We need to make it harder to buy pills in bottles of 50 or 100 that can be easily dumped out and swallowed. We should not be selling big bottles of Tylenol and other drugs that are typically implicated in overdoses, like prescription painkillers and Valium-type drugs, called benzodiazepines. Pills should be packaged in blister packs of 16 or 25. Anyone who wanted 50 would have to buy numerous blister packages and sit down and push out the pills one by one. Turns out you really, really have to want to commit suicide to push out 50 pills. And most people are not that committed....
Why haven’t we seen more blister packages? One reason is money. Manufacturers would have to redesign packaging, and the blister packaging would cost more compared with loose pills in a bottle. The other main reason is that some consumers — notably people with arthritis — might find it challenging to open the packages.But if we could save one life... the life of the insufficiently committed... suicidal but too lazy to poke enough pills out of the blister packs...
You know the type. For them, life is not worth the trouble. And then suddenly killing yourself is also a lot of trouble. What's more trouble? Living or these damned blister packs?
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৮৩টি মন্তব্য:
Why not ban large piles of useless Regulations that are like rat droppings from Governance Agencies with no real purpose.
Libruls, including so-called Dr. Ezekial, are kinda dumb.
Darwin would not be pleased.
You would suppress far more suicides if we had a law that said; for every new regulation we have to delete a regulation. For the major regulatory agencies like EPA, IRS, and HHS, etc...make that write one, delete two for the next 50 years.
Leftist tyranny strikes again. I'm seriously beginning to think that armed targeted vigilantism against these fools is becoming the answer. They will not stop unless they are stopped. When they begin to extol the power of government over your ability to be free, do they really deserve constitutional protections anymore. one group or one person cannot and should not be able to create, maintain, and sustain this type of power of other that clearly do not want it. When do we say enough? When will the tipping point come. How long will we stay in the pot?
I truely believe that we could cut suicide in half, if we could get half of the population to wear straight-jackets.
The same type of people worried about suicides are the ones encouraging assisted suicide or euthanasia.
.
OTOH, what if those blister packs caused an arthritic person to commit suicide? Should we not ban bhlister packs it it saves just one life?
.
This world would clearly be better off without leftist thought or that it had never come into existence. It has been nothing but a collective of evil, misery, and death and it's been heaped upon us for to long. That and Islam. Something has to be done and I don't think people are going to take it much longer.
Put me in the category of consumers who HATE blister packs. I don’t have arthritis but it is more difficult to open a blister pack rather than just open a bottle and take what I need. Not to mention the waste from the extra and unnecessary packing material.
There is a simple way to make [fill in the blank] less accessible ...
This is really the aim of progressives...limit ordinary access to things. This way we can skip pipelines across the Canadian border that makes too much common economic sense. We can not bother to develop energy independence. We can control just about every aspect of citizen-serf life .... B. F. Skinner would be so proud of this regulatory technique.
The same people who are worried about suicides are the same people who brought us Obamacare's death panel.
It's easy to get bunch of pills out of blister packs quickly with simple tools, such as scissors. And, if you're not picky about cutting the pills (say you're going to take a bunch at once), a paper cutter is even faster.
I realize that NYT folks don't do much manual labor, but shouldn't they at least have some familiarity with common household items?
> Not to mention the waste from the extra and unnecessary packing material.
The left hand wants to ban products in wasteful packaging while the right hand wants to mandate wasteful packaging.
It's a cunning plan - they're going to drive down health care spending by banning healthcare products.
Methadras said...
Leftist tyranny strikes again. I'm seriously beginning to think that armed targeted vigilantism against these fools is becoming the answer.
Let me know if you get contact outside this blog about this wording. I said something similar no long ago here, and I did.
It isn't paranoia if there really is someone watching you. :-))
His brother is the Mayor of Chicago where they have lots of gun control and also a lot of murders but he thinks his idea is a good one. Liberals just aren't as smart as they think they are and they cause so many unintended adverse consequences. They never learn from their mistakes.
It's a stupid idea, but Tylenol is nasty, poisonous stuff -- I won't have it in the house. What's really terrible is how they add Tylenol to opiates (e.g. Hydrocodone) not to make them work better, but to try to prevent abuse (while killing a few unfortunates who don't know and take too many):
http://www.psychologytoday.com/blog/archevore/201103/tylenol-and-the-war-drugs
Before the government starts restricting bottle sizes, perhaps they could stop effectively forcing people to take Tylenol (and risk liver damage) just to get effective pain relief.
