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ABC Listen, podcasts, radio,

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news, music and more.

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I know you like to talk about

0:07

your ailments. Is that clear?

0:09

No, no, no, come on. You like

0:11

asking about them or do you

0:13

just raise them? It's hard to

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know. Well, let's say, that goes

0:18

through to the keeper. So what

0:20

do you want to ask me

0:22

about this week? Priya. Do you

0:24

have any. osteoarthritis

0:26

going on, hips, knees. Funny you

0:29

should say that. The answer is

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yes I imagine. Yeah yeah it's my

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knee. Tell me more how long how does

0:35

it affect you? I was cycling to

0:37

school at the age of 14 in

0:39

Scotland in the snow fell off the

0:42

bike and damaged my knee and the

0:44

knee kept on jumping out the knee

0:46

cap and eventually I had it operated

0:49

on at the age of 18. The

0:51

surgeon said, it's a great operation for

0:53

stopping the knee cap jumping out, but

0:56

you'll have osteoarthritis by the time you're

0:58

60. Yeah. And I had it by

1:00

the time I was 40. Oh, Norman, so you get

1:02

knee pain. Well, interestingly, everybody around me

1:05

has been saying, you gotta have

1:07

a knee replacement. Got to have

1:09

a knee replacement. Do you? Do

1:11

you need a knee replacement? That's

1:13

the million dollar question. Well, I don't

1:15

think I do. And I've managed to

1:17

hold it at bay by... doing stuff

1:19

to my knee and to my leg.

1:21

I've discovered all sorts of interesting things

1:23

about rehabilitation of the knee. And there

1:25

you go. That's exactly what we're covering

1:27

on the health report today. That's your

1:29

story. And actually, even despite the pain,

1:31

you want to keep moving. That's the

1:34

kind of interesting paradox. It is. We'll have

1:36

much more on that today on the health support.

1:38

I'm Norman Swan on Gaddigoland. And I'm

1:40

Pre Alexander on Wur and Jerry Land.

1:44

Also on this show, a study that

1:46

shows that screening students from mental health

1:48

issues almost in its own right improves

1:50

the mental health without using extra services.

1:53

Even that can be quite protective for them

1:55

as they walk around the school knowing that

1:57

we're caring for them. And more evidence that

1:59

clients... changes hurting our health,

2:01

high temperatures are driving up

2:03

the risk of cardiovascular disease. To

2:06

the news now, so there are some

2:08

medication shortages and they appear to be

2:10

getting worse. Yeah, it just keeps on

2:12

going, doesn't it? I mean, you'd see

2:14

a lot of it in practice where...

2:16

HRT patches and what we call MTT

2:18

patches, drugs for ADHD, I mean just

2:20

the list keeps on going on and

2:22

on and on. It is really tricky

2:24

to navigate. Often we don't hear

2:26

about these things until the patient

2:29

comes and says I couldn't get

2:31

this. The pharmacist said there's a

2:33

shortage. It's very hard to keep

2:35

up and at the moment the

2:38

menopause hormone therapy space there are

2:40

lots of shortages of the transdermal

2:42

estrogen patches and ADHD so at

2:44

the moment we're experiencing methylphenidate shortages

2:47

it really impacts best practice you

2:49

can't do what the patient might need.

2:51

And so just before you panic if

2:53

you are on ADHD medication it's not

2:55

all methylphenidate which is a bit of

2:57

slower release it's called concerta. I thought

2:59

we might just chat a little bit

3:02

about it so that we kind of

3:04

understand a bit more aware of these

3:06

shortages, but it's more of a 400

3:08

I think listed in Australia at the

3:10

moment in the TGA website. And we're

3:12

better off in the United States by

3:14

the way. They have more shortages and

3:16

they are lasting longer. What's really interesting

3:19

about this is when you delve into it,

3:21

60% of the time, they've no idea

3:23

why the shortages occurred. Really? Yeah,

3:25

really no idea. The manufacturer will

3:27

say we've got manufacturing issues. Yes.

3:29

But it's quite hard to get

3:32

to the bottom of it. And

3:34

I thought what we might do

3:36

to illustrate the complexity of this

3:38

is use menoposs hormone treatment patches

3:40

as a case study so we

3:42

can just understand. the intricacy of

3:45

this. So let's start at the

3:47

front end. So at the front

3:49

end here, and this is often

3:51

the case by the way, with

3:53

IV fluids, with ADHD drugs as

3:56

well, is that demand changes. And

3:58

we've talked about hormone. replacement therapy

4:00

or MCT quite a bit recently

4:02

on the show. Prescription rates around

4:04

the world have probably doubled in

4:06

the last few years. So there's

4:08

an enormous number of new prescriptions

4:10

been written which weren't written before

4:12

for all sorts of reasons. Doctors

4:14

are a bit more relaxed about

4:16

prescribing and women are realizing that

4:19

they can have their menopause symptoms

4:21

or the pain and menopause symptoms

4:23

helped. As a result worldwide there's

4:25

more demand, perhaps doubling of demand

4:27

in a very short space of

4:29

time for MCT. And you've got

4:31

high demand in a manufacturing process

4:33

that is incredibly complicated and very

4:35

hard to just switch on and

4:37

off or dial up or down.

