[hinkley]

I'll never forget a coworker telling me that in a previous job hunting round he had interviewed with a pharmaceutical group that was tracking the manufacturing process for batches of drugs and comparing the little tolerance mistakes (heated a little too high or held at temp a little too long or not quite long enough) and finding a market where they can sell that batch.

You'd like to think that companies have factories with quality control laws and there are local people trying to ensure that all of their product are up to the local standards. What you don't expect is that they are binning them like Intel CPUs, where they just make a batch and hope for the best, take cream off the top until the priority orders are done and then everyone else gets whatever is left. You might get a slightly better product sometimes but not be so lucky the next time.

[energy123]

The same thing happens in food processing. The low quality stuff gets sold under a different, cheaper brand, or reprocessed into another product.

I'm not going to cast stones at this practice because as always the alternative isn't some magical world where all produce is perfect, the real alternative is that it gets thrown in the trash and wasted, and everyone is worse off despite feeling better about themselves.

[close04]

> the real alternative is that it gets thrown in the trash and wasted, and everyone is worse off despite feeling better about themselves

Depending on what's the minimum quality you consider acceptable for the product, you might want to throw away something and have good reasons to feel good about yourself doing it. There is a point where something dips below good ("less effective medication") and even neutral ("it's an empty pill"), into actively harmful ("it will kill you faster"). Discarding it instead of monetizing it is the positive outcome.

[SeriousM]

Happy to live in a country with very strong food control. Yes we have the alternative labels yet it must be at least as good as the original.

[yorwba]

They only need to be as good as the minimum standard for the category they're sold in. If you have a "good" bin and a "bad" bin, and the good bin easily exceeds the minimum requirements while the bad bin just barely meets them, that's fine, too. Or the good bin can be sold as class I, while the bad bin needs to be labeled as class II. Of course those categories usually aren't about safety-relevant aspects of quality, but things like weight or shape or appearance.

[energy123]

I want more good regulations, and less bad regulations, so I am not necessarily against anything you said here.

[hinkley]

If the product is ineffective you’re stealing from people. And in the case of pharma, probably ruining their lives in the process, since we rarely do more than two care plans at once and if one is busted then they should be doing something else instead.

[nosianu]

> the real alternative is that it gets thrown in the trash and wasted

My view is a bit different nowadays, but this is very much an extreme bird's eye view from very high up, looking at only the smaller processes I have no disagreement. So, my point is more like an alternative co-existing higher level view, not a replacement of what you and others say. You will still be right to want to optimize your processes of course.

I view it as different streams. Everything is a circle. There is a significant cost - energy (and time and space and effort). As long as we use ancient sun-energy dug out of the ground it's bad, but if we could power the circles with current sun energy it would not matter much.

You have one overall stream or flow, all materials, and output streams are various sizes of end products. The good stuff stream flows to the customers (and forms bigger circles), the mistakes are instead rerouted into the recycling stream.

In chemical engineering and in manufacturing you have the same. Making food, whether completely natural, or including any kind of processing even if it's just separation and packaging, will have similar properties. Quality varies, and you have additional processing streams for various qualities.

Sure, one would want to optimize the streams, but if we did not have the fossil energy source limitation, and maybe also space, if you have to go back to the growing fields, it would not matter too much.

----

Imaginary picture:

Imagine in the far future somebody set up a fully automated closed system for making food, from growing to putting it in a huge cafeteria buffet, fully stocked all day. But there is no more people. As long as there is energy, food is created, processed, put on the buffet, and then recycled, since there is nobody to actually eat anything.

Is it a waste? Well, yes and no.

The whole of earth is like that!

As long as there is energy the cycles continue. What is "waste"? If you take the very big view, everything just "is".

But again, our actual limitation is the energy source for our food cycles. Using ancient stored sun energy releases the carbon stored underground, and it also slowly depletes those stores. The real problem first of all is where we get the energy for our cycles from, not really if parts of it don't make it to the end customers. Opportunity cost, what we could use the space and general effort for instead of on recycling cycles comes a distant second, I think.

