"Death Panels" Redux

The New York Times' Robert Pear outlines the Obama administration's plan for reviving "end of life counseling," which Sarah Palin labeled "death panels."  Barack Obama & Co. denied that they were any such thing, of course, but the provisions of Section 1233 were left out of the Obamacare legislation, signed into law earlier this year.

But now, during a slow news time, they have returned as regulations issued by Medicare authorities, supported by many Democrats in Congress, such as Rep. Earl Blumenauer of Oregon.  Yet the proof that Democrats think that they have something to be defensive about is found in this passage from the Times article: 

Mr. Blumenauer, the author of the original end-of-life proposal, praised the rule as “a step in the right direction.”

“It will give people more control over the care they receive,” Mr. Blumenauer said in an interview. “It means that doctors and patients can have these conversations in the normal course of business, as part of our health care routine, not as something put off until we are forced to do it.”

After learning of the administration’s decision, Mr. Blumenauer’s office celebrated “a quiet victory,” but urged supporters not to crow about it.

“While we are very happy with the result, we won’t be shouting it from the rooftops because we aren’t out of the woods yet,” Mr. Blumenauer’s office said in an e-mail in early November to people working with him on the issue. “This regulation could be modified or reversed, especially if Republican leaders try to use this small provision to perpetuate the ‘death panel’ myth.”

Yes, that's exactly what could happen.  

As an aside, we can note the url that the Times used for this story.  Note that the "slug," as it would have been called in the old days, is "death": 

Evidently the Times does believe in calling it like it is--at least some of the time.  

How to stop organ smuggling: The ultimate answer is technological abundance, not scarcity and criminality.

The Guardian today reports on credible accusations that the prime minister of Kosovo has run Kosovo as a mafia state, trafficking in human organs, as well as drugs and guns.    In the meantime, though, we might be thinking about a better way to provide organs to people.   And we might note that what people want, desperately, is organs and other ways to improve and extend physical life.  Nobody tries to smuggle health insurance.  

The Guardian report opens up myriad questions, but from a Serious Medicine point of view, we might dwell on the phenomenon of organ trafficking, which seems to have been centered on kidneys; as the Guardian puts it, “a number of Serbs are said to have been murdered for their kidneys, which were sold on the black market.”  These alleged crimes are horrendous, and the perpetrators should be pursued with the full force of the law.  

However, we might note that black markets arise as the result of two related phenomena: illegality and shortages.   If something is illegal but also in demand, it will likely be in short supply, and that in turn will create a black market.   And so it is with human organs, including kidneys.   Thus even if the Kosovar black market is shut down, it’s a safe bet that it will continue elsewhere in the world.   

It’s easy to see why dangerous drugs are in short supply, because they should, of course, be illegal--because they are toxic.   They are intrinsically bad.   And so the black market in dangerous drugs, too, should be snuffed out.   

Yet organs are in a different category: Their provenance--say, from someone murdered for the sake of the organ--may make them contraband, but the organ itself is not intrinsically bad.  This is not an argument for some sort of benign treatment of the illegal organ trade.  Instead, we should be looking for ways to expand the supply of kidneys and other organs, so that the black market disappears.  After all, we want the organs, we just don’t want the criminals.  

Legal organ donor programs are one meritorious approach to expanding the supply, but the organ-donation process is still hit or miss, because there aren’t enough organs being donated.  Moreover, on short notice--as in the case of a donor who dies suddenly--it’s difficult and expensive to match the right organ with the right recipient.  The result is an illiquid organ “market” characterized by long wait times--and that means, of course, that the legal supplying of organs can still take on black-market features, starting with queue-jumping.    

So what’s the answer?  The answer is to increase supply.  Some have suggested creating a “white market” for organs, but such a system--which inevitably would become some sort of auction-- will always be disturbing to some, and will inevitably blend back into a black market, as in the case of the incompetent or the unwitting being “persuaded” to become organ sellers.   

The real answer is to cut the connection between the organ leaving one body and entering into another body.  That is, create new organs in the lab, and then the factory.   There’s plenty of work going on in this field, through cloning and 3-d printing, but we’re not there yet.   We don’t yet have a Henry Ford of organ manufacture, providing organs in a legal and ethical manner--even using workers being good wages in good working conditions.  

Until we do get there--until we embrace a Serious Medicine Strategy aimed at abundance, not scarcity--we will always see stories such as the one in the Guardian, excerpted here:  

Kosovo's prime minister is the head of a "mafia-like" Albanian group responsible for smuggling weapons, drugs and human organs through eastern Europe, according to a Council of Europe inquiry report on organised crime.

Hashim Thaçi is identified as the boss of a network that began operating criminal rackets in the runup to the 1999 Kosovo war, and has held powerful sway over the country's government since.

The report of the two-year inquiry, which cites FBI and other intelligence sources, has been obtained by the Guardian. It names Thaçi as having over the last decade exerted "violent control" over the heroin trade. Figures from Thaçi's inner circle are also accused of taking captives across the border into Albania after the war, where a number of Serbs are said to have been murdered for their kidneys, which were sold on the black market.

Legal proceedings began in a Pristina district court today into a case of alleged organ trafficking discovered by police in 2008. That case – in which organs are said to have been taken from impoverished victims at a clinic known as Medicus – is said by the report to be linked to Kosovo Liberation Army (KLA) organ harvesting in 2000. It comes at a crucial period for Kosovo, which on Sunday held its first elections since declaring independence from Serbia in 2008. Thaçi claimed victory in the election and has been seeking to form a coalition with opposition parties.

Once again, the imperative of law enforcement aside, the ultimate answer to the organ shortage is is technological abundance, not scarcity and criminality.  

'The Alzheimer's Strategy We Need," for the Manhattan Institute's Medical Progress Today

Full text here.

James Watson’s Quest: “A Geneticist's Cancer Crusade: The discoverer of the double-helix says the disease can be cured in his lifetime. He's 82.”

