Tuesday, June 30, 2009
SanofiAventis looking for jumpers
Preclinical activities in some sites of Spain, the United Kingdom, the United States and Japan will also be reorganized, with divestment or reconversion solutions sought for certain activities. The firm is also reevaluating the resources needed for central group functions located in the Paris area.
Source
Now Roche quits PhRMA
Hoffman La Roche is severing its ties to Big Pharma.
Now the venerable drug maker this week plans to drop its membership in the Pharmaceutical Research and Manufacturers Association.
PhRMA, as it is known informally, is the leading trade group for the U.S. pharmaceutical industry.
After taking over a biotech giant and relocating to its windswept corporate campus in South San Francisco, Roche is shedding its century-old identity as a traditional U.S. pharmaceutical company.
As part of its evolution, Roche is aligning itself with a new lobbying force, the Biotech Industry Organization (BIO) and plans to pull out of another pharma-related affiliation, its sponsorship of a special pharmaceutical management program at Rutgers Business School.
Monday, June 29, 2009
Is the ABPI falling apart?
This new move highlights the recurring question of what the organisation can do when a member company breaches its code of practice, when it has no power other than to suspend its members?
A Roche statement in the FT said it had “decided not to rejoin the ABPI for the time being” and that it would continue to work within the code of practice.
Roche pull Accutane in the US
Roche notified the U.S. Food and Drug Administration today that it was withdrawing Accutane after a “reevaluation” of its product lines showed it faced serious challenges from generic competitors, company officials said in a statement.
Medical Science Liasons - secret salespeople
The Journal reports: "Though still small, the number of MSLs has increased steadily, totaling 1,970 in 2008, up 48% from 1,335 in 2003, according to data for 12 major pharmaceutical and biotech companies compiled by PharmaForce International, a market-research firm. Partial numbers for 2009 indicate a decline to 1,640, but Sean McCrae, an executive at PharmaForce, says that number is 'an aberration,' reflecting across-the-board cuts in the industry. And companies appear to still be hiring MSLs: The online job-search site Monster.com lists many MSL job postings. At the same time, drug makers have been cutting their conventional sales forces. By the end of 2008, the number of U.S. sales reps had dropped to 90,000 from a peak of about 106,000 in 2006, according to ZS Associates, a consulting firm."
The Journal notes that "the drug companies themselves argue that their medical-science and sales forces have different functions." It also adds that: "MSLs generally make at least 50% more than primary-care sales reps, who are paid an average of $86,000, including bonus" (Wang, 6/26).
Sunday, June 28, 2009
AstraZeneca - Seroquel: mess tort contd. - different from Zyprexa?
Auralis expands
The Royal Bank of Scotland has agreed to back the firm founded in 2005 by entrepreneurs Andy Sneddon and Simon Bryson. The Cheshire-based firm specialises in the development of niche, non-brand pharmaceuticals for which there is a critical need. It currently supplies an opiate pain relief injection to a number of NHS trusts, for both primary care and hospital use, and nearly half of all retail pharmacies across the UK. The funding that has been secured allows Auralis to grow through the development of products, focusing on the paediatrics market, and to extend its reach into continental Europe.
Sneddon expects the additional finance, two-thirds of which was provided by RBS through the UK Government's Enterprise Finance Guarantee scheme, to lead to additional revenue for the business within 12 months. The firm has a track record in taking commercial products from conception to commercialisation.
Sneddon and Bryson recently signed up Clive Dix as non-executive chairman of Auralis. Dix is a former chief executive of Oxford-based vaccines company PowderMed and is the current chairman of the UK BioIndustry Association. Sneddon says: "Our business is sustainable as it stands but we are very ambitious and believe we have a great opportunity to develop and provide more products that will make a significant difference to patients – particularly young children – with a range of medical conditions."
Ken Brown, director of healthcare at RBS business and commercial banking, Scotland, said: "The business already has strong revenue streams underpinned by long-term supply contracts, and it now has the capital necessary to develop much needed products."