[jorvi]

The alternate also happens though.

Over here in The Netherlands, the milk for all milk products comes out of the same cows and is processed in the same tanks. When you're paying 2x the price for brand name milk, you're getting seriously scammed.

[hinkley]

There are a couple cooperatives here that own their own processing facilities. As food businesses got bigger the distance between processing plants has grown and grown and it ends up netting the farmers less and less.

I learned recently that there was a small coop near where I live that got bought up by a larger one, Organic Valley. Which has a semi famous permaculturist as a member (Mark Shepard), and the only reason I knew it to be a coop. They don’t advertise that fact well.

[throwawayqqq11]

A quality increase does not mean "perfection" and so "magical" turns into "more expensive".

Id like to live in that world.

[monster_truck]

If you've taken a prescription over a long enough time you'll know this to be true even if you've never really considered it.

Some time ago I was very frustrated with the massive swings in how well a prescription was working so I started looking into it. Saved a pill from every month, sent 12 of them off for testing.

+/- 30% accuracy on that dosage, and that's within spec for the US. Some months your 20mg pills are 26mg. Others? 14mg. Later repeated this test with a family member's blood pressure medication, which has a dosage of just 0.5mg. Same deal, 0.35-0.65

[Hojojo]

There are labs where you can just send prescription pills for testing as an end user?

[nerdsniper]

For something like amphetamine, could get it tested at Energy Control lab in Spain. Valisure used to offer this kind of service for most pharmaceuticals in the USA but faced lawsuits and pushback: https://www.bloomberg.com/news/features/2023-12-05/pentagon-... [ https://archive.md/eyWSn ]

[sizzle]

Generic amp huh? Thought I was going crazy. Who does name brand? Shire sold to Teva?

[speff]

Is this system not preferable over just trashing anything not perfectly made? Sure it would be nice if everyone can have perfectly manufactured medicine, but that's not reality. I would think something that's still likely good is still better than nothing.

[selcuka]

How do we assess that it's "still likely good" and "still better than nothing"? If they are defective it also means that they might make things worse.

[ben_w]

Hopefully that's up to the laws of where the incorrectly processed stuff was allowed to be sold.

Hopefully those countries don't reduce standards due to lobbying.

[gmueckl]

A fair number of countries can't do the proper inspections required for this, either due to lack of resources or government corruption (or both). They could put a literal carbon copy of FDA standards into their regulations, but it's meaningless without enforcement.

[lotsofpulp]

>They could put a literal carbon copy of FDA standards into their regulations, but it's meaningless without enforcement.

This is funny because the USA itself doesn't do proper inspections.

https://en.wikipedia.org/wiki/Katherine_Eban

See the book "Bottle of Lies".

[Hikikomori]

I believe we have a long history of companies selling toxic or non working stuff to countries not able to test or make sure its safe themselves.

[reginald78]

See the HIV infected blood products scandal with Bayer. The infected blood was pawned off on the third world since they (correctly) figured they'd have much less success suing them.

[hinkley]

You can tell what a bunch of assholes Bayer is made up of by the fact they were even willing to entertain purchasing Monsanto. Which they ended up doing. The lawyers are clearly in charge there.

[hinkley]

Including the article we are all responding to.

[hinkley]

And this is victim blaming. It’s not the government that suffers it’s billions of people.

[colechristensen]

There's a difference between a few percent difference in efficacy which is understandably still marketed (the same kind of thing happens when you leave meds on the shelf a while) and meds that are no longer effective at all to a reasonable level or toxic.

[hinkley]

This is literally a post about bad drugs being sold to brown people because they can.

[Spooky23]

Why should a person in Somalia suffer and die from cancer while a person in Ohio, lives, soley on the basis of where they live?

[protocolture]

Why should they not get access to drugs because the drugs would fail some bogus test made up by an american senator?

[bilbo0s]

More accurate to say they should get access to drugs that contain the actual molecules they are advertised to have across markets.

You shouldn't be able to sell what is basically sugar water in Somalia and call it cyclophosphamide. That's fraud if I do it as a private citizen.

