Saturday, July 23, 2011

Shortages, Ethics and the Scramble to Stay Alive

There is a nationwide shortage of Doxil, a chemotherapy drug used to treat recurrent ovarian cancer among other cancers. My oncologist told me two days ago when he said that I would need to start Doxil in combination with carboplatin to treat my now recurrent cancer.  New supplies are not expected until mid or late August.  The drug is distributed by Johnson & Johnson and manufactured by Ben Venue Laboratories in Bedford, Ohio, a unit of Boehringer Ingelheim GmbH of Germany. A representative of the manufacturer explained that the company is facing "manufacturing capacity constraints" that have held up some products, and it is working diligently to prioritize and expedite manufacturing for current orders." (WSJ 7/21/11)  The devil in me wonders if it is the priorities are set by the lower financial return Doxil brings or the fact that it is a woman's disease that Doxil mostly treats.

However, I also am grappling with an ethics issue.  I have joined an ovarian cancer forum on the internet where it came to my attention in one discussion that women from around the country are scrambling to get to places remote from their regular treatment centers to get the precious Doxil before it runs out.  One woman said a small supply was available in Texas; another thought some could be had in Boston.  I must say that such behavior makes me very uncomfortable.  Why should a scarce product be given to someone who shows up on a doorstep wanting it?  One of the women insisted that she was doing well and needed to finish 6 cycles even though my own oncologist said that six cycles may not be necessary for everyone (particularly someone who is "doing well").

I suppose the "battle" against cancer is like every other battle-- get in there and slug it out to get what you need and want.  I have a lot of fight in me but I find it unlikely that at this point I would fly 2000 miles to get a treatment that may not give you much more of an edge anyway.  But maybe I am still too new to this chronic cancer treatment situation.  The odds are that the rest of my life, whether it is a few years or many more, I will be going regularly for treatment.  I wonder if the more you go through treatment, the more you are desperate to make sure you get it.  If you don't, maybe the next recurrence will be your last because the cancer will have spread too far.

Is there a principled way to decide who gets the limited supplies of this cancer drug other than the slugfest for the last drops? All of us burdened with ovarian cancer need treatment to stay alive.   Is it anymore principled for me to have access to top rate health care because I have excellent health insurance whereas someone else will not get the needed drug or treatment because insurance will not pay and it is otherwise unaffordable?  Perhaps it is my diminished IQ due to learning of the recurrence of cancer, but I do not have any answers.  I just know that it makes me uncomfortable.

Friday, July 15, 2011

Hetch Hetchy and the Environmental Cause

On our fourth full day in Yosemite National Park we ventured out of the overpopulated Yosemite Valley to the other valley of Yosemite--Hetch Hetchy.  That valley is  not full of people but of water, thanks to the needs and wants of San Francisco after the 1906 earthquake and fire.  In the late 19th  century, James Phelan, a San Francisco politician, including for a while Mayor, decided that SF needed a new source of water in order to grow its population and stature as a major US economic force.  He set his sights on Hetch Hetchy valley in Yosemite, which he thought would be an ideal water source if the Tuolomne River were dammed and the valley turned into a reservoir.   Environmentalists,  including the newly formed Sierra Club and the famous John Muir, fought this project for over 20 years  until they lost their support in Washington after Wilson's election to the presidency and his appointment of  another SF politician, Walter Fisher, as Secretary of the Interior, who supported building the dam.  Federal law, the Raker Bill, was enacted in 1913 to create the reservoir for SF in Hetch Hetchy. Construction of the O'Shaughnessy Dam was completed in 1923 and Hetch Hetchy to this day remains flooded, notwithstanding efforts to have it restored.

The struggle between preserving the environment and exploitation by people of natural resources is one that continues to this day in many forms.  The Hetch Hetchy debate concerned the tension between the desire for growth and the desire to preserve the beauty of nature.  Today, the debates seem, to me at least, to concern  a more serious tension for the desire to provide energy to insatiable demand of an overgrown world population and the need to keep the environment healthy so that our grandchildren and great grandchildren will not suffer more deleterious effects from pollution and global climate change.  Although certain powers in SF in the early 20th century wanted more energy for that city, as even the New York Times recognized then, SF did not need the water/power supply that the Hetch Hetchy project would deliver.  Other sources were available at the time which did not involve destroying part of a national park, but also did not supply as much as wanted by those who sought to push the growth of SF.  Ironically, the city of SF has not grown much since the horrible 1906 earthquake and fire. The population then was about 400,000 and currently is about 800,000, a mere doubling in 105 years.  Where the growth has occurred, however,  is in the overall SF/ Bay Area, which increased almost twelvefold from a population of 600,000 in 1906 to about 7.15 million today.  Hetch Hetchy supplies water to about 2 million people in SF/Bay Area.

I spend more time than I should worrying about the legacy of the decimation of resources  for my children and grandchildren.  Overfarming, overfishing, air pollution, water pollution seem to me to be serious environmental concerns.  However,  I need to remind myself that the early Sierra Club members and John Muir were perhaps prescient about unrestrained use of natural resources even if the long term impact of the choices pushed by James Phelan and his ilk were not as obvious at the time.  By flooding Hetch Hetchy, Phelan got his wish of tremendous growth in the SF/Bay Area in line with belief that natural resources of the United States were endless and could supply huge growth.  Now that we feel the pinch of that growth around the world with a world population projected to be 7 billion this year and continue to grow to over 10 billion by the end of the century, perhaps I need to give their position more credit.  People should not have messed with  "nature's . . . temples" (John Muir).

Hetch Hetchy today is remote and quite beautiful even with the water where the valley should be.  However as you will see from the historic pictures (many by Herbert Gleason) that follow and my own pictures of it currently, Hetch Hetchy was indeed a rival to Yosemite Valley in grandeur and beauty before it was flooded.

View of Valley floor with Kolana Rock

View from O'Shaughnessy Dam today

Herbert W. Gleason photograph

View of Kolana Rock today

Wamapo Falls then
Wamapo Falls now
Hetch Hetchy Valley 1908 or before

Hetch Hetchy today

O'Shaughnessy Dam