Friday, December 05, 2014

Iraq snapshot

Friday, December 5, 2014.  Chaos and violence continue, the persecution of Sunnis continue, the US Senate explores the costs for the VA of treating hepatitis C, and much more.

"It is estimated that the VA will spend $1.3 billion over the next two years just on this hepatitis C treatment," Senator Mazie Hirono declared at Wednesday's Senate Veterans Affairs Committee.

The issue was hepatitis C in the veterans community.  And it was one of two hearings the Senate committee held this week in the final month of the Committee.  Next January, new senators take office and the Senate will be under Republican control.  Longterm Ranking Member Richard Burr should transition over to Committee Chair with current Chair Bernie Sanders transferring to Ranking Member.

Democrats have controlled the Senate since the results of the November 2006 mid-terms.

During that time, Daniel Akaka and Patty Murray have been Committee Chair and now Vermont's Bernie Sanders.

A very wealthy corporation, Giliad, is getting extremely rich off the price of medications.  They refused to attend the hearing,

Committee Chair Bernie Sanders:  Prior to the developments of the new drugs from Giliad, the primary method for treating Hepatitis C was interferon -- an injectible medicine that has many side effects that are terribly painful for many patients.  Additionally, many patients required additional intervention including liver transplants.  These treatments were expensive.  According to research by Dr. John Gaetano of the University of Chicago who has special expertise in hepatitis, it is estimated the costs for a person with liver damage over a ten year period can exceed $270,000 and the average liver transplant in 2011 cost $577,100.  This brings us to the purpose of today's hearing -- the new treatments for Hepatitis C now on the market and the exorbitant price tag associated with them.  Gilead, the manufacturer of Sovaldi, is selling the drug at an astounding price of $84,000 for a twelve-week course of treatment, or about $1,000 per pill.  I had invited Gilead to testify today.  I had hoped they could share their perspective on the cost of their new hepatitis C drugs.  Maybe they could have explained to this Committee why they believe their pricing is fair and reasonable.  But unfortunately they declined our invitation because all of their executives who could have spoken on this issue are traveling internationally.  Just like any for-profit company, drug companies charge what they think the market will bear.  Gilead clearly made the calculation that they could charge excessive prices for this groundbreaking drug and that the federal government would pay.  And I get it -- companies are motivated to make a profit.  But Gilead is making profits in spades.  They purchased Pharmasset -- the original developers of Sovaldi -- for $11 billion and, according to some estimates, are expected to make more than $200 billion on the sales of the drug.  With numbers like these, we're not talking about a company looking to make ends meet -- or even fund their next great medical breakthrough.  So we must ask, how much is too much?

The issue of cost was at the heart of the hearing which consisted of two panels. The first panel was composed of the VA's Chief Consultant on Pharmacy Benefits Michael Valentino and the Director of HIV, Hepatitis C and Public Health Pathogens Programs Dr. David Ross.  The second panel was the president of Public Citizen Robert Weissman and the National Coalition on Health Care president John Rother.

Senator Hirono insisted the current spending on hepatitis C was "not sustainable.  It will strain VA resources at a time when veterans are increasing in number and complexity of conditions."

Her concerns included that hepatitis C was "three times higher" in the veteran population than in "the general population" and that "many people infected are unaware that they have it."  She also noted that 35 patients at Hawai's VA -- Hirono's home state -- have benefited from the new treatments.

But the new treatments, from Giliad, are very expensive.

Chair Bernie Sanders: Very interestingly, and maybe we can explore this in the second panel, Giliad is making this drug available to countries like Egypt which have a very serious problem with hepatitis C, my understanding and please correct me if I'm wrong, that they are selling -- in this country, they are selling the product for $1000 a pill, in Egypt it is a few dollars a pill. Is that correct?  Do you know anything about that?

Dr Michael Valentino: I personally don't.  Dr. Ross might.

Chair Bernie Sanders: Dr. Ross, are you aware of that?

Dr. David Ross: I-I --

Chair Bernie Sanders: My understanding is it's ten dollars a pill.

Dr. David Ross:  I-I couldn't speak to the specifics of that.

Chair Bernie Sanders: Okay, we'll get more into that in the second panel.  Why do you think it's the case that they're selling it to a general American consumer who walks in for a thousand, they're selling it to a huge federal agency -- the VA, which treats more hepatitis patients than anyone else in the country -- at $540 but they're selling it in Egypt for $10?  How come they negotiated a better price than you did?

Dr. Michael Valentino:  I can't answer that question. I don't know what Giliad's business model is.  I don't know how that was able to -- able to be achieved.  Uhm, you know those -- A lot of other countries have different regulatory processes.

