Global differences in disease and treatment (BBS3011)
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BBS3011: GLOBAL DIFFERENCES
IN DISEASE AND TREATMENT
All lectures, cases, and debates
Abstract
All lectures and cases are summarized. I used the pictures from literature and lectures.
,CONTENTS
Cases .............................................................................................................................................................. 3
Case 1 .................................................................................................................................................................. 3
How does the health care system in the Netherlands work? ......................................................................... 3
How does the health care system in the UK work? ......................................................................................... 3
How would Frank be treated in both systems? ............................................................................................... 5
How does the durg approval process work (same for UK and NL)? How will the drug be made available for
use for the population (UK vs. EU)? ................................................................................................................ 5
Doctor and patient responsibility, patient rights ............................................................................................ 8
Case 2 ................................................................................................................................................................ 11
What is the difference between health system and healthcare system? ..................................................... 11
Discuss the literature provided ..................................................................................................................... 11
Case 3 ................................................................................................................................................................ 17
How are lead compounds identified? ........................................................................................................... 17
What are NSAID’s? How do they work? ........................................................................................................ 22
If you have a compound, how do you know if it’s biologically active?.......................................................... 24
What is the structure-activity relationship of a drug? .................................................................................. 24
Case 4 ................................................................................................................................................................ 25
Background on autoimmune diseases. Focus on myasthenia gravis. ........................................................... 25
What therapies are available for autoimmune diseases? How do they work? ............................................. 30
Off-label use / experimental use ................................................................................................................... 33
Case 5 ................................................................................................................................................................ 34
Why has the (efficay of the) drug development process slowed down? (describe curve) ........................... 34
Changes in drug development policies.......................................................................................................... 34
How are drugs priced? (focus more on orphan drugs).................................................................................. 34
Prioritising niche buisiness ............................................................................................................................ 35
What is a blockbuster drug, what is a generic drug? .................................................................................... 35
What is a patent? how is it generated in pharmabusiness?.......................................................................... 36
Debates ........................................................................................................................................................ 38
Debate 1: is obesity a disease? .......................................................................................................................... 38
A History of Obesity, or How What Was Good Became Ugly and Then Bad, Garabed Eknoyan ................... 38
FDA (2018). One Health: It’s for All of Us ...................................................................................................... 39
Gordon-Larsen & Heymsfield (2018). Obesity as a Disease, Not a Behavior................................................. 39
Katz (2006). Obesity… Be Damned! What It Will Take to Turn the Tide ....................................................... 40
Cultural Influences on Body Size Ideals: Unpacking the Impact of Westernization and Modernization, Viren
Swami ............................................................................................................................................................ 40
Debate 2: dams (against) .................................................................................................................................. 41
Lectures ........................................................................................................................................................ 43
Lecture 4: genetic diversity in populations Lars Eijssen ..................................................................................... 43
1. Basics of genetic variation ......................................................................................................................... 43
2. Technology to measure variation .............................................................................................................. 46
3. Traits .......................................................................................................................................................... 47
4. Linking SNPs to traits ................................................................................................................................. 48
Lecture 5: Access to Medicines NHS, a case study Prof. Dr. D. Townend .......................................................... 51
Right to health? ............................................................................................................................................. 51
Lecture 6: Population diversity in drug response Martina Summer-Kutmon ..................................................... 54
Introduction Drug development and prescriptions ....................................................................................... 54
Factors relevant for drug action and efficacy Mechanisms of drug response effect .................................... 54
1
, Pharmacogenetics Protein structures, regulatory mechanisms.................................................................... 55
Examples / summary ..................................................................................................................................... 59
Lecture 7: Global differences in health systems & treatment provision ............................................................ 61
Milena Pavlova .................................................................................................................................................. 61
Public health systems .................................................................................................................................... 62
Understanding universal health coverage..................................................................................................... 64
Advancement towards Universal Health Coverage ....................................................................................... 64
Alternative public health system models ...................................................................................................... 66
Conclusions.................................................................................................................................................... 66
Lecture 8: Diversity in access to drug treatments and treatment standards across countries - A view from
ethics (debate 3) Dr. phil. Peter Schröder-Bäck ................................................................................................. 67
3 classic / standard theories to discuss the problem .................................................................................... 67
Summary theories ......................................................................................................................................... 69
Lecture 9: Main drug classes and molecular target identification Gertjan den Hartog .................................... 71
Drug development......................................................................................................................................... 72
Structure-activity relationship ....................................................................................................................... 74
Lecture 10: Immunotherapies / immunotherapies M. Losen............................................................................. 76
Myasthenia gravis – a model autoimmune disease .......................................................................................... 79
Conclusions.................................................................................................................................................... 83
Lecture 11: Drug development – from early beginnings till now A. Weseler ..................................................... 84
Lecture 12: Drug development business A. Weseler .......................................................................................... 92
Pharma industry in crisis – putative causes ....................................................................................................... 93
1. Reduced patent life and generic erosion................................................................................................... 93
2. “Better than the Beatles” .......................................................................................................................... 94
3. “Cautious regulator”.................................................................................................................................. 94
4. “Throw money at it” .................................................................................................................................. 94
Pharma industry in crisis – effective ways out? ................................................................................................. 95
1. Reduced patent life and generic erosion................................................................................................... 95
Conclusions.................................................................................................................................................... 98
2
,CASES
CASE 1
HOW DOES THE HEALTH CARE SYSTEM IN THE NETHERLANDS WORK?