A terrific and hopeful piece in The Wall Street Journal today: An interview with James Watson, the legendary co-discoverer of DNA, sharing the 1962 Nobel Prize for medicine with Francis Crick and Maurice Wilkins.    

The headline atop Allysia Finley’s story speaks to a positive can-do spirit rarely seen in healthcare journalism these days: “A Geneticist's Cancer Crusade: The discoverer of the double-helix says the disease can be cured in his lifetime. He's 82.”   In fact, Watson has been making this point for a while now; last year, in the midst of the Obamacare debate, he wrote a New York Times op-ed calling for victory in the war on cancer.  Yes, Watson was willing to use the “w” word: war.  Serious Medicine is a war against disease, while health insurance can be seen as a kind of accommodation--some might even say appeasement.   Yes, its true: cures are more important than care, even if the power class of Washington DC thinks the opposite--or at least acts that way.  

Here are some good parts of the new Journal piece:  

'We should cure cancer," James Watson declares in a huff, and "we should have the courage to say that we can really do it." He adds a warning: "If we say we can't do it, we will create an atmosphere where we just let the FDA keep testing going so pitifully."

The man who discovered the double helix and gave birth to the field of modern genetics is now 82 years old. But he's not close to done with his life's work. He wants to win "the war on cancer," and thinks it can be won a whole lot faster than most cancer researchers or bureaucrats believe is possible.

What’s missing in the political-medical discussion, Watson declares is one word: leadership:  

He says he's the better for it because it taught him how to be a leader, something he thinks there are too few of nowadays. "The United States is suffering from a massive lack of leadership. There are some very exceptional, good leaders. I'm not saying they don't exist, but to be a good leader you generally have to ruffle feathers," which Dr. Watson believes most people aren't willing to do.

Finley notes that Watson has some new enemies: 

"The FDA has so many regulations," Dr. Watson says. "They don't want you to try a new thing if there's an old thing that might work. . . . So you take the old thing, but we know cancer changes over time and we would really like to get it whacked early, and not late. But the regulations are saying you can't do these things until we give you a lot of s— drugs," he snorts. "Shouldn't this be the patient's choice to say I would rather beat the odds with a total cure rather than just to know that I am going to have all my hair fall out and then after a year I'm dead? . . . Why should [FDA commissioner] Margaret Hamburg hold things up? There's the cynical answer it gives employment to lawyers.” 

Ah, the lawyers. "Right now America is being destroyed by its lawyers! Most of the people in Congress just want work for lawyers." He quickly adds: "I was born an Irish Democrat, so I wasn't born into a family which instinctively says these things. But my desire is to cure cancer. That's my only desire."

And then some final words:

"I'm going to look optimistically and of course sometimes it doesn't work," he says. But "you move forward through knowledge. You prevail through knowledge. I love the word prevail. Prevail!"

Yes, prevail.  Win the war on cancer.   

South Korea goes to war against Alzheimer's Disease, and the rest of the world should join them.

“In a Land of the Aging, Children Counter Alzheimer's”--that’s the headline, datelined Seongnam, South Korea, in The New York Times this morning.   In that story, we see seeds of hope on Alzheimer’s Disease (AD)--not only for South Korea, but for the rest of the world.  Indeed, here in the US, the challenge is to get our policymakers to consider lessons, and to seize opportunities, from overseas as part of our own medical--and fiscal--strategy.

Times Reporter Pam Belluck, alongside another Times reporter, Gina Kolata, has performed a great service, opening our eyes to the worldwide dimensions of AD.  In  traveling around the world, covering what is, in fact, an international epidemic, she reminds Americans that we are not alone in this problem--and that we have many potential allies, if we can figure out how to ally with them.

In South Korea, a full nine percent of the population suffers from AD, compared to less than two percent of the population of the US.  And because advanced cases of AD require round-the-clock care, the disease is horrendously expensive to treat.  In the US, we already spend about $170 billion on AD, more than one percent of our GDP on AD; in South Korea, where the diseases is more than four times as prevalent, the burden is even greater.   And of course, there’s the even greater financial cost of lost productivity--not only for the afflicted, but also among caregivers--as well as the enormous humanitarian toll.

For their part, the South Koreans are taking positive measures.  According to the Times, South Koreans freely describe their anti-AD effort as a “war.”  And with a war comes society-wide mobilization.  (Yes, as we know, the South Koreans are also, of necessity on a war footing against North Korea; the fact that South Korea is under so much pressure, from so many directions, is an argument for the full utilization of productive resources, including helping people stay productive for as long as possible, so that their skills and talents can be utilized for the defense of the nation, as well as for medical cures.)

Indeed, the South Koreans are taking positive measures against AD.   They are organizing students to be part of caregiving, and consciousness-raising.  Belluck describes some of the lessons being drilled into a young student:

“Dementia is very bad for you, so protect your brain,” he said, with exercise, “not drinking too much sugar,” and saying, “ ‘Daddy, don’t drink so much because it’s not good for dementia.’ ”


At a Dementia March outside the World Cup Soccer Stadium, children carried signs promoting Dr. Yang’s Mapo district center: “Make the Brain Smile!” and “How is Your Memory? Free diagnosis center in Mapo.”

One might say that such efforts, in and of themselves, have limited value.  After all, right now AD is incurable; indeed, there is no real evidence that any sort of screening or palliative therapy does much good.   Yet still, it’s important to start somewhere; building a consciousness about AD  is a way of signaling to other aspects of society that AD is a problem, and that will hopefully trigger a problem-solving response.   In the words of one anti-AD activist:


“I feel as if a tsunami’s coming,” said Lee Sung-hee, the South Korean Alzheimer’s Association president, who trains nursing home staff members, but also thousands who regularly interact with the elderly: bus drivers, tellers, hairstylists, postal workers. “Sometimes I think I want to run away,” she said. “But even the highest mountain, just worrying does not move anything, but if you choose one area and move stone by stone, you pave a way to move the whole mountain.”