Chair Bernie Sanders:  They sure do. Which results in the United States paying the highest prices of all in the world for prescription drugs.  And this may be outside your portfolio in a sense but if the VA is going to spend -- I mean, we have a deficit and some of my colleagues don't like spending a whole lot of money on things -- if the VA is spending billions of dollars -- 1.3 now and maybe more later -- to treat one illness, is it fair to suggest that that will mean that we have less money available to take care of veterans needs in other areas?  Is that a fair supposition?

Dr. Michael Valentino: Well, we did -- we did ask for more money and-and-and so, uhm, VA is undergoing a lot of changes right now with, uh, --

Chair Bernie Sanders:  All that I'm asking, which I think is pretty common sense.  I mean there's a limit to how much -- I'm a strong supporter of the VA, would like to put more money into the VA, but there's a limit to what can be done.  All that I'm saying is that if you're spending billions of dollars in one area, common sense suggests that we may not be able to spend in others.  That may be a fair supposition?

Dr. Michael Valentino:  I would not disagree with that.

Nor on the second panel did John Rother.

This is not just a matter of a thousand dollars a pill.  This is a matter primarily of a drug that is potentially beneficial to three to five million people so it's not an orphan drug at all.  It's a drug that would be appropriate for a large number of Americans.  And, uh, the problem is the total cost of treatment, not so much the individual pill price. Inevitably as you suggest -- as your question earlier suggested, this kind of costs is going to force trade offs with other necessary treatment within the VA, within Medicaid, within prisons, within private health insurance.  We are seeing this every day today.  And, uh, it's-it's a deep concern because in many cases the services not delivered are the very preventative services that have the greatest return on investment and if we neglect those than we are just making the problem more difficult down the road. 

Let's stay with the first panel to note an exchange covering a few basics on hepatitis C.

Senator Mazie Hirono:  I think my series of questions deals with whether the marketplace really can -- is operating in a way where there really is more competition for different kinds of treatments that are effective and much less costly though is there a way to prevent hepatitis C?  Because once one is infected, there is a progression to the disease.  So what are we doing on the prevention side?

Dr. David Ross: Briefly, there is no vaccine for hepatitis C.  Transmission for most people occurred decades ago. There are about 20,000 or so new infections a year.  The number is actually going up -- almost entirely because of the sharing of needles from injection drug users.  So thinks that we are doing within VA is to -- and this is done within hepatitis C care -- help people with substance abuse disorders.  We also are doing things -- and again this is integrated with their medical care to try and reduce exposures that could also damage the liver -- particularly thinking of alcohol abuse.  And an integrated care approach is much more effective at getting people ready for treatment.  One brief anecdote, I have a patient who I saw yesterday who I started on methadone maintenance about six months ago and he is now ready for treatment. In other words he'll be able to reliably take the pills 

Senator Mazie Hirono:  So these prevention  methods that you are utilizing do they -- are they working?  I realize it's not that easy to determine whether something that you're doing is actually preventing --

Dr. David Ross:  I-I-I think yes.  I think the-the-the-the -- It's a matter of keeping people from getting it in the first place but it's also a question of getting people ready for treatment.  We're -- What we've done in VA has shown that if you take people who have these barriers to treatment because of other diseases -- frequently substance abuse or alcohol abuse -- and you give them integrated psycho-social care in the same clinic -- this is what has worked at Minneapolis VA and I should mention this is what was done at the Matsunaga VA in Honolulu -- they are more likely to complete therapy and be cured than people who don't have those problems in the first place would be who don't get that kind of supportive care.

But for most Americans with hepatitis C, the costs for the needed treatment are too high.

It doesn't have to be that way, as Robert Weismann explained:

