Kevin Sites in the Hot Zone - Chapter 15: Coming HomeIn this final chapter of "A World of Conflict," Kevin Sites returns home to the U.S., only to confirm what he suspected -- that in the year that he was gone little had changed.
Kevin Sites in the Hot Zone - Chapter 14: Israel-Hezbollah WarThe war between Israel and Hezbollah shook the landscape in the Middle East.
Kevin Sites in the Hot Zone - Chapter 13: Sri LankaKevin Sites covered Sri Lanka as violence erupted between the government and Tamil Tiger rebels, pushing a nation with so much to lose back to the brink of all-out war. In rebel-held territory Sites interviewed Tiger fighters about their tactics and reported on the many effects of war still seen in the region.
Kevin Sites in the Hot Zone - Chapter 12: Nepal and KashmirKevin Sites covered Nepal during a time of sweeping political change that followed mass nationwide protests, forcing the autocratic King to cede power.
Kevin Sites in the Hot Zone - Chapter 11: Child BrideIn Afghanistan, Kevin Sites met a 12-year-old girl named Gulsoma, whose incredible story of resilience resonated with millions of people worldwide. She was only six years old when she was sold to a neighbor family in Kandahar as a child bride.
Kevin Sites in the Hot Zone - Chapter 10: AfghanistanReporting from Afghanistan in spring 2006, more than four years after the U.S.-led coalition ousted the Taliban, Kevin Sites found that war is not over in the country.
Kevin Sites in the Hot Zone - Chapter Nine: ChechnyaIn Chechnya during the winter of 2005-2006, Kevin Sites reported on a region still reeling from lingering conflict between Russia and Islamic separatists. The conflict engulfed Chechnya in the 1990s, and even now, half of the population is yet to return. Those that have eke out a living amid the rubble.
Kevin Sites in the Hot Zone - Chapter Eight: Iran
Kevin Sites in the Hot Zone - Chapter Seven: IsraelIn Israel, Kevin Sites interviewed Kinneret Boosany, a victim of a suicide bombing at a Tel Aviv cafe in 2002.
Despite the best efforts of the security community, the details of a critical internet vulnerability discovered by Dan Kaminsky about six months ago have leaked. Hackers are racing to produce exploit code, and network operators who haven't already patched the hole are scrambling to catch up. The whole mess is a good illustration of the problems with researching and disclosing flaws like this.
The details of the vulnerability aren't important, but basically it's a form of DNS cache poisoning. The DNS system is what translates domain names people understand, like www.schneier.com, to IP addresses computers understand: 204.11.246.1. There is a whole family of vulnerabilities where the DNS system on your computer is fooled into thinking that the IP address for www.badsite.com is really the IP address for www.goodsite.com -- there's no way for you to tell the difference -- and that allows the criminals at www.badsite.com to trick you into doing all sorts of things, like giving up your bank account details. Kaminsky discovered a particularly nasty variant of this cache-poisoning attack.
Here's the way the timeline was supposed to work: Kaminsky discovered the vulnerability about six months ago, and quietly worked with vendors to patch it. (There's a fairly straightforward fix, although the implementation nuances are complicated.) Of course, this meant describing the vulnerability to them; why would companies like Microsoft and Cisco believe him otherwise? On July 8, he held a press conference to announce the vulnerability -- but not the details -- and reveal that a patch was available from a long list of vendors. We would all have a month to patch, and Kaminsky would release details of the vulnerability at the BlackHat conference early next month.
Of course, the details leaked. How isn't important; it could have leaked a zillion different ways. Too many people knew about it for it to remain secret. Others who knew the general idea were too smart not to speculate on the details. I'm kind of amazed the details remained secret for this long; undoubtedly it had leaked into the underground community before the public leak two days ago. So now everyone who back-burnered the problem is rushing to patch, while the hacker community is racing to produce working exploits.