So the South Koreans are mobilized and motivated.  And given the miraculous rise of the South Korean economy--actually, nothing miraculous about it, South Korea has simply outworked and outproduced most other countries--we should allow for the possibility that South Korea, on its own, could generate a medical breakthrough on AD.  And of course, were South Korea to accomplish such a breakthrough, the country would have developed yet another export industry, featuring a medical product that could be sold to the world. 

But of course, the South Koreans aren’t there yet, and maybe they will never reach that point--at least by themselves.   Today, the greatest resources for treating and perhaps curing AD are in the US, although there’s shockingly little policy focus on developing a cure here--as Sandra Day O’Connor and two co-authors recently pointed out, we spend 350 times more on AD treatment than we do on an AD cure.   That’s about as penny-wise and dollar-foolish as we can get.   And in addition, hurdles of regulation and litigation are seemingly designed to block progress: the crucial progress of “translation”--that is, turning a bright idea into an effective drug.

George Vradenburg, co-founder of US Against Alzheimer’s, suggests that one way to accelerate progress against AD is to build a “network of excellence” around the world, in which different research nodes--institutes, cities, even entire countries--could contribute to developing the knowledge base needed for a cure, as opposed to mere care.  Such a network is in keeping with the spirit of the Internet, and that’s not surprising, since Vradenburg was one of the visionaries behind the meteoric growth of AOL back in the 90s.   But of course, as Vradenburg is fully aware, the development of such a network would require a significant rethinking of laws and regulations concerning not only liability, but also privacy and intellectual property.  Indeed, since the creation of such an anti-AD network would be so complicated, genuine leadership--public, private, civic--would be required to fully mobilize available resources.   So no, there’s no guarantee that such new networking can, in fact, be realized.

But one guarantee we can make is that progress against AD would accelerate if we could develop a robust AD information network, because as Bob Metcalfe was the first to articulate, the processing power of a network is the square of the number of participants in the network.

And an even firmer--and grimmer--guarantee  we can make is that AD costs will be ruinous if present trends continue.  Not just in the US, not just South Korea, but around the world. 

Meanwhile, back in the US, we can note that three recent deficit reports--one from a presidential commission, co-chaired by Erskine Bowles and Alan Simpson, another from the Bipartisan Policy Center, led by Alice Rivlin and Pete Domenici,  and a third report, from Rep. Jan Schakowsky (D-IL), have all weighed in with ideas for dealing with future deficits--each venturing different ratios of spending cuts and tax adjustments and/or increases.   What’s remarkable, though, is that none of these deficit groups, however well-meaning, seem to have thought in international terms about how to solve problems.  For all the talk about “globalization” these past few decades, our policy process seems strangely parochial. 

What would have happened if the deficiteers here in the US had communicated with the South Koreans about a pooling strategy for AD research?  And with the Japanese?  And with Germany, China, and all the other rich countries that confront rapidly rising AD?    What sort of answers would have emerged from such networked thinking?   Answers including, perhaps, prospects for a cure, or even a significant easing of AD onset?  Or other ideas?   For example, the Japanese are making a huge investment in robots, many of them designed for geriatric care.  The world outside of Japan might not be ready for “geri-bots,” but maybe we will be ready in another decade?

Indeed, what’s so striking about the deficit debate here in the US is how limited it has been, in its intellectual scope. 

And so we come to a paradox: We need to think ahead, and think freely, even as we keep our perspective about what, precisely, can be known.   Throughout history--it has been virtually impossible to see, with any degree of accuracy, what the world will be like 50 years ahead.  So all straight-line projections are bound to be wrong.   That was the fate, for example, of Thomas Malthus, who predicted that England would run out of food in the 19th century, or Paul Ehrlich, who predicted worldwide starvation in the late 20th century.  Of course, it’s not just population projections that are proven wrong.  In 1865 the eminent economist William Stanley Jevons predicted that England would run out of coal in the 20th century and so argued for cutbacks in his own time.  While Jevons was right about the limitations of English coal reserves, he missed the impact of petroleum, which had in fact, been discovered seven years earlier.  Similarly, those today who hypothesize about “peak oil” have similarly missed not only the ever-greater discoveries of coal and oil, but also the emergence of vast new natural gas resources.  

Returning to health, we can recall a US government estimate from 1950, projecting national expenditures for polio by the year 2000 at $100 billion.  Adjusted for inflation that $100 billion would be about $1 trillion today.  Such an expenditure would have been a huge burden on the government and on the economy, but of course, it didn’t happen--because we developed the vaccine for polio back in 1955.

The point here is not to make fun of earnest efforts at forecasting the future--although we might note that many forecasts are not earnest, but rather part of a different political and intellectual agenda.  Instead, the point is argue for a bit of humility, and, at the same time, to argue that in technology issues, the optimists are usually right, at least in an overall sense.  If we allow scientific inquiry its free rein, we will more often than not be pleasantly surprised by what we come up with.

And so the deficit groups of 2010, as they sought to save us from fiscal wreck in 2030 or 2050 and beyond, would have better served the rest of us if they had factored in the best guesses of scientists and medical researchers.   Answers from experts would have been all over the spectrum, of course, but it might have been possible to tease out solutions for not only cutting costs, but also for improving personal health and economic productivity. 

In fact, it would have been useful to include other forward-thinkers as well.   Not because, as we have seen, all forecasts are correct--just the opposite, in fact--but because forecasters and trendspotters can at least point us in the right direction.   And the right direction is technological improvements and productivity growth, which are inevitably coupled with per-unit cost reductions.  

Moreover, this forward-looking consultation process could have been international.  We could have reached out to the South Koreans, and to the Japanese, and others, and said, “How are we going to pool our resources so that we can solve the AD problem?”