AllenS said...
I truely believe that we could cut suicide in half, if we could ...
...could stop people from fucking.
...could declare it public open gun season along borders for anyone crossing other than through official crossing points.
...could hang people who propose and implement blister packaging of any kind from lamp posts.
Pssst: Along the Detroit River it could become a regular sporting sport year round. Boaters beware.
"One reason is money. Manufacturers would have to pay more for blister packs."
Ah, money. So consumers pay fifty cents a pill instead of five cents. So, make 'em pay, and start a government program to provide OTC-drug assistance?
Of course, the result will be a proliferation of tools to get the pills out quicky and easily- perhaps you could just roll the blister pack in, turn the crank, and the pills would drop into a receptacle underneath.
Is step two to ban the machines (thus creating a black market in them)?
Perhaps that's what "progressives" mean when they talk about progress- not things that work better and cost less, but stuff that costs more and doesn't work as well?
BTW, suicide by Tylenol is not an easy way to check out.
It kills you by destroying your liver. But you can live without a working liver ... for a few days.
As if..... someone who is determined to end their life can't save up the pills and buy them over time until you have a suitable amount. Even depressed people can plan ahead.
Or find some other method that would then need a whole new slew of regulations that affect everyone who isn't planning to kill themselves.
I like AllenS' suggestion.
Walgreens is in favor, Costco opposes.
So where is the line between this and force feeding Guantanamo detainees? Is it a matter of scale, or are we just getting in the way of people wanting to "self-slaughter"?
"It's a stupid idea, but Tylenol is nasty, poisonous stuff -- I won't have it in the house."
I agree, I've taken lots of aspirin and later in life a lot of ibuprofen in my time but if you take too much tylenol, you can destroy your liver. Anyone who has had chronic pain knows that when you are hurting, you will keep taking pills to get relief and that's usually okay if you're taking ibuprofen or aspirin but not so with tylenol.
Aridog said...
Methadras said...
Leftist tyranny strikes again. I'm seriously beginning to think that armed targeted vigilantism against these fools is becoming the answer.
Let me know if you get contact outside this blog about this wording. I said something similar no long ago here, and I did.
It isn't paranoia if there really is someone watching you. :-))
Yeah, let's see what happens. Oh believe me, the threats I receive from leftists is without a doubt the most entertainment I get throughout the day.
Combine this with today's decision in Maryland v. King: in order to reduce suicides, DNA testing of all expectant mothers should be mandtory, at the time that the pregancy is diagnosed, so that anyone carrying a baby with a gene linked with suicidal tendencies can get an abortion (at gov't expense, of course). In China and other more advanced societies than ours, the abortion would be required, but only an anti-social expectant mom would resist in any case.
Aborting early will save the trouble (and larger gov't expense) of cleaning up after the sucessful suicide later on. No more detailed purpose sufficient to support the constitutionality of the provision would be necessary -- administratively it would simplicity itself to make it part of mandatory ObamaCare for pregnant patients -- and since the purpose of the DNA testing was not 'ordinary crime solving,' there would be no problem even under Scalia's view of the Fourth Amendment.
What could possibly go wrong?
De blistering machine do exist, mainly for industrial use
http://www.pharmaceutical-equipment.com/VB-Deblister.htm
It will open 40 blister packs per minute, all day long.
For someone in a real hurry, Gemel has a model that will open 80 blister packs per minute.
http://www.gemel.com/deblister.htm
John Henry
De blistering machine do exist, mainly for industrial use
http://www.pharmaceutical-equipment.com/VB-Deblister.htm
It will open 40 blister packs per minute, all day long.
For someone in a real hurry, Gemel has a model that will open 80 blister packs per minute.
http://www.gemel.com/deblister.htm
John Henry
I know! Let's pass a law against suicide!
We should not be selling big bottles of Tylenol and other drugs that are typically implicated in overdoses, like prescription painkillers and Valium-type drugs, called benzodiazepines
Yeah, because the opiates and benzos are just like acetaminophen.
Even apart from the ludicrous top-level argument of "saving us from our insufficiently suicidal selves", lumping those sets together is daft.