Now some have held out hope that new treatments will lead to price competition or that hard bargaining by payers -- of which the VA is the best -- will be able to yield sufficient price reductions and I think that's misguided.  Based on prior experience, new drugs don't necessarily come in at a lower price.  In fact, they often come in at a higher price.  In general, brand name competitors try not to compete on price.  And when you have a starting point price of $84000 even if we have substantial reductions in price due to negotiations we're still going to be stuck with a super high price just because the starting point was so high.  However, we do have solutions available to us and really fundamental solutions. Now we should say -- I think it's correct, everything you say, Senator Burr about both the importance of innovation and looking at government policy.  The reason for this price level -- as both of you asked -- is a single thing which is Giliad has a monopoly.  Giliad doesn't have a market created monopoly, they've got a government granted monopoly, a patent monopoly, a monopoly that comes from other exclusivities. If we choose to address that monopoly through government policy -- since We The People gave the monopoly in the first place -- we can bring the price down.  And we know we can bring it down to less than 1% -- at least at the manufacturing level -- leaving aside whatever fair compensation we need to pay to Giliad because of the price reductions that already exist in developing countries as you referenced, Senator Sanders. Two methodologies we might pursue to reduce price.  One. we might have just government use of the product -- government use of the patent and other technologies -- in that case we could source the product to generic competitors and pay Giliad a royalty.  If we pay Giliad a royalty of five thousand dollars per patient, we'd actually still have cut the price overall by 90%.  We've got existing staturoty atuhority to do that under 28 USC Section 1498.  A different approach might be to look to buy out Giliad's patent all together.  We could do that in one way which would be to say we're just going to give Giliad as much money as we anticipate the company will make by virtue of it's patent monopoly.  Why would we do that?  Well we'd do that because we're already going to pay them that much money but we could then provide treatment to everyone whereas under the current system we're going to pay all that money and have rationing.  Now I wouldn't advocate doing that.  I think we can adjust down significantly what we would pay for a patent buyout but it is another method we might consider to provide treatment for all.

Staying with the US Senate, Michael McAuliff (Huffington Post) reports:

Many members of Congress have been seeking a debate and vote on the president's military actions in Iraq and Syria, but a new letter being sent Friday by Sens. Tammy Baldwin (D-Wis.) and Brian Schatz (D-Hawaii) marks the strongest demand yet from the left that Obama request explicit authority for the fight.
House Speaker John Boehner (R-Ohio) has called repeatedly on Obama to make such a request, but has rebuffed members of his own caucus, as well as Democrats who think Congress should take matters into its own hands rather than let the White House proceed as it wishes.
Baldwin and Schatz agree with most members of Congress and the administration that the Islamic State threatens U.S. interests, but argue that Obama should stop dithering.

Wow.  Tammy Baldwin.

Remember when she was the great 'progressive' hope.  Now she's demanding a vote on the never-ending war's latest phase -- not to stop it -- but to make it legal.

What a proud moment for her.

And for Matthew Rothschild who promoted her non-stop.

When she was in the House, Baldwin was against the Iraq War, voted against it in 2002.

So she's against war -- when a Republican's in the White House.

I guess it could be worse.  She could be only a lesbian when Republicans were in the White House.  At least she sticks with something regardless of who's in the White House.

While Tammy Baldwin goes coo-coo for war, Theo Sitther (The Hill) explains what could really help Iraq:

Instead of continuing to prioritize a military-first approach to addressing a crisis that is inherently rooted in political and economic grievances, Congress and the administration should get beyond platitudes and invest in Iraq’s people by helping to build an inclusive, non-sectarian government.   
It is important to take a long view. The building of open and free democratic states that truly serve the needs of their citizens is a long-term process. It is a process of working to understand the cultural, religious, and political contexts and basing any intervention on that knowledge.
But unfortunately, the President’s FY 2015 request for U.S. civilian programs in Iraq goes in the opposite direction. It cuts USAID commitments by 69 percent from 2013 levels with a meager $22.5 million for long-term economic development, support for Iraqi civil society, and governance programs. While the Senate Appropriations Committee’s markup of the State, Foreign Operations, and Related Programs bill increased this number to $50 million, it remains vastly inadequate compared to the needs on the ground.

Barack repeatedly stated that the only answer for Iraq was a "political solution." But those were apparently just more empty words, pretty lies from someone who's offered so many.

The last time I saw Richard was Detroit in '68
And he told me all romantics meet the same fate someday
Cynical and drunk and boring someone in some dark café
You laugh he said you think you're immune
Go look at your eyes they're full of moon
You like roses and kisses and pretty men to tell you
All those pretty lies pretty lies
When you gonna realize they're only pretty lies
Only pretty lies just pretty lies

-- "The Last Time I Saw Richard," written by Joni Mitchell, first appears on Blue

Pretty lies let Shi'ite militias terrorize Sunnis in Iraq all while everyone pretends a new day has dawned with a new prime minister (Haider al-Abadi).  Matt Bradley and Ghassan Adnan (Wall Street Journal) report:

Shiite militia leaders say their recent successes reflect their holy warrior zeal, superior training compared with Iraqi government troops, less corruption in the ranks and freedom from the legal, bureaucratic and human-rights restrictions on regular Iraqi forces. But some Sunni politicians, tribal leaders and human-rights advocates are worried that the take-no-prisoners tactics of many militia groups are turning them into a mirror image of the Sunni jihadists fighting on behalf of Islamic State.
Militia groups have been accused of a plethora of human-rights violations, including mass shootings of prisoners and Sunni civilians and the forced displacement of Sunni families on a scale approaching ethnic cleansing.