What's the moral here? It's easy to condemn Kaminsky: If he had shut up about the problem, we wouldn't be in this mess. But that's just wrong. Kaminsky found the vulnerability by accident. There's no reason to believe he was the first one to find it, and it's ridiculous to believe he would be the last. Don't shoot the messenger. The problem is with the DNS protocol; it's insecure.
The real lesson is that the patch treadmill doesn't work, and it hasn't for years. This cycle of finding security holes and rushing to patch them before the bad guys exploit those vulnerabilities is expensive, inefficient and incomplete. We need to design security into our systems right from the beginning. We need assurance. We need security engineers involved in system design. This process won't prevent every vulnerability, but it's much more secure -- and cheaper -- than the patch treadmill we're all on now.
What a security engineer brings to the problem is a particular mindset. He thinks about systems from a security perspective. It's not that he discovers all possible attacks before the bad guys do; it's more that he anticipates potential types of attacks, and defends against them even if he doesn't know their details. I see this all the time in good cryptographic designs. It's over-engineering based on intuition, but if the security engineer has good intuition, it generally works.
Kaminsky's vulnerability is a perfect example of this. Years ago, cryptographer Daniel J. Bernstein looked at DNS security and decided that Source Port Randomization was a smart design choice. That's exactly the work-around being rolled out now following Kaminsky's discovery. Bernstein didn't discover Kaminsky's attack; instead, he saw a general class of attacks and realized that this enhancement could protect against them. Consequently, the DNS program he wrote in 2000, djbdns, doesn't need to be patched; it's already immune to Kaminsky's attack.
That's what a good design looks like. It's not just secure against known attacks; it's also secure against unknown attacks. We need more of this, not just on the internet but in voting machines, ID cards, transportation payment cards ... everywhere. Stop assuming that systems are secure unless demonstrated insecure; start assuming that systems are insecure unless designed securely.
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Bruce Schneier is chief security technology officer of BT, and author of Beyond Fear: Thinking Sensibly About Security in an Uncertain World.
It's 10 am on a Thursday, and the line at Ritual Coffee Roasters in San Francisco snakes out the door. Inside, an espresso machine hisses like an angry tomcat as customers order their cappuccinos. But the real action is taking place a few steps away, where a scruffy barista stands at a stainless steel contraption, introducing the coffee he's about to serve to his rapt audience. "The Honduran is sweet," he says, "with a refined acidity and an excellent finish." He lets one perfectly measured scoop of fresh grounds shimmy deep into the machine, then goes to work, twiddling knobs, pushing buttons, and whirling a whisk in a chamber at the top of the silver box.
Forty-five seconds later, he sets down a single cup of custom-made coffee that's Jessica Alba hot, Bill Gates rich, and as unique as a snowflake. No foam. No caramel. No whip. Just beans and water — pushed through a cool little machine called the Clover — for a pricey $4 a pop.
The Clover coffeemaker debuted in a handful of cafés in 2006 and was promptly hailed as the best thing to happen to coffee lovers since the car cup holder. With an $11,000 asking price, the Clover has become a fetish object among the coffee-obsessed. Long queues signal its arrival in new cities, and self-described "Cloveristas" post videos on YouTube demonstrating the machine's flashy brewing process. There are more photos on Flickr paying homage to this shiny gadget (700 and counting) than actual Clovers in existence (roughly 250 worldwide).
Writer Mathew Honan tries out the Clover machine at Ritual Coffee Roasters in San Francisco.
The Clover also wowed Howard Schultz, founder and CEO of Starbucks. Last year, Schultz stumbled upon the machine in New York City when he had spotted a line of people standing outside a tiny joint called Café Grumpy. He tried a sample and declared it "the best cup of brewed coffee I have ever tasted." In March 2008, Starbucks announced the acquisition of the Coffee Equipment Company — the Seattle-based startup that manufactures Clovers in a converted trolley shed. His hope is that the Clover will bolster Starbucks' bottom line.