Saturday, June 27, 2009
Kat Sanders writes
A Few Problems in the Pharmaceutical Industry
The pharmacy industry has come in for its share of criticism, mostly because of the undue importance being given to publicizing, prescribing and advertising drugs, especially the newer ones that are costlier than their predecessors. There are many benefits that the pharmaceutical industry can provide society, but only if they people concerned resolve the problems that plague this industry. They need to focus on:
· Prevention rather than cure: Medicines that prevent are currently not publicized as much as they could be, mainly because the profits come when people are not well. Not many people know about preventive medicine, but if they did, they would focus on not being affected by disease rather than trying to cure it after it strikes. The pharmaceutical industry must do more research into preventive medicines and the benefits they can provide for society.
· People rather than profits: Medicine and its related fields are meant to provide altruistic benefits towards society instead of being purely profit-driven. But with the huge amount of money that is being made in the pharmaceutical industry, it’s hard to keep your goals in sight without being overwhelmed by the immense profits. People should matter more than money, and drugs, especially the ones that are necessary to save lives, must be made available when necessary.
· Creating awareness about drug abuse and adverse reactions: Most people are not aware of the dangers of drug abuse and overdose, and this results in addictions and deaths that could have been prevented. Besides this, some people are allergic to certain drugs and suffer from adverse reactions if they are taken. The pharmaceutical industry should play a more active role in creating awareness of the ill-effects of drug abuse and overdose and also help people in dealing with the side-effects of prescription drugs.
· Preventing medication errors: More emphasis must be placed on ensuring that prescriptions are filled out correctly and that the right medicines and dosages are given to patients. Ensuring the safety and well-being of patients must be a top priority for pharmacists.
By-line
This article is written by Kat Sanders, who regularly blogs on the topic of pharmacy technician certification at her blog The Pharm Tech Blog. She welcomes your comments and questions at her email address: katsanders25@gmail.com.
Carry On Up The Pfizer!!! - a Pharma Giles production
Coming To A Cinema Near You…
The latest comedy smash from the Carry On Team…
Carry On Up The Pfizer!!!
Pfizer’s crack regiment of Highlanders try and pull off a massive off-label marketing scam, but wind up disappearing up their own Khybers...
Laugh at Pfizer’s attempt to try and sweep the bad news about the resultant record-breaking $2.3 billion malfeasance settlement under the carpet of their desperation-stakes take-over of Wyeth…
Gasp in amazement as marketing execs Tom Farina and Mary Holloway each take one for the team, just so that the Pfizer executive can distance itself from the company’s criminal activities…
Guffaw as Mary lifts the kilt and exposes Pfizer’s attitude to illegal practices…
Howl with hilarity at the breathtaking hypocrisy of senior management in relation to the company’s much-vaunted corporate values and leader behaviours
Oh, What a Carry On, Pfizer…
Jim Edwards at BNET has the entire fun-packed background. And if PharmaGossip’s US readers don’t know what Carry-On films are all about, go here…
Friday, June 26, 2009
BMS/AZ - Onglyza: ok to add on
Pharma Giles writes ,,,
Phoni Europe PLC will announce a reorganization of its research and development operations in coming weeks, Senior Executive Klaus Vilebastard said.
“We have a number of things to address in terms of how we get our people to work together, how we can provide more latitude for creativity, how we can develop them scientifically and how we can encourage external collaboration, because there is a world of science out there,” Vilebastard told reporters in an interview published today.
“And all of those things involve outsourcing R&D, firing scientists and buying into generics,” he explained.
Industry analysts reacted to the announcement with weary scepticism.
“Vilebastard’s ‘exciting new strategy’ is just the same as every other pharmaceutical company’s “exciting new strategy”, said one. “These executives just don’t get it, do they? Firing R&D staff to improve morale and discover new drugs? There’s a serious disconnect here…”
Vilebastard was in an upbeat mood, however.
“Our reorganisation strategy may seem like we are just following the herd, but we’re not. What makes us different is that we’ve spent a fortune to ensure that our bold new strategy has far better corporate logos and snappier named initiatives than our industry competitors,” Vilebastard boasted, “and that’s an investment that will really pay off in the long term…”
News of yet another dynamic breakthrough in increasing R&D efficiency can be found here. Ho hum…
Thursday, June 25, 2009
Loving spoonful?
'Most vitamins and cold remedies available over the counter are a complete waste of time.' So says Prof Steve Field, the chairman of the Royal College of GPs
SanofiAventis - incoming
“We have a number of things to address in terms of how we get our people to work together, how we can provide more latitude for creativity, how we can develop them scientifically and how we can encourage external collaboration, because there is a world of science out there,” Viehbacher told Reuters in an interview published today. Geoffroy Bessaud, a spokesman for Sanofi in Paris, confirmed the comments.