In fact it's even fraud for me if I buy actual cyclophosphamide, and cut it with a bio compatible totally non reactive filler compound. How are these people getting away with it without the president and senators being on the take? When they'd run you or I down in less than a month for effectively the same act?

To be clear, I don't believe you or I should be able to do this. But I know what happens to private citizens who try to do things of this nature. So there is no question that this is a crime. The only question is why is it not prosecuted for larger corporations.

[MichaelZuo]

How do you know they would advertise it as unmodified cyclophosphamide (identical to the US product) in Somalia?

[hinkley]

Do you remember what thread yours responding to?

Here I’ll remind you: nearly 20% of cancer drugs defective in four African nations.

That’s the context. What on earth are you talking about?

[protocolture]

Did you read tfa?

>roughly one in six — were found to have incorrect active ingredient levels

>But some drugs are also counterfeit, and that increases the risk of discrepancies between what's on the product label and the actual medicine within.

If I was desperate, and given a choice between either 1 of "Might have incorrect active ingredient levels" "Might be counterfeit" "Might have been stored improperly" or "No cancer drugs for you" I know which way I would be leaning.

"Defective" is doing a lot of work in this headline.

[Spooky23]

The point of the article was that counterfeit drugs are ineffective or killing people, bro.

[EnPissant]

Who is going to pay for the replacement drug?

[beeflet]

the person in somalia likely has a different cost/effectiveness preference vs the american, which is expressed through the lack of regulation.

[jenny91]

To elaborate on this, if the individual in Somalia didn't want to die from said cancer and preferred better regulation, they would readily move to Ohio.

[nhaehnle]

I sincerely hope both of you are just trying to make a joke. I don't think a web forum like this one is the right place for it, though.

[itsanaccount]

hope all you want i think understanding what this site reveals about the world view of investor/dev types is a kind of sociological? shock.

its like everyone learning during covid their neighbors would kill every service worker to avoid the inconvenience of making their own coffee. it leaves a mark.

see what happened to the poor n-gate.com fellow, burned him out

[LtWorf]

The person in somalia doesn't live in a country where the managers of the pharmaceutical company live and can be arrested.

[Kwpolska]

Can the managers of the pharmaceutical company really be arrested in the US? Arrests are for poor people.

[overfeed]

As Matt Levine would say: inefficacious cancer drugs sold in the American market would be egregious securities fraud[1] if the shareholders are not informed by company offices ahead of time. The resulting shareholder lawsuit may cost some managers their jobs. There is also the (minute) risk of getting Luigi'd by someone a state over, whose loved one they suspected to have gotten a bad batch and didn't get better.

1. "Everything is securities fraud" is a running series showing the breadth and depth of how shareholders exercise their rights in creative ways.

[supertrope]

Larry Summers is that you?

[monero-xmr]

Why shouldn't every single person on earth immediately be granted citizenship to America and allowed access to all forms of welfare given to citizens? It's unfair to them

[ben_w]

Speaking as a non-American, the dysfunction of US healthcare was one of the reasons I decided against the USA when considering an international move.

Not the primary reason, but it was part of it.

[monero-xmr]

America is weird in that the poorest get significantly more benefits than the merely lower-middle class. And the majority of Americans pay no federal tax after EITC and other refunds.

You can get SNAP (free food), Section 8 (free housing), Medicaid (healthcare, CHIP for kids is easier than adults, but still many people get it), and if you manage to raise smart kids despite poverty they will get college for free as well (most highly-selective universities are free for the poor, but extremely expensive for even the middle class).

I own a lot of rental property and I have a Section 8 tenant who has never worked, completely gamed the system with a subjective disability that renders her unable to ever hold a job (supposedly). A good tenant but is constantly trying to give away tons of food she buys because she always tries to spend the SNAP she gets every month. And she gets free heat, and electricity, and public transportation pass, and on and on.

[xandrius]

What a weird take: I'd definitely expect the poorest/sickest to get the most additional benefits of all, the middle to get none and the top to get charged extra to cover up.

