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Sunday, May 14, 2023

Why US medical care can't be fixed

 On February 15, 1993, new president Bill Clinton presented his agenda to Congress.  He promised a sweeping reform of health care, which, he said, threatened to swallow up the US economy.  The nation now spent 14 percent of its GDP on health care, he said, and if present trends continued that figure might reach 20 percent by 2020.  It has in fact topped 18 percent now.  A clue to this apparently inexorable increase comes from a review essay by a medical specialist named Jerome Groopman entitled "Saving Lives and Making a Killing" in the current New York Review of Books.  

The article deals with the development of new drugs--specifically, anti-cancer drugs, and more specifically, breakthrough drugs to control chronic lymphocytic leukemia, or CLL.  One such drug (I will omit the long names, which would only confuse the issue) replaced toxic chemotherapy in 2014.  Only 1 million people worldwide, have the disease, but that drug has been generating $5.4 billion in revenue every  year--$5,400 for every single patient.  We must keep in mind that that represents cost, as well as income.  Now, someone else has developed a new and significantly safer drug of the same type which will almost surely replace the first one.  Running trials to test and prove the effectiveness of drugs is very expensive, and large financial investors, Groopman explains, become involved with possible new treatments at a very early stage because of the enormous potential payoff. In the critical two paragraphs of the review, the author of the book under review, For Blood and Money--a financial journalist named Nathan Vardi---explains why these particular drugs looked like such a good investment.

"For financial investors, the beauty of the drug…was that even though the drug worked, it didn’t work too well. Ibrutinib was not a magic bullet cure. The cancer was never fully cleared from the blood and rarely went away completely…. Patients would need to take a pill once a day, every day, for a long time—years….

"The analysts [at banks and hedge funds] took the relatively large number of CLL patients and multiplied it by the sky-high price that similar cancer drugs commanded in the market. Then they tried to estimate how long those patients would continue taking the drug. The analysts figured the drug could generate billions of dollars."

As a child I read a number of books about the great medical discoveries of the late 19th and 20th centuries, including Pasteur's vaccinations for anthrax and rabies, the development of diphtheria antitoxins, other vaccines, sulfa drugs, and antibiotics.  Many of those breakthroughs almost eliminated what had been significant causes of death.  Most of them were developed by single researchers (such as Sir Alexander Fleming, who discovered penicillin accidentally in a petri dish) or small teams.  Now private US companies spend billions on drug research but only occasionally yield such spectacular results.  Those two paragraphs explain why.  Today's researchers are not primarily focused on saving lives. Their bosses--and thus, they themselves--focus on making money.  To do that, they need to develop drugs that people will have to take for long periods of time--perhaps even for the rest of their lives.  A drug that quickly and simply cures people, or a vaccine that will protect them for life with a single dose, will not be nearly so profitable.

That is why our huge pharmaceutical industry has failed to meet a critical challenge: the development of new antibiotics to deal with newer, resistant strains of common bacteria that can cause tuberculosis, staph infections, and many other infections.  This is a serious and increasing problem because of the use of more and more invasive surgeries for joint replacements, which are producing increasing numbers of infections which can be very difficult to treat.  Yet big pharma doesn't want to develop them because they would not yield so much profit. 

The role of profit in US medicine has other impacts as well.  More than 10 years ago I got a taste of French emergency medicine when a fell on a steep ski slope and slid a few hundred yards down the hill on my back.  Coincidentally my roommate on the trip (run by a group) was an American urologist who helped me get back to the lodge and the infirmary.  For the next 24 hours he obsessed about worst case scenaries, including a lung possibly punctured by a rib and a concussion leading to internal bleeding.  The doctor at the clinic dismissed those concerns with a chest x-ray and a few simple tests.  He was working for a single-payer system where the incentives favored sensible, cheaper care. 

It seems obvious to me that the federal government should completely take over drug research--which it could put on a completely different footing.  Scientists working without any profit motive could focus on our most urgent needs--such as new antibiotics--and actively try to find new treatments that would save the most money--something Big Pharma, evidently, will never do.  I feel certain that there are thousands of very bright young men and women who would be delighted to spend their lives on that endeavor for the kind of money that senior federal bureaucrats make.  The government, not venture capitalists or hedge funds,. would fund the necessary trials, and license production for very low profit margins--if it chose not to manufacture the drugs themselves.  And a certain number of breakthrough discoveries targeting common diseases might allow us, for the first time ever, significantly to reduce the size of our medical establishment and its cost.

Having written that, I have to acknowledge how unlikely it is.  Big pharma is enormously profitable and thus has the resources to work its will in Congress, as they have done again and again.  That's why no Democratic president has ever dared push for single-payer insurance that might also save the citizenry the insurance industry's profits.  Our political system sustains our largest corporations, and vice versa.  Yet eventually our values could change--how and why I cannot say--and someone, somewhere, might try this experiment, and once again rid the world of some very serious diseases.

1 comment:

Energyflow said...

This reminds me of the story I heard about snack foods like chips or similar which are not designed to be nutritious but to always make us need to eat more of them due to chemical composition purposefully made to avoid satiation, unlike natural foods or the electronics whose cooler is next to the motor, designed to fail just at the warranty date. Obviously such an approach is antisocial. Adam Smith might have invoked the invisibe hand or one could say "let the buyer beware"(latin forgot). Systemic changes of regulatory agencies may help. However America, as opposed to Europe, migt find tricks around this. Americans culturally may be less accepting of the concept of fairness, equality, or equity due to the frontier , mixed cultural makeup. So the bad side is an inborn exploitative tendency against others, less related to one as in old world with a more relaxed pace. Creative change has brought new technologies and change to the fore however, " advancing humanity". One takes the good with bad, a static French or German culture with cheap public goods or exciting USA with music, film, culture, tech but dog eat dog reality. Increasingly I think America's middle class is being destroyed and big monopolies like in the gilded age built up. Income gap is severe, life expectancy is falling and health in decline compared to Europe.Foreign countries have adapted innovation, university research, etc and kept the good sides of their cultures, french cuisine over fast food for example. With its instability, limited resource base and moderate population America is falling behind. It can only afford such exploitation, effectively mass waste of human lives in healthcare and elsewhere due to its dominant postwar position. Rationalization will occur as that era ends gradually. Dollar hegemony, the debt limit and military spending are deeply entwined. If America lived within its means common sense would dictate sensible eating habits, walkable cities, local handmade produced goods, few university graduates or hi-tech gadgets, cars. Star Trek is not our future.