Wednesday, June 24, 2009
FTC wants end to "collusive deal$"
The FTC’s chairman Jon Leibowitz says that an internal analysis projects that stopping what he describes as “collusive” settlements between brand and generic pharmaceutical firms would save consumers $3.5 billion a year. He added that a ban would also reap significant savings for the federal government, which pays around one-third of all prescription drug costs in the USA.
Mr Leibowitz said that “the decision about whether to restrict pay-for-delay settlements should be simple”. He went on to claim that “on the one hand, you have savings to American consumers of $35 billion or more over ten years…and the prospect of helping to pay for health care reform as well as the ability to set a clear national standard to stop anticompetitive conduct”. On the other hand, “you have a permissive legal regime that allows competitors to make collusive deals on the backs of consumers,” he added.
Atypical antipsychotics - The Healthy Skepticism Files
Internal company documents regarding 3 atypical antipsychotic drugs
The so called “Zyprexa documents” are examples of internal pharmaceutical company (in this case Eli-Lilly) documents that have been subpoenaed to court cases in the USA and other countries. They are available in full at http://www.furiousseasons.com/zyprexadocs.html with a description by the website’s host, Philip Dawdy.
The so called “Seroquel documents” relate to a similar trial involving Astra-Zeneca. Jim Edwards gives a description of some of the documents which pertain to weight gain and diabetes athttp://industry.bnet.com/pharma/10001228/e-mail-astrazeneca-knew-in-1997-that-seroquel-caused-weight-gain/. They are available in full, along with other commentary, via Philip Dawdy's Furious Seasons site again, at: http://www.furiousseasons.com/zip/seroqueldocs.zip (43.9 MB).
A third set of documents, regarding Janssen's atypical antipsychotic, Risperdal, and the Janssen/MGH Center for Child & Adolescent Bipolar Disorders, is available at:http://psychrights.org/research/Digest/NLPs/Risperdal/081112Opp2BiedermanQuash-Seal.pdf(14MB)
The series of powerpoint presentations linked here contain excerpts from the Zyprexa documents (9 powerpoints - 1 2 3 4 5 6 7 8 9) and Seroquel documents (1 powerpoint at this time). The excerpts highlight issues to do with:
1. Marketing and the desire of companies to maximize sales, suggestive of practices that can be described as “disease mongering” to expand indications for the drug in question.
2. Sophisticated marketing science and strategies to “influence”, applied to “key players” i.e. mainly physicians, researchers, academics, “thought leaders” and pharmacists, but also to allied health professionals, health institutions, government, private payers and patient advocacy groups.
3. Efforts suggestive of pharmaceutical companies seeking to control the research, the scientific literature and regulatory product labeling to enhance emphasis on benefits and minimize emphasis on harms of the drugs in question.
However the companies argue that the documents need to be read in context. To some extent these powerpoints can be accused of “cherry-picking” (a practice referred to in the Seroquel documents, which describes the selection for publication of only limited sections of the data analysis). The presentations do highlight a limited selection of the documents which illustrate the issues above, but our reading of the documents found plentiful examples of all 3 issues. Readers are therefore encouraged to access the original documents by using the file code number on each slide and matching it with the original documents located via the links above.
The powerpoint slides were created by Dr Peter Parry, Senior Lecturer in Child & Adolescent Psychiatry, Flinders University, South Australia in collaboration with A/Prof Glen Spielmans, Dept. of Psychology, Metropolitan State University, Minnesota, USA.
An abbreviated version was presented at the Royal Australian and New Zealand College of Psychiatrists (RANZCP) Congress 2009 in Adelaide, South Australia. Click here for a pdf (6.2 MB) of the handout from that talk. Glen Spielmans' paper "The promotion of olanzapine in primary care: an examination of internal industry documents" has been published online as an article in press at Social Science & Medicine.