Chalk up some of the excitement — and the equipment's hefty price tag — to artisanal tech. A robotic hybrid of a French press and a Dirt Devil, the Clover is the first coffeemaker that lets the user program three key variables: dose, water temperature, and brew time. (Example: 37.5 grams of Brazilian Fazenda São João at 204 degrees for 43 seconds.) After the coffee steeps, a piston mechanism extracts the liquid from spent beans, resulting in a fresh cuppa in less than a minute. A filter platform pops a hockey puck of grounds out of the top, where it's easily wiped away. An Ethernet port connected to an online database is designed to let users save favorite recipes for specific beans. Made of stainless steel and copper, a single Clover typically takes several hours to assemble by hand. Fast, fancy, and idiot-proof? No surprise that Starbucks is all over the Clover — the company has been rolling them out since last summer. Half-caf nonfat toffee-nut latte lovers, get ready for a real cup of coffee.
I'm a coffee achiever, as that old ad campaign goes. I own two French presses, a stainless steel Cuisinart grinder/drip, a retro De'Longhi espresso machine, an Italian Vev Vigano moka pot, and a Vietnamese drip that I purchased in old Hanoi for making ca phe sua nong. My San Francisco neighborhood has five coffee shops within a five-block radius: four mom-and-pop operations and a Peet's. But compared with David Latourell, CEC's 42-year-old resident coffee expert, I'm a Sanka-slurping rube.
Latourell and I are standing in the middle of CEC's cupping room, a tasting area next to the company's small Seattle factory. The Clover is specifically designed to bring out the nuances of high-end coffees like Los Delirios, which comes from a Portland, Oregon, company called Stumptown Coffee Roasters. Los Delirios is a blend of Caturra, Typica, and Bourbon beans grown near Esteli, Nicaragua. Actually, it's on a micro lot located at 13° 22'45.99"N x 86° 28'50.45"W, between 1,050 and 1,450 meters above sea level, according to a manila "origin" card that comes with each bag of beans. Underneath the farm's GPS coordinates are flavor descriptions that read in part, "violets and black cherry, baking chocolate, and chocolate covered raisins."
Latourell hands me a cup of Los Delirios coffee made in the Clover. We both take slow, even sips. "I'm picking up a little chocolate," he says with a toss of his shoulder-length hair. I sip again, summoning every taste bud. I just taste — well, coffee. Delicious, sure, but coffee.
Like wine and, more recently, chocolate, a quality coffee bean must reflect a certain terroir — the climate, soil composition, and elevation of its place of origin. At least in theory, this gives a bean its unique and desirable flavor. Whether or not your average caffeine fiend can tell a Guatemalan Maragogype bean from a Honduran Catuai is debatable, but terroir explains how Stumptown can sell bags of beans for $40 a pound (about 10 times the price of commercial-grade coffee) and cafés can charge from $3 to $7 for a single cup of joe. "For $7, you can get a bad glass of wine," says CEC cofounder Randy Hulett. "Or you can get one of the best cups of coffee in the world."
Clover looks like just another countertop coffee machine. But peek under the hood and you'll find an innovative brewing system. Here's how it works: 1. A barista selects dose, water temperature, and steep time. 2. A piston pulls down the filter platform while freshly ground coffee is poured into the chamber. 3. Hot water flows into the chamber. 4. The barista briskly stirs the grounds with a whisk, and the water and beans steep for several seconds. 5.The piston rises, creating a vacuum that separates the brew from the grounds, then lowers, forcing the joe out of a nozzle below. 6. The piston rises to the surface again, pushing up a disc of grounds, which are squeegeed away.
Then there's the top-shelf stuff. Stumptown sells beans from Nicaragua called Las Golondrinas for $80 a pound. On the international market, Esmeralda Special, a rare kind of Panamanian bean, can go for $130 a pound wholesale. And consider Kopi Luwak, also known as catshit coffee: It's an Indonesian bean that's eaten by a civet cat, then "harvested" from the animal's dung. (The bean's bitter flavor is apparently greatly improved by passing through a cat's digestive tract.) A single cup of Kopi Luwak at the Peter Jones espresso bar in London goes for $100, and a pound of the beans can cost as much as $600.
