The drug that could save tens of thousands of lives - if only doctors could be told about it

The clotting drug tranexamic acid has already been included in the White House Medical Unit treatment protocols for President Obama. But until more people know about it, thousands of trauma victims all over the world will die needlessly without it.

Nothing could have saved President Lincoln. Kennedy might have survived the bullet in his back but not the one in his head. Garfield and McKinley, shot in the abdomen, died from massive internal bleeding. With four out of forty-four incumbents assassinated, and many more failed attempts, the job of US President is among the world’s more hazardous occupations.

However, the recent inclusion of the drug tranexamic acid into White House Medical Unit treatment protocols will increase the chance that Obama and future presidents will survive their terms. Being Commander in Chief means that presidential medical care is a military matter. The White House Medical Unit is in the White House Military Unit. Obama’s doctor is a Navy Captain.

In March 2010, results from the largest clinical trial ever conducted in trauma patients were reported in medical journal the Lancet. The CRASH-2 trial had randomly allocated over 20,200 bleeding victims of accidents or violence to receive either an injection of a drug called tranexamic acid or a matching placebo.1,2 Tranexamic acid had been used for decades to treat heavy monthly bleeding in women, but could it help in life threatening bleeding say from a knife in the ribs or bullet in the groin?

The results were spectacular. There were 160 fewer deaths in the tranexamic acid treated group. If given soon after injury, tranexamic acid reduced the risk of bleeding to death by about one third and without any side effects. Two weeks later, the British Army were using tranexamic acid to treat combat casualties in Afghanistan.

US military medics were not convinced. They had only recently burned their fingers on a new blood clotting drug called activated Factor VII. Seduced by industry hype and dubious expert advice, they had started using activated Factor VII to treat bleeding American soldiers even before results from randomised controlled trials were available. When the trials eventually reported they showed no evidence of benefit but significant side effects from unwanted clotting, with more heart attacks, strokes and gangrene.3 Lawyers smelled blood. And so even though there was a truckload of controlled trial evidence for tranexamic acid, they still wanted more data. The Taliban were more than happy to provide it.

Between January 2009 and December 2010, around 900 seriously wounded soldiers were treated by military medics at Camp Bastion in the Helmand province of Afghanistan. Improvised explosive devices had wreaked bloody havoc and double, triple, even quadruple amputees were not uncommon. One military surgeon described how he had worked on three soldiers wounded in the same explosion who had only two remaining testicles between them.

Of the 900 wounded, one third had been treated with tranexamic acid. Although the treated third were more severely injured than the untreated group, they were significantly less likely to die (17 per cent dead with tranexamic acid versus 25 per cent dead without). After statistical adjustment, the treatment benefit was even more dramatic.4 Although results from a randomised controlled trial with more than 20,000 participants should pack much greater scientific clout than the Helmand data, the experience of seeing a treatment effect in their own data was a powerful one and on 11 August 2011 US Tactical Combat Casualty Care Guidelines (pdf) were revised to include tranexamic acid.

A flag draped over a military coffin is politically inflammable. In large numbers, they can even smoke a president out of the White House. It takes the precise choreography of an Arlington funeral to get the corpse safely underground. Much less pomp and political risk surrounds the routine urban slaughter of young black Americans even though the number of deaths is considerably higher. A recent study estimated that the use of tranexamic acid to treat bleeding trauma patients in US hospitals could prevent more than 3,500 premature deaths each year.5 It was with these deaths in mind that the CRASH-2 investigators sent the entire clinical trial dataset to the US Food and Drug Administration (FDA) in March 2011 in the hope that the FDA would scrutinise the data and consider amending the licensing indications for tranexamic acid so that it could be marketed for use in trauma. Until this happens, any pharmaceutical company that promotes the use of tranexamic acid in trauma risks large fines.

Sadly, saving lives is not as easy as that. According to Dr Susan Shurin acting Director of the US Department of Health and Human Services, the FDA does not approve drugs unless the marketing company requests it and the marketing company will only request it if there is a demand. So we have a drug that could save a lot of lives if doctors knew about it but no one can tell them about it until it is licensed and it cannot be licensed until doctors know about it.

In an attempt to break this vicious circle, the trial investigators have had to take over the role of a pharmaceutical marketing department. Art students have been are enlisted to create informational cartoons that might go viral but might not.6 Doctors and university professors have had to lobby drug companies, to persuade them to take more interest in one of their own drugs, which is now generic and so not particularly profitable. If we do manage to raise the profile of this lifesaving treatment, the drug company will pay the FDA the license application fee, the FDA might give them permission to tell US doctors about tranexamic acid, the company will make some money and a few thousand Americans will not die.

It is absolutely right that those who risk their lives in the service of the President deserve the same standard of emergency medical care as the president. But so do the many tens of thousands of victims of violence and accidents who die needlessly every year around the world.

Ian Roberts is Professor of Epidemiology & Public Heath and Director of the WHO Centre for Injury and Violence Prevention at the London School of Hygiene & Tropical Medicine

_____________________________

1CRASH-2 Collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376:23-32.

2The CRASH-2 collaborators. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. The Lancet 2011;377:1096-101.

3Levi M, Levy J, Andersen H, Trulof D. Safety of recombinant factor VII in randomized clinical trials.  N Engl J Med 2010;363:1791–1800.

4Morrison J, Dubose J, Rasmussen T, Midwinter M. Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study. Arch Surg. 2012;147:113-119.