Powerpoint presentations:
1. Zyprexa-Marketing Issues 1 (9.3 MB)
2. Zyprexa-Marketing Issues 2 (4.1 MB)
3. Zyprexa-Marketing Issues 3 (8.7 MB)
4. Zyprexa-Managing Adverse Drug Events 1 (6.5 MB)
5. Zyprexa-Managing Adverse Drug Events 2 (9.2 MB)
6. Zyprexa-Managing Adverse Drug Events 3 (10.1 MB)
7. Zyprexa-Influencing Key Players 1 (8.6 MB)
8. Zyprexa-Influencing Key Players 2 (7.0 MB)
9. Zyprexa-Global Value Committee Review (5.5 MB)
10. Seroquel (5.7 MB)
**A remarkably revealing recently released document is: Astrazeneca correspondence on Investigator Initiated Trials
These documents, particularly perhaps the last one of AZ correspondence re IIT's, help to give background to the views expressed by Richard Smith, former editor of the BMJ group of 25 journals, in PLoS Medicine 2005 - "Medical journals are an extension of the marketing arm of pharmaceutical companies."
Peter would like to acknowledge Philip Dawdy, journalist, and his very insightful blog www.furiousseasons.comwho bravely performed the public service of first posting the documents online.
A cross Pharma Giles writes....
Looking back to when he got the top job at Phoni(UK) a little more than a year ago, Andrew Whohe says that morale was terrible in the imaginary pharma giant's troubled, unproductive UK R&D department. High turnover left staff angry as Phoni reoriented its approach to drug discovery and development. But it's all just fine now, says the CEO.
"Many of the people we had in the discovery organization left in the period of change, either through their own volition due to our aggressive HR policies, or because we fired them," Whohe told a conference late last week. "Today, a year or so later, I'm pleased at how fast this has bedded down."
Whohe describes the improvement in R&D in numerical terms.
“Firing or retiring anybody who was even remotely competent or experienced meant that our middle managers didn’t have to justify their random decisions to a load of bolshie scientists,” he said, “in line with our plan to radically reorient R&D. And indeed, shutting down all of our UK R&D sites and outsourcing all of the work to the Orient has allowed us to achieve our aims.”
“Who needs a load of clever-clever scientists in the UK when those little far-eastern chappies are so much more amenable, eh? And cheaper…” Whohe told the crowd. “Our research teams now are properly oriented—or at least oriental. It’s all part of the radical shift in R&D towards low quality and high margins…”
Real world story here...
Takeda - Velcade: slapped wrist
A mailing from Takeda's Millennium Pharmaceuticals Inc unit overstated Velcade's effectiveness and failed to contain the appropriate information about its approved uses and risks, the Food and Drug Administration said in a letter to the company.
Tuesday, June 23, 2009
Introducing The Prescription Addiction Radio Show
-The Prescription Addiction Radio Show is dedicated to the thousands of families who are being or have been affected by the misuse of prescription drugs.
-The Prescription Addiction Radio Show is here to explore some of the challenges we face in trying to turn the explosion in the misuse of prescription drugs around.
-The Prescription Addiction Radio Show believes that addiction is a predisposed disease, whether created by poor personal choices or created from following the advice of your doctor. No individual wishes it upon themselves.
Alliance Medical Research Group - clinical trials, ain't they a bitch
CLEARWATER — Vladimir Martin called himself "doctor" and ran 17 clinical trials of new drugs for major pharmaceutical companies before one patient noticed he didn't have a medical license.
The patient alerted the St. Petersburg Times, whose resulting story led to a state investigation. On Saturday, Martin, 43, was arrested on charges of practicing medicine without a license. He was later released from the Pinellas County Jail on $10,000 bail. The felony charge carries a maximum sentence of five years in prison and maximum fine of $5,000.
The Clearwater man, who changed his last name from Kossatchev after moving to Florida in 2003, went to medical school in the former Soviet Union and practiced in a hospital in his native Ukraine.
"I don't have to tell them I'm not a doctor," Martin told the Times last year when asked about his failure to become licensed in Florida. "I am not practicing medicine."
But Ruth Weber, a 74-year-old Clearwater resident, told the Times in April 2008 that the man who called himself Dr. Martin enrolled her in a study for lower-back pain and adjusted the dosage of her medicine. Only licensed physicians are supposed to conduct such activities. Patients in the study were randomly selected to receive a new Johnson & Johnson painkiller called tapentadol, a placebo or the potent narcotic oxycodone.
Monday, June 22, 2009
Pfizer - Bextra: drug rep manager gets fine and probation
BOSTON, MA - A Branchburg, NJ, woman was sentenced today for violating the Food, Drug and Cosmetic Act, for marketing the drug Bextra for uses and dosages that were not approved by the Food and Drug Administration.