Shiite fighters boast about executing enemy soldiers after they surrender. In Jurf al-Sakher, some Al Qara’a members hurried out of a meeting with a reporter for The Wall Street Journal to deliver the severed head of an Islamic State fighter to relatives of a slain militia member before his funeral ended.

Shi'ite militia groups terrorize Iraq and everyone looks the other way.

Sunnis are terrorized still in Iraq.  And the 'new' government?

It's made clear that Sunnis are still targets.

Let's drop back to the December 30, 2013 snapshot:

Sunday, December 22nd, Nouri yet again called peaceful protesters 'terrorists' and announced he would stop the protests.

He wanted to attack last Tuesday but a last minute flurry of meetings by various officials and political blocs caused Nouri to withdraw the forces he had encircling the Ramadi protest square.  Then came Friday.  From that day's snapshot:

Wael Grace (Al Mada) reports Nouri al-Maliki again threatened the protesters today.  He declared this will be their last Friday protest and that he will burn the tents in the protest squares down.  He declared that the protesters were guilty of sedition.  Sedition?  Nouri as William Bligh?  I can see it.  Kitabat notes that he made these remarks in a televised interview.  Kitabat also notes Nouri's been insisting 30 terrorist leaders are hiding in protest tents.  

We still can't get to today yet.

That's Falluja on Saturday as tons poured into the street to protest Nouri's latest stunt.

They were protesting the Saturday dawn raid that Nouri's forces carried out on an MP.  MP Ahmed al-Alwani was illegally arrested.  But there's more.  Alsumaria reported that his home was stormed by Nouri's SWAT forces at dawn and that 5 people (bodyguards and family) were killed (this included his brother) while ten family members (including children) were left injured.

By now, we all know the drill.

What is al-Alwani?

Yes, he's Sunni.

And he's also, we all know this, a member of Iraqiya.

If you're targeted by Nouri, then you are both things.

Or, as conservative Max Boot (Commentary) put it today, "If it’s the end of December or the beginning of January, it must be time for Prime Minister Nouri al-Maliki to arrest another prominent Sunni politician."

The people of Anbar did not respond well to Nouri breaking the law and arresting an MP.

That was 'old' Iraq.  Let's go to the November 24th snapshot:

Today,  All Iraq News reports it's been decided to put former MP Ahmed al-Alwani to death.  He was arrested December 29, 2013 the outlet notes.  His brother was killed in the arrest ordered by thug Nouri al-Maliki, an arrest that was actually a raid in the early, pre-dawn hours of the morning.
This will have huge implications.
For example, the tribe he belongs to is one of the key tribes in the fight against the Islamic State. Equally true, his arrest (and the murder of his brother) outraged the Sunni community.
This is the wrong time to be  executing a Sunni politician -- with the new prime minister Haider al-Abaidi having done nothing of significance to improve Sunni relations or to include them in the government.

It's not a good time for that stunt.

Thursay, Mustafa Habib (Niqash) observed:

The fact that some Sunni Muslim tribes had joined with the mostly Shiite Muslim Iraqi army seemed to be good news for the country. It’s well acknowledged that in order for Iraq to resolve the current security crisis, sectarian and ethnic rifts must be healed and in areas held by the IS group, which are home to a mainly Sunni Muslim population, it is the locals – Sunni Muslims - who must push the extremists out.

But almost immediately there was bad news from Baghdad that seemed to negate the good. It also the dispirited Sunni Muslim tribal leaders who had been fighting the IS group. The news: the Iraqi judiciary had issued a death sentence against a prominent Sunni Muslim MP, Ahmed al-Alwani.

As the BBC reported at the time of his arrest in December 2013, al-Alwani had backed Sunni Muslim protests against the government led by former Iraqi Prime Minister Nouri al-Maliki. Al-Alwani was arrested on charges of terrorism and his capture in Ramadi, after a deadly gunfight, was part of the reason that protests in the area became more heated and violent.

“This verdict is like a knife in our backs from the Iraqi government,” one of the leaders of the al-Bu Ulwan tribe, Hazem al-Alwani, told NIQASH. “The sons of my tribe have been fighting against the IS group for days, helping the Iraqi security forces to prevent Ramadi from falling.”

The case against al-Alwani has been widely criticised. Amnesty International released a statement declaring that the trial had had many irregularities, with al-Alwani denied access to his lawyer and his family, among other things.