If you're going to pay that much for beans, of course, you want to have the right machine. Back in the cupping room, Latourell fires up the Clover and goes to work on a second cup of Los Delirios: He measures out 46 grams of beans, grinds them, and then slides them into the recessed chamber on top. Next, he programs a new brew time and temperature, raising the heat from 205 degrees to 207 and increasing the brewing time from 45 seconds to 50. As the hot water rushes into the chamber from a topside nozzle, Latourell stirs the blend with a metal whisk, being careful not to break the stream, which would cool the water. "The temperature has a massive effect on the extraction of chemicals that affect flavor," he explains.
I take a swig. Bang, there it is: chocolate. Scharffen Berger, eat your heart out! A few tweaks and I have a new beverage. And it's not just the chocolate flavor; the mouthfeel and acidity are completely different from the first cup. All Latourell did was adjust the brew time and temperature and add 6 grams of beans. Taste-testing it against the earlier brew, I wouldn't have guessed they were the same bean. I'm starting to become a Clover convert.
Brewed coffee is awful.That's what Zander Nosler thought back in 2001, when he was developing a commercial coffeemaker for — of all places — Starbucks. The bespectacled, rail-thin product designer had previously spent 18 months at Ideo developing everything from sunglasses to medical supplies. As he tinkered with a revolutionary single-serve, push-button brewing machine targeted for the workplace, he realized that most makers were as stale as the coffee. "I got to see firsthand how coffee was better by the cup," Nosler says. "The coffee coming out of those glass office pots is wretched." (Starbucks later called the prototype the Interactive Cup.) When the project was finished, Nosler kept thinking about the single-brew concept. He soon decided he could do better, making a superior brewer that wasn't one-size-fits-all.
By 2004, Nosler had cooked up a business plan. He recruited other Stanford alums, including Hulett, 34. Within a year, the team raised half a million dollars from friends and family and set up shop inside an old trolley shed a few minutes north of downtown Seattle. The Coffee Equipment Company was born.
For months, the group reworked the design. They abandoned the office market in favor of cafés, ditched the grinder, and shrunk the countertop footprint. By spring 2005 they had the first Clover prototype. Code name: Chalupa. Made of particleboard, with its guts bolted crudely on the outside, it looked like Mr. Coffee designed by Dr. Frankenstein. But to roasters wanting a high-end single-serve option, it was gorgeous. CEC demo'd a final prototype that October at a local party and sold three units before they were even built. When Clover debuted at the Specialty Coffee Association of America event in 2006, Nosler was mobbed. "People saw us walking in and began chanting, 'Clo-ver, Clo-ver!'" he says, his eyes wide at the memory. To the little indie guys, Nosler was a god.
While interest in CEC was percolating, Starbucks was crashing. Its share price had dipped from nearly $40 in 2006 to around $19 in January 2008. The company that brought macchiato to the masses had lost its way — and a chunk of its profit margin. Was Starbucks in the market of selling coffee drinks or fancy milk shakes? Cappuccinos or compact discs? Was it competing with Peet's or Mickey D's? After just three years, CEO Jim Donald was on his way out, and Schultz, Starbucks' founder, retook the helm. On Valentine's Day 2007, Schultz wrote an internal memo (later leaked to the press) lamenting the state of the company. "I'm not sure people today even know we are roasting coffee," the missive read. "You certainly can't get the message from being in our stores ... At a minimum [we] should support the foundation of our coffee heritage."
