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Agree with Bens comment: EBM important and should guide policy, however It’s a shame that EBM continues to be hijacked and used to justify top down public health policy. I think Neal’s almost throw away comment: “Both the population and the individual perspectives (and nota bene the plural) seem to me to be entirely legitimate.” carries dangers based as it is on a false premise. Thus: The idea that all views on e.g. use of Tamiflu; [i.e. the competing views that either ‘everybody’ should have Tamiflu (as under the criteria of the guidelines) versus the decision/choice that Tamiflu is too risky for a given healthy individual and shouldn’t be prescribed or taken] are of equal moral status, is flawed. This liberal ‘all views are fine by me’ stance assumes that everybody has equal access to and understanding of the ‘real’ state of affairs when it comes to the risk benefit ratio of this intervention. This is akin to pretending that we live in a ‘real’ democracy (which is of course an impossible fiction to attain) instead of an ‘organised democracy where the outcomes e.g. of elections are preordained and the ‘people’ misinformed. With Tamiflu, the government, health spokesmen and the drug industry – with the help of the corporate media conspire to mislead the public by over-egging the dangers of e.g. Mexican/Swine Flu and overstating (even if it is by implication i.e. simply by recommending its use) the benefits of Tamiflu. We actually know that the evidence of benefit is weak and benefit is small; and there are continuing anxieties about harms especially in the young, but we choose to ignore this knowledge. (ref. Carl Heneghan et als excellent journal club report in the BMJ rapid responses in the last 2 years or so). The knowledge for EBM is there but we are manipulated with falsehoods, therefore the choices/decisions people are making, including professionals, are ‘forced by public policy’ and are based on a deceit, so it is ridiculous to say all choices have equal value. What can be said is that most people are making choices that in part maintain the status quo of a society that is still exploitative, and in part simply makes profits of one sort or another for politicians, drug companies and the self esteem of the medical profession. A bit more honesty about the evidence from public health and our esteemed spokesmen would be welcome. By the By: Zizek talks about the Theories of Fiction of Bentham and Lacan’s notions on democracy in his book Sublime Object of Ideology. Is it a necessary that society believes in the fiction of public health policy? Is it true to say that here is no such thing a society, or, that a fully paid up member of society that believes unquestioningly in public health policy is like a good Stalinist, ‘made of special stuff’ that special stuff being Lacan’s ‘petit objet a’, a surplus left over as desire tries to fulfil fantasy, it doesn’t actually exist. It’s a lack. People try to make up for this lack by conforming AS IF the fantasy were true. If you don’t believe in public health policy then you are no longer a bona fide member of society (but a dissident to be outcast or ignored). People take Tamiflu, Doctors prescribe Tamiflu (not because they expect any noticeable benefit but because they fear what might happen if they don’t) and they get better, and the epidemic subsides; and everybody has been a good citizen and so thus proves that the Tamiflu and public health policy must have worked. Best wishes Owen -----Original Message----- From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Djulbegovic, Benjamin Sent: 24 September 2009 14:38 To: [log in to unmask] Subject: Re: Do the antivirals reduce mortality in flu? Niel, no doubt the efforts like these should be commended and appreciated… Just quick comment on your remark “The caveat is that this topic is, in some circles, controversial.” This is in fact even more important reason to develop evidence profiles/decision aids. Knowing what we know and what we don’t know (and how good is the quality of our knowledge) is what EBM is all about, as you well know it. Tom Jefferson has done a lot of work synthesizing the evidence on the effects of flu vaccine. Tom: have you created evidence profile (or, even decision aid) that it can be shared with the public? (BTW, one of the reasons that Cochrane reviews are not being used as they should is because until recently they have not included Summary of Evidence/Evidence Profile tables.) Thanks to both of you on working on such an important topic best ben From: Maskrey Neal [mailto:[log in to unmask]] Sent: Thursday, September 24, 2009 8:56 AM To: Djulbegovic, Benjamin; [log in to unmask] Subject: RE: Do the antivirals reduce mortality in flu? Thanks