5Ker K, Kiriya J, Perel P, Edwards P, Shakur H, Roberts I. Avoidable mortality from giving tranexamic acid to bleeding trauma patients: an estimation based on WHO mortality data, a systematic literature review and data from the CRASH-2 trial. BMC Emergency Medicine 2012, 12:3 doi:10.1186/1471-227X-12-3

6The Lancet. CRASH-2 goes viral. The Lancet 2011;378:1758

 

The inclusion of tranexamic acid in White House treatment protocols will increase the chance that Obama and future presidents will survive their terms. Photo: Getty

Ian Roberts is Professor of Epidemiology & Public Heath at the London School of Hygiene & Tropical Medicine

Getty
Show Hide image

Bernie Sanders is America’s most popular politician – and he’s coming after Donald Trump

Sanders, unlike Clinton, had a clear and coherent vision. As of now, he is the best hope the Democrats have of retaking the White House in 2020.

“I like Bernie Sanders,” my four-year-old niece in Texas said to me last month. “Why isn’t he president?” More than six months on from the defeat of Hillary Clinton, it’s a question that countless frustrated progressives across the United States continue to ask aloud.

Remember that the election of Donald Trump was not the only political earthquake to shake the US establishment last year. A 74-year-old, self-declared socialist and independent senator from the tiny state of Vermont, in a crumpled suit and with a shock of Einsteinian white hair, came close to vanquishing the Clinton machine and winning the Democratic presidential nomination. Sanders began the campaign as the rank outsider, mocked by the former Obama strategist David Axelrod as the candidate with whom Democratic voters might “flirt” and have a “fling” before settling down with Clinton. By the end of the campaign he had won 13 million votes and 23 states, and raised more than $200m.

In this dystopian age of Trump, it is remarkable that Sanders is now by far the most popular politician in the US – and this in a country where “socialist” has long been a dirty word. Increasing numbers of Americans seem nevertheless to “feel the Bern”. As such, Sanders supporters cannot help but ask the big counterfactual question of our time: would Trump be the president today if he had faced Bernie rather than Hillary in the election? Throughout the campaign, polls showed him crushing Trump in a head-to-head match-up. In a poll on the eve of the election, Sanders trumped Trump by 12 percentage points.

Democratic voters were told repeatedly that Clinton was more “electable” – but had they opted for Sanders as their candidate, there would have been none of the backlash over her emails, Benghazi, Bill, her Iraq War vote, or her Goldman Sachs speeches. So did the Democrats, in effect, gift the presidency to the Republican Party by picking the divisive and establishment-friendly Clinton over Sanders the economic populist?

I can’t prove it but I suspect that Sanders would have beaten Trump – although, to be fair to the much-maligned Clinton, she, too, beat Trump by nearly three million votes. Also, one-on-one polls showing Sanders ahead of Trump in a hypothetical match-up fail to tell us how the independent senator’s support would have held up against a barrage of vicious Republican attack ads during a general election campaign.

Then there is the matter of race. Clinton, despite deep support in African-American and Latino communities, was unable to mobilise Barack Obama’s multiracial coalition. Sanders would have done even worse than she did among minority voters. Trump voters, meanwhile, were motivated less by economic anxiety (as plenty on the left, including Sanders, wrongly claim) than – according to most academic studies, opinion polls and the latest data from the American National Election Studies – by racial resentment and an anti-immigrant, anti-Muslim animus. Sanders, who at a recent rally in Boston defended Trump voters from accusations of bigotry and racism, would probably have struggled as much as Clinton did to respond to this “whitelash”.

Nevertheless, Sanders, unlike Clinton, had a clear and coherent vision and I would argue that, as of now, he is the best hope the Democrats have of retaking the White House in 2020. His support for greater Wall Street regulation, debt-free college tuition, universal health care and a higher minimum wage is not only morally correct and economically sound but also hugely popular with voters across the political spectrum.

The Democrats have a mountain to climb. They have to find a way to enthuse their diverse, demoralised base while winning back white voters who are concerned much more by issues of race and identity than by jobs or wages. A recent poll found that the party had lower approval ratings than both Trump and the Republicans as a whole.

Yet press reports suggest that at least 22 Democrats are thinking about running for president in 2020. This is madness. Few are serious contenders – thanks to the dominance of the Clinton machine in recent years, the party doesn’t have a deep bench. There is no new generation of rising stars.

The only two people who could plausibly prevent Sanders from winning the nomination next time round are the former vice-president Joe Biden and the Massachusetts senator Elizabeth Warren. The good news is that all three of these Democratic contenders are, to varying degrees, economic populists, willing to stand up passionately for “the little guy”. The bad news is that the Democratic base may fantasise about a young, dynamic Justin Trudeau or Emman­uel Macron of their own but, come the 2020 election, Sanders will be 79, Biden 77 and Warren 71. (Then again, they’ll be up against a sitting Republican president who will be 74, behaves as if he has dementia and refuses to release his medical records.)

Bizarrely, that election campaign has already begun. On 1 May, Trump released his first official campaign ad for re-election, 1,282 days before the next presidential vote. Biden visited New Hampshire last month to give a speech, while Warren is on a national tour to promote her new bestselling book, This Fight Is Our Fight.

Sanders, however – riding high in the polls, and with his vast database of contacts from the 2016 race as well as a clear, popular and long-standing critique of a US political and economic system “rigged” in favour of “the billionaire class” – is the man to beat. And rightly so. Sanders understands that the Democrats have to change, and change fast. “There are some people in the Democratic Party who want to maintain the status quo,” he said in March. “They would rather go down with the Titanic so long as they have first-class seats.”

Mehdi Hasan is a contributing writer for the New Statesman and the co-author of Ed: The Milibands and the Making of a Labour Leader. He was the New Statesman's senior editor (politics) from 2009-12.

This article first appeared in the 18 May 2017 issue of the New Statesman, Age of Lies

0800 7318496