Health insurance in the Netherlands is mandatory
Healthcare in the Netherlands is covered by four statutory forms of insurance:
• Zorgverzekeringswet (Zvw) – often called ‘basic insurance’, covers common medical care.
• Wet langdurige zorg (Wlz) – covers long-term nursing and care.
• Wet maatschappelijke ondersteuning (Wmo) – covers every day support services offered by the
government, such as household help, cleaning and cooking for those who need additional care.
• Jeugdwet – covers short and long-term medical care for youth under 18 years old.
While Dutch residents and employees are automatically insured by the government for long-term nursing and
care (as covered by the Wlz), everyone has to take out their own basic healthcare insurance (basisverzekering)
except in a few situations.
The basic Dutch insurance package covers all costs for the most common medical care. The Dutch government
decides yearly what is included in the basic insurance.
The 2017 basic health coverage in the Netherlands includes the following:
• GP consultations
• Treatments from specialists and hospital care
• Certain mental health care
• Medication
• Dental care and physiotherapy up to 18 years
• Care from certain therapists, such as speech therapists
• Dietary advice
• Basic mental health services
• Stop-smoking programs
• Maternity care and midwives.
You will need extra insurance if you want coverage for extensive dental treatments, physiotherapy or anything
else the government considers to be your own responsibility, and it is in these additional areas that companies
compete.
It is possible to purchase the additional coverage (aanvullende pakket) from a different insurer than your basic
insurer. This may make things more complicated when processing bills, but it can sometimes lower your overall
costs, or allow you to purchase additional coverage tailored for the needs of international persons residing in
the Netherlands.
Costs
• Your employer will pay 6.75 percent of your salary for you for the Zvw component, and deduct 9.65
percent from your pay for the Wlz part. The self-employed pay slightly less Zvw, at 5.65 percent.
• You will generally have to pay monthly contributions to your health insurer, which in 2017 amount to
around EUR 109 per month or EUR 1,300 per year (it varies slightly from insurer to insurer)
• The insurance policy will also have an ‘excess’ (eigen risico). This means that you have to pay the first
EUR 385 (in 2017) of some treatments.
à not for services supplied by GPs, obstetric and post-natal care: these are completely free.
HOW DOES THE HEALTH CARE SYSTEM IN THE UK WORK?
Tax-funded, you can have private insurance (to avoid waiting times)
Emergency: funded by NHS in UK, own risk in NL
NHS (National Health Service) Constitution
o Renewed every 10 years, with the involvement of the public, patients and staff.
o Accompanied by the Handbook to the NHS Constitution, to be renewed at least every 3 years, setting
out current guidance on the rights, pledges, duties and responsibilities established by the Constitution.
3
, Principles that guide the NHS
1. Comprehensive service, available to all
a. Available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief,
gender reassignment, pregnancy and maternity or marital or civil partnership status.
b. The service is designed to improve, prevent, diagnose and treat both physical and mental
health problems with equal regard.
c. It has a duty to each and every individual that it serves and must respect their human rights.
d. Wider social duty to promote equality through the services it provides and to pay particular
attention to groups or sections of society where improvements in health and life expectancy
are not keeping pace with the rest of the population.
2. Access to NHS services is based on clinical need, not an individual’s ability to pay
a. NHS services are free of charge, except in limited circumstances sanctioned by Parliament.
3. The NHS aspires to the highest standards of excellence and professionalism
a. High quality care that is safe, effective and focused on patient experience
b. Commitment to innovation and to the promotion, conduct and use of research to improve
the current and future health and care of the population.
c. Respect, dignity, compassion and care should be at the core of how patients and staff are
treated à patient safety, experience and outcomes
4. The patient will be at the heart of everything the NHS does
a. Support individuals to promote and manage their own health.
b. Services must reflect, and should be coordinated around and tailored to, the needs and
preferences of patients, their families and their carers.
c. Patients, with their families and carers, where appropriate, will be involved in and consulted
on all decisions about their care and treatment.
d. The NHS will actively encourage feedback from the public, patients and staff, welcome it and
use it to improve its services.
5. The NHS works across organisational boundaries
a. It works in partnership with other organisations in the interest of patients, local communities
and the wider population.
b. The NHS is an integrated system of organisations and services bound together by the
principles and values reflected in the Constitution.
c. The NHS is committed to working jointly with other local authority services, other public
sector organisations and a wide range of private and voluntary sector organisations to
provide and deliver improvements in health and wellbeing.
6. The NHS is committed to providing best value for taxpayers’ money
a. It is committed to providing the most effective, fair and sustainable use of finite resources.
Public funds for healthcare will be devoted solely to the benefit of the people that the NHS
serves.
7. The NHS is accountable to the public, communities and patients that it serves
a. The NHS is a national service funded through national taxation, and it is the government
which sets the framework for the NHS and which is accountable to Parliament for its
operation.
b. Most decisions, especially those about the treatment of individuals and the detailed
organisation of services, are rightly taken by the local NHS and by patients with their
clinicians.
c. The system of responsibility and accountability for taking decisions in the NHS should be
transparent and clear to the public, patients and staff.
d. The government will ensure that there is always a clear and up-to-date statement of NHS
accountability for this purpose.
NHS values
• Patients come first in everything we do.
• Respect and dignity
• Commitment to quality of care
• Compassion
• Improving lives
à improve health and wellbeing and people’s experiences
4
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