If you're middle class, that should be the average and that means you only get things which are the foundation of the system covered by the taxes.

[Aeglaecia]

through my eyes i see a similar implication to disproprortionate judicial punishment - aspects of a hegemonic system designed to suppress individual voices. for example, pirates in the UK being handed jail terms of greater duration than those given to individuals having killed other humans - people daring to go against the powerful have their lives taken away from them, whereas infighting within the working class is almost encouraged by miniscule sentencing.

or in this case, why bother putting any effort into life when doing nothing provides a greater reward? why attempt to make something of oneself at the risk of losing everything forever?

all in all, whether or not intentionally curated, these societal facets serve to foment an atmosphere of fear - individuals are forced to exist either in ignorance, or otherwise must live with the knowledge that minor infractions may end one's dreams, while concurrently one's dreams may be ended at any time for no reason but the whim of another.

such a dichotomy between ignorance and fear effectively suppresses societal change, which if it were to happen anyway, would be instantly detected by automated surveillance, and promptly quashed under fully legal pretences. but that's not even necessary. the populace is already addicted to living vicariously through screens (now from birth thanks to parents being forced to devote energy to work instead of their children).

yet the world keeps turning

[watwut]

The say you write about it, being poor in America is easy and great. And then you look at powerty in America and see hopeless desperate people with no access to justice,lite chances in life, little access to healthcare and raising homelessness on top of it.

And funny enough, the poor are just about to loose their healthcare and food stamps via big beautiful bill. Which is official name of that bill.

[Spooky23]

You're so programmed to knee-jerk about some political bullshit that you're not thinking.

These companies are making defective drugs and shipping them to people. The only thing preventing that from happening in the United States is the regulatory system, which we are in the process of smashing.

[SoftTalker]

They will both die. Cancer treatment is largely useless (this is an editorial statement) Survival statistics are largely dependent on early detection. Detect the cancer early, you live longer after treatment.

[andsoitis]

> Cancer treatment is largely useless

Cancer treatment effectiveness has improved substantially, with many treatments now achieving high cure rates or significantly extending survival.

Highly effective treatments:

Surgery remains the most curative treatment when cancer is localized and can be completely removed. Complete surgical resection often leads to cure for early-stage solid tumors.

Chemotherapy can be curative for several cancers, particularly blood cancers like leukemias and lymphomas. Some testicular cancers and certain pediatric cancers also respond extremely well to chemotherapy alone.

Radiation therapy achieves excellent local control and can be curative, especially when combined with surgery or chemotherapy. It’s particularly effective for head and neck cancers, early-stage lung cancers, and certain brain tumors.

Revolutionary newer treatments:

Immunotherapy has transformed outcomes for melanoma, lung cancer, kidney cancer, and others. Some patients with advanced disease achieve long-term remissions that were previously impossible.

Targeted therapies work exceptionally well when tumors have specific genetic mutations. Examples include imatinib for chronic myeloid leukemia (transforming a fatal disease into a manageable condition) and HER2-targeted drugs for breast cancer.

CAR-T cell therapy has achieved remarkable results in certain blood cancers that failed other treatments, with some patients achieving complete remissions.

Combination approaches:

Modern treatment often combines multiple modalities - surgery plus chemotherapy plus radiation, or immunotherapy plus targeted therapy. These combinations frequently outperform single treatments.

Current limitations:

Some cancers like glioblastoma and pancreatic cancer still have limited treatment options, though research continues. Metastatic disease remains challenging, though increasingly manageable as a chronic condition rather than immediately fatal.

[mrosett]

This is an oft-refuted trope that does harm to patients. Numerous randomized phase 3 studies show meaningful survival advantages for modern treatments.

[DangitBobby]

If the treatment were useless, early detection wouldn't help. Or are you saying, the extended lifespan is just the difference in time between "early" and "late" detection?

[SoftTalker]

Yes. I'm not saying all treatments are useless. Surgical removal of an isolated tumor or melanoma for example. But medical/chemo/radiation in all cases I've seen the person died anyway and spent many of their remaining days feeling awful from the side-effects.