Yet instead, the deficit commissions chose to see everything in purely parochial US terms.  And yet absent the transformative potential of technology, the ideas that two of the three commissions--Bowles-Simpson and Bipartisan Policy Center--had for cutting spending, such as imposing the Sustainable Growth Rate (SGR) on Medicare doctors--will never happen, or at least not in any time frame that the deficiteers envision.   The SGR is always pushed back by Congress, because Congress is receptive to the popular demand that seniors should get the best possible medical care, from the widest possible selection of doctors.   An article in today’s Washington Post this morning provides an example of the hard pushback to come; the doctors will almost certainly beat back the SGR, now, and for years to come.

As for the Schakowsky report, calls for big tax increases are similarly unpopular, and thus improbable.

So we get back to an oft-made point: If a big chunk of our population ages and sickens with AD, it will be expensive, no matter what the financing or rationing scheme.  The better answer is to cure the disease.   Such a cure might be a long time coming, but the spinoffs along the way will be valuable, and the goal itself will be even more valuable.

The Missing Element From the Policy Discussion over Deficit and Debt: Dynamic Transformation.

The New York Times this morning publishes an interactive graphic feature--a "puzzle," it calls it--on cutting the deficit.  It's a nifty little game you can play, but the problem is that the simulation doesn't begin to simulate all the possible solutions to the current deficit/debt conundrum.   Indeed, the Times actually excludes the most promising solutions.

And thus what the Times really accomplishes, with this puzzle, is to underscore the limitations of the current debate.  As we can note--see arrow above--all of the deficit reductions that the game-player can choose are supposed to come from either revenue increases or spending cuts.  This is completely static analysis--never satisfactory in a dynamic world.   No room in this little "puzzle" for either increasing economic growth or technological transformation.  

What if economic growth went up a point or two a year?  What if we cured Alzheimer's Disease and raised the retirement age?   Those possibilities, and a hundred others do not compute to the Times, nor to most of those conducting the debate.

And so we can add something else that is missing from the debate: Hope.  It feels sometimes, as if we are back in the 1970s.

David Corn on Serious Medicine: "Transcend the Status Quo." Prospects for a Grand Compromise on Alzheimer's have just increased.

Can left and right come to agreement on Serious Medicine?  If the November 4 episode of Bloggingheads.TV is any indicator, there is, indeed, the potential for a harmonious convergence on the issue of cures.   Because, after all, our common bonds of humanity should transcend ideology.


David Corn, Washington bureau chief of Mother Jones magazine, author and co-author of several well-regarded books on national security and intelligence, as well as a fixture on cable news, appeared with me on Bloggingheads, and also wrote this column, on what Obama might do next.  That column included these paragraphs:


But I saw a glimmer of an answer the other day, while taping a diavlog forBloggingheads.tv with James Pinkerton, a quirky conservative (who worked in the George H.W. Bush White House). We were engaging in (what we hoped was) an amusing exercise: I would give the House GOPers advice, and Pinkerton would do the same for the White House. My recommendation to Boehner & Co. (or is it, Boehner Inc.?) was for the R's to show they are serious about governing by cutting a quick deal with Obama on energy that would avoid the more contentious matters (cap-and trade, nuclear energy, and drill-baby-drill) and focus on serious conservation measures, efficiency standards, and research and development for alternative energy, going further than what Obama and the Democrats included in the stimulus package. Pinkerton suggested that Obama announce a major initiative to cure Alzheimer's disease and invite the Republicans to join in this grand project. He noted that recently former Supreme Court Justice Sandra Day O'Connor co-wrote a New York Times op-ed calling for an Apollo-like project to stop Alzheimer's by 2020. And Maria Shriver has been making a similar case.

Pinkerton may be on to something. I'm not certain how such a presidential move would play with the public when unemployment is still near 10 percent. Would voters -- and Obama's die-hard opponents -- criticize him for focusing yet again on health care rather than jobs, jobs, jobs? (Noted: it is conceivable that Obama cannot do anything to help himself or his party while the economy remains stalled, even if his policies have prevented conditions from worsening.) O'Connor is asking for about $2 billion a year -- which is about 2 percent of the cost of the Afghanistan war. But is this the sort of big government spending that tea partiers and Republicans would decry? (The tea partiers are generally an older bunch and should appreciate such an effort.) And is there a reason to pick this illness over another?

Such an act, though, could convey boldness and imagination, and, yes, spark inspiration. Obama needs to find some manner in which to transcend the current political status quo. 

"The Age of Alzheimer's" by Sandra Day O'Connor

Sandra Day O’Connor, appointed by Ronald Reagan to be the first woman on the Supreme Court, has published a profound  op-ed in The New York Times this morning, calling for a massive effort to cure Alzheimer’s Disease (AD). In so writing, O’Connor and her two co-authors echo Maria Shriver, who has been making the same argument about AD: It’s cheaper, as well as more compassionate, to cure the malady than it is to care for it. As the op-ed notes, we don’t spend money on polio anymore, not because we streamlined treatment, or because we are heartless, but because we eliminated the disease itself. Quality is free, they say, and freedom from disease is almost free.

Yet for the last two years--indeed, for the past two decades--Americans have been told that the key issue in health and medicine is national health insurance. The Democrats won the policy battle in Washington, although it appears to be a Pyrrhic victory--Democrats seem destined to be drubbed at the polls this November. The voters don’t seem to agree with Vice President Biden that Obamacare is a big bleeping deal--or if they do, they don’t particularly like the deal.