MARY HOLLOWAY, age 47, of Branchburg, New Jersey, has been sentenced by United States Magistrate Judge Judith Dein to pay a $75,000 fine and twenty-four months of probation after pleading guilty to an Information charging her with distribution of a misbranded drug.
At the plea hearing, prosecutors told the Court that, had the case proceeded to trial the Government’s evidence would have proven, the following:
From approximately November 2001, through April 2005, HOLLOWAY was employed as a Regional Manager at a pharmaceutical company and was responsible for sales in her region of the drug Bextra. Bextra was a Cox-II inhibitor and had been approved in by the Food and Drug Administration (FDA) in November 2001 for the signs and symptoms of osteoarthritis, adult rheumatoid arthritis, at 10 mgs and primary dysmennorhea at 20 mgs, twice a day as needed. In 2001, the FDA specifically denied the request of the pharmaceutical company to approve it for acute pain, including the pain of surgery. The FDA told the pharmaceutical company that it could not approve it for these other indications because the safety in these other uses had not been established. Specifically, the FDA was concerned about the results of a study in which there was an excess of cardiovascular events in patients who had undergone coronary artery bypass graft surgery and used Bextra.
HOLLOWAY was aware of the FDA’s safety concerns, but that she nonetheless had her sales staff of approximately 100 employees sell Bextra for precisely the uses that the FDA refused to approve. For example, HOLLOWAY trained and encouraged her sales teams to promote Bextra by obtaining protocols from doctors that instructed that Bextra be used for the pain of surgery, an unapproved use, and at 20 mgs, an unapproved dose. HOLLOWAY also instructed her staff to market Bextra for use before, during and after surgery to reduce the risk of deep vein thrombosis, which is a form of life threatening blood clots, even though she knew there were no studies showing that Bextra was safe and effective for this use. Finally, HOLLOWAY encouraged her staff to make false safety claims about Bextra in order to sell the drug.
Acting United States Attorney Michael K. Loucks said, “We will continue to hold individuals responsible for their conduct in promoting pharmaceutical drugs outside of the uses for which they have been found to be safe and effective by the United States FDA. The conduct at issue here undermined the FDA’s regulatory scheme and put patients at risk for the purpose of pursing profits for the individual and the pharmaceutical company.”
Bextra was withdrawn from the market in April 2005.
The case was investigated by the Federal Bureau of Investigation, the Office of Inspector General for the Department of Health and Human Services, Special Prosecutions Staff for the U.S. Food and Drug Administration, Office of Inspector General for the Department of Veterans Affairs, the Defense Criminal Investigative Service, and the Office of Inspector General for the United States Postal Service. It was prosecuted by Assistant U.S. Attorneys Sara Miron Bloom and Susan M. Poswistilo of Loucks’ Health Care Fraud Unit.
Sunday, June 21, 2009
Saturday, June 20, 2009
Friday, June 19, 2009
AstraZeneca - Seroquel: mess tort contd. the Disneyworld trip is on kids!
AstraZeneca Plc can’t block testimony by a medical expert that its antipsychotic Seroquel can cause weight gain and diabetes, a federal judge ruled.
The witness, Donna Arnett, professor and chairwoman of the epidemiology department at the University of Alabama at Birmingham, contends that Seroquel causes metabolic changes, which can lead to diabetes without weight gain. She also contends metabolic risks occur with Seroquel throughout treatment, according to court papers.
AstraZeneca, based in London, sought to have Arnett disqualified, saying she cherry-picked data favorable to her opinion. U.S. District Judge Anne C. Conway said yesterday that Arnett will be allowed to testify in Seroquel trials, with a jury deciding whether her conclusions are credible.
“The admissibility of Dr. Arnett’s general causation testimony is a close question,” Conway said in her 39-page decision. “The court finds that any weaknesses in Dr. Arnett’s methodology bear on the weight of her testimony, not its ultimate admissibility.”
The decision will apply to about 6,000 cases pending in federal court in Orlando, Florida, said plaintiffs’ attorney Paul Pennock.
Thursday, June 18, 2009
All change
Reese Witherspoon is Pharm Girl
Reese Witherspoon is going into Big Pharma.