[drawfloat]

"Cancer treatment is largely useless" is an objectively false statement.

[Neil44]

This anecdote is interesting, but the article cites poor storage and counterfeiting as the main causes of the issue.

[itsdrewmiller]

Thanks for this comment - I didn’t read the article and might have taken away a largely incorrect belief based on the parent. And you handled it so politely too!

[sigmoid10]

The comment you replied to also paints an incorrect picture. The real quote from the article regarding the origin of the poor quality is:

>[...] Those causes can include faults in the manufacturing process or product decay due to poor storage conditions. But some drugs are also counterfeit, and that increases the risk of discrepancies between what's on the product label and the actual medicine within.

So this is actually pretty in line with the top level comment, since no mention of the actual ratio among reasons is made. It certainly doesn't say that counterfeiting and after production storage are the main reasons.

[xdfgh1112]

Does that mean that generics really are worse than the brand pharmaceuticals. Or are they binned the same way?

In the UK I know the NHS buys generics, which implies they are effective, but I wonder.

[nick__m]

here in Canada the active ingredient must be identical in identical quantity but the binding agents, excipient, and propellant are proprietary. The generics have to have the same bioavailability +-20%.In some drugs it doesn't matter, in others there is a world of difference.

I pay the 2$ it cost for brand name ventolin (my insurance cover the cost generic and I pay the difference) as the generic give asthma attack. But I would not pay one cent more for the brand name Vyvaanse. Effect wise the generic is indistinguishable (but damm the pills colors make them looks like a cheap gray market knock-off).

My wife has a paper from her oncologist for original femara because the generic made her faint a few times ( the insurance cover the whole cost because of that paper)

[vladvasiliu]

As a layman who fortunately has never had to deal with any "serious" medicine, how would I know which drug is good-enough is generic form, and which should be the brand name? To someone not in the know, +/-20% bioavailability sounds like a lot. Hopefully, the doctor will account for that when prescribing it, and know which way the 20% goes.

You also make it sound like 2$ isn't much to go from the generic to brand-name Ventolin. How much is too much? And is there a difference between generics of the same drug (I assume multiple manufacturers can actually produce generics) and how do you know which is better?

[matthewdgreen]

It’s a huge amount. I have a seizure disorder and I have to carefully increase my dosage by as much as 50% to compensate for the difference between generics and brand-name. The 20% is an average: one of the big differences between the two is absorption before/after you’ve eaten, so taking the medicine on an even slightly full stomach dramatically reduces absorption. The brand-name manufacturer now charges $300/mo for an off-patent drug you can buy generic for less than $25 (without insurance) which illustrates their view of the perceived value.

[johnisgood]

> the doctor will account for that when prescribing it

Sadly they do not. I got prescribed 12.5 mg tianeptine to take three times a day, except that amount is minuscule for my brain & body. You would think they take into account that I have fast metabolism, have many brain lesions, and so forth, but no, they do not, and there are no legal frameworks either to do so. They would have to account for these lesions in my brain for many reasons, but they do not.

[nick__m]

  how do you know which is better?

Well you try the generic first, if it's does what it says on the tin, you continue the generic! Antibiotics, pain killer, antidepressants are usually not problematic.

  Hopefully, the doctor will account for that when prescribin...

I never saw a doctor or pharmacist do that. Probably because you cannot predict the difference in a specific individual.

  is there a difference between generics of the same drug ?

Sometimes the generic are better and yes there is a variation between manufacturers, when the pharmacy change my clonazepam supplier, I feel it. Sometimes I feel drugged out, sometime I am sleepless, but it take a few nights and then I feel the same. When that happen, I check the letter before clonazepam on bottle and systematically they changed, ex: apo-clonazepam to pms-clonazepam (the first three letters indicate the manufacturers, and I couldn't tell you which is better, just that there is a subtle difference when you switch) .

For stuff like that works on the hormonal system the difference between them is more pronounced. Like the femara, an aromatase inhibitors the block estrogen production, the brand name was significantly better for my wife but reading MBC survivors forums it's not the case for everyone. And reading those forums, it's a problem in place like the UK where the only things available is the brand NHS choosed for you.

  How much is too much ?

Now about how much is too much, well it's an hard question. It depends mostly on the alternative available, there are a lot of asthma drugs so switching from generic ventolin to something else like xopenex is easy so it limits the pricing power of the original manufacturer. Thing like anticancer with a specific mechanism where no direct alternative exists, the price is significantly higher, something like 300$ a month instead of 60-80$. But for my insurance it's relatively nothing compared to the Kisquali that cost 5700$/month. They have to reauthorized it every 6 months (it's a bureaucratic formality but they don't want to pay for it if the cancer has reappear because it's useless to continue the treatment)

Note that I have something my pharmacist call a gold-plated drugs insurance. If we were only covered by Québec's public regime, my wife would probably be dead by now as they still do not reimburse Kisquali, it's suppose to change soon but I am not that informed on that because of my gold-plated insurance. (which is fucking stupid because the alternative was weekly in hospital chemotherapy that cost a lot more than 5700 a month, but then people with that treatment doesn't usually live that long so cynically it probably cost less to the system that way even)

Edit:

  Why do I know that

A friend of my parents is a pharmacist and I used to ask him a lot's of questions when I was a child. Two of my female cousin (cousines in French) are pharmacists and I ask them questions on every new year day since at least the last 25 years. One practice in a drugstore, the other negotiate with the federal government for a big company that I won't name. Let's says they have a quite complementary vantage point. And I had quite the motivation to ramps up my knowledge of oncology to be the best advocate I can be for my wife.

[hinkley]

Unfortunately pharma has the US patent office in their pocket and they release most drugs in a default form and then when the patent is running out they make a slow release version and get a new patent on it. It doesn’t take them a dozen years to figure out how to make a slow release version, and another ten to come up with an extended release version.

I’m on an extended release generic only because it’s older than dirt.

[hinkley]

I’ve known people who claim up one side and down the other that Advil is more effective than generic ibuprofen and it’s thought to be down to the other ingredients. I had at one point convinced myself of this as well, but these days even Advil doesn’t always help. Bummer is that only a couple of CBD products do anything for me either. May be why I’m so grumpy.

[Retric]

Generally it’s different companies manufacturing generics.

Instead this mostly comes down to how effective each countries regulations are.

[hinkley]

This is also my understanding, but perhaps I am meant to understand that to be the case.

[Perenti]

In my experience as a medically complicated person, generics generally work, but may have different side effects, both in scale and style. One of the worst was a duloxetine generic that came on so hard and strong that I felt serontoninised.

My friend the John the Pharmacist explained that the binders etc can accelerate absorption. His advice was be careful the first two days of a new generic formulation.

I would assume the NHS (like the TGA here in Oz) looks _very_ carefully at the side-affect profile before they buy any particular generic. Government agencies tend to try not to poison voters.

[johnisgood]

I take dimethyl-fumarate, which is a serious medication for MS, but sadly ever since "Tecfidera" got withdrawn for some reason, I can only get a "shittier" generic. That said, side-effect profile appears to be the same, thankfully. All in all, I think they are "almost" identical, if not identical.

[hinkley]

I’ve had decent luck with slow release generics, but they go out of their way to make SR generics take a quarter of a human lifetime to come out after the original is available.

[johnisgood]

Generics are not supposed to be worse. They are supposed to have the exact same active ingredient. The binders or fillers may differ.

[lmpdev]

Generics lack the ownership of the intellectual property, but that’s about it

Generics are effective

[phil21]

I have sent in drug samples for testing, in my case they were name brand.

Variance per dose is about plus/minus 15% across the board. You might get 9mg one day, and 11.5mg another for a drug with a nominal 10mg label. Injectables are typically better than oral tablets it seems but not by a lot.

Purity was pretty good though, it was mostly a dosing variance I saw.

[Spooky23]

There can be variances. I’ve measured it with my blood pressure a few times when the pharmacy swaps manufacturers.

[throwawaysleep]

Generics tends to be different companies altogether.