For their part, Republicans seem focused on repealing Obamacare, as part of an overall effort to reduce the size of government. But even if Obamacare were repealed “lock, stock, and barrel,” as Rep. Mike Pence (R-IN) has pledged to do, joined by many other GOPers, the right should understand the limits to such a repeal. Deracinating Obamacare would not make it more likely that treatments for AD will emerge from laboratories. The roadblock to better medicine is not that someone is getting health insurance (although more aggressive efforts to restrict costs could take a toll on research funding). Instead, the current roadblocks have more to do with regulations, a capital shortage in the R&D sector, and the pervasive influence of the tort bar. It would be a shame if Republicans invested the next two years in repealing Obamacare, only to find--even if they are successful in their repeal-quest--that the mounting medical cost of AD has dwarfed whatever budget savings they might achieve in healthcare.

The two issues, health insurance and medical research, are essentially different. They are, to use the voguish business term, different “silos.” Unfortunately for the health of all of us, the health-insurance silo has come to predominate, at least in Washington, over the medical-research silo.

But to put it bluntly, medical research is more important than health insurance. If our population were still stalked by ancient killers, such as the plague, or smallpox, or tuberculosis, it wouldn’t matter much if we had insurance. Indeed, if we are stalked in the future by new threats, such as AD and diabetes, insurance will matter little--and might well be unaffordable. The key issue of life and death is the delivery of health, not health insurance.

And so, in the political distance, we can see a great wheel turning on healthcare policy, as we shift from reactive to preemptive thinking about medicine and health. In reactive thinking, we pay for the disease after it happens. That’s good and compassionate, but it’s a shame that the spending comes after the affliction has struck. And that is, in fact, where most of our healthcare money goes--to help people after they get sick. Indeed, only about 4 cents out of every healthcare dollar in the US goes to medical R&D; the other 96 percent goes to treatment. We can liken those expenditures to the capital budget and the operating budget in a business. But it is that capital expenditure that offers the only hope for truly “bending the curve” on AD. We will defeat AD by preempting it. If we merely treat AD reactively, then it has defeated us.

After considering the psychic and financial cost of AD, O’Connor, Dr. Stanley Prusiner, recipient of the 1997 Nobel Prize in Medicine, now director of the Institute for Neurodegenerative Diseases at the University of California, San Francisco, as well as Ken Dychtwald, a psychologist and gerontologist, lay out their plan:

Just as President John F. Kennedy, in 1961, dedicated the United States to landing a man on the moon by the end of the decade, we must now set a goal of stopping Alzheimer’s by 2020. We must deploy sufficient resources, scientific talent and problem-solving technologies to save our collective future.  


As things stand today, for each penny the National Institutes of Health spends on Alzheimer’s research, we spend more than $3.50 on caring for people with the condition. This explains why the financial cost of not conducting adequate research is so high. The United States spends $172 billion a year to care for people with Alzheimer’s. By 2020 the cumulative price tag, in current dollars, will be $2 trillion, and by 2050, $20 trillion.

If we could simply postpone the onset of Alzheimer’s disease by five years, a large share of nursing home beds in the United States would empty. And if we could eliminate it, as Jonas Salk wiped out polio with his vaccine, we would greatly expand the potential of all Americans to live long, healthy and productive lives — and save trillions of dollars doing it.

O’Connor, Prusiner, and Dychtwald offer science-based hope that a cure, or at least a significant improvement, is possible within a decade:

A breakthrough is possible by 2020, leading Alzheimer’s scientists agree, with a well-designed and adequately financed national strategic plan. Congress has before it legislation that would raise the annual federal investment in Alzheimer’s research to $2 billion, and require that the president designate an official whose sole job would be to develop and execute a strategy against Alzheimer’s. If lawmakers could pass this legislation in their coming lame-duck session, they would take a serious first step toward meeting the 2020 goal.

Yet unfortunately, if past is prologue, we can expect that the leadership of both parties will ignore O'Connor's argument, and Shriver's, because it doesn't jibe with their health-insurance-centric healthcare agenda.  Indeed, the changes needed to make the quest for cures a viable proposition once again--concerning tort law, the FDA, and information sharing--are so enormous that both parties might conclude that it is easier to fight the same old fight about Obamacare. And it would be easier for the parties, indeed, if we simply refought the policy fight of the last two years over the the next two years--or 20 years.

But that fight, in and of itself, won’t do a thing to cure AD. And yet it’s a cure that the country needs and that the voters will reward.

Pictured above: Sandra Day O'Connor and her late husband, John J. O'Connor, who died of AD in November 2009.

"Diabetes may affect as many as 1 in 3 Americans by 2050" Why this problem isn't being solved--and how to solve it.

An important article on the future of diabetes in USA Today this morning; reporter Mary Brophy Marcus cites data from the Centers for Disease Control showing that the incidence of diabetes in the US could double, or even triple, in the next 40 years.  Today, about 10 percent of Americans are being treated for the disease  and the cost to America is $174 billion, of which $116 billion is direct outlays. (Another four percent suffer from the disease, and aren't being treated, so if the untreated become the treated, costs will explode all the more.)   Now we might ask: What happens if the incidence of diabetes rises as predicted? The answer, of course, is that such a rise would be ruinous, medically and financially.

Some will say that the answer is to cut back on obesity, and that's fine--we should all avoid getting fat and we should all exercise more.  But as a practical matter, in a culture full of food, where most work is sedentary, it's hard to keep excess weight from accumulating--our bodies evolved for a much different, and hungrier, set of circumstances.   Indeed, lectures about proper diet can easily degenerate into hectoring, at which point, the teachable moment is lost.

In addition, of course, plenty of people develop diabetes for reasons not connected to weight--juvenile diabetes, or Type 1 diabetes--seems to have nothing to do with weight.   Type 1 is estimated to afflict three million Americans.

What's really needed is fresh thinking about a technical solution to the problems of diabetes, and, for that matter, obesity.   In the past, when we found that much of the population was contracting a certain malady, we looked for population-wide solutions, such as better sanitation, vitamins, vaccines, even fluoridating water.  (Imagine how the last 75 years of dental care would have played out if the great and the good had said in response to the plague of cavities, "Don't eat sweets!"  It might have seemed to be good advice, but it was impractical advice.  And impractical advice, by definition, is not good advice. Instead, we fluoridated the water and improved toothbrushes and toothpaste--technical solutions.)  