Universal Pictures is developing "Pharm Girl," an aspirational comedy centering on one woman's odyssey through the drug industry.
"Bad Santa" screenwriters Glenn Ficarra and John Requa are writing the screenplay and in talks to direct. Witherspoon is producing via her Type A banner and will play the lead role.
The project concerns a woman who gets a job at a pharmaceutical powerhouse and begins to see the underbelly of the industry as she rises through the company's ranks.
Wednesday, June 17, 2009
AstraZeneca - Seroquel: mess tort?
In an e-mail Tuesday, Weitz & Luxenberg partner Paul Pennock wrote that, "far from going away, Seroquel is about to reveal AstraZeneca as one of the worst managers of a mass tort litigation in history." In a follow-up phone call, Pennock told us why he thought we'd missed the big picture.
About 20,000 Seroquel users--who took the drug to manage schizophrenia and bipolar disorder--have sued AstraZeneca claiming that the drug caused their diabetes. Earlier this week, we reported that a Delaware state court judge dismissed the third Seroquel case in a row after plaintiffs' expert testimony on causation was struck on Daubert grounds. As we noted, Delaware superior court judge Joseph Slights wrote that, "it is appropriate to wonder aloud" about the future of the cases pending in his state.
But, Pennock stresses, only 700 cases are pending in Delaware. More importantly, roughly 13,000 cases are alive and well in New York and New Jersey state courts, where, Pennock believes, the law is more favorable to the plaintiffs. "We have little concern that we'll have the same Daubert problems" in New York and New Jersey, he said. The first trial in New Jersey is scheduled for January 18, 2010.
In addition, there are 6,000 Seroquel cases in multidistrict litigation that Pennock said will be remanded for trial in federal court in 41 districts. "This [litigation] is not just alive and kicking," Pennock said. "It's about to go into full sprint in district courts around the country.
As for AstraZeneca mismanaging the litigation, Pennock compared the company's strategy with that of Eli Lilly when it was sued over its own antipsychotic, Zyprexa. There, the company settled the first 8,100 cases for about $700 million. "AstraZeneca is three years into this and they've spent about $700 million on litigation," Pennock claimed. "If this gets out of hand and we start winning cases and banging trials for $4 or $5 million a case, how is anyone going to convince a client with diabetes to settle the remaining cases for anything that AstraZeneca could afford?"
Dechert, which is coordinating counsel for AstraZeneca, said they were not authorized to comment. But we did get a statement from AstraZeneca spokesperson Tony Jewell: "In the cases prepared for trial to date, plaintiffs have been repeatedly unable to prove their claims in court. The evidence--looked at fully and fairly--does not back up the allegations that Seroquel was responsible for the plaintiffs' alleged injuries. AstraZeneca is committed to a strong defense effort and will evaluate the remaining cases on their individual merits."
Synthes execs charged by Feds
A medical device maker, Synthes Inc., and four of its executives were indicted Tuesday on federal charges that they improperly promoted a bone filler for purposes not approved by the Food and Drug Administration, including encouraging its use in what prosecutors called “unauthorized” human trials.
The indictment, sought by the United States attorney in Philadelphia, is one of the strongest actions taken in recent years against a maker of drugs or medical devices. Federal prosecutors typically file civil lawsuits seeking fines for such infractions, rarely bringing criminal charges against corporate executives.
“They put their profits ahead of responsible business practices and the truth,” Michael L. Levy, the United States attorney, said in a statement.
Tuesday, June 16, 2009
Chet Baker - My Funny Valentine
Just heard his version of "I'll get along without you very well" - haunting!
Monday, June 15, 2009
Obama's price cuts
The proposed new savings - which come on top of the $635 billion “down payment” on health reform which Pres Obama detailed in his February budget – will also include an estimated $106 billion to be saved from reduced hospital subsidies for treating the uninsured, as coverage increases.
Announcing the new proposals in his weekly Radio Address on Saturday (June 13), the President said these savings would come from “commonsense changes. For example…if the drug makers pay their fair share, we can cut government spending on prescription drugs. And if doctors have incentives to provide the best care instead of more care, we can help Americans avoid the unnecessary hospital stays, treatments and tests that drive up costs.”
A statement from the White House giving more details about the proposals emphasises that the President is committed to undertaking health reform “that is completely paid for and deficit-neutral over the next decade.”
.jpg)