4:39

And it starts, believe it or

4:41

not, with soybean farmers in China.

4:43

Oh, I was not expecting that.

4:45

Eastern based patches or even double

4:47

patches. The patches are either go

4:49

Eastern alone or Eastern with pedestrian.

4:51

The Eastogen is Easter dial. So

4:53

it's a very effective form of

4:55

synthetic estrogen. And it comes from

4:57

plants, mostly from soybeans. It can

4:59

come from sweet potato. So it

5:01

starts with soybean farmers and most

5:03

of the supply comes from China.

5:05

They have a process which produces

5:07

cooking oil from soybeans. But there's

5:09

also another oil that's produced in

5:12

that process, which is rich in

5:14

plant-based estrogens. Okay, and that's what

5:16

you need for the patches. Well,

5:18

not yet. They then put that

5:20

through a chemical process, turn it

5:22

into a white powder, it then

5:24

goes overseas to manufacturers. who then

5:26

process that in reactors to Easterdile.

5:28

So you can have a farming

5:30

issue which affects soybeans. You could

5:32

have bad weather on soybean farms,

5:34

which means that their production goes

5:36

down. You could have pollution problems

5:38

on Chinese farms. You could have

5:40

problems with transportation. You can have

5:42

international trade wars. I mean, during

5:44

the first Trump administration, there were

5:46

major issues about soybeans, for example,

5:48

between the United States and China.

5:50

So there's so many ways. that

5:52

the chain can be impacted. And

5:54

all I see on the TGA

5:56

website when I look for information

5:58

before I prescribe the estrogen transdermal

6:00

patch is whether or not it's

6:02

there. And it just says supply

6:05

issue or manufacturing issue. But there's

6:07

nothing about soybeans. No. And the

6:09

point here is, analysts have said

6:11

this more than once, is that

6:13

the supply chain. for a medication

6:15

like an HRT patch is as

6:17

complicated as an iPhone. Point being,

6:19

you go to the pharmacy with

6:21

a script from Dr Alexander and

6:23

the pharmacist says, so I can't

6:25

fill it out. It could be

6:27

a problem on a farm in

6:29

China. Yeah, isn't that amazing? I

6:31

never realized it was that complex.

6:33

It does impact clinical practice significantly.

6:35

I think there are probably a

6:37

lot of people listening going, I

6:39

have had this happen, I've had

6:41

to change the dose of the

6:43

medication or the type of medication,

6:45

often what's best practice is really

6:47

hard to implement as the clinician

6:49

because it's just not available. And

6:51

for something like menopause symptoms or

6:53

peri menopause symptoms, people are often

6:55

struggling with hot flushes and impaired

6:57

sleep quality and mood. and you

7:00

think well I can't actually prescribe

7:02

the medication that you need. Now

7:04

the good news here is that

7:06

some other formulations have come onto

7:08

the PBS from the first of

7:10

March so hopefully that helps to

7:12

alleviate some of the pressure. But

7:14

I had never realized it was

7:16

that complex. No, and just to

7:18

finish off on this, it's not

7:20

just soybean farmers. With other drugs

7:22

or medications, it's also demand. So

7:24

for example, you go of a

7:26

natural disaster, which increases demand for

7:28

IV fluids. You can have a

7:30

tornado going through North Carolina damaging

7:32

a Pfizer factory, which is what

7:34

happened in 2003. You can have

7:36

floods affecting factories. So there are

7:38

multiple reasons why you end up

7:40

with a problem. at your local

7:42

pharmacy and then there's the business

7:44

side which is less true of

7:46

Australia than it is for the

7:48

United States where for some medications

7:50

despite the fact that America is

7:53

a very expensive place for medications.

7:55

They drive very low profit margins

7:57

on generics and some generics manufacturers

7:59

simply get out of the business.

8:01

Because that's the other problem with

8:03

hormone replacement patches is that one

8:05

manufacturer just got out of the

8:07

business with a drug called Klimara.