I hope nobody ever shows that person that bedsheets and extension cords can be used to hang yourself.
And then there are aspirin and ibuprofen that can cause stomach bleeding, or duodenal or intestinal bleeding. I got the duodenal.
Peter said...
Ah, money. So consumers pay fifty cents a pill instead of five cents. So, make 'em pay, and start a government program to provide OTC-drug assistance?
Actually, this has essentially been done for over-the-counter Omeprazole ...aka "Prilosec OTC" in 20 mg doses. Let me know if anyone finds it available in other than blister packs?
I was prescribed it for stomach ulcer issues some time ago and, yes, it is covered by prescription coverage in my health insurance package.
I have no idea if it works or helps. Sometimes I just do what I am told...rare, but it happens.
A good way to kill yourself is by overdosing on Tylenol or other pills.
Another way to cut down on suicides might be not having op-ed writers offer pro-tips on the subject. Just an idea.
And vlister packs have already driven up hospital costs.All of the hospitals around here have to use expensive blisterpacks for everything.Combination DEA tort liability and FDA.Congrats all lawyers.
I think Coca Cola should only be sold in blister packs.
He goes through that long article with all sorts of stats conflating all sorts of things together such as suicide, drug poisoning. overdoses and all poisoning.
He gives us percentage reductions in England after they went to blisterpackaging suicide deaths declined by 43%.
Does that mean it went from 10,000 to 6,000? Or 10 to 6? Same percentage decline in both cases. One might be worth changing laws for.
The other definitely note.
I spend a lot of time in plants that package Tylenol and similar products in both blister and bottle. Blister packing is a LOT more expensive. Lot more labor intensive, lot more complex machinery.
He also mentions "paracetamol" as Tylenol's active ingredient. Has anyone else ever heard of this? 35 years working in pharmaceutical industry and I had to look it up. Synonym for "acetaminophen"
Why not use the regular name that everyone knows?
And why pick on Tylenol? There are a couple dozen companies that make equivalent products such as Panadol. What has McNeill done to annoy good ol' Zeke?
Perhaps he is getting money from Uhlmann, Klockner, Bosch, CAM or other blister machine manufacturers. I know marketing people at all of them and as long as I've known them they have been bitching about how Americans do not, generally, like tablets in blisters. (Unlike Europeans who prefer blisters).
Perhaps he is shilling for one of them? We should follow the money.
John Henry
Richard Dolan re: Maryland v King .... Whoa! How often do Scalia, Ginsburg, Sotomayor, and Kagan join in dissent?
If we are going to make decisions based on saving even one life, shouldn't all bridges be rebuilt at water level?
Jeff Teal said...
And blister packs have already driven up hospital costs. All of the hospitals around here have to use expensive blister-packs ...
Ah, that explains the hospital delivered $5.00 aspirin.
Exactly Aridog.My GM had to do a stint in rehab several years back and my father and I went in to talk to the president.Guy was in my organizational theory class 20+years ago.Not the brightest guy but we got talking about the cost of government regs and cookie cutter treatments due to lawyering.Be surprised how many procedures have been "tested"by legal.
For Aridog.
The same type of people worried about suicides are the ones encouraging assisted suicide or euthanasia.
Funny isn't that?
He also mentions "paracetamol" as Tylenol's active ingredient. Has anyone else ever heard of this?
It's the snob card. That's the British (European) name. Sniff.
He is a d.o.c.t.o.r. and knows more than the hoi polloi.
And he has to let us know.
We should not be selling big bottles of Tylenol and other drugs that are typically implicated in overdoses, like prescription painkillers and Valium-type drugs, called benzodiazepines.
Exactly, because people who are in enough pain to need prescription painkillers need to be required to go get refills at the pharmacy every few days.
If you really want to reduce suicides, maybe quit doing things like this.
I'm against doing anything to impair a mentally sound adult who wishes to commit suicide. Why is this "choice" something we must all oppose and restrict while others are no one's business? It's their life, Let them do what they want with it.
Our local WalMart is now delivering two of my 96 year old mother's meds in blister packs. If she were living at home her blood pressure would stroke her just trying to get them out of the blue plastic "holders" not to mention popping them out.
They are helpfully marked out by day (Sun Mon Tue) which is fabulous, just fabulous if you can read it. Except then you have to remember to start punching out in the middle of the week if you start on a Wednesday.
