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?


  1. This is your best post ever in this blog. Smart thinking like this is the essence of good government. Can we ever get from here to there?

  2. Like our country isn’t screwed up enough!
    We have enough lawyers killing medicine ... sadly, they are proving it.
    We need “Caps” on awards and “Losers Pay.”

    Maybe our new Congress will fix this?
    Nah, I’m kidding myself, the President is a lawyer; he would just veto it!

    So, I come back to my Walter Mitty dream: What we need are 535 Grandmas on Capitol Hill, so long as none of them are attorneys! As Connie Francis use to sing,”I can dream can’t I.”

    Good column Jim. Diabetes is just as bad as AD and just as expensive. Diets are good, but on this one a cure is needed too because the poor house is just around the corner. BTW, my son once told me there are 23 different Diabetes. It’s not going to be easy.

  3. Correction
    It was Joni James “I can dream can’t I”
    Listen to her; what a voice and a nice person!

  4. Just about all of the risk factors that predispose to stroke and vascular dementia also cause type 2 diabetes - overweight, inactivity, smoking, high cholesterol, high triglycerides. Type 2 diabetes is a multifactoral disease but if you can prevent it, you can also prevent many other costly, chronic diseases of old age. Talk about bending the healthcare cost curve!

  5. Diabetes today is a major problem in the UK and in the rest of the world; the treatment of which costs millions of pounds for which purchasing medical insurance for diabetics is a good solution.

  6. Diabetes is one of those deadly diseases that inflict our people for centuries. I remember my classmate in grade school, at a young age she injects herself with insulin just to keep her alive because if she forgot to, under our watch she will die. I feel for her so much. We were so young then but because of her our eyes we're opened to the truth that no one is too young to die. I see that diabetes needs a lot of monitoring; it must be so hard for her with all her paper records. I hope she feels better now with electronic health records that would surely help ease the burden. Thanks for medical billing companiesfor providing the software that is such a relief to everyone.