8:09

And so you had fewer drugs

8:11

on the market. Complicated stuff. Very

8:13

complicated. I'll just add that there

8:15

was an understanding the impact of

8:17

medicine shortages in Australia report that

8:19

came out late last year. A

8:21

big criticism was the lack of

8:23

communication with health care providers on

8:25

the ground. It would be lovely

8:27

to know what's potentially not in

8:29

supply, how we manage it, and

8:31

a bit of a guide as

8:33

to potential replacements. To avoid confusion.

8:35

Yeah, communication is not necessarily the

8:37

TGA's strongest suit, we might say.

8:39

But the PBS has also been

8:41

in the news this week or

8:43

two. It has from two angles

8:46

here. Firstly... The federal government's just

8:48

come out and said we're going

8:50

to slash the price of most

8:52

PBS medication so you won't be

8:54

paying $31.60. it will go down

8:56

to 25 which is going to

8:58

be a huge win for lots

9:00

of people. Just to be clear

9:02

it's not the price, it's what

9:04

you pay in terms of your

9:06

contribution to the subsidy, the price

9:08

is another matter which is another

9:10

key issue, the price is negotiated

9:12

with the manufacturer. And I guess

9:14

that's an important point that the

9:16

PBS is really there to subsidise

9:18

the cost of medication so that

9:20

you the patient pay less in

9:22

the government subsidises the cost for

9:24

you. But it's come under fire

9:26

from the United States which is

9:28

surprising to me that they would

9:30

be talking about the PBS but

9:32

apparently we're kind of the forefront

9:34

leaders here. Well it's not new

9:36

so when we were negotiating the

9:38

free trade agreement the pharmaceutical industry

9:41

in the United States had a

9:43

major goal at the PBS and

9:45

said this is a non-tariff trade

9:47

barrier even then and we're complaining

9:49

about it and they complain about

9:51

it for all sorts of reasons

9:53

but what they what really irks

9:55

them is that we negotiate very

9:57

low prices by international standards. and

9:59

this is the Pharmaceutical Benefits Advisory

10:01

Committee, largely responsible for this, is

10:03

that they go through new medications,

10:05

looks at their true value to

10:07

the community, to taxpayers and to

10:09

patients, and works out what a

10:11

fair cost would be. The manufacturer

10:13

comes back and says, well, you

10:15

know. get stuffed our international price

10:17

for this is why you're only

10:19

going to pay us X and

10:21

they have a commercial negotiation. They

10:23

haggle they haggle it. That's right

10:25

they haggle and they come to

10:27

an answer and as a result

10:29

we get very good prices discounts

10:31

on new medications into Australia. What

10:34

the what international pharmacy, American pharmacy,

10:36

well first of all that delays

10:38

our entry into the Australian market

10:40

and the price. And what you're

10:42

going to remember here is that

10:44

they have a good time of

10:46

it in the United States, where

10:48

parts of the health industry are

10:50

barred by law from negotiating pricing

10:52

with the pharmaceutical industry. So the

10:54

pharmaceutical industry, not entirely, but to

10:56

a significant extent can charge what

10:58

they like for the pharmaceuticals, which

11:00

is why America has the most

11:02

expensive drugs in the world, pretty

11:04

much. So they don't like the

11:06

haggling here. So the criticism is...

11:08

They've essentially said that the peaback

11:10

makes it really difficult for them

11:12

to introduce medications. They haggle about

11:14

pricing. And get the price that

11:16

they want. But I think the

11:18

real reason that's underneath this is

11:20

that we were amongst the first

11:22

to do this effectively and systematically,

11:24

and other countries in the world

11:27

have copied our system. So my

11:29

understanding is that if there's a

11:31

belief in the pharmaceutical industry in

11:33

the United States, is that if

11:35

they could knock us off... That

11:37

would be the start of knocking

11:39

off other subsidized systems and if

11:41

they could get that undermined here

11:43

and they had a good go

11:45

at it during the free trade

11:47

agreement discussions. They would love to

11:49

get rid of it because then

11:51

we'd be the chink in the

11:53

armour. Watch this space I guess

11:55

with fingers. ties is

11:57

that fair? fair? Yeah, but

11:59

the larger story with all

12:01

story with all

12:03

this and the

12:05

Trump trade trade

12:07

policies, such as they are,

12:09

are is that they are

12:12

trying to invagle themselves

12:14

into local social and economic

12:16

So they're talking about VAT value-added tax

12:18

GST, goods and services tax,

12:21

as non -tariff barriers, barriers. as if

12:23

you don't pay sales tax

12:25

when you go to New York

12:27

New York mean, I mean, there are you

12:30

go in the United States, the United

12:32

States. There are and somehow and somehow VAT

12:34

are different. are you know, there

12:36

are problems here of getting

12:38

involved in sovereign policies. sovereign And as

12:40

you say, as this space. space.