Indeed, across American history, technological solutions, from the McCormick Reaper to the Model T to the personal computer, are, frankly, the American Way.  So the technology for improving pubic health  should not be any different.   Maybe we need better medicine for diabetes--more on that in a bit.  Or maybe we need different approaches to obesity--not just consumer guides and and action against menus, but even more ambitious approaches, such as new kinds of appetite suppressants.   But either way, we need new thinking.

Yes, such research might be expensive, but of course, if we could develop effective and long-lasting techniques appetite suppressant, we would have the equivalent of a wonder drug.   Indeed, we have a product that Americans would want, and so would much of the world.  There's big money--not just for the government, but also for the private sector--to be found in solving such problems.  And jobs, too.

Unfortunately, at the same time, the research effort on diabetes is going in the opposite direction.  How so?  The trial lawyers are busy draining money out of the system.   For example, look what's happening to GlaxoSmithKline, maker of Avandia, the diabetes drug.   Hit with a blizzard of lawsuits, even though no proof exists that Avandia does any harm, analysts are now projecting that GSK could suffer a $6 billion hit in legal judgments.   And what about diet pills, as a proxy for diabetes?  Well, the fen-phen settlement took $3.75 billion from another Pharma company.   So much that line of weight-loss inquiry.

So let's ask: Who among us thinks that these legal judgments will increase GSK's eagerness, or the eagerness of any other company, to pursue new diabetes medications?    No hands up?  Nobody thinks lawsuits stimulate innovation?  I agree.

Thus we'll be left with a familiar treatments for diabetes, including dialysis (which can cost as much as $30,000 per year) amputation--and, well, it gets worse from there.

Does that sound like a good plan, either for the individual patient or for the nation as a whole?  Especially when the incidence of the disease, in the US alone, is expected to double or triple?    Once again, no one rises in the affirmative?  Very well. We all agree--non-treatment is a non-answer.

So what's needed is more and better medical treatment, to "bend the curve" not just on the cost of diabetes, but on the incidence and ravages of the disease itself.   And it would be nice if we had a better technology for weight control, too.  And yet progress is exactly what we are not going to get, as lawsuits chase out the drugmakers.

We will eventually have to confront a blunt reality: Every drug--any substance--has an adverse effect on someone, somewhere.   That's diversity for you.  So how does one make a drug that helps the patient, not hurts the patient?  The answer, of course, is "personalized medicine," which entails lots and lots of data-crunching.  Out of that data-crunching will come better answers as to who is in the "risk" category for a certain drug--and those people will be warned away from that drug.  (Or down the road somewhere, perhaps the chemistry of the drug could be tweaked so as to make it safe for whoever uses it.)

As we can see, such data-acquisition and utilization will be an enormous effort--an effort, truly, on a civilizational scale.   A data architecture that protects privacy, but also fosters research, innovation, and, most of all, better treatment.   And yet the only thing more enormous would be the upside, if we could make all this work. If we could we would all enjoy longer and better lives.

Sadly, the needed free flow of information is currently being crippled by privacy regulations, and even more cripplingly, by the trial lawyers.  As Jim Wootton of NationsCourt  points out, there is nothing that the John Edwardses of the world would like better than a huge national health database that would allow them to search for suits.  That is, simply keystroke "F2"--the command for a word search--and sit back while the computer combs through a hundred million files and plucks out the lawsuit-worthy key words.

It's that threat, Wootton argues that makes the complete and full realization of personalized medicine a chimera.  And also, he continues, the vision of fully usable electronic health records.  Both personalized medicine and EHR will always be more promise than reality until these liability issues are sorted out.  And by "sorted out," we really mean, "blocked."   As in, sorry, trial lawyers. Society has greater objectives than your enrichment.

Medical progress and lifesaving is too important to be left to trial lawyers.  That should be obvious, but so far, at least, it isn't.  And so we have an ever expanding supply of trial lawyers, and a stagnating supply of useful drugs.

That could change, but only if we make the change.  Meanwhile, if nothing is done and present trends continue, 1/3 of us will have diabetes in 40 years.  Is that really what Americans want?

Maria Shriver's Kennedy-esque Dream: A World Without Alzheimer's

This piece is a featured post on Huffington Post.

Maria Shriver asks: Why is Alzheimer's Disease so underfunded? Echoing her late uncle, John F. Kennedy, she calls for a "moon shot" solution to AD.

Maria Shriver has a vision that can truly be called John Kennedy-eseque: She wants to see a cure for Alzheimer's Disease (AD). 

She has been all over the news in the last couple of days, talking about malady  that took the life of her father, R. Sargent Shriver, and also the lives of many others--and many more in the decades ahead, as we Baby Boomers age.  

Tonight Shriver was a guest of Diane Sawyer on "ABC World News," alongside Dr. Richard Besser, who has distinguished himself with his serious and determined coverage of medical issues--and his skepticism of government rationing schemes.   Shriver made the point that AD receives just a fraction of the funding that goes to cancer and heart disease--see screen grab above.  She raises a good point: Why is AD so under-funded?   

When Sawyer asked about AD funding, here's the way Shriver answered:

It's six billion dollars to cancer, four billion to cancer, five hundred million for Alzheimer's.  I think we're sitting at s is an incredibly exciting point in our history.  We can launch an expedition on the brain, much like President Kennedy launched an expedition to the moon.  And we can galvanize all our best researchers and scientists, to uncover the secrets of the brain, to Huntington's, to Parkinson's . . . We've never done that as a nation.  We've  got to find a cure to this disease, otherwise it will bankrupt every family in this country, and it will bankrupt as a nation.