Schultz announced that Starbucks would return to its roots. No more vacuum-sealed bags of beans or breakfast sandwiches (the smell of bacon and eggs overwhelmed the coffee aroma). Starbucks would once again grind beans in the store. It would introduce new blends and better espresso machines. But most important: It was going to road-test a little machine that Schultz had discovered a few months before on a walk through New York's Chelsea district. "In my 25 years at Starbucks, the Clover machine unquestionably delivers the best cup of brewed coffee I have ever tasted," Schultz later gushed to his stockholders. "And we want to share this experience with our customers."
Starting in summer 2007, Starbucks discreetly purchased and installed a few Clovers at stores in Seattle and Boston. It sold a cup of Clover-made coffee for as much as $3.05, about a dollar more than Starbucks' regular brew. The early reviews were glowing. As one Yelper put it, "If you're a coffee snob who normally scorns Sbucks and its burnt offerings, you might try the Clover pressed coffee at this location and be pleasantly surprised."
After roughly six months of successful trials, Schultz proposed buying Clover's maker, the Coffee Equipment Company. "We thought Starbucks wanted to take us out on a few dates," Nosler says of the deal. "But they wanted to go steady." Michelle Gass, a senior VP of global strategy for Starbucks, is slightly less romantic: "Frankly, we just don't want anyone else to have it."
Starbucks is willing to share custody, however, of the 250 machines already out there, plus maintain and repair them, but it won't sell any more Clovers to independent cafés. The company has already pulled the plug on CloverNet, the online database that tracks sales, maintenance, and brewing preferences for Clover owners.
Clover's early adopters are outraged to see their coffee machine become part of the Coffee Machine. "We made the decision to purchase the Clover to support this small independent manufacturer," says Stumptown owner Duane Sorenson, who bought the first Clover in the US. "When we found out that CEC was sold to Starbucks, we made the decision to sell our Clovers."
Nosler shrugs off the criticism: "Everyone has their favorite little band that they've watched change as it signs with bigger labels," he says. "But I can defend to anyone that selling to Starbucks was absolutely the right thing for us to do. Starbucks has a larger market than all the independent roasters and specialty shops combined. I'm a product designer first, a coffee guy second. I love coffee; I'm passionate about it, but I want to make products, plural. Having a gigantically hungry customer is appealing on a lot of levels. It was the best of all possible paths for us — and the coffee industry as well."
By the end of 2008, there will 80 machines installed in upscale urban markets across the country. Next year, Starbucks plans to remodel those stores with the Clover as their centerpiece. "Other than espresso, there's been no innovation in brewed coffee to speak of," Schultz says. "Now we're driving new traffic because of the Clover." Then there's that other counter where the Clover is destined to end up — the one in your kitchen. "The Clover is a commercial machine," he says, "but there's potential to create more consumer-based opportunities, specifically at home." Today, you buy a $10 bag of Starbucks French Roast to take home. Soon, you might buy a $40 bag and use your very own Clover to brew it.
Coffee snobs are skeptical. "Clover will differentiate them from the Dunkin' Donuts, the McDonald's," says Tony Konecny, an industry consultant who runs the coffee blog Tonx.org and was one of the first to see a Clover prototype. "But it comes down to the coffee." The machine is only as good as the beans you put in it. Which is a problem for Starbucks, a chain that purchases coffee in mass quantities and can't deliver fresh bags of beans as quickly as the indie cafés. Then there's quality control: "By the time the customer experiences it, the beans have been blended and have been sitting in a bag for six weeks. Anything special about the coffee is lost."
A few days after my cupping room challenge, I'm standing in line at a hilltop Starbucks in Seattle's Queen Anne neighborhood — one of Clover's beta sites. I do a taste test: a cup of Clover coffee versus brewed coffee. A young barista tells me they're out of the first two specialty coffees I request and suggests instead Starbucks' everyday blend, called Pike Place. During brewing, the barista stirs the grounds into the Clover with a clunky rubber spatula — not a metal whisk — and pours the concoction into a crummy paper cup. I smell, I sip, I inhale. I can't tell which cup of coffee is which — and neither is anything special. Is it the beans? My palate? After a few minutes, I finally pick it out: This coffee tastes a little bit like hype.