I ignore it all and punch them out a week a time and pop them in her compartmented pill box.
Remember Reagan? "The nine most terrifying words in the English language are, 'I'm from the government and I'm here to help."
Please. Stop helping us.
I am looking for people to run for office who want to stop helping us.
"He also mentions "paracetamol" as Tylenol's active ingredient. Has anyone else ever heard of this? 35 years working in pharmaceutical industry and I had to look it up. Synonym for "acetaminophen"
Why not use the regular name that everyone knows?"
That's apparently what the UK pharmacists (or are they properly called "chemists" over there?) call it. That confused me quite a while ago until I was clued in to the fact. I'm just glad that the internet is good for at least one thing - looking up pharmaceuticals names - because it'd stink to have the use the IUPAC nomenclature ("N-(4-hydroxyphenyl)ethanamide").
---
As a side note, I'd criticize Emanuel's employment of the risk statistic regarding blister packing and Tylenol/acetaminophen/paracetamol toxicity cases (the ones he mentions separate from the suicide statistics). A correlation between the reduction and introduction of blister-packing is simply not causation, and I'd want other factors accounted for. For example: Ibuprofen was approved for generic use in "oral suspension" (re: in liquids) in 1998, which meant that it could take acetaminophen's place in those liquid cold meds. Did the increasing availability of liquid suspension ibuprofen have any effect on acetaminophen use? Maybe it didn't and the blister packs are indeed the cause, but my point is that the causation is not established, and we're forced to either trust the word of the author or verify independently.
Plus the name "blister" has too many painful associations for my sensibilities. Which are very, very fine.
Abdul Abulbul Amir, 11:41:
"OTOH, what if those blister packs caused an arthritic person to commit suicide?
That's exactly what I was thinking: Adopt this idea, save a few people who were ready to swallow a massive number of pills but not if they had to work at it, and I would bet a lot that more people die from unintended consequences.
I was thinking about people in pain who aren't as clear-minded behind the wheel because they were in a rush and didn't pause to snip some analgesics free, but Death is an imaginative bastard, more than I am anyway.
John, re "paracetamol": Heard it when I spent some time around the French. I thought maybe it's the more European nickname for para-acetyaminophenol.
Rabel said...
For Aridog.
Thanks, but no cigar :-) Every one of those boxes are chock full of individually blister packed pills in neat little rows. Maddening to punch out one at a time.
I finally have an Rx for the same thing, in capsule form, loose in bottles of 180 each for 90 day supply.
PS...I am glad you returned to your crazy lady avatar...I read your very concise and thoughtful comments regularly, and looking for them is easier with the scowling lady image.
Are there that many people trying to commit suicide by overdosing on decongestants that decongestants need to be blister-packed? The stuff I take isn't the kind used to make meth - so why does this annoyance persist? Especially when there are other, more lethal drugs to overdose on, available OTC.
Put me in the column of people who oppose blister packs.
Aridog,
Is Prilosec the same as Tagamet? I have GERD which I control mainly by diet but I learned long ago to always have some OTC Tagamet with me.
I buy it in blisters because as infrequently as I use it I find it more convenient. I have bought it in bottles in Walgreens, though.
Someone mentioned blisters in hospitals. There is a reason for that. Blisters make it much easier to dispense and monitor the patient's medicine.
There are some significant advantages to tablets in blisters. There are some significant advantages to tablets in bottles.
And disadvantages to both.
Let the consumer decide what works best for them.
My local Walgreen carries about 90 varieties of Tylenol (plus other competing brands). Daytime, nighttime, caplet, tablet, softgel. 30 count, 50 count 100 count. Blisters in various counts and so on.
I say good on them. Let us decide what we want.
And, since I make my living helping manufacturers do faster changeovers between 30 and 50 count, caplets etc, it puts food on my table.
Please Mr Emmanuel, don't kick over my rice bowl.
John Henry
Over the weekend, a friend of a friend took himself out. He came home after a night of drinking, got in an argument with his wife, walked into the bedroom and blew his head off. That'll teach her. His friends had to come over and clean up the substantial mess. That's not a cool way to be remembered.
Aridog,
Sorry to disagree but I buy the three pack of bottles of loose capsules regularly at Walmart.
And thanks for the kind words.
This isn't very pro-choice.
A few thoughts on medical packaging.