Exactly.  So why aren't we doing more?  A cure--or even better treatment--would save money, for us as individuals, and for us as a nation.   And AD progress could be the key to solving the entitlement crisis, if it were linked to raising the retirement age, as argued here at SMS back in June.  

We can only admire Shriver for her determination and vision, but we can also note that such an effort is obviously good politics.   Good health is at the basis of all ideologies and belief systems.  From left to right, from blue to red, from socialist to tea partier, everyone wants to be healthy.  And so the voters, across the ideological spectrum, stand ready to reward the politicians who help them find a better life and a dignified old age.  

Health vs. Health Insurance: How Mental Silos Blind Us to What Matters Most in Healthcare.

The Drudge Report today linked to an AP story on the spread of cutaneous leishmaniasis, the incidence of which has quadrupled in the past few years.   The parasitic skin disease comes from the female phlebotomine sand fly. There is treatment, but treatment is expensive, and of course, in Afghanistan it can be dangerous to be a caregiver.

It's tragic that this disease is afflicting Afghans, and it will be even more tragic if the disease spreads.  Once again, a reminder: The public health victories of one era can be lost in a subsequent era.

And so once again, we are reminded, health itself is more important than healthcare finance.  As it happens, I am reading Rebecca Costa's new book, The Watchman's Rattle: Thinking Our Way Out of Extinction, in which the author talks about the problem of "silos"--mental walls that keep us from thinking outside of our lane.  More often than not, these silos are self-imposed, and yet even though they are "voluntary," they can be paralyzing, intellectually.

And that's what has happened to the US in the healthcare debate.  We have "healthcare finance" in one silo, and that's been the hot silo for decades.  And in the other silo, we have Serious Medicine, which has been much neglected over the same period.   There is little interchange between the two.

Yet a look at this boy's face should tell us which is is the ultimately more important silo.

"Nemesis" by Philip Roth, recalls the scourge of polio before the vaccine

Philip Roth has written a new novel, Nemesis, about a polio epidemic in Newark, NJ back in 1944.  In the absence of a cure or vaccine--the polio vaccine was 11 years away--Roth's work is necessarily about suffering and stoicism, as opposed to a cure.  

Review Roth's half-century in American letters, New York Times reviewer Michiko Kakutani, recalling one of Roth's most famous books, observes, "Whereas 'Portnoy’s Complaint' was an outrageously comic tale about the throwing off of duty, 'Nemesis' is a pleasantly told parable about the embrace of conscience." 

Read an excerpt here.

The Nancy Brinker Ethos: "When you see someone in need, you give. When you see something wrong, you fix it."

Those words appear in Nancy Brinker's new book, Promise Me: How a Sister's Love Launched the Global Movement to End Breast Cancer, reviewed in The Washington Post this morning.   Brinker, the founder of the Susan G. Komen for the Cure, recalls the words of her mother: "When you see someone in need, you give.  When you see something wrong, you fix it."

Susan G. Komen died of breast cancer in 1980, still in her 30s.  Ever since, her sister, Nancy Brinker, has been a dynamo on behalf of fighting breast cancer.  Not just paying for its treatment, but seeking to fix it.  That is, seeking a cure.

The Hebrew words tikkun olam don't mean provide care for the world, they means heal the world.

What do Wounded Warriors with Traumatic Brain Injury now need most? Answer: Serious Medicine--More Serious Medicine.

Startling--and also inspiring--photos of Wounded Warrior Robert Warren appearing in The Washington Post this morning.   The photos accompany a long and detailed article by Christian Davenport, explaining the issue of traumatic brain injury. As the photo above makes clear, Robert Warren received horrible injuries from a rocket attack in Afghanistan, and his recovery will be long, difficult, and incomplete--not only was part of his skull and brain blown away in the explosion, but a piece of shrapnel remains embedded in his cranium.

It's fair to say that up until not long ago, a soldier with Warren's injuries would have died on the battlefield, or, if he had survived, would not be able to resume much of his previous life.   Once again, the variable is Serious Medicine.  But we shouldn't stop with what we have. We own it to Warren, and his family, to go further.  If we really wanted to, we could be working to regenerate his brain tissue, and heal the rest of his numerous injuries.  That would be a great and noble healthcare project.

Federal healthcare rationers called out: ABC News' Dr. Richard Besser repudiates government's breast screening recommendations. And why the government will undoubtedly try to ration care in the future.

Last night on "ABC World News," Diane Sawyer and Dr. Richard Besser delivered a tough critique of those breast-screening guidelines that the federal government pushed late last year.   The ABC report was plenty tough, leading the broadcast, but still not tough enough, because while Sawyer and Dr. Besser refuted the government's effort to ration breast-screening, they didn't go further and tell us why the government wants to ration such care--and why even after this rebuke, the government will likely try again.

Sawyer began: "Less than a year ago, you'll remember a government panel said women do not need regular mammograms till the age of 50."  Now, she continued, a new study of one million Swedish women found that "mammograms in your 40s can dramatically save lives from breast cancer."

Then she turned over the segment to Dr. Besser, who added that he sent the Swedish study to 24 doctors and cancer specialists around the country; 21 of them, he said, were already telling their patients just that--get checked regularly in your 40s, don't wait till age 50.   Besser added that the screenings could cut deaths from breast cancer by 26 percent; saving the life of 1 out of every 1200 women screened.   He concluded, "Today's study flies in the face of those controversial government recommendations last year when a panel found mammograms for women under 50 should be an individual decision, rather than a general recommendation."

OK, so scientific recommendations come, and scientific recommendations go.  That's the flux of science, as scientists push toward the best answer.  Right?  Actually, no.

The original recommendation from a government panel, the US Preventive Services Task Force, which came to light on November 16, 2009, should not be seen as a scientific recommendation--they were a political recommendation, aimed at giving the Obama administration, and the overall cause of healthcare rationing, a boost.   We're spending too much on healthcare, the larger argument went, and besides, much of our healthcare spending is counterproductive--so why don't we spend less and call it a win-win?