Mathew Honan (mhonan@gmail.com) offers tips on Twittering in our How To: Self Promote package.
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Trevor Foltz was six months old last fall, fresh off a visit to Disney World in Orlando, when the spasms first began.
Healthy until that point in his life, he began thrusting backward in his car seat, repeatedly and forcefully, as he rode with his parents north toward home in Rhode Island. "I thought it was temper tantrums," says his mother, Danielle. The next day, at home, Trevor was hit with a series of 40 convulsions and rushed to the hospital, where he was diagnosed with infantile spasms, a rare form of epilepsy. Treatment would cost $1,600 per vial of steroid drug H.P. Acthar Gel, and Trevor would need three of them.
As if the idea of a $4,800 tab wasn't bad enough, when the Foltzes submitted their claim, they found out the company that made the drug, Questcor Pharmaceuticals, had just recently jacked up the price—to $23,000 per vial, or $69,000 for a three-vial treatment—and the insurance company wasn't going to pay. And all the while, unbeknownst to anyone at that time, an alternative, for $15, existed.
On Thursday, the Joint Economic Committee will open hearings in Congress on dramatic price hikes for drugs used to treat children, with a focus on companies such as Questcor and Ovation Pharmaceuticals, which in 2006 bought rights to a drug that treats heart problems in premature infants, and increased the price 1,800 percent to $1,875 per three-vial treatment.
"We need answers to why a company would increase the price of a drug 18-fold when costs related to marketing, physician education, and research appear stable," says hearing chair Amy Klobuchar, a Democratic senator from Minnesota.
Politicians say they are not opposed to drug companies earning strong returns on the costs of researching innovative drugs, and understand the high prices of many medications. But they are investigating whether some companies are price-gouging, concerned more about executive stock options than about running innovative companies.
Some of those drugs, like Questcor's, are decades-old drugs that were bought on the cheap and redesignated under the federal government's Orphan Drug Act, which marks its 25th anniversary this year. Not infrequently, the drugs' new owners pass on big price hikes to consumers.
At Questcor, the increase is explained as the cost of doing business with an orphan drug.
"The company was heading toward bankruptcy," says Steve Cartt, executive vice president for business development at Questcor, which is based in Union City, California, an industrial enclave on San Francisco Bay.
"The whole rationale for the price increase was to ensure availability of the product," says Cartt. "We talked to physicians. They wanted the drug to be available. The choice was risk of availability or a price increase."
Originally approved for multiple sclerosis in 1952, Acthar Gel had been owned by pharma giant Aventis, which was losing money on it, when the 11-year-old Questcor acquired it in 2001. Questcor, too, failed to gain traction with M.S. patients, so it sought a new track.
Now the gears at Questcor began to turn more quickly. It won orphan designation for Acthar Gel in 2003, and proceeded to the next step: getting F.D.A. approval to market the drug explicitly for infantile spasms, which under the orphan act would also include a seven-year monopoly for Questcor. The company prepared for a marketing blitz and doubled its sales force early last year. But when the F.D.A. rejected Questcor's application in May 2007, the company quickly slashed its staff and jacked up the price.
Cartt says the price was set "within the range of other orphan drugs," noting that many others go from $50,000 to $500,000 a year or higher. For instance, BioMarin, an orphan-drug specialty company, charges $70,000 a year for Kuvan, a drug to treat phenylketonuria, a genetic enzyme disorder that can cause mental retardation and brain seizures. But unlike BioMarin, which spends 64 percent of sales on research and development, Questcor spends very little; in 2007, Questcor's research and development accounted for 9.5 percent of sales revenue.
What other considerations played into the price Cartt would not say. Sales for 2007, when the price hike took effect, were $49.7 million, and net income was $37.5 million—a net profit margin of 75 percent. It was significant not only for its size, but also because it was the first profit since the company was formed, as Cypros Pharmaceuticals, in 1990.
