Thursday, October 28, 2010

"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 But even if Obamacare were repealed “lock, stock, and barrel,” as Rep.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.

Friday, October 22, 2010

"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?

Thursday, October 21, 2010

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

This piece is a featured post on Huffington Post.

Monday, October 18, 2010

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.  

Saturday, October 16, 2010

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.

Tuesday, October 5, 2010

"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.

Sunday, October 3, 2010

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.