Those recommendations caused such a firestorm last year that they were withdrawn--or where they?  In a bureaucracy, nothing ever dies. Bureaucrats wishing to advance a particular position might have to make a tactical retreat every so often, but they never give up.

So the original finding should not be seen as an isolated incident.  There will be more.  The bean counters and rationers--here at Serious Medicine we call them Scarcitarians--will be back.  They have not in any way given up in their efforts to define American healthcare downward.

But there is hope, if the people are made aware of their own interests.   And the media, too.  Interestingly, while the politics of the Mainstream Media are firmly on the side of the Obamacare rationers, the ratings eyeballs are to be found on the opposite side of the argument--the Serious Medicine side.  People want to know about how they can stay alive, and they will reward TV networks that help them in that perfectly understandable goal.  It's real people, after all, who consume all the medical information in the larger culture; it's only a few policy wonks who think just the opposite--that people should have less information, and less access to care, pursuing, as they do, their "less is more" vision.

They are less interested in saving the government money in the shortest of short runs.  In the long run, of course, we would be better off, financially as well as medically, if breast cancer were reduced and then eliminated.

"Health Care: Booster Shot For Jobs"

“Health Care: Booster Shot for Jobs?” is the title of a new post by Michael P. Scott, an associate with the Denver-based urban consulting firm Centro, appearing in NewGeography.com.  I agree with everything about Scott’s title--except the question mark.  As his piece makes clear, healthcare is a booster shot for jobs. 

Scott starts with a paradox: Why it is that cities and their economic-development officials so often ignore the bird in the hand (the palpable reality that lots of people work in healthcare) in favor of the more speculative, perhaps even non-existent bird in the bush (the jobs to be found by luring in tourist attractions).  As Scott puts it: 

The local medical center complex is often the largest employer in town, it would seem that strong fiscal returns would be rewarded to those cities that strategically aligned their economic development efforts to capitalize on growing this sector. Unfortunately, the health industry has historically been viewed as a local disaster, replete with quality of care issues, bureaucratic inefficiencies and high costs.

As noted here many times at SMS, the dominant policy classes in Washington and New York, plus satellite nodes in Cambridge, San Francisco and elsewhere, have concluded that economic growth is great--but not in healthcare.  In healthcare, as we know, we have to “bend the curve” downward.  To be sure, these “Scarcitarian” elites wrap up their arguments in statistics,  but as far as I can tell, this is basically an aesthetic judgement these elites are making: we spend too much, and so we should spend less.    

But of course, aesthetics often makes for poor economics.   In this case, it means that the policy elites wish to provoke a recession in the healthcare sector even as they seek to “stimulate” the economy out of the recession.  Given that healthcare is one-sixth of the economy, it’s a challenge to shrink such a huge component while seeking to enlarge the overall whole; and, as we have seen, policymakers have not been very successful in this hit-the-healthcare brake-while-hitting-the-macro-accelerator approach.    


But the mantra of cutting healthcare, no matter what the cost, has been heavily programmed into these policymakers, so they keep going, and going, and going, even when they are no longer making policy.

Typical of this persistence is a recent post from Peter Orszag, the former director of the Office of Management and Budget in the Obama administration until last month.  Just a few days ago, he published a blog-post for The New York Times, in which he linked cuts in healthcare to not only the cause of deficit reduction, but also to increases in take-home pay and even improvement in public education:  

Containing health care costs is not just an abstraction central to addressing our long-term fiscal gap. It is also central to raising workers’ take-home pay, because increasing costs for health care are holding down wages.   And perhaps most unexpectedly, slowing the growth of health costs may be among the best things we can do to help the next generation attend a high-quality public college.

But as Scott laments in his post: 

Little attention is given to health care jobs as springboards to enliven local and regional economies. The steady parade of doctors, nurses, technicians and support staff at our medical establishments provide cities with a huge multiplier effect on nearby housing, restaurants and retail businesses. The trickle-down effect spreads outward to hospital manufacturers, suppliers, pharmaceutical companies, and other ancillary firms that serve as the lifeblood of a functioning health care system. The economic activity of the medical business extends well beyond hospital walls; it's a high-octane job engine, with the buying power of health professionals helping to sustain struggling communities.

But unfortunately, as Scott describes, cities with big healthcare complexes ignore those healthcare complexes, the bird in the hand, in favor of speculative new stadiums and museums.  As Scott describes the situation in Cleveland:

Cleveland, Ohio, is a prime example of a city that has undermined its economic potential by permitting dubious redevelopment efforts – centered on sports complexes and museums – to overshadow assets such as the Cleveland Clinic and the University Hospitals Health System, which together encompass 51,000 employees.

Like most Rust Belt cities, Cleveland sorely needs an infusion of jobs outside of the long diminished blue collar sector. It could build collaboratively on its health care niche, creating complementary clusters of medically related firms in the life sciences and health information systems that would bring new opportunities and life to the area. The city's world-class medical establishments could supply the ideal springboard for branding Cleveland as a global medical hub, rather than as the home of the Cleveland Cavaliers and the Rock and Roll Hall of Fame museum.

One Cleveland-area organization, BioEnterprise, is taking the lead in fueling the growth and commercialization of health care companies in the bioscience sector. A collaborative effort between top medical and higher education institutions in the region, BioEnterprise is a promising attempt to alleviate Cleveland's persistent difficulties in generating jobs and economic growth.

Scott further notes that these are good jobs at good wages; nationwide, the average salary is $43,000.   And Scott describes efforts to use health care as an economic engine in cities as different aOakland, Sacramento, and Spokane.  He concludes:

When cities and regions choose to create synergies between their communities and their medical campuses, the prognosis is promising for an economic cure.

And oh, by the way, in addition to the economic benefits of healthcare, there are other benefits, too, that one can’t get from another urban galleria.