Investors were pleased, driving up Questcor's share price from 40 cents to over $6 after the August 2007 price hike. But executives at the company started selling their shares in December, seven months after the former C.E.O., James Fares, stepped down and around the time Questcor executive Don Bailey took his place. Since December, Cartt himself has sold shares based on grants and options totaling $1.68 million; many of those options were granted at 46 cents a share. He holds nearly a million more options on Questcor stock.
Doctors were unhappy with the price hikes.
"Most of us in the child-neurology community were outraged at the extent of the price hike, unusual even for orphan drugs," says Eric Kossoff, a pediatric neurologist and infantile spasms expert at Johns Hopkins Children's Center. "Most of us had no choice, unfortunately. At the time it was felt to be the best drug out there, and they're the only company that makes it. This is an incredibly serious form of epilepsy with devastating implications if not treated."
Curiously, though, he found that the price hike "was one of the best things that could have happened." Why? "Because we found something better and cheaper." Far cheaper, it turns out. "We spent a few days going through all the medical literature, looking for what works, what doesn't."
The team turned up a study from the United Kingdom that gave infants high doses of prednisolone, a well-known, generic steroid. Prednisolone had been dismissed as relatively ineffective for infantile spasms-based research that used low doses. The high doses made all the difference: The British study found efficacy rates reached 70 percent and more. Johns Hopkins began using high-dose prednisolone and found it worked in about 70 percent of cases, on par with the hospital's experience with Acthar Gel. And the price was $15 per injection—essentially free—compared with the three-injection $69,000 treatment from Questcor. "It was like in times of war. You get focused, and amazing things come out," Kossoff says. "We don't use [Acthar Gel] at Hopkins anymore for infantile spasms because the oral steroids [high-dose prednisolone] work just as well."
It's unclear, though, how many other doctors and hospitals in the U.S. will switch from the $69,000 drug to the $15 drug.
"I don't understand what's behind the price increase," says Finbar O'Callaghan, a pediatric neurologist at the Bristol Royal Hospital for Children and coauthor of the United Kingdom Infantile Spasms Study, or UKISS. The study showed that high-dose prednisolone and a synthetic form of ACTH, the active hormone in Acthar Gel, were equally effective. He cautioned that the purpose of the study was not to compare the two, but to compare steroid treatment with another drug called vigabatrin. "Having said that, you couldn't get a piece of paper between the results of the prednisolone and the results of the ACTH."
Costs aside, Hopkins is achieving the same results against Acthar Gel. "There is no reason to favor one over the other, unless there is a financial reason for doing so. That's been a big issue in the U.S.," says O'Callaghan. Comparing $15 against $69,000 "puts a different perspective on it," he says.
"Historically, and unfortunately," he adds, "doctors in general are very traditional and tend to use what's worked before."
Asked about the $15 price on prednisolone, Cartt said studies from the 1990s show low efficacy rates for the drug. When informed that those studies looked at low doses, not high doses, Cartt said no one knows the long-term implications of high-dose prednisolone, and said the company's higher profits will help it find out. "We can afford to study the long-term effects" of Acthar Gel and the alternatives, he said.
What the congressional hearing may find is that Questcor had a business problem: While its drug had a potential market of 300,000 multiple sclerosis patients, not enough of them were buying. But among a smaller market, just 2,000 babies per year, Acthar Gel was extremely effective in fighting infantile spasms. Questcor's astronomical rates may simply be a matter of hard business realities in a small potential market.
For the Foltzes, Questcor's high prices proved irrelevant, after much struggle. When at first his insurance company, WorldWide Insurance, rejected the claim, Trevor's doctor faxed in a letter stating that there was a good chance Trevor would end up mentally retarded for life without treatment; the insurer relented. But on Thursday, his mother, Danielle, will join those who testify against companies like Questcor. She says, "I feel they're going to soak every penny if they can get it."
