ongoing（n. 前进,举止,行为） convergence of biology and engineering.
The potential health and welfare benefits of this revolution are breathtaking, every bit as much as the wave of innovation that earlier produced vaccines, for example, which are among the most powerful of all health interventions. But the coming grand convergence could, some argue, instead turn into a tale of need versus greed, a conflict between the haves and have nots.
Even if such a battle royal is not on the cards, the pace of medical innovation and the seemingly insatiable（a. 不知足的,贪求无厌的） growth in demand for health care certainly raise the question of how to pay for future medical marvels. Some argue that commonsense tests of economics, ranging from cost-benefit analysis to comparative effectiveness reviews, are essential to weed out the worthy from the wasteful. But others argue that such tools are crude and anti-innovation at best, and, if wielded by stingy governments, implements of cruel health-care rationing (or "death panels", as Sarah Palin, the former Alaskan governor, famously called this) at worst.（先简单陈述两方观点）
One of the most prominent voices making the latter case of late has been Newt Gingrich, the former Speaker of America's House of Representatives. In his aggressive opening defence of the motion for our debate, he makes a clear link between comparative effectiveness reviews (CERs) and patient harm: when such tools are "combined with the pressure to control costs and the power to decide who gets what," he insists, "innovation will suffer and patients will suffer."
（评价别人的观点）Mr Gingrich's strident arguments appear to flow from a political philosophy, much more commonly expressed in America than in Europe, that emphasises individual rights and choices over collective action or the optimal societal outcome. On his view, a rational health-care future will emphasise personalised therapies tailored to the genetic needs of the individual, not the number-crunched and coldly utilitarian calculus offered by CERs. The sharp end of his argument is summed up by this simple question: "Do you want the government to decide?"
Britain's National Institute for Health and Clinical Excellence (NICE) is a government body that has pioneered the use of CERs and other related policies. Sir Michael Rawlins, its chairman, offers a full-throated defence of that approach as his opening salvo in opposition to the motion. He makes it plain early on that his faith in comparative effectiveness tools flows from a respect for the social compact by posing this revealing rhetorical（a. 修辞学的,符合修辞学的,修辞的） question: "On what basis should nations use their resources to treat ill-health in a manner that is fair to all?" This suggests his thinking is more in line with European sensibilities. Defenders of America's individualistic and market-oriented health system often say that it is better and more innovative than its rivals（n. 竞争者,对手）, but few dare to claim that it is "fair to all".
Sir Michael insists that the use of CERs has grown into a "sophisticated scientific discipline" that seeks to answer two critical questions: does a new technology offer benefits when compared with existing options, and if so by how much? He points to various case studies, including the increased use of thromolytic technology to treat heart attacks and diminished use of SSRI ('selective serotonin reuptake inhibitors') anti-depressants to treat children, that prove the value of CERs. Taking all the evidence into account, he thunders（vt. 大声喊出,轰隆地发出）: "It is inconceivable that any rational person would either object to, or want to stand in the way of, comparative effectiveness reviews."
The topic of our debate is a timely（d. 及时地） and important one. Our debaters are genuine heavyweights（重量级的） and, as their opening arguments make plain, are spoiling（变[损]坏） for a fight. The first shots have been fired. Now is the time for you, gentle reader, to weigh in with your vote.