If I was going to kill myself, I'd make good use of it, and go out a hero. Find a murdering mafia guy or drug cartel leader, and take him out. Just go full bore superhero vigilante until they finally get you. That would be epic.
bagoh,
Just be sure you have an appropriate superhero costume.
Here's one with a pleasing Christmas color theme.
Retraction, with an apology to Rabel...I didn't look far enough down...at the box of "Equate" which does contain bottles of loose pills. Thanks.
However, the Wal-Mart price is about $0.40 per capsule, retail, while the hospital pharmacy price is $0.24 per capsule, retail, of which I pay $0.06 per capsule after Rx insurance.
Never-the-less, you DID find loose capsules in a bottle packaging. 1/2 Cigar, okay? :)
The Green Lantern is really packing.
"OTOH, what if those blister packs caused an arthritic person to commit suicide?"
That's not a joke. I know people who can't get the blister packs open or the bottles either. They are old and they sit around in pain till someone comes and helps them and it depresses them to be helpless and in pain. Depressed, helpless, in pain - next stop, suicide. Why don't people know these things?
I agree with the crowd of commenters saying that these days people in the government just want to pass regulations so as to get a good performance review. So we should put "Repealed unnecessary regulation" into civil service performance reviews as expected level of performance and no can get into the Executive Service who hasn't repealed regulations and demonstrated benefit to taxpayers - not to lobbyists.
Ha! I've been telling you this is already the way it is in England. You have to be 18 to buy pain relievers, they are sold only in blister packs and only pacs of 16 (maybe 24 for some), and you can't buy multiple packs.
Apparently, a few people still eek out a suicide each year and there is discussion about limiting access even further.
It doesn't stop. You get rid of guns, you limit knives, and then you have to keep going.
When I first started taking medication for high blood pressure, I got it from Walmart and it came in blister packs with the days of the week marked on each blister and a complicated plastic frame to manipulate. After a few refills, I asked if could get it just in a regular pharmacy container. The pharmacist, smiled and said 'OK'. I only had to ask.
I get it by mail order now, in 90-day bottles.
Wildswan said ...
So we should put "Repealed unnecessary regulation" into civil service performance reviews as expected level of performance and no can get into the Executive Service who hasn't repealed regulations and demonstrated benefit to taxpayers - not to lobbyists.
Unfortunately, if you save money or decrease regulation of the populace as a bureaucrat, you will never be promoted. You may be fired or demoted.
And frankly, there is absolutely no need for an "executive service"...go back to civil service grades GS-16 thru 18 and be done with it. Full civil service rules, then they are at least partially insulated from political pressure...as "appointees" are not.
If you decreased the executive service by 50% tomorrow, as well as military flag ranks by 50%, NO ONE purportedly served by them would notice. Check it out - just the military where our Navy is close to having more Admirals than ships. The SES and above ranks are worse...and growing.
We should only have bottles of aspirin that have 3 aspirin in them. It has to be a low enough dose where you can't kill yourself by eating the whole bottle.
If we don't save the people from themselves they will DIE!
AllenS wrote:
I truely believe that we could cut suicide in half, if we could get half of the population to wear straight-jackets.
If you believe population bomb type thinking then cutting the suicide rate in half would be a bad thing. And I'm ok with people suiciding, so long as they are espousing Population Bomb type rhetoric. They know the problem and yet REFUSE to do the only responsible thing that will help society - namely, off themselves.
It's immoral to say we need to reduce populations and then expect others to die even if they don't believe the "science".
They should go first.
Apparently, we're talking about 500 deaths a year in the US from Tylenol poisoning. The left really is incapable of a cost/benefit analysis and just rejects the idea of scarce resources as a concept -- there's no problem so small that we can't spend billons to solve it.
I think all blister packing and vacuum packing should be illegal.
It should only be used to secure young Islamists when they are passengers flying on commercial flights.
@ ken in sc re getting rid of those unwieldy plastic blister pack containers: While I was writing I thought, "I need to ask the pharmacist." Thanks for the nudge.
(As it is we get G'ma 90 days at a time.)
Maybe rope should be sold in blister packs, in lengths no longer than 2 feet.
Ann, you might want to consider how these idiotic proposals will help save the lives of attorneys. According to article cited by Drudge lawyers are six times more likely to commit suicide than the general populations - a good start? - and there's been a rash of attorneys committing suicide in Kentucky. (Of course, living in Kentucky is a real downer.)