Ben, I’ll file that appraisal in my revalidation folder :-) The response has been very positive and we’re grateful to this group for all the inspiration. I strongly suspect we won’t get lots of clinical outcomes-based effectiveness data on swine flu vaccination in time for the early programmes, but it would perhaps be worth us taking a look again at the existing data (such as it is) on vaccination for seasonal influenza. The caveat is that this topic is, in some circles, controversial. Bw Neal _____ From: Djulbegovic, Benjamin [mailto:[log in to unmask]] Sent: 24 September 2009 13:14 To: Maskrey Neal; [log in to unmask] Subject: RE: Do the antivirals reduce mortality in flu? Neil, this is great! Have you (or anyone else) developed a decision aid for flu vaccine? With this panic about getting any possible vaccine one can get, it would be nice to have similar aid (of reason). Thanks ben From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Maskrey Neal Sent: Monday, September 21, 2009 10:32 AM To: [log in to unmask] Subject: Re: Do the antivirals reduce mortality in flu? Sorry list, two postings in the same day is too much I know. Do these help, Martin? We’ve trawled the literature for oseltamivir to produce the best patient decision aids we can. You can access them via the link from our home page here http://www.npc.co.uk/ …..or directly on our NPCi e-Learning site here http://www.npci.org.uk/therapeutics/infect/commonintro/patient_decision_aids /patient_decision_aid1.php It’s not great data but the best we can find. If you can find better please tell us, but the UK national committee haven’t. In terms of decision making, values matter. National or regional public health values (driven by onerous responsibilities to see the health system optimally prepared, no avoidable catastrophes, disruption to essential services avoided / minimised, and an excess of flu related deaths at least as low as other developed countries) would indicate wide use of oseltamivir as being entirely reasonable despite the data being limited, at least in some patient groups. The trade off is the remoter risk of future resistance and the cost - but the swine flu is now and the resistance is a future possibility. Cf clopidogrel in ACS, any antibiotic prescribing for RTIs and many more examples. Individuals (patients and clinicians) might make different choices based on their perspective and values, none of which are likely to be exactly the same as each others. And we might all make a different choice when we actually have the flu, or someone we know has had flu-related pneumonia or worse, as opposed to dispassionate discussions when we don't. Australian hospital docs on a recent UK documentary were apparently also all for taking an antiviral too, based on the unavoidable problem that looms large in their values. They were most worried because no one can say at presentation whether an individual will be one of the many who will have a mild uncomplicated illness or be one of the few who gets very very very sick. We seem to be hard wired as humans to be prepared to treat lots unnecessarily to reduce the risk of an error of omission. That's one of our ways of dealing with stochastic uncertainty. Both the population and the individual perspectives (and nota bene the plural) seem to me to be entirely legitimate. Bw Neal Neal Maskrey, National Prescribing Centre, Liverpool UK _____ From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Brian Alper MD Sent: 21 September 2009 14:06 To: [log in to unmask] Subject: Re: Do the antivirals reduce mortality in flu? It depends on what outcome you are promoting the antivirals for: If for mortality – there is observational evidence for seasonal influenza for hospitalized adults If for duration of illness – there are randomized trials (seasonal influenza) If for other complications – there some randomized trials (seasonal influenza) If for reducing transmission to others – I’m not sure of evidence for “treatment” but there is evidence for prophylaxis Brian S. Alper, MD, MSPH Editor-in-Chief, DynaMed (www.ebscohost.com/dynamed) -----Original Message----- From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Martin Dawes, Dr. Sent: Monday, September 21, 2009 8:59 AM To: [log in to unmask] Subject: Do the antivirals reduce mortality in flu? Sorry Naïve question but I could not find any RCT's - am I missing something here or are we promoting unproven therapy? Thanks Martin (neuraminidase and influenza and mortality) AND (randomized controlled trial[Publication Type] OR (randomized[Title/Abstract] AND controlled[Title/Abstract] AND trial[Title/Abstract])) No virus found in this incoming message. Checked by AVG - www.avg.com Version: 8.5.409 / Virus Database: 270.13.112/2392 - Release Date: 09/24/09 05:52:00