The verdict had been postponed previously and now, Hazem al-Alwani thought, the timing of the announcement of a death penalty was strange. “I don’t believe it is a coincidence,” he said. “It seems that there are certain political actors that do not want the Sunni Muslim tribes in Anbar to play any role in the fight against the IS group.”

Haider al-Abadi has still done nothing to demonstrate to Sunnis that there's a 'new' Iraq or that they'll be included and welcomed.  He did promise, September 13, 2014, that the bombing of Falluja's residential neighborhoods would stop.

Those bombings never stopped.

Those bombings continue and continue to wound and kill Sunni civilians.

Where's that political solution, Barack?

Let's note this from Paul D. Shinkman (US News and World Reports):

“Aside from setting broad priorities, there’s no plan, no indication of progress, no measures of effectiveness,” says Anthony Cordesman, a former State Department and Pentagon official who regularly advises leaders in both departments. The Obama administration tends to take too long to adopt serious military advice, he says.
“Events and reality certainly have to shape strategy,” says Cordesman, now with the Center for Strategic and International Studies. “But if you don’t have a strategy and clear plans, you lack the ability to shape events.” 

Barack has no plan.  Despite this, Mu Xuequan (Xinhua) quotes Barry O insisting  "slow but steady progress"  was taking place.

Al Arabiya notes, "The Islamic State of Iraq and Syria (ISIS) has executed three Iraqi tribal leaders outside a government building in the northern Iraqi city of Mosul, Iraq’s Ministry of Human Rights reported on Friday."  Margaret Griffis ( counts 65 dead in Iraq today from violence.

In the United States IAVA's Paul Reickhoff Tweets a movie review:

  • . is for Iraq what Platoon & Full Metal Jacket were for Vietnam. It's soaringly heroic & terribly tragic. Just like the war.
  • Just saw an advanced screening of . It's an instant classic war movie. And the defining film of the Iraq war so far.

  • American Sniper is the new film directed by Clint Eastwood starring Bradley Cooper.  We'll close with this from Iraq and Afghanistan Veterans of America:

    Washington D.C. (December 5, 2014) – Today, President Obama announced Ashton Carter as his nominee for Secretary of the Department of Defense (DoD). Iraq and Afghanistan Veterans of America (IAVA), the largest nonprofit, nonpartisan organization representing post-9/11 veterans and families, welcomed the nomination. Paul Rieckhoff, IAVA CEO and Founder, was at the White House today for the announcement at the invitation of the President.
    “IAVA congratulates Ashton Carter on his nomination as Defense Secretary,” said Rieckhoff. “Carter has proven to be an advocate for both active-duty servicemembers and veterans. With his breadth of experience at the Pentagon, we trust that Carter is prepared to meet the unique demands of today’s national security challenges.
    “Carter returns to the Pentagon at a critical time. As conflict continues in the Middle East and more troops are sent into combat, our country must remember to care for the veterans we are still welcoming home. IAVA looks forward to our continued partnership with the Pentagon on critical issues such as combating suicide and improving access to quality mental health care. We hope Carter will continue to engage the veteran community with the same drive and passion as Secretary Chuck Hagel.”

    Since the beginning of 2014 IAVA has been calling on DoD, Congress, the White House and the Department of Veterans Affairs to address the veteran suicide crisis. IAVA veteran members delivered a petition to Majority Leader Harry Reid (D-Nev.) yesterday calling on him to bring the Clay Hunt Suicide Prevention Bill to the Senate floor before Congress adjourns next week. The bill, named after Iraq and Afghanistan war veteran Clay Hunt, a Marine who died by suicide in 2011, will help combat veteran suicide and improve access to quality mental health care. Hunt’s mother, Susan Selke, recently met with DoD officials to press for veteran mental health care reforms and to garner their support of the Clay Hunt bill.

    IAVA's Founder and CEO Paul Rieckhoff and Political Director Bill Rausch visit the White House for the President's announcement of new Defense Secretary Ashton Carter.

    IAVA’s Founder and CEO Paul Rieckhoff (right) and Political Director 
    Bill Rausch (left) visit the White House for the President’s announcement of 
     new Defense Secretary Ashton Carter.

    Note to media: Email or call 212-982-9699 to speak 
    with IAVA CEO and Founder Paul Rieckhoff or IAVA leadership.
    Iraq and Afghanistan Veterans of America ( is the 
     nation's first and largest nonpartisan, nonprofit organization representing 
    veterans of Iraq and Afghanistan and has nearly 300,000 Member 
    Veterans and civilian supporters nationwide. Celebrating its 
    10th year anniversary, IAVA recently received the 
    highest rating - four-stars - from Charity Navigator, 
    America's largest charity evaluator.