If I was going to kill myself, I'd make good use of it, and go out a hero. Find a murdering mafia guy or drug cartel leader, and take him out. Just go full bore superhero vigilante until they finally get you. That would be epic.
Bagoh, have you seen the movie Short Time?
It's not a classic, but a great performance by Dabney Coleman elevates what would have been a mediocre film into something greater.
Thorley Winston,
Put me in the category of consumers who HATE blister packs. I don’t have arthritis but it is more difficult to open a blister pack rather than just open a bottle and take what I need. Not to mention the waste from the extra and unnecessary packing material.
Me too, Thorley. I'm a classical string player, whose fingernails are pared way, way back. I take an OTC antihistamine that typically comes packaged in those annoying puppies. All I want to do is get some sleep, and I'm reduced to poking holes in the damn things with a ballpoint pen and then (if that doesn't work) attacking them with scissors.
The solution with opioids and benzodiazapenes isn't blister-packing them, for heaven's sake; it's not prescribing them in large quantities in the first place, except (with opioids) for people who are in extreme pain, and then requiring reevaluation to renew the prescription. Why you wouldn't do that anyway -- unless it's that just take the "blue pill," it's so much cheaper -- I don't know.
Tylenol is another mess altogether. I'd wager that most "suicides" on Tylenol are actually just people who have ripped their livers to shreds with alcohol and/or other drugs and don't realize what acetominophen can do to a compromised liver.
John,
He also mentions "paracetamol" as Tylenol's active ingredient. Has anyone else ever heard of this? 35 years working in pharmaceutical industry and I had to look it up. Synonym for "acetominophen."
Why not use the regular name that everyone knows?
Well, not "everyone," or he wouldn't keep calling it "Tylenol." "Tylenol" is the trademark, not the drug. It's still available although the patent's long expired. Then again, there have been some scary reports about the quality of foreign-manufactured generics (Megan McArdle had one a week or two ago) that suggest that it might not be completely paranoid to want branded OTC medications.
I had to pick up a fluoxetine prescription once, and I'd swear that for a second or two the pharmacist didn't know what I was talking about.
It's not that Dr. EE actually wants to prevent suicides.
He just wants the government to decide (via his death panels) when and how you are allowed to die and how much money he won't allocate towards your care while you are living your pathetic life.
I think doctors who write columns should be put in straight-jackets. After all, if it would save just one life...
Conveniently ole Zeke doesn't incorporate the cost arising from the pain and suffering of people who wouldn't get such medications because of the price increase.
How about if you kill yourself with a razorblade. Surely, razor blades should be dulled to the point where you can't draw blood if you should try to cut your skin with them.
And they should only come 1 in a pack.
"and there's been a rash of attorneys committing suicide in Kentucky."
I can remember when Jim Dinwiddie played basketball for Kentucky.
Some pills should come in a blister pack but pre-crushed, and you puncture the blister pack with a little snorting straw.
Leave it up to Kentucky to pioneer new ways of drug abuse technology.
"Ah, that explains the hospital delivered $5.00 aspirin. "
That, plus hiring someone to hand-deliver the aspirin to you two tablets at a time, and keep a complete written record of the same.
When I was in the Air Force, we were on our 24 hour break between shifts so a lot of us spent the day drinking before going on three days of the midnight shift which started that night at midnight. At about 1:30 or 2:00 AM one of the guys who had been drinking with us earlier in the day shot and killed himself while on guard duty so I was assigned to replace him on guard duty where I could see some of his watery looking brains on the floor of the guard shack. I always thought he was one of the cool smart guys so I was really surprised. He was twenty years old and that happened in 1964 almost fifty years ago, such a waste of what could have been a good life.
"Aridog said...This is really the aim of progressives...limit ordinary access to things..."
No - it's about ways to increase safety not limit access. This article referred to a study done in Europe where this sort of packaging is, I believe, required. However, many drugs which are controlled substances here can be purchased without a prescription in European pharmacies including higher dosage pain medications, e.g., standard medications (Aspirin, Ibuprofen, etc.), Vicodin, etc.
Access is not "limited" by the packaging. Access is less restricted by removing the physician from the equation. And, by the way, all those countries have greater access to health care and spend less.
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