More than 70% of all medicines used to treat children were never intended for children and have not been tested on children. This shocking information was given during a speech by the director of the Israeli children's clinic Hadassah Eitan Kerem in his Moscow branch in Skolkovo.
The only official branch of the Israeli hospital, Hadassah Medical Moscow, the first of the clinics of the Moscow International Medical Cluster, conducts a series of talks “Let's Talk about Medicine”. Professor Kerem's speech initiated the second such discussion and was dedicated to the future of paediatrics in a rapidly changing world.
“Let's Talk about Medicine” with Professor Kerem (center). On the left is the presenter Konstantin Ivanov, on the right is Olga Simonova M.D. (Morozov Children's Clinical Hospital). Photo: Hadassah Medical Moscow.
The figure of 70% mentioned during his lecture is a manifestation of a more general problem, known as ‘off-label medication’ i.e. such drugs that are not used for their original intended purpose prescribed in the instructions. In certain situations, doctors have to use such drugs, but in paediatrics the problem of off-label has reached a truly enormous scale, which, according to Eitan Kerem, is directly related to how the big pharma companies work.
Director of the Hadassah Israeli Children's Clinic Eitan Kerem. Photo: Hadassah.
In general, the current problems of paediatrics, as can be concluded from the report of the director of the Israeli children’s clinic, are in a sense the result of the success of medicine in previous decades. Until the 1970’s (in the terminology of Professor Kerem “the first era”), paediatricians around the world saw their main goal as the reduction of child mortality, and the main emphasis was on the treatment of acute and infectious diseases.
In developed countries, impressive progress has been made in this regard. The child mortality rate has fallen sharply. Now, the main group at risk are children under one year old, and within this group, babies in the first month of life, i.e. in the neonatal period.
What is the main cause of child mortality? Prematurity. According to the World Health Organisation 1.6% of all babies born are accountable for so-called extreme prematurity, but this small number accounts for the much larger figure of 82% of all neonatal deaths.
The reduction in child mortality in Europe over the last 30 years has been radical. Slide from the presentation of Professor Kerem.
The "second era" is upon us. With the development of medical technology, doctors are able to nurse more and more tiny new-born’s. One of the slides that Professor Eitan showed us, was a photo of a heart operation performed in a Hadassah Children's Clinic on a child weighing only 860 grams. The development of ultra-thin catheters now permits such operations. The question is what happens next?
At the Hadassah Children's Clinic, a heart operation is performed on a baby weighing 860 grams. Photo: Hadassah Medical Moscow.
The curing of children from the most serious diseases at an early age does not automatically mean that in their subsequent adult life they will be healthy people. The most serious ailments, all have side effects, as the treatment methods themselves have side effects. In Israel, up to 80% of children with cancer recover, but many of them will feel the consequences of their treatment throughout their lives.
With the advent of the “second era”, doctors now focus on the treatment of chronic diseases (including cerebral palsy, autism, cystic fibrosis, mental retardation and neuromuscular disorders) and disability. Paediatrics itself is characterized by an increasingly narrow specialization of doctors, clinics and medicines, which inevitably results in a sharp increase in the cost of treatment.
This leads us to the idea that purely medical problems, acquire the character of social and economic problems for society. More children with severe chronic illnesses and disabilities, mean a lower quality of life for themselves and their families; weakening of social ties and increased government spending on related programs.
In the US state of Maryland, more than two-thirds of childhood deaths occur in patients under 1 year old. Slide from the presentation of Professor Kerem.
Diverting from the presentation, prof. Eitan said that he was consulting a teenage girl in Moscow with a serious chronic illness. The girl admitted that she is thinking about how to die: “Who needs me like this? Who will marry me?” Society, according to the doctor, has no right to leave the teenager alone to fend for herself with such perceptions and expectations.
A significant part of the presentation was devoted not to medical problems themselves, but to the organization of medical services. Paediatricians need to identify the symptoms of chronic disorders in the smallest of patients. And it should be recognized that most doctors simply do not have the necessary skills for this. In Israel, there is a state program for retraining paediatricians, created taking into account these realities.
“The earlier the disease is discovered, the greater the therapeutic effect the treatment will have and the lower its cost. Modern healthcare does exactly the opposite. And this is true all over the world,” says Professor Eitan.
According to him, investments in paediatrics in early childhood are totally insufficient. One of the central points of his speech is: “Investing in early childhood is the best investment a country can make.”
This Israeli doctor does not suffer from political naivety. For politicians, the effect that detailed investments will give society is too long-term: politicians operate on much shorter periods of the political cycle. And this is one of those problems that paediatricians of the future will increasingly face. In Israel, for example, special lobbying groups are being created; their task is to bring to society the need for a rational redistribution of funds for health care.
Slide from the presentation of Professor Kerem.
Among the topics addressed at the lecture were purely medical issues. The ability of doctors to care for extremely premature infants rests in the absence of the ability to place a new born in an artificial uterus. The creation of an artificial uterus is not a matter for today, but in the coming decades this will certainly happen and will become a real breakthrough in paediatrics, Professor Kerem believes.
But it is equally important to deal with social problems, which in the "second era" are the causes of new epidemics, such as obesity.
“We are poisoned by food,” says an Israeli professor, emphasizing that obesity is already being recorded in children aged 2-3 years. The question is not just limited to unhealthy food. Malnutrition is exacerbated by a lack of physical activity. One of the Israeli schools conducted a simple experiment: students had added to their school week, two hours of additional exercise. In another control school, the time for sports remained unchanged. After some time, it was noted that the average weight of students in the first school began to drop.
In all cases, building trust between parents and doctors, breakthroughs in medicine costs little. Prof. Kerem admitted that he had very little experience with Russian patients, but it seemed to him that the parents of sick children in our country look at doctors as representatives of the establishment. This, in its own way, is also a diagnosis.
Hadassah Children's Clinic has created a family paediatrics center for genetic and chronic diseases. The principle of its work: doctors unite around the patient, and not around the disease. Photo: Hadassah.
One of the questions from the audience was how to establish trust between the parents, whose children were in the emergency room of the hospital in a serious condition, and the medical staff?
“At our hospital, we teach doctors that no matter what action they take, they should do it with a smile,” says Eitan Kerem. In many cases, psychologists are involved in discussions with parents. The doctor may not have much time to talk to relatives, he needs to save the child, but the psychologist must stay with mums and dads and help them digest the information, sometimes it can be very difficult.
“Otherwise, the doctor becomes the messenger who delivered the bad news,” he concludes.
“A natural reaction to this is the desire of